PES Research: Look to the Future

Brown JF. Psychiatric emergency services: a review of the literature and a proposed research agenda. Psychiatr Q. 2005;76:139-165.

Summary

Articles on psychiatric emergency services (PESs) published between 1983 and 2003 were reviewed to evaluate research on providers, clients, and services; access, use, evaluation, treatment, and continuity of care; and outcomes of the use of PESs. Eighty-five articles were selected as representative of the literature on variation in PES arrangement and effectiveness. The Donabedian model (structures, processes, and outcomes) was used to evaluate health care services.

In terms of structure, little research compares the variations seen across different types of PESs or within the same PES. Studies are available that show differences in clinical decisions, based on the number of years of experience of the provider.

Studies on the use of the PES provide conflicting reports on the influence of such factors as weather, location, and time of day on an increase or decrease in use of the PES. Evaluation studies point out the lack of standardization of assessment tools and the lack of studies comparing the effectiveness of assessment instruments.

Although some studies have reviewed the outcomes of PESs, there have been no comparisons of outcomes from different types of PESs. Some studies are limited because of questions as to the reliability of patient self-reports.

The author highlights areas of structure, process, and outcome that she considers priorities for future research. A helpful appendix briefly describes the articles included in the literature review.

Commentary

The field of emergency psychiatry is maturing rapidly. Yet as pointed out in this review article, the literature base lags behind the increasing importance of the field. Several factors contribute to this, but other recent developments suggest that the situation may improve quite quickly.

First, as in the case of emergency medicine 20 years earlier, emergency psychiatry is only now consolidating its structure and defining professional competencies. However, unlike hospital-based emergency department services, emergency psychiatry can be construed as covering a variety of community-based programs, including mobile teams, crisis residences, hot lines, etc. Accumulating a sufficient research base that captures what is going on in any of these areas has been tricky, given the scope of services.

Second, research evolves along a more or less predictable pattern, starting with descriptive studies, as outlined by Dr Brown, and progressing to more complex interventional efforts. The studies reviewed, although flawed in many respects, were a necessary starting point for the next generation of research, and I would argue that the time is now ripe for that to occur.

Third, informed consent issues have been tough obstacles to any prospective work in emergency settings. Patients have been perceived to be unwilling or unable to sign on to research efforts in the midst of a crisis. Yet as many of us doing this research have learned, if patients are approached in a respectful and collaborative manner, these barriers to research in the PES are by no means insurmountable.

Fourth, the NIH historically has been disinterested in health services research in general and in emergency programs in particular. Given the importance of emergency psychiatric intervention, this seems unfortunate. The Substance Abuse and Mental Health Services Administration (SAMHSA) has been keen on funding community-based efforts in crisis work, but the track record of publication from these grants has not been as good as it could be. Both these factors are changing rapidly, and several career development awards and R-01-level research studies pertaining to emergency psychiatric interventions are now funded. Likewise, SAMHSA is incorporating more requirements that programs be studied rigorously in order to be disseminated.

Finally, on a positive note, several pharmaceutical trials (not reviewed here), particularly those involving atypical antipsychotic medications, have been successfully carried out in the PES in recent years. Several centers with experience in clinical trials methodology and techniques now exist. It will be easier to conduct trials of intervention services instead of medications with all this experience under our collective belts.

All of these changes are occurring now, and with them I believe we can look forward to the publication of numerous high-quality, PES-based empiric studies over the next several years.

Glenn W. Currier, MD, MPH Associate Professor of Psychiatry and Emergency Medicine University of Rochester School of Medicine and Dentistry Medical Director of Hospital Services Department of Psychiatry University of Rochester Medical Center Rochester, NY