Use of an Agitation Measure to Screen for Suicide and Self-Harm Risk Among Emergency Department Patients.

BACKGROUND: Suicidality alone is insensitive to suicide risk among emergency department (ED) patients. OBJECTIVE: We describe the performance of adding an objective assessment of agitation to a suicide screening instrument for predicting suicide and self-harm after an ED encounter. METHODS: We tested the performance of a novel screener combining the presence of suicidality or agitation for predicting suicide within 90 days or a repeat ED visit for self-harm within 30 days using retrospective data from all patients seen in an urban safety net ED over 27 months. Patients were assessed for suicidality using the Columbia-Suicide Severity Rating Scale-Clinical Practice Screener and for agitation using either the Behavioral Activity Rating Scale or Richmond Agitation Sedation Scale. We hypothesized that a screener based on the presence of either suicidality or agitation would be more sensitive to suicide risk than the Columbia-Suicide Severity Rating Scale-Clinical Practice Screener alone. The screener's performance is described, and multivariable regression evaluates the correlations between screening and outcomes. RESULTS: The sample comprised 16,467 patients seen in the ED who had available suicide screening and agitation data. Thirteen patients (0.08%) died by suicide within 90 days after ED discharge. The sensitivity and specificity of the screener combining suicidality and agitation for predicting suicide was 0.69 (95% confidence interval, 0.44-0.94) and 0.74 (0.44-0.94), respectively. The sensitivity and specificity for agitation combined with positive suicide screening for self-harm within 30 days were 0.95 (0.89-1.00) and 0.73 (0.73-0.74). For both outcomes, augmenting the Columbia-Suicide Severity Rating Scale-Clinical Practice Screener with a measure of agitation improved both sensitivity and overall performance compared to historical performance of the Columbia-Suicide Severity Rating Scale-Clinical Practice Screener alone. CONCLUSIONS: Combining a brief objective measure of agitation with a common suicide screening instrument improved sensitivity and predictive performance for suicide and self-harm risk after ED discharge. These findings speak to the importance of assessing agitation not only for imminent safety risk during the patient encounter but also for reducing the likelihood of future adverse events. This work can improve the detection and management of suicide risk in emergency settings.

Evaluation of the BEAT Meth Intervention for Emergency Department Patients with Methamphetamine Psychosis.

OBJECTIVES: Methamphetamine is the second leading cause of overdose death in America and a leading cause of emergency department (ED) visits. Methamphetamine-induced psychosis is a dangerous and difficult-to-treat consequence of methamphetamine use. We describe the pilot implementation and outcomes of a multimodal treatment intervention for ED patients with methamphetamine psychosis, Beginning Early and Assertive Treatment for Methamphetamine Psychosis (BEAT Meth). METHODS: BEAT Meth was implemented in an urban safety net health system. The protocol includes early identification and treatment of methamphetamine psychosis, a protocolized hospitalization, and support for transitioning patients to specialty addiction treatment. Patients receiving BEAT Meth were compared with ED patients with methamphetamine psychosis who were discharged. Implementation fidelity was measured to assess feasibility. RESULTS: BEAT Meth patients were nearly 3 times more likely to attend an outpatient specialty addiction appointment in the 30 days after discharge than comparison patients (32% vs 11%, P < 0.01). Subsequent ED utilization was common among all patients, and there was no significant difference in 30-day ED return rates between BEAT Meth and comparison patients (28% vs 37%, P = 0.10). Exploratory analyses suggested that increased attendance at outpatient treatment reduced ED utilization. CONCLUSIONS: BEAT Meth is an intervention framework to support identification, management, and treatment engagement of ED patients with methamphetamine psychosis. Treatment strategies like BEAT Meth are necessary to manage the unique challenges of methamphetamine addiction. These findings will guide clinical care, program development, and research.

More Than Suicide: Mortality After Emergency Psychiatric Care and Implications for Practice.

BACKGROUND: Emergency departments (EDs) provide vital mental health services. ED patients with behavioral health presentations, particularly suicidal ideation, are at increased risk of death by suicide, medical illness, trauma, or overdose. Causes of death for patients who receive specialty emergency psychiatric services remain undescribed. OBJECTIVE: We describe the incidence and cause of death after care in a psychiatric emergency service (PES). METHODS: Mortality data were obtained for all adult patients treated in a safety net ED from April 2016 to June 2020. Causes of death were categorized as medical, external (accidents, overdoses, and homicide), or suicide and compared between PES patients and ED patients who were not treated in the PES. Correlates of mortality were described for PES patients. RESULTS: We analyzed 164,422 encounters including 6063 PES visits. Mortality in the 30 days after discharge was 0.3% among PES patients and 0.6% among medical ED patients. At both 30 and 365 days, PES patients were more likely to die by suicide than medical ED patients, and ED patients were more likely to die by medical causes. Among PES patients who died within 365 days, 46% died by medical causes, 32% by external causes, and 23% by suicide. In multivariable analyses, age was associated with all-cause, medical, and external mortality after a PES visit; opioid and stimulant use disorders were associated with all-cause and external mortality. CONCLUSIONS: Most patients who die after receiving emergency psychiatric care die by medical and external causes such as accidents, overdose, and homicide. Patients who are older and have opioid or stimulant use disorders are at higher risk of nonsuicide mortality. We propose interventions to reimagine emergency psychiatric care and address nonsuicide mortality among psychiatric patients treated in emergency and crisis settings.

The Impact of the COVID-19 Pandemic on Psychiatric Emergency Service Volume and Hospital Admissions.

BACKGROUND: During the COVID-19 pandemic, there have been an increasing number of emergency department visits for behavioral health reasons, even as overall emergency department volumes have decreased. The impact of the pandemic and related public health interventions on specialized psychiatric emergency services has not been described. These services provide high-intensity care for severely ill patients who are likely to be homeless and underserved. OBJECTIVE: We describe the change in total volume and psychiatric hospitalization rates among three psychiatric emergency services across the United States. METHODS: Changes in volumes and hospitalization were assessed for statistical significance using a seasonal autoregressive integrated moving average with exogenous factors model from January 2018 to December 2020. RESULTS: The pandemic's impact on volumes and hospitalization varied by site. In Denver (CO), there was a statistically significant 9% decrease in overall volumes, although an 18% increase in hospitalizations was not significant. In New York City (NY), there was a significant 7% decrease in volumes as well as a significant 6% decrease in hospitalizations. In Portland (OR), volumes decreased by 4% and hospitalizations increased by 6% although differences did not reach statistical significance. CONCLUSIONS: There has been a decrease in volume at these services after the pandemic, but there are substantial variations in the magnitude of change and demand for hospitalization by region. These findings suggest a need to understand where patients in crisis are seeking care and how systems of care must adapt to changing utilization in the pandemic era.

Identifying the Most Important Consultation-Liaison Psychiatry Publications in 2020 Using a Novel Literature Assessment Instrument.

BACKGROUND: As the science of consultation-liaison psychiatry advances, the Academy of Consultation-Liaison Psychiatry's Guidelines and Evidence-Based Medicine Subcommittee reviews articles of interest to help academy members remain familiar with the latest in evidence-based practice. OBJECTIVE: We identify the 10 most important articles for clinical practice in consultation-liaison psychiatry from 2020 using the new Importance and Quality instrument for assessing scientific literature. METHODS: The subcommittee published annotated abstracts for 97 articles on the academy website in 2020. Reviewers then rated all articles on clinical importance to practice and quality of scholarship using the Importance and Quality instrument. We describe the 10 articles with the highest aggregate scores and analyze the reliability of Importance and Quality instrument. RESULTS: Twenty-four raters identified the top 10 scoring articles of 2020. These articles provide practical guidance on key areas of consultation-liaison psychiatry including management of COVID-19, lithium treatment for complex patients, medical risks among patients with severe mental illness, and substance use disorders in medical settings. The assessment instrument demonstrated good to excellent interrater reliability. CONCLUSION: These articles offer valuable guidance for consultation-liaison psychiatrists regardless of their practice area. Collaborative literature reviews with standardized assessments help clinicians deliver evidence-based care and foster a high standard of practice across the specialty.

Kappa-opioid antagonism impairs forebrain-dependent associative learning: A trace eyeblink conditioning study.

The opioid receptor system is well known for its relationship to painful stimuli but has also been discovered to have a role in acquisition and consolidation of associative memories. Most opioid receptor specific studies have focused on, and attributed these findings to, modulation of the mu-opioid receptor (MOR); however, some studies have suggested that the kappa-opioid receptor (KOR) also plays in role in memory modulation. The following study set out to determine KOR involvement in acquisition for forebrain-dependent associations. Using the forebrain-dependent associative task whisker-trace eyeblink conditioning (WTEB), the current study demonstrated that KOR inhibition via NorBNI (10 mg/kg) significantly delayed acquisition. To explore the brain region mediating these NorBNI-induced learning impairments, subsequent experiments focused on primary somatosensory cortex (S1). S1 plays a pivotal role in the acquisition of WTEB with lesions either before or after conditioning inhibiting acquisition or retrieval respectively. NorBNI (10 µg or 20 µg) in S1 was found to significantly delay acquisition, similar to that observed following systemic injections. In support of these findings, studies have suggested a role for dynorphin (KOR's endogenous ligand) expressing GABAergic interneurons in cortical processing of whisker information. Although, additional studies will be required to determine the specific mechanism for KOR and these GABAergic interneurons; these findings strongly support previous studies suggesting KOR involvement in learning mechanisms, while elucidating an unexplored neocortical learning mechanism.

Opioid antagonism impairs acquisition of forebrain-dependent trace-associative learning: an eyeblink conditioning analysis.

While the opioid system is predominantly known for its properties governing nociception, it has also been found to play a role in learning and memory. Opioid involvement in task acquisition and retention has been examined using various associative paradigms. These analyses have demonstrated that depending upon the associative paradigm and timing of opioid modulation relative to the task, it can either impair acquisition or facilitate memory consolidation. However, opioid involvement in forebrain-dependent trace-associative learning paradigms has never been examined. In associative paradigms, a subject learns to associate two stimuli, while in trace paradigms the two stimuli are separated in time, which is thought to increase task difficulty due to utilization of forebrain structures. The current analysis utilized the trace paradigm whisker-trace-eyeblink (WTEB) conditioning with a trace interval of 250 ms, in conjunction with pre- and post-training opioid inhibition with naloxone, a well-characterized nonspecific opioid antagonist. Naloxone administration prior to training (pre-training) was found to significantly impair acquisition of the WTEB association; however, administration following training (post-training) did not significantly differ from saline controls. These findings demonstrate that opioid inhibition impairs acquisition of forebrain-dependent trace-associations, further suggesting that opioid activation plays a modulatory role in trace-acquisition. Prior behavioral analyses have suggested that hippocampal µ-opioid receptors are most likely facilitating this effect; however, subsequent analyses will be needed to determine the specific brain region(s) and opioid receptor subtype(s) mediating this effect.