Incident of violence escalation of patients with psychiatric emergencies boarding in the emergency department in the central region of Thailand and its association: a prospective observational study.

BACKGROUND: This study investigates the incidence of violence escalation among psychiatric emergency patients admitted to general emergency departments in hospitals in central Thailand. In addition, patient and service delivery system factors associated with the survival time of violence escalation in 16 emergency departments in the central region of Thailand are determined. This is a prospective observational study, and the study sample includes 507 psychiatric emergency patients who are ≥ 18 years old. The patients are selected through stratified random and purposive sampling. METHODS: Patient data-including demographic data, emergency services used, and clinical characteristics-are analyzed using descriptive statistics. The Kaplan-Meier method estimates the violence escalation curve, and the log-rank test compares the violence escalation-free time between the levels of the violent behavior group. In addition, univariable and multivariable Cox proportional hazard analyses are performed to investigate the factors affecting violence escalation. RESULTS: The incidence of violence escalation in psychiatric emergency patients in the emergency department is 7.3%, whereas the incidence rate of violence escalation is 3 per 100 psychiatric emergency patient visit hours. Factors affecting violence escalation include the violent behavior score at triage (aHR = 2.004; 95% CI: 1.051-3.823) and the nurse competency score (aHR = 0.147; 95% CI: 0.032-0.680). CONCLUSIONS: Assessing the violent behavior of psychiatric emergency patients at triage may assist emergency providers in monitoring patient behavior and providing early intervention to prevent the escalation of violent behavior. Furthermore, training emergency nurses in psychiatric emergency care is necessary.

Management Strategies for Psychiatric Emergencies in a Community Setting. The Role of the Crisis Team at the Trento Mental Health Centre.

The Mental Health Service of Trento has consistently adopted a community-based, recovery-oriented approach. Adhering to these paradigms, and aiming to facilitate an intervention centred on the individual and their needs within their familial and social context, it is imperative to ensure a prompt and effective response to crises at the community level. Psychiatric emergencies present a significant challenge for health systems globally. Timely and appropriate management of these crises is crucial to prevent negative short and long-term outcomes. Providing such management in an extra-hospital setting, adaptable to the situational needs, can enable the individual to better achieve their recovery goals. Trento, with its dedicated Crisis service and the active involvement of Peer Support Specialists ("ESP" in italian), exemplifies how an integrated, multidisciplinary territorial approach that values the role of the socio-family context can enhance the outcomes of acute psychopathological crises and user engagement. This article discusses the organisation, advantages, and challenges compared to intra-hospital management, and the impact this intervention can have on public stigma regarding mental health.

"New" Psychiatric Emergencies Between Hospital and Territory. Survey Results on the Innovative Protocol Between the Emergency Department and Mental Health Center in Trento.

In 2022, psychiatric condition-related admissions constituted 3.2 per cent of all emergency room admissions in Italy, according to the Ministry of Health's latest mental health report. Psychiatric crises are an increasingly significant portion of emergency department (ED) visits nationwide, with around 1 in 8 visits involving mental health and substance use disorders. Patients facing psychiatric emergencies tend to experience longer lengths of stay and boarding times in the ED, along with higher admission rates compared to those with other medical conditions. Extended boarding times for psychiatric patients in the ED increase their vulnerability to adverse events, such as medication errors, the use of restraints, and assaults. Moreover, the prolonged boarding of psychiatric patients contributes to ED overcrowding, which negatively impacts all ED patients, leading to increased morbidity and mortality due to delays in treatment and preventable errors. One of the most effective strategies to counteract this phenomenon has been the choice of directing psychiatric emergencies that are deferrable or compatible with a territorial crisis management from the Trent ED to the Mental Health Center in the territory. This option, promoted through the application of experimental procedures that are currently in the process of being definitively ratified as official company procedures, has, first and foremost, numerous advantages for psychiatric users, who are received in less medicalized settings that are more attentive to the relational and psychological component, while still having suitable medical and nursing equipment. It also fosters continuity of care with the territorial therapeutic network, allows early interception of situations that are promptly taken care of by the territorial specialist center, and more easily offers treatment alternatives to hospitalization. This approach allows for the optimal utilisation of resources and expertise available at Mental Health Centres within the community, thereby preventing the overcrowding of hospital emergency departments.

Positive and negative correlates of suicidal ideations and behaviors in the emergency department of a university hospital in Beirut: A cross-sectional comparative study.

This study aims to identify the prevalence and correlates of current suicidal ideations and past suicidal behaviors among psychiatric emergencies. A cross-sectional comparative study was conducted using the Ask Suicide Screening Questions (ASQ) as a screening tool that targeted all patients presenting for a psychiatric emergency in a university hospital in Beirut during a four-month period. One hundred and three patients of all age groups have been divided into a group of patients with a positive suicidal screening (n=67, 65%), and another one with a negative suicidal screening (n=36, 35%). Suffering from a personality disorder was found to be a positive correlate of suicide screening (OR: 21.6, 95% CI: 2.6-179.0). Female gender (OR: 4.5, 95% CI: 1.6-13.2) and an elevated number of previous hospitalizations were found to be positive correlates of past suicidal attempts. These correlates should be assessed in the emergency room department (ER) to prevent any subsequent suicidal behavior.

Is Home Treatment for Everyone? Characteristics of Patients Receiving Intensive Mental Health Care at Home.

We aimed at determining differential characteristics of patients treated by a home treatment (HT) team compared to patients treated on hospital wards. Of 412 consecutively admitted patients, 194 (47.1%) were at least partially treated at home, whereas 218 (52.9%) received inpatient treatment only during an episode of acute illness. A multivariate logistic regression model identified current employment to increase the odds of HT (p < 0.001). A primary diagnosis of anxiety or stress-related disorder (p < 0.001), other rare primary diagnoses such as personality disorders (p < 0.001), and more pronounced clinician-rated social problems (p = 0.041) decreased the odds of HT. Overall, it remained difficult to clearly specify suitability for HT based on available sociodemographic and clinical characteristics. This might indicate that responsible clinicians consider HT to be a viable alternative to hospital care and hence initiate HT for a relatively broad spectrum of patients.

[The Pharmacological Management of Emergencies in Child and Adolescent Psychiatry]. / Das pharmakologische Management kinder- und jugendpsychiatrischer Notfälle.

The Pharmacological Management of Emergencies in Child and Adolescent Psychiatry Abstract. Emergencies in child and adolescent psychiatry are highly prevalent and often pose significant challenges to physicians, since substantial danger to the patient or others must be avoided through the application of largely moderate interventions. Besides using de-escalating strategies and exploiting psychotherapeutic options, the physician frequently employs psychopharmacological interventions. because of a lack of systematically assessed data, however, in emergencies in child and adolescent psychiatry most administrations of psychotropic drugs occur "off label." This review deduces practice-relevant recommendations for the pharmacological management of occurring child and adolescent emergencies such as acute suicidality, acute psychotic episodes, delirium, disorders of consciousness, acute intoxication, and alcohol withdrawal syndrome. We discuss the issue of quality and safety in pharmacological emergency strategies.

When contextual realities hinder the process of welcoming new patients in psychiatric emergency units / Quand les réalités contextuelles entravent le processus d'accueil aux urgences psychiatriques

Introduction: Questioning the implementation of care in psychiatry requires a reflection on and around the moment when patients first arrive at an emergency unit. In other words, it is necessary to take a look at the contextual conditions of this first moment of care. Our objective is to study the ingredients that contribute to the development or maintenance of a welcoming attitude. Methods: Grounded theory allowed us to better understand the complexity of the phenomenon by meeting people working in crisis and psychiatric emergency units. Results: The results present three pathways associated with the welcoming process: (1) pathway to activate the process; (2) pathway to weaken the process; (3) pathway to counteract the weakening pathway and feed the activation pathway. Reintroducing time to think and "spaces to speak" remains a challenge in the welcoming of patients in psychiatric emergency units. Discussion: A welcoming reception depends on a favorable context-societal, political, institutional and environmental-being fostered and maintained in the professional and personal world of professionals.

Introduction: S'interroger sur la mise en place des soins en psychiatrie nécessite de prime à bord de nourrir une réflexion sur et autour du moment de l'accueil des patients au sein des services d'urgences. Dit autrement, de porter un regard sur les conditions contextuelles de ce primo moment du soin. Notre objectif est d'étudier les ingrédients qui participent au développement ou au maintien d'une attitude dite accueillante. Méthode: La théorisation enracinée nous a permis d'approcher au mieux la complexité du phénomène, en allant à la rencontre d'intervenants exerçant en unité de crise et d'urgences psychiatriques. Résultats: Les résultats exposent trois voies impliquées dans le processus d'accueil : (1) voie d'activation du processus ; (2) voie d'affaiblissement du processus ; (3) voie pour contrer la voie d'affaiblissement et alimenter la voie d'activation. Réintroduire le temps de penser et des « espaces du dire ¼ reste l'enjeu à l'accueil des urgences psychiatriques. Discussion: Accueillir dépend avant tout qu'un contexte propice ­ sociétal, politique, institutionnel et environnemental ­ soit encouragé et maintenu dans l'univers professionnel et personnel des intervenants de la crise.

Recognition and Treatment of Psychiatric Emergencies for Health Care Providers in the Emergency Department: Panic Attack, Panic Disorder, and Adverse Drug Reactions.

Mental health disorders are common in the United States and may cause significant disturbances in all aspects of a person's life. Individuals with mental health disorders often present to emergency departments for health care. Recognizing and managing common psychiatric emergencies may be challenging for non-mental health providers. The Diagnostic Statistical Manual-5 diagnostic criteria will be discussed and reviewed for panic attack and panic disorder. Both pharmacologic and nonpharmacologic treatment strategies will also be addressed. Adverse drug reactions associated with antipsychotics and selective serotonin reuptake inhibitors are another common psychiatric emergency that will be examined, offering potential management strategies. The objective of this clinical manuscript is to educate emergency health care providers about specific psychiatric emergencies, including panic attack, panic disorder, and adverse drug reactions associated with mental health treatment medications.

Psychiatric Emergencies in the Community: Characteristics and Outcome in Switzerland.

Psychiatric emergencies occur frequently in the community setting, e.g. the patient's home or public places. Little is known about the characteristics and outcome of these situations. This study describes psychiatric emergencies in the canton of Zurich, Switzerland, and examines determinants of their outcome. We retrospectively analyzed 620 medical records of consultations classified as psychiatric emergencies of a 24/7 service of community-based emergency physicians. Information on sociodemographic, clinical and situational factors was extracted. The observation period was 6 months in 2017. Binary logistic regression was used to examine predictors for involuntary admissions. Most emergency consultations (64.5%) took place at the patient's home, followed by police stations (31.0%), public places (3.2%), and somatic hospitals (1.3%). Patient characteristics and reasons for consultation varied considerably between the locations. The first involved person was commonly a relative. Of all consultations, 38.4% resulted in involuntary admissions, mainly in patients with psychosis, suicidality, aggression, refusal of necessary treatment and previous involuntary admissions. Situation-related factors and the involvement of relatives were no significant predictors of the outcome. Psychiatric emergencies occur in different places and in patients with a variety of psychiatric symptoms. Although half of the emergency situations were resolved in the community, the rate of involuntary admissions was still high. For additional reduction, the further development of quickly available alternatives to psychiatric inpatient treatment is required. These should be specifically geared towards acute situations in patients with the described risk factors. Additionally, the role of relatives during psychiatric emergencies should be further studied.

[A sharp drop in psychiatric emergency admissions during lockdown]. / Les urgences psychiatriques pendant l'état d'urgence sanitaire.

Since France was put into lockdown on 17 March 2020 in an unprecedented step to attempt to limit the spread of coronavirus, there has been a sharp fall in the number of psychiatric emergency admissions despite the COVID-19 pandemic which has increased stress levels. The first part of this study shows the reorganisation and adaptation of mental health services to meet the needs in the psychiatric department. The second part is a brief analysis of patient flows to CPOA and the presentation of different hypotheses explaining these disruptions during lockdown. Finally, this study discusses the facts of three clinical cases during this period.

[Public telemental health during COVID-19 pandemic: preliminary approaches on mental-health help-line program (MHLP)]. / Dispositivo público de telesalud mental durante la pandemia COVID-19: aproximaciones preliminares del Programa Salud Mental Responde (SMR).

This paper focuses on the remote mental health care program developed at DGSAM, in Buenos Aires City during the COVID-19 pandemic. It is based on the concepts of telemental health. The change carried out from a previous phone orientation program towards a healthcare system with comprehensive health electronic records (HIS) and carried-out by mental health professionals, intersectorial articulation and progressive mental health care networks are the most outstanding aspects of the program. As well as the strengthening on health information systems and training professionals in telemental health care. During the first six months of operation, 7.154 calls were attended, 95,62% were solved within the program protocols and the remaining 4,38% were referred for georeferenced treatments and for re-linking with the respective health care teams. It was also useful in solving psychiatric emergency situations.

Psychiatric Emergencies in Nonpsychiatric Settings: Perception Precludes Preparedness.

BACKGROUND: The implementation of emergency codes has become standard practice in hospitals to provide system-wide preparedness for the early detection and prevention of crises. Psychiatric emergencies in medical/surgical locations, however, are not typically regarded as distinct entities from general security threats. The "security-first" paradigm is a nonclinical intervention that focuses on behavioral containment rather than on the treatment of underlying psychopathology. OBJECTIVE: This article provides the perspective that countless opportunities to medically intervene upon mental health emergencies are being overlooked due to a national misconception of these entities as security-based functions. A secondary consequence of this misperception is that hospital systems often fail to prioritize an infrastructure onto which clinically-informed emergency response protocols similar to other medical emergency codes may be dependably mounted in the event of accurately detecting psychiatric emergencies. Numerous adverse clinical, workplace safety, and financial outcomes ensue. Using a behavioral emergency response team as a collaborative care model in medical/surgical locations is a promising alternative. CONCLUSIONS: Behavioral emergency response teams re-establish patient care within the intervention without omitting security containment. They help rapidly address acute comorbid psychiatric needs without demanding additional psychiatric resources by functioning as trained surrogates of consult-liaison psychiatry as they provide direct clinical oversight into primary teams who would otherwise be unsupported in navigating clinical scenarios extending beyond their typical range of expertise. An analysis using the "Swiss cheese" model of human error trapping offers a comprehensive illustration of how behavioral emergency response teams add multilayered perceptual and mechanistic advantages to barriers commonly encountered when psychiatric emergencies arise in nonpsychiatric settings.

Cryptococcal Meningoencephalitis Presenting as a Psychiatric Emergency.

BACKGROUND: Organic conditions can often mimic neuropsychiatric disorders, leading to delays in diagnosis and treatment for the most vulnerable populations presenting to the emergency department (ED). CASE REPORT: Here we discuss a case of cryptococcal meningoencephalitis seemingly consistent with psychosis on initial evaluation, and present strategies to recognize and treat this condition. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Due to the indolent time course of this disease, initial symptoms of altered mental status and personality changes may be attributed to drug use or psychiatric illness before more overt evidence for increased intracranial pressure and neurologic infection develops. It is important for emergency clinicians to maintain a high level of suspicion for this condition in at-risk patients and reassess them frequently during their ED visit.

Weather conditions influence the number of psychiatric emergency room patients.

The specific impact of weather factors on psychiatric disorders has been investigated only in few studies with inconsistent results. We hypothesized that meteorological conditions influence the number of cases presenting in a psychiatric emergency room as a measure of mental health conditions. We analyzed the number of patients consulting the emergency room (ER) of a psychiatric hospital in Berlin, Germany, between January 1, 2008, and December 31, 2014. A total of N = 22,672 cases were treated in the ER over the study period. Meteorological data were obtained from a publicly available data base. Due to collinearity among the meteorological variables, we performed a principal component (PC) analysis. Association of PCs with the daily number of patients was analyzed with autoregressive integrated moving average model. Delayed effects were investigated using Granger causal modeling. Daily number of patients in the ER was significantly higher in spring and summer compared to fall and winter (p < 0.001). Three PCs explained 76.8% percent of the variance with PC1 loading mostly on temperature, PC2 on cloudiness and low pressure, and PC3 on windiness. PC1 and PC2 showed strong association with number of patients in the emergency room (p < 0.010) indicating higher patient numbers on warmer and on cloudy days. Further, PC1, PC2, and PC3 predicted the number of patients presenting in the emergency room for up to 7 days (p < 0.050). A secondary analysis revealed that the effect of temperature on number of patients was mostly due to lower patient numbers on cold days. Although replication of our findings is required, our results suggest that weather influences the number of psychiatric patients consulting the emergency room. In particular, our data indicate lower patient numbers during very cold temperatures.

Psychiatric Patient Length of Stay in the Emergency Department Following Closure of a Public Psychiatric Hospital.

BACKGROUND: Psychiatric patient boarding in the emergency department (ED) is a ubiquitous problem associated with increased morbidity and mortality. OBJECTIVE: We evaluate the effect of closing a public psychiatric facility in a major metropolitan area on the ED length of stay (LOS) of psychiatric patients. METHODS: This was a retrospective chart review at two metropolitan EDs of all patients assessed to require inpatient psychiatric hospitalization. The time of arrival, time of disposition, time of transfer, insurance status, and accepting facility type were collected prior to and following the closure of a local inpatient psychiatric facility. RESULTS: We analyzed a total of 1107 patients requiring inpatient psychiatric hospitalization, with 671 patients who presented prior to the closure of the closest public psychiatric facility and 436 patients that presented following the facility closure. Following hospital closure, patients with private insurance (620 min before, 771 min after) and Medicare/Medicaid (642 min before, 718 min after) had statistically significantly longer ED LOS, as well as patients transferred to a private psychiatric hospital (664 min prior, 745 min after). However, overall ED length of stay following hospital closure for transfer of all psychiatric patients requiring inpatient hospitalization was not found to be statistically significant (1017 min prior, 967 min after). CONCLUSION: There was a statistically significant increase in ED LOS for patients with private insurance, Medicare/Medicaid, and for those patients transferred to a private psychiatric facility following closure of a public mental health hospital; however, overall, ED LOS was not increased for patients transferred to an inpatient psychiatric facility. This study highlights the significant impact that the closure of a single inpatient psychiatric facility can have on nearby EDs. We hope to bring attention to the need for increased psychiatric services during a time when there is a nationwide trend toward the reduction of available inpatient psychiatric beds.

Using Mental Health Outreach Teams in the Emergency Department to Improve Engagement in Treatment.

Engagement in treatment for a person having a behavioral health crisis is critical to fully address the concerns of the individual as well as to prevent future crises. This study explored the benefits of establishing outreach visits from a local community mental health provider to psychiatric patients in an emergency department. Using retrospective analysis of data collected by a local mental health agency, the effect of receiving face to face contact in the emergency room with a community mental health worker (and/or telephone follow up) was compared to no outreach interaction. The effect of this intervention was a significant increase in initial appointment attendance at the local mental health clinic in the aftermath of a psychiatric crisis. Community mental health services provided in partnership with community emergency departments may improve patient engagement in aftercare and consequently help alleviate future behavioral health crises as well as return visits to the emergency department.

Children and adolescents in the Psychiatric Emergency Department: a 10-year survey in Copenhagen County.

BACKGROUND: Knowledge on psychiatric emergencies in children and adolescents is limited. The Psychiatric Emergency Departments (PED) in Copenhagen enable the acute examination of children and adolescents 24 h a day, 7 days a week. However, very little is known about who presents to the PED, and the reason for their visit. AIM: To describe the prevalence and characteristics of presentations in PED and treatment provided. METHODS: A retrospective population based study comprising data of more than 4000 visitors presenting to PED from 2001-2010. In 2003 and 2006, two randomly chosen years, a more thorough analysis was performed, based on the individual emergency charts. Inter-rater reliability was high. RESULTS: Visits increased nearly threefold during the period. Symptom score for 2003 and 2006 revealed that more than one third of the visitors had suicidal ideation. Depressive and anxiety symptoms together with suicidal ideation rose significantly (P < 0.001). Psychoses and suicidal attempts remained unchanged. In one third of the visits, the discharge diagnosis was anxiety and stress-related disorders, followed by personality, behavioural and emotional disorders. Between 15% and 20% of the visits resulted in admission and more than 50% in referral for outpatient follow-up. CONCLUSIONS: The number of presenting psychiatric emergencies has increased over the last 10 years. Comparing symptoms from 2003 and 2006 showed a significant rise in their severity. This study highlights the need for 24-h access for acute evaluation by physicians skilled in child and adolescent psychiatry, and raises concern that the severity could increase.

Long-term COVID-19 pandemic impact on suicide Thoughts and Behaviors (STB): An interrupted time series analysis in Spain 2-year after pandemic outbreak.

This study assessed the impact of the COVID-19 pandemic on suicidal thoughts and behaviors (STB) by age and gender in Cantabria, Spain, from January 2019 to March 2022, using interrupted time series analysis. Post-lockdown, STB declined in males (-42 %, p = 0.01) and females (-25 %, p = 0.58), with a gradual increase in both genders. The reduction was most pronounced in older adults (-39 %, p = 0.56), followed by middle-aged (-26 %, p = 0.36) and younger groups (-8.3 %, p = 0.25). Subsequent upward trends in STB were more pronounced in younger (p = 0.15) and older age groups (p = 0.25), likely due to prolonged isolation and economic hardship.

Pattern of adult psychiatric emergencies at a tertiary care center before and after the onset of the COVID-19 pandemic.

A gap exists in published data on psychiatric emergencies presenting to Indian centers over the entire pandemic. We assessed 2,048 consecutive adult psychiatric emergencies for the period April 2019-September 2021 to compare 18 months following the onset of the pandemic, with the pre pandemic year as the control. Mean age was 33.8 ± 13.6 years, with 55% females. The proportion with ICD-10 schizophrenia and related psychotic disorders (18.9% vs 15.3%; P = 0.031), mood disorders (21.8% vs 18.1%; P = 0.038), and personality disorders (3.8% vs 2%; P = 0.018) showed a significant increase during a pandemic, while those with no diagnosable illness reduced (28.6% vs 34.3%; P = 0.006). Suicidality was the reason for referral in 43%, comparable to pre pandemic year. Those with stay ≥24 hours increased (14% vs 11%; P = 0.034). Benzodiazepines remained the commonly prescribed medication, but a notable rise was seen in mood stabilizer prescriptions.

Suicide Attempt Violence: Gender Differences, Diagnosis and Psychiatric Care Seeking in Mexico City.

BACKGROUND: Suicide cases in Mexico have increased during the last two years and are the second-leading cause of death in the young adult population. AIM: To describe gender differences in violent suicide attempts as relates to diagnosis and the seeking of psychiatric care. METHODS: A descriptive retrospective study was conducted. The referral forms of 241 patients who had attempted suicide were analyzed. RESULTS: The mean age of the patients was 29.1 (SD=10.8) years, n=140 (58.1%) of the sample were women. Affective disorders were the most frequent diagnoses for both sexes. Women were more likely to delay seeking psychiatric care: 60 days versus 30 days of delay for men (p=0.009). Men were shown to more frequently resort to violent suicide methods. Both women and men who used violent suicide methods were shown to delay by more days the seeking of psychiatric care than those who were found to have used non-violent suicide methods. CONCLUSION: We found that patients who use more violent methods of suicide took longer before seeking psychiatric care. This delay in accessing psychiatric care can be thought to contribute to the fact that completed suicides are more frequent within that category of patients. The majority of suicide attempts occurred in the 17-24 years age group; therefore, it seems reasonable to analyze the existing barriers to seeking psychiatric care, mainly in the young adult population, and to design strategies to bring mental health services closer to this population group.