Psychiatric Outcomes of Patients With Severe Agitation Following Administration of Prehospital Ketamine.

BACKGROUND: Ketamine is an emerging drug used in the management of undifferentiated, severe agitation in the prehospital setting. However, prior work has indicated that ketamine may exacerbate psychotic symptoms in patients with schizophrenia. The objective of this study was to describe psychiatric outcomes in patients who receive prehospital ketamine for severe agitation. METHODS: This is a retrospective cohort study, conducted at two tertiary academic medical centers, utilizing chart review of patients requiring prehospital sedation for severe agitation from January 1, 2014, to June 30, 2016. Patients received either intramuscular (IM) versus intravenous (IV) ketamine or IM versus IV benzodiazepine. The primary outcome was psychiatric inpatient admission with secondary outcomes including ED psychiatric evaluation and nonpsychiatric inpatient admission. Generalized estimating equations and Fisher's exact tests were used to compare cohorts. RESULTS: During the study period, 141 patient encounters met inclusion with 59 (42%) receiving prehospital ketamine. There were no statistically significant differences between the ketamine and benzodiazepine cohorts for psychiatric inpatient admission (6.8% vs. 2.4%, difference = 4.3%, 95% CI = -2% to 12%, p = 0.23) or ED psychiatric evaluation (8.6% vs. 15%, difference = -6.8%, 95% CI = -18% to 5%, p = 0.23). Patients with schizophrenia who received ketamine did not require psychiatric inpatient admission (17% vs. 10%, difference = 6.7%, 95% CI = -46% to 79%, p = 0.63) or ED psychiatric evaluation (17% vs. 50%, difference = -33%, 95% CI = -100% to 33%, p = 0.55) significantly more than those who received benzodiazepines, although the subgroup was small (n = 16). While there was no significant difference in the nonpsychiatric admission rate between the ketamine and benzodiazepine cohorts (35% vs. 51%, p = 0.082), nonpsychiatric admissions in the benzodiazepine cohort were largely driven by intubation (63% vs. 3.8%, difference = 59%, 95% CI = 38% to 79%, p < 0.001). CONCLUSIONS: Administration of prehospital ketamine for severe agitation was not associated with an increase in the rate of psychiatric evaluation in the emergency department or psychiatric inpatient admission when compared with benzodiazepine treatment, regardless of the patient's psychiatric history.

The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder.

(Reprinted with permission from Am J Psychiatry 2018; 175:86-90).

The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia.

(Reprinted with permission from American Journal of Psychiatry 2016; 173:543-546).

The Peregrinating Psychiatric Patient in the Emergency Department.

Many emergency department (ED) psychiatric patients present after traveling. Although such travel, or peregrination, has long been associated with factitious disorder, other diagnoses are more common among travelers, including psychotic disorders, personality disorders, and substance abuse. Travelers' intense psychopathology, disrupted social networks, lack of collateral informants, and unawareness of local resources complicate treatment. These patients can consume disproportionate time and resources from emergency providers. We review the literature on the emergency psychiatric treatment of peregrinating patients and use case examples to illustrate common presentations and treatment strategies. Difficulties in studying this population and suggestions for future research are discussed.

Who's boarding in the psychiatric emergency service?

INTRODUCTION: When a psychiatric patient in the emergency department requires inpatient admission, but no bed is available, they may become a "boarder." The psychiatric emergency service (PES) has been suggested as one means to reduce psychiatric boarding, but the frequency and characteristics of adult PES boarders have not been described. METHODS: We electronically extracted electronic medical records for adult patients presenting to the PES in an urban county safety-net hospital over 12 months. Correlative analyses included Student's t-tests and multivariate regression. RESULTS: 521 of 5363 patient encounters (9.7%) resulted in boarding. Compared to non-boarding encounters, boarding patient encounters were associated with diagnoses of a primary psychotic, anxiety, or personality disorder, or a bipolar manic/mixed episode. Boarders were also more likely to be referred by family, friends or providers than self-referred; arrive in restraints; experience restraint/seclusion in the PES; or be referred for involuntary hospitalization. Boarders were more likely to present to the PES on the weekend. Substance use was common, but only tobacco use was more likely associated with boarding status in multivariate analysis. CONCLUSION: Boarding is common in the PES, and boarders have substantial psychiatric morbidity requiring treatment during extended PES stays. We question the appropriateness of PES boarding for seriously ill psychiatric patients.

Risk for physical restraint or seclusion in the psychiatric emergency service (PES).

OBJECTIVE: We describe risk factors associated with patients experiencing physical restraint or seclusion in the psychiatric emergency service (PES). METHODS: We retrospectively reviewed medical records, nursing logs and quality assurance data for all adult patient encounters in a PES over a 12-month period (June 1, 2011-May 31, 2012). Descriptors included demographic characteristics, diagnoses, laboratory values, and clinician ratings of symptom severity. χ(2) and multivariate logistic regression analyses were performed. RESULTS: Restraint/seclusion occurred in 14% of 5335 patient encounters. The following characteristics were associated with restraint/seclusion: arrival to the PES in restraints; referral not initiated by the patient; arrival between 1900 and 0059 hours; bipolar mania or mixed episode; and clinician rating of severe disruptiveness, psychosis or insight impairment. Severe suicidality and a depression diagnosis were associated with less risk of restraint or seclusion. CONCLUSION: Acute symptomatology and characteristics of the encounter were more likely to be associated with restraint/seclusion than patient demographics or diagnoses. These findings support recent guidelines for the treatment of agitation and can help clinicians identify patients at risk of behavioral decompensation.

Clinical prevalence and correlates of substance use in adolescent psychiatric emergency patients.

OBJECTIVES: This study used clinical and administrative data to describe the clinical prevalence and correlates of substance use disorders (SUDs) in 622 adolescents aged 12 to 17 years who were evaluated with 1 or more psychiatric diagnoses after presenting to an urban psychiatric emergency service. METHODS: Clinical and administrative data including demographics, diagnosis, psychiatric severity, suicidality, treatment history, treatment disposition, social support, and overall functioning were retrospectively obtained from patient records. These data were used to describe the prevalence and correlates of SUDs in this sample of adolescents with psychiatric disorders. RESULTS: Twenty-eight percent of youth had an SUD. Marijuana and alcohol use disorders were the most common. The diagnosis of SUD was not associated with specific psychiatric diagnostic categories (mood, anxiety, and psychotic), psychiatric symptom severity, or suicidality, in the overall sample. There was limited evidence for a mediating/moderating effect of sex on the correlation between psychiatric measures and SUD diagnosis. Older age, SUD treatment history, and role dysfunction (ie, poor school functioning) were independently associated with any SUD diagnosis or a drug use disorder when accounting for sex. Older age and history of SUD treatment were independently correlated with alcohol use disorders. Twenty-three percent of youth with SUDs were referred for SUD treatment. CONCLUSIONS: Substance use disorders were prevalent in this population, and the rate of SUD treatment disposition was lower than anticipated. Substance use disorders were associated with lower functioning but not independently correlated with psychiatric diagnostic categories or symptom severity. This study supports the need for improved screening, intervention, and referral options for SUDs in this setting.

Methamphetamine users in the psychiatric emergency services: a case-control study.

The purpose of this study is to examine the sociodemographic, clinical, and service use characteristics of patients with positive methamphetamine (MA) urine toxicology and compare with non-MA users seen in an urban Psychiatric Emergency Services (PES). One hundred twenty patient charts were extracted for demographics, mode of arrival, clinical information, medication treatment of MA-intoxication, and disposition. Compared with non-MA patients, MA patients were significantly younger, male, referred by police, with cardiac symptoms, psychosis, dysphoria, past substance use, and were less likely to have a diagnosis of Schizophrenia, a past psychiatric history/hospitalization, and a history of suicide attempts. Subsequent hospitalization rates did not differ. MA patients treated with medications more readily accepted the referral to chemical dependency treatment. This study shows that hypertension and tachycardia upon arrival to the PES, symptoms of dysphoria and psychosis, past substance use and not having the diagnosis of Schizophrenia are all related to methamphetamine use.

"Excessive tears": a diagnostic sign for cocaine-induced mood disorder?

OBJECTIVE: This study aims to investigate excessive tearfulness as a sign to help determine the etiology of depressive symptoms. METHODS: Clinicians were instructed to document the occurrence of excessive tearfulness in all patients seen in the Psychiatric Emergency Service. Excessive tearfulness was defined as crying to the severity that at least 1 tear drops off the face. A comparison group was formed from the general population of the Psychiatric Emergency Service. RESULTS: Excessive tearfulness was documented in 36 different patients. The prevalence of the sign in the general population was 1.9%. Patients with excessive tearfulness were more likely to have cocaine in their urine (P < .0001, chi(2) test), receive a substance-related primary diagnosis (P < .0001, chi(2) test), and be admitted for psychiatric hospitalization (P < .001 chi(2) test). Patients with excessive tearfulness had significantly shorter voluntary hospital stays (P < .05, t test). CONCLUSION: Excessive tearfulness could be a useful clinical sign of cocaine-induced depression.

High utilizers of psychiatric emergency services.

OBJECTIVE: The purpose of this study was to examine the sociodemographic and clinical characteristics of high utilizers of psychiatric emergency services. METHODS: Data were collected over four years for 761 patients who were identified as high utilizers according to three definitions (two standard deviations above the mean number of visits to an urban psychiatric emergency service, six visits in a year, and four visits in a quarter) and for 1,585 nonfrequent utilizers (control group). Univariate analysis of variance and logistic regression models were used to determine group differences. RESULTS: Two distinct groups of high utilizers emerged: high utilizers by quarter and high utilizers by standard deviation. Compared with the control group, the high utilizers were more likely to be homeless, to have developmental delays, to be enrolled in a mental health plan, to have a history of voluntary and involuntary hospitalizations, to be uncooperative, to have personality disorders, to have unreliable social support, and to have a lifetime history of incarceration and detoxification. Compared with the high utilizers by quarter, the high utilizers by standard deviation had more visits and were more likely to have a history of incarceration and psychiatric hospitalization, more likely to be enrolled in mental health plan, and less likely to be homeless. CONCLUSIONS: High utilizers make up a small percentage of individuals who seek care in psychiatric emergency services and disproportionately use resources. It may be helpful to use two definitions of high utilizer to identify patients at different phases of their illness and to guide clinical interventions and mental health policies.

Lack of depression effect on platelet activation in patients with heart failure.

P-selectin is a marker of platelet activation. Previous studies have reported elevated P-selectin in patients with congestive heart failure (CHF) and depression as separate disorders. We examined if comorbid depression had an effect on platelet activation in CHF patients. Soluble (s)P-selectin was measured in 108 CHF patients; 24 with comorbid depression. There were no significant differences in age, cardiac parameters or (s)P-selectin levels between CHF-only patients and patients with comorbid depression. Our data show no group differences in P-selectin values, which suggests that comorbid depression has no additive effect on platelet activation in CHF patient.

Cytokines in depression and heart failure.

OBJECTIVE: There is a convincing body of evidence linking depression, cardiovascular disease, and mortality. There is also growing evidence that depression is a risk factor for congestive heart failure (CHF) and that CHF patients with major depression have higher rates of mortality and repeat hospitalizations. Currently there are no proposed neurobiological or neuroimmune mechanisms for the comorbidity of heart failure and depression. METHODS: This review focuses on the recent literature about the role of cytokines in CHF and depression as separate conditions. This review also attempts to identify the overlapping immunological mechanisms that have a potential for future research in the pathophysiology of comorbid depression and CHF. RESULTS: Results of current studies suggest that cytokines exert deleterious effects on the heart and that soluble tumor necrosis factor (TNF) receptor 2 leads to reversal of the cardiotoxic effects of TNF, although the clinical significance of this is unclear. Major depression has been associated with alteration of various aspects of the innate immune system, including cellular components (such as microphages, neutrophils, and natural killer cells) and soluble mediators (such as acute-phase reaction proteins and cytokines). It is inconclusive whether antidepressants have immunoregulatory effects. CONCLUSIONS: The literature has not yet addressed the role of cytokines in comorbid depression and CHF. But cytokines may provide a new avenue in understanding brain-body interaction in depression and heart failure.