Psychiatric Issues in Emergency Care Settings Vol 4 No 4

Carpenter LL, Schecter JM, Underwood JA, et al. Service expectations and clinical characteristics of patients receiving psychiatric emergency services. Psychiatr Serv. 2005;56:743-745.

Opiate detoxification in the outpatient setting often depends on what services are available in the community. Many clinicians think that a methadone maintenance or taper regimen, combined with substance abuse treatment therapy, offers the best chance to prevent relapse. If possible, enrolling a patient promptly in such a program should be considered. Regardless of detoxification method, referral for psychosocial drug treatment is indicated.

A number of highly publicized cases in the lay press have underscored the significance of, and dangers associated with, perinatal psychiatric illness. Unfortunately, the field of psychiatry has failed to use these tragic cases to disseminate accurate information and educate the public about the high frequency of perinatal depression and anxiety, as well as the relative rarity of postpartum psychosis and infanticide. Moreover, psychiatrists continue to have difficulty in educating their medical colleagues about the need to screen for these illnesses, so most obstetricians and pediatricians still do not screen for perinatal depression and anxiety, much less manage it effectively. Decisions about appropriate treatment are further complicated by a lack of empiric outcome data.

New mothers may present to the emergency department (ED) with symptoms ranging from mild anxiety to severe psychosis. Postpartum psychosis has abrupt onset and severe symptoms and usually occurs in the immediate postpartum period. Patients who have had a previous episode of postpartum psychosis or have first-degree relatives with postpartum psychosis or bipolar disorder are at higher risk.

Pregnancy and new motherhood are considered happy and hopeful times. Bad outcomes, such as miscarriages and stillbirths, occur, however, and even with good outcomes, psychiatric disorders can present or worsen at this time. The incidence of depression in women during pregnancy is about the same as that for matched controls, and because depression is common in all women, this is a significant public health issue. More than 10% of women with panic disorder describe first symptoms as occurring around pregnancy, and there is evidence that pregnancy exacerbates psychotic disorders. Within a few days of giving birth, 25% to 75% of new mothers experience emotional lability, or the "baby blues," and 10% to 20% of new mothers experience postpartum depression. The peripartum is thus a time of great joy potentially complicated by the entire range of psychiatric illness.

Women with postpartum depression frequently experience intrusive, obsessive ruminations that are part of a depressive episode. Many women with postpartum depression have significant anxiety, and many reach the level of meeting criteria for full-blown anxiety disorders. An anxiety disorder may also precede and contribute to the development of a depressive episode.