The role of violence in decisions about hospitalization from the psychiatric emergency room.

OBJECTIVE: The authors evaluated the relationship between violent behavior and decision making about hospitalization from the psychiatric emergency room. METHOD: The medical charts of 321 patients evaluated in an urban psychiatric emergency room during a 4-week period were reviewed retrospectively. Violent behavior was defined as physical attacks on persons or fear-inducing behavior before or during the evaluation in the emergency room; and its value in predicting hospitalization decisions was assessed with logistic regression analyses that also included 12 demographic, clinical, and contextual variables. RESULTS: A model predicting hospitalization decisions was developed and cross-validated. Although violent patients were more likely to be hospitalized than nonviolent patients, clinical variables such as diagnosis and overall severity of psychiatric impairment were more important than violent behavior in predicting hospitalization decisions. CONCLUSIONS: Despite legal pressures to focus on overt behaviors such as violence as a basis for liability prevention and civil commitment, clinicians in this study did not allocate inpatient resources to preventively detain persons unlikely to benefit from treatment. Rather, they hospitalized the most severely disturbed patients, with diagnoses such as schizophrenic and manic disorders for which a widely accepted therapeutic armamentarium exists. The results are consistent with clinical recommendations that in the evaluation of the violent patient, attention needs to be given to the underlying disorder, since violent behavior itself can result from diverse causes only some of which require inpatient psychiatric treatment.

Dual diagnosis patients in the urban psychiatric emergency room.

Substance abuse among the mentally ill has become increasingly prominent. This article describes the problems presented by dual diagnosis patients in the urban, publicly funded, psychiatric emergency room. When such patients become acutely ill, neither the public health system nor the mental health clinician is adequately prepared to provide care. The inability to effectively treat these patients has become strikingly clear in recent years. In 1986, the Psychiatric Emergency Service at San Francisco General Hospital began to overflow with patients who required overnight stays. The intoxicated substance abusers with acute psychiatric complaints were the most difficult to manage clinically and administratively. Suggestions are offered for innovative approaches to this group of public patients: dual training of clinicians, flexible treatment programs prepared to deal with the whole person, and public funding that reflects patients' needs rather than clinicians' preferences.