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Emergency PsychiatryReview - Emergency Psychiatry
Review of Psychiatry, Vol 21
by Michael H. Allen (Editor)
American Psychiatric Press, 2002
Review by Tony O'Brien
Jul 9th 2003 (Volume 7, Issue 28)

This brief overview of emergency psychiatry is the 21st in the Review of Psychiatry series published by American Psychiatric Publishing Inc. The series is aimed at practicing clinicians, and Emergency Psychiatry presents 'the latest thinking of psychiatrists experienced in emergency work' (p. xiii). Its target audience is general and intensivists working in different psychiatric specialties, although the back cover note extends the intended readership to all mental health workers. The book is divided into five chapters, which can be read individually, as each is an overview of a specific area of emergency care.

The first chapter discusses models of psychiatric emergency services. A range of emergency mental health services is reviewed, although the chapter focuses primarily on hospital based psychiatric emergency services. A limitation of this focus, acknowledged by the authors, is that such centers are staff intensive and therefore expensive. They require a up to 3000 visits a year to justify their cost, making this model untenable outside major urban centers. The chapter contains a review of the goals of emergency care, and discusses some of the common service level issues of emergency services. These include limitations of space, the role of time in de-escalating psychiatric emergencies, and the limitations of space in traditional medical emergency departments. The consultation model of service is discussed, and found to be limited compared to the comprehensive service offered by specialist hospital based centers. There is a long discussion of the potential conflict between the clinical imperatives of clinicians and those of funders, particularly managed care organizations. The chapter is a useful introduction to service level issues of emergency psychiatry.

Chapter two covers assessment, perhaps the core skill of psychiatric emergency services. The first part of the chapter is given to an extended discussion of the role of psychiatrists in providing medical care for patients seen in psychiatric emergencies. While acknowledging the limited experience of psychiatrists in general medicine, the authors nevertheless argue strongly that medical care is a function of psychiatric services. Several reasons for this position are advanced. They are; the high rates of undetected physical illness in psychiatric patients, the contribution of organic factors to psychiatric presentations, the side effects and potential complications of commonly used psychotropic medications, and problems experienced by mentally ill patients in accessing primary care services. Despite this, the issue of the appropriate setting for medical care of psychiatric patients is not settled, and the role of psychiatrists in providing medical care is therefore not always clear. The chapter contains a brief discussion of triage, and reviews the place of diagnosis in predicting disposition decisions. The latter part of the chapter is given to psychosocial and cognitive assessment, meaning that psychiatric evaluation, the systematic observation of the patient at interview, history taking, and weighing up diagnostic considerations were, for me, lightly addressed.

Attempted suicide, one of the most commonly presenting psychiatric emergencies, is discussed in Chapter Three. Rates of suicide increased in western countries in the second half of the twentieth century, and many countries now have national suicide prevention strategies. In psychiatric emergencies, assessment of suicide risk is a fundamental skill, and the outline of risk factors, intervention strategies and modifiable contributors to suicide is a useful guide to management of suicidal individuals. While there is an understandable concern to focus on suicide prevention in emergency psychiatry, the process of differentiating recurring deliberate self-harm from suicide attempts is only briefly covered. Much of the coverage of non-suicidal self-harm is focused on self-harm as a predictor of suicide. This means that management of self-harm related to emotional dysregulation seen in borderline personality disorder is not covered. This chapter also contains some statements that are difficult to justify, for example, that "it is generally accepted that 90% of individuals who commit suicide have a serious mental disorder" (p. 87), and "suicide is almost always the result of inadequately treated mental illness" (p. 105). However there are also some useful pointers to clinicians. There is evidence that the intensity of suicidal thoughts at their worst point in a patient's life is a better predictor of risk than current suicidality, and a reminder that access to means, especially guns, is another strong predictor of completed suicide. The authors recommend that well managed risk in the community is a more therapeutic option than hospitalization, despite the common perception that more restrictive care is advisable in case of legal action. They state that a well-documented, effective plan of care, especially one that involves review of decisions with another clinician, can provide substantial protection against legal action. The commonly used 'no-suicide contract' is rightly dismissed in favor of thorough assessment and establishment of a therapeutic alliance. The chapter contains guidance for clinicians in managing the professional risks involved in treating vulnerable patients.

Chapter Four covers agitation and aggression, common problems in psychiatric emergencies. There is an extensive discussion of the pathophysiology of these behaviors, which I found a distraction from the focus on understanding their immediate precipitants and effective interventions. Violence is a common sequel of agitation, and the section on assessment covers the range of factors known to be associated with violence. If there was one aspect of this section I would like to have seen covered in more depth it is the role of substance abuse in violence, and the implications for treatment. The chapter reviews the options of treatment settings, and provides some sensible advice on verbal and behavioral interventions, including restraint and seclusion. The final section of the chapter considers pharmacological interventions, with the authors favoring benzodiazepines as the pharmacological agents of choice for reducing arousal.

The final chapter on psychosocial interventions is a welcome inclusion. The chapter takes the view, consistent with the literature on crisis intervention, that a psychiatric emergency is an opportunity for change, even if that change does not occur in the current period of contact. The authors contrast procedural and process approaches to the psychiatric interview, emphasizing that with appropriate attention to the immediate and medium-term needs of the patient, the objectives of both can be met. The interview can achieve the dual function of obtaining necessary information about risk, as well establish a therapeutic alliance that will contribute to greater engagement and, ultimately, to improved outcome. Models of psychosocial intervention are outlined and illustrated with short vignettes demonstrating the responses that typify each approach. The limitations of using cognitive, psychodynamic, and behavioral approaches are acknowledged, and their application to psychiatric emergencies is discussed in terms of the likely barriers to their use caused by clinical features of presenting problems. This makes this section practically useful, although effective use of any of these models requires some background in the theory and practice particular to each of them. The chapter takes a realistic approach to the constraints under which psychiatric emergency work takes place. Sense of coercion, agitation and anxiety, and aspects of the physical environment are all acknowledged as limitations on how much therapeutic interpersonal work can be achieved in the emergency setting. Nevertheless the emergency is regarded as an opportunity to begin the task of change with the important objective of preventing future presentations.

In a book which aims to provide an overview there will inevitably be omissions. The needs of specific populations such as children and adolescents, older people, and those whose primary problems derive from substance misuse are not specifically covered. The book is written in plain language, and in a readable style. It is very well referenced, providing adequate opportunity to readers to pursue issues of particular concern in greater depth. The focus on psychiatric assessment and diagnosis is balanced by discussion of psychological and social factors, and there is a concern throughout to provide care to the least restrictive standard. For a clinician new to psychiatric emergency work, or a generalist clinician wishing to broaden their understanding of psychiatric emergencies it is a useful introduction; experienced clinicians may want a more in-depth coverage. The book is recommended to mental health workers, and especially to students and especially to those new to psychiatric emergency work. It would be a useful resource in libraries for students of health and medical studies.

 

2003 Tony O'Brien

 

Tony O'Brien, Senior Lecturer, School of Nursing, University Auckland, New Zealand.


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