Legal Considerations in Emergency Psychiatry.

Emergency psychiatry stands at the fulcrum between the general principles of autonomy and liberty balanced against illnesses that both subvert autonomy and amplify risks for violence and suicide. Although all specialties of medicine must operate in adherence with the law, emergency psychiatry is particularly constrained and guided by state and federal laws. Routine matters of emergency psychiatric care-including involuntary assessment, admission and treatment, management of agitation, medical stabilization and transfer, confidentiality, voluntary and involuntary commitment, and duties to third parties-all occur within carefully delimited legal boundaries, rules, and processes. This article provides a basic overview of critical legal principles relevant to the practice of emergency psychiatry.

High Resource Utilization of Psychiatric Emergency Services by Methamphetamine Users.

Methamphetamine use has increased throughout the United States in recent years, and is historically prevalent in Hawai'i. This retrospective study aimed to determine the effect of methamphetamine use on emergency department (ED) resources, by examining visits to an emergency department (ED) in an urban hospital in Hawai'i from 2007 - 2011. The rate of patients who tested positive for amphetamine was measured and broken down by year. Primary outcomes included length of ED stay, the administration of medication or physical restraints for safety, and the rate of psychiatric hospitalization. Overall, 15.1% of drug-screened patients (N = 16,018) tested positive for amphetamines over the study period. Amphetamine-positive patients spent more time per visit on average in the ED, and were more likely to require medication and physical restraints, compared to amphetamine-negative patients. Amphetamine positive patients were admitted to inpatient psychiatry less frequently than negative-testing patients. In summary, there is higher resource utilization per psychiatric emergency service visit by amphetamine-positive patients; however if patients can be stabilized in the ED, the increased ED resources utilized may be offset by the reduced burden on inpatient facilities.

Toxic effects of psychotropics related to possible p450 enzyme inhibition by kava: report of 2 cases.

Kava is an herbal remedy popular for centuries among native Pacific Islanders for its sedative effects and use in religious ceremonies. Kava gained popularity in Western countries due to its anxiolytic properties; however, very little is known about potential adverse reactions to kava other than reports of hepatotoxicity. Two cases of patients seen on the psychiatric emergency and consult service who developed severe side effects from psychotropic medications in the context of kava use are presented. In both cases, kava use may have affected the metabolism of the psychotropic medications, leading to serious side effects. Growing research indicates that kava most likely alters concentrations of coadministered psychotropics possibly by inhibiting cytochrome P450 enzymes. This case series highlights the need for greater awareness of safety issues among kava users who also take medications that, when combined with kava, can be life-threatening at toxic levels. Pharmacogenomic testing along with further research about kava and its metabolites could help determine a pharmacologic solution for patients who require psychotropic medications but who would like to preserve cultural traditions and religious practices.