Factors predicting admission of psychiatric emergency contacts after presenting to the emergency department: results of a regression analysis.

BACKGROUND: Psychiatric emergency patients have great relevance in the interdisciplinary emergency department. Emergency physicians in this setting often have to make decisions under time pressure based on incomplete information regarding the patient's further treatment. The aim of this study was to identify possible predictors associated with an increased likelihood of inpatient psychiatric admission. METHODS: A retrospective cross-sectional study of all psychiatric emergency contacts in an interdisciplinary emergency department (ED) of a general hospital in a large German city was conducted for 2015. A binary regression analysis was performed to identify possible predictors. RESULTS: In 2015, a total of 21421 patient contacts were reported in the emergency department, of which 1733 were psychiatric emergencies. Psychiatric emergency was the fourth most common cause presenting to the ED. The most common diagnosis given was mental and behavioral disorders due to the use of psychotropic substances (F1). Factors associated with an increased probability of inpatient psychiatric admission were previously known patients, patients under a legal care order (guardianship), and previous outpatient medical contact. No association for gender or age was found. Data demonstrated a negative relationship between a neurotic, stress-related and somatoform disorder diagnosis and admission. CONCLUSIONS: The present study shows some significant characteristics associated with an increased likelihood of emergency admission. Independent of the health care system, the predictors found seem to be relevant with regard to the probability of admission, when compared internationally. To improve the treatment of patients in emergency units, these factors should be taken into account.

[Analysis of the psychiatric emergency inpatients in an ER setting at a general hospital]. / Charakterisierung des stationär aufgenommenen psychiatrischen Notfallpatienten in einer interdisziplinären ZNA.

OBJECTIVES: Evaluation of psychiatric emergency contacts in an interdisciplinary emergency room. METHODS: We conducted a retrospective examination of all psychiatric consultations of 2015. RESULTS: The three most common emergency syndromes could be assigned in descending order to the F1 (32.2%), the F2 (25.9%) and the F3 diagnoses (21.2%). The admission rate was 58.9% and more than half of the patients came to the emergency room on foot (55.7%). Diagnosis-specific differences were found between first-time presenters and patients who had presented previously. CONCLUSION: The psychiatric emergency has high relevance in the emergency room. The majority of the patients admitted to hospital meet the emergency criteria according to the guideline.

Do antipsychotics lead to cognitive impairment in dementia? A meta-analysis of randomised placebo-controlled trials.

Behavioural and psychological symptoms in dementia (BPSD) are common and often treated with antipsychotics, which are known to have small efficacy and to cause many side effects. One potential side effect might be cognitive decline. We searched MEDLINE, Scopus, CENTRAL and www.ClincalStudyResult.org for randomized, double-blind, placebo-controlled trials using antipsychotics for treating BPSD and evaluated cognitive functioning. The studies identified were summarized in a meta-analysis with the standardized mean difference (SMD, Hedges's g) as the effect size. Meta-regression was additionally performed to identify associated factors. Ten studies provided data on the course of cognitive functioning. The random effects model of the pooled analysis showed a not significant effect (SMD = -0.065, 95 % CI -0.186 to 0.057, I 2 = 41 %). Meta-regression revealed a significant correlation between cognitive impairment and treatment duration (R 2 = 0.78, p < 0.02) as well as baseline MMSE (R 2 = 0.92, p < 0.005). These correlations depend on only two out of ten studies and should interpret cautiously.

[Psychiatric Emergencies in the Preclinical Emergency Medicine Service in Ulm, Germany in 2000 and 2010, and Practical Consequences]. / Psychiatrische Notfälle im Notarzt- und Rettungsdienst in Ulm in den Jahren 2000 und 2010 und Konsequenzen für die Praxis.

Background Psychiatric emergencies (PE) in preclinical emergency medical services are about 5 - 10 % of all emergencies and represent often a source of difficulties in handling for the non-psychiatric professional helpers that deal with them. Studies informing about quantitative and qualitative changes of PEs in preclinical emergency medicine in Germany are scarce. Methods Therefore, we conducted a retrospective cross-sectional study of PE in a preclinical emergency medical service based on the protocols of the emergency ambulance of the Section for Emergency Medicine at the University Hospital Ulm comparing the years 2000 and 2010. Results We observed a significant increase of PEs from 8.8 % in the year 2000 (n = 285, from a total of n = 3227) to 10.3 % in 2010 (n = 454, from a total of n = 4425). In both years intoxications were the most common PE [2000: n = 116 (44.4 %); 2010: n = 171 (37.7 %)], followed by suicide-related behavior [2000: n = 59 (22.6 %); 2010: n = 78 (17.2 %)] and acute anxiety disorders [2000: n = 37 (13 %); 2010: n = 105 (23.1 %)]. The mentioned three conditions accounted for about 80 % of all PE. Most frequently PE occurred at the weekend and with the highest density in the evening and at night (18 - 24 h) in both years. Patients with PE were predominantly men, but the rate of women causing PE increased between 2000 and 2010. Discussion/Conclusion This study provides preliminary data on current trends in PEs in preclinical emergency medicine in Germany and has implications for improving the medical care provided.

[Treatment of intoxication with new psychoactive substances and methamphetamine]. / Behandlung der Intoxikation durch neue psychoaktive Substanzen und Methamphetamin.

Fatal outcomes subsequent to the use of new psychoactive suostances are increasingly common in Germany. In this article, we present the clinical effects and associated side effects of the different classes of substances, as synthetic cannabinoids, synthetic cathinones, phenylethylamines, piperazines and methamphetamine, as well as diagnostic aspects and treatment options in case of symptoms of poisoning.

[Impact of the 2020 lockdown on prehospital psychiatric emergencies in a large city]. / Auswirkungen des Lockdowns 2020 auf präklinische psychiatrische Notarzteinsätze in einer Großstadt.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic represented a serious challenge for healthcare systems worldwide. Special psychiatric patients represent a vulnerable group and are particularly affected by lockdown interventions. Knowledge on the possible effects for this group of patients in an emergency physician setting is low. OBJECTIVE: The aim of this paper is to investigate the impact of the first lockdown during the COVID-19 pandemic in 2020 on emergency ambulance services for psychiatric patients in a large German city. MATERIAL AND METHODS: A retrospective analysis was conducted on all prehospital psychiatric emergencies in a large German city during the first pandemic-related lockdown from 22 March 2020 to 4 May 2020, with the same period in 2019 serving as a reference. RESULTS: During the first lockdown there was a significant increase in the number of emergency missions with respect to psychiatric cases. A substantial rise in substance-associated deployments was observed. Moreover, there was an increase in the proportion of psychiatric patients who did not meet emergency criteria. Suicidal tendencies and agitation status played a minor role during the lockdown. CONCLUSION: The lockdown had a notable impact on the frequency and profile of emergency physician calls in the metropolitan area studied. The substantial increase in substance-associated callouts can be interpreted as both a deterioration in access to the healthcare system and an expression of the increased stress faced by the general population and vulnerable groups in particular.

["Is there a Link Between Heat Waves and Mental Health Emergencies in the Emergency Department?"] / "Gibt es einen Zusammenhang zwischen Hitzeperioden und dem psychiatrischen Notfall in einer Zentralen Notaufnahme?".

OBJECTIVE: There is evidence suggesting that climate change, coupled with an increase in the frequency and severity of heatwaves, affects mental health. The aim of this study was to investigate potential associations between high temperature and the utilization of an emergency department (ED) by individuals with psychiatric disorders. METHODS: A retrospective analysis of all psychiatric emergency patients from 2015 to 2022 (N=15478) was conducted and compared with local temperature data. RESULTS: Particularly during heatwaves, more psychiatric emergency patients presented to the ED. CONCLUSION: Beyond the results identified during heatwaves, our extensive analysis of the examined ED revealed no additional significant effects of heat on psychiatric emergencies. This contradicts findings from other studies. Other systemic influences, such as the utilization of the ED during the Covid-19 pandemic, could have modified the results.

The effect of aerobic exercise on cortical architecture in patients with chronic schizophrenia: a randomized controlled MRI study.

Via influencing brain plasticity, aerobic exercise could contribute to the treatment of schizophrenia patients. As previously shown, physical exercise increases hippocampus volume and improves short-term memory. We now investigated gray matter density and brain surface expansion in this sample using MRI-based cortical pattern matching methods. Comparing schizophrenia patients to healthy controls before and after 3 months of aerobic exercise training (cycling) plus patients playing table football yielded gray matter density increases in the right frontal and occipital cortex merely in healthy controls. However, respective exercise effects might be attenuated in chronic schizophrenia, which should be verified in a larger sample.

[Emergency medicine interventions for psycho-social crisis]. / Notärztliche Interventionen bei psychischen Krisen - Konzepte, Strategien und Vorgehensweisen.

Psycho-social crisis intervention has emerged to be a routine treatment application in the pre-hospital emergency medical system in Germany. It is applied to both patients with psychiatric disorders and in psycho-social crises. For the latter, a psycho-physiological reaction is typical that can be treated with the BELLA concept. Psycho-social crisis intervention for the emergency physician must be regarded as psychological first-aid and is characterised by an immediate start, a limited time frame, consideration of security aspects, flexibility and a determination to pre-set goals and their achievements. We recommend to adequately document this complex service.

[What Influence did the Lockdown 2020 have on the Use of a Central Emergency Room by Psychiatric Emergency Patients]. / Welchen Einfluss hatte der Lockdown 2020 auf die Inanspruchnahme einer zentralen Notaufnahme durch psychiatrische Notfallpatienten.

OBJECTIVE: The current coronavirus pandemic (Covid-19 disease) poses major challenges to healthcare systems worldwide. The aim of this work was to identify the impact on psychiatric emergency presentations in an ED during the implemented lockdown. METHODS: A retrospective survey of all psychiatric emergency presentations in the ED during the lockdown was conducted. The same period in 2019 served as the reference year. RESULTS: There was a decrease in psychiatric patients. Changes were observed in the age and diagnoses. CONCLUSION: Some clear effects of the lockdown on psychiatric emergencies in an ED setting can be described. However, the changes were smaller than in other countries with other health care systems.

Trauma and stress-related disorders in German emergency physicians: the predictive role of personality factors.

Emergency medical personnel (EMP) are repeatedly exposed to traumatic and stressful events with possible consequences on their mental wellbeing. Out of the group of EMP, we chose German Emergency Physicians (EP), because they represent a distinct group within the German pre-hospital emergency services. In this group, we studied the prevalence rates of posttraumatic stress disorder (PTSD), burnout and depression. We specifically focussed on the role of personality and other factors of vulnerability. Four hundred eighty-seven German EPs answered questionnaires with scales assessing probable PTSD, burnout, depression, and personality factors. Additionally, we asked for biographic, occupational and mental health information. More than 90% of the participants reported at least one traumatic event. We found low to moderate levels of stress-related disorders with 16.8% of participants meeting the criteria for probable PTSD, 4.1% for burnout, and 3.1% for clinical depression. We identified four clusters of personalities that were related to the prevalence of PTSD and depression. The type of personality seems to be more predictive of the development of trauma and stress-related disorders than the EPs' traumatic experiences.

[Mental disorders in intensive care medicine - Part 2: Prevention and therapeutic approaches]. / Psychische Störungen in der Intensivmedizin - Teil 2: Prävention und Therapie.

This two part article "Mental disorders in intensive care medicine" aims to give an understanding of the most frequent mental disorders in critical care medicine. Part 1 highlights the basics, disturbances and diagnostics, part 2 prevention and therapeutic approaches.

[Mental disorders in intensive care medicine - part 1: Principles and diagnostics]. / Psychische Störungen in der Intensivmedizin - Teil 1: Grundlagen, Störungsbilder und Diagnostik.

This two-part article on mental disorders in intensive care medicine aims to provide an understanding of the most frequent mental disorders in critical care medicine. Part 1 highlights the basic principles, disturbances and diagnostics and part 2 deals with prevention and therapeutic approaches. The most frequent mental disorders in the intensive care unit are delirium, substance abuse or, respectively, intoxication, suicide attempts, anxiety disorders, depression or psychosis. Mental disorders may be the reason for admission or can develop in the course of intensive care treatment, such as, for example, a post-traumatic stress disorder. The consequences thereof include increased morbidity, mortality, and duration of hospitalization. The early participation of a psychiatrist in the diagnostic process is to be recommended.

[The emergency treatment of the psychotic patient]. / Der psychiatrische Notfall - Behandlung von Psychosen im Notarztdienst und in Notaufnahmen.

Psychosis can cause multiple psychiatric and somatic emergencies. Due to the complex character of the disease the communication and accessibility of the patient can be severely disturbed. In the pre-clinical emergency medical care the etiology of a psychosis remains often unclear, the most common causes are schizophrenia and drug-induced psychosis. Frequent emergencies are states of psychomotor agitation, self-endangerment and endangerment of others including suicidal tendencies/acts as well as catatonic and manic states. Antipsychotic drugs and benzodiazepines are the most efficient pharmacotherapeutic treatments. Extrapyramidal side effects of the prescribed medication can also cause the need for urgent medical care. In any case needs to be considered a severe somatic comorbidity. It is particularly necessary that all available information at the scene of emergency should be transferred to the clinicians since the further diagnostic and therapeutic assessment will rely hereon.

The illness and everyday living: close interplay of psychopathological syndromes and psychosocial functioning in chronic schizophrenia.

The interaction of psychopathological states and psychosocial functioning determine the long-term course of schizophrenia and its treatment. To be able to achieve this interplay better, exact assessment of psychosocial functioning is needed besides measurement of psychopathology. Using the Personal and Social Performance (PSP) Scale, examination of the association between psychosocial functioning and psychopathology was conducted in a sample of 103 patients with chronic schizophrenia. Rating instruments were in addition Global Assessment of Functioning Scale and Social and Occupational Functioning Assessment Scale, as well as Positive and Negative Syndrome Scale (PANSS), Clinical Global Impression Scale, and Mini-ICF-APP-Rating for Mental Disorders (Mini-ICF-APP). Besides good psychometric properties for the PSP scale in this chronic sample, we found, as expected, significant associations between the two relevant outcome domains: results showed significant negative correlations between PSP and PANSS. Findings prove the close interplay between social functioning and psychopathology in the chronic course of schizophrenia.

Personality traits of emergency physicians and paramedics.

OBJECTIVE: Personality influences behaviour and decision-making. This may play a particular role in emergency medical personnel (EMP) dealing with critical situations. So far very little is known about personality traits that distinguish paramedics (PM) and emergency physicians (EP) from other medical staff. METHODS: A questionnaire including the ultra-short version of the Hamburg Personality Inventory (HPA) was distributed to EP, PM, medical doctors not practicing emergency medicine (MD) and medical students (MS). RESULTS: 274 EPs, 245 PMs, 48 MDs and 60 MSs returned the questionnaire. Four personality clusters in EPs and PMs were identified and to be found largely independent from demographic and job-related variables. For both groups one cluster revealed personality characteristics that seem particularly suitable for EMP ('resilient crisis manager'). 'Anxious' and 'insecure' personality traits were found in two clusters in PMs and in one cluster in EPs. Mental health problems in the participants or their relatives or the experience of loss increased scores in the dimensions neuroticism and openness. CONCLUSIONS: The personality characteristics of EPs and PMs are not homogenous and do not differ substantially from those of MDs and MSs. 50-70% of EMP can be characterised as 'resilient and stable', up to 30-40% as 'anxious and insecure'. The presence of mental health problems in participants or their relatives or the experience of loss may lead to openness for new experiences and alternative behaviour or--on the other hand--may trigger feelings of insecurity and/or anxiety in emergency situations.

[Excited Delirium Syndrome (ExDS): emergence and emergency management]. / Erregungssturm ­ Entstehung und Notfallbehandlung.

The Excited Delirium Syndrome (ExDS) is a state of maximum psychophysiological excitation far beyond mental agitation. Patients themselves are at an acute risk and put others at a high risk. We present data from eleven patients and a short literature review. Results: 9 of 11 patients were acutely intoxicated (alcohol, magic mushrooms, THC, ecstacy, or "flakka"). Eight had a history of substance abuse and 4 of other mental illness. None of the patients responded to attempts at verbal de-escalation. Seven had significant injuries at the time of admission to the hospital. The aggressive "psychiatric" presentation of ExDS can lead to vital risks being overlooked (hyperexcitation, acidosis, rhabdomyolysis, hypoxemia, and cardiovascular decompensation), which may even be increased by severe methods of restraint (hogtie; positional asphyxia). Early recognition of ExDS and its risks, comprehensive management and the prevention of inappropriate treatment will help to reduce fatal outcomes.

[Characterization of Ambulant Emergency Contacts in an Emergency Room at a General Hospital]. / Charakterisierung von ambulanten Notfallkontakten in einer interdisziplinären Notaufnahme.

OBJECTIVE: Scientific interest in emergency psychiatric patients has increased significantly over the last two decades. Nevertheless, current knowledge of this group of patients in the setting of an interdisciplinary emergency department is surprisingly low. METHODS: A retrospective examination of all ambulatory psychiatric emergency contacts in the emergency room of a regional hospital in 2015 took place. RESULTS: Solely F4 diagnoses accounted for 48.1 % of all first-time patients. Female patients younger than 25 years used the ER twice as often as their male control-group. Almost half of all outpatients fulfilled no emergency criteria. CONCLUSION: There are specific age and gender differences. The proportion of patients without any emergency criteria was surprisingly high. More scientific research is needed in order to scrutinize this possible inappropriate use of an ER by psychiatric patients.

Patient participation in antipsychotic drug choice decisions.

Patient inclusion in antipsychotic drug decisions is recommended by international treatment guidelines. For N=300 in patients with schizophrenia, we analysed patients' preferences for inclusion in decisions and physicians' estimates which patients actually participated in drug choice. Path analysis was used to examine the relationships between patients' preferences/actual participation and clinical variables measured. Forty percent of the patients expressed a wish to participate in clinical decisions. Those patients wishing to participate in medical decisions had less insight into the necessity of treatment. Psychiatrists gave better ratings of the doctor-patient relationship to those patients whom they rated as having participated in their drug choice. These patients had more positive attitudes towards antipsychotic medication. There was no relationship between the desire to participate and actual participation in the drug choice. When working with patients exhibiting poor insight and negative drug attitudes, psychiatrists use authoritative decision-making styles despite the patient's desire to participate.