PRESCRIBING PSYCHOTROPICS AT PES DISCHARGE Ernst CL, Bird SA, Goldberg JF, Ghaemi SN. The prescription of psychotropic medications for patients discharged from a psychiatric emergency service. J Clin Psychiatry . 2006;67:720-726.

Summary

Considerable debate exists about the value and wisdom of initiating "definitive" pharmacotherapies, particularly antidepressants, in the psychiatric emergency setting. In this article, the nature and prevalence of medication prescriptions for patients discharged from an urban psychiatric emergency service (PES) and the extent to which pharmacotherapy initiation was predictive of patient follow-through with aftercare were evaluated.

Records were reviewed for 675 consecutive patients discharged from a community-based PES over a 3-month period (January through March 2003). Information was obtained regarding diagnoses, past and current treatments, and demographic and clinical features, as well as outcomes for the subgroup of patients who received aftercare appointments within the institution's system.

Of all PES visits, 55% resulted in discharge, with psychotropic drug prescriptions given to about 30% of persons discharged. Antidepressants (64%), benzodiazepines (25%), nonbenzodiazepine sedatives (20%), antipsychotics (18%), and mood stabilizers (10%) were the most commonly prescribed. The decision to prescribe was significantly associated with a clinical diagnosis of major depressive disorder or bipolar disorder and the preexisting use of psychotropic medications. Nonprescribing occurred most often in discharged patients with suicidal ideation, substance abuse or dependence, and an existing outpatient psychiatrist. Follow-up emergency service and new outpatient appointments were more often given to patients discharged with a prescription, but patient follow-through with aftercare was not more likely in this group.

Psychiatrists in a PES prescribe antidepressants or other major psychotropics for about one third of discharged patients, rarely in the presence of suicidality or substance abuse or dependence, and with little evidence that initiating such medications in the emergency setting promotes more successful bridging to outpatient treatment.

Commentary

This is an interesting retrospective review of interventions for persons with mental illness who were evaluated and then discharged from a PES in Boston. The finding that an antidepressant or other psychotropic medication was prescribed for nearly a third of discharged patients was not outside of usual practice. However, the number of patients with substance abuse in this sample is lower than one might expect. The use of antidepressants is noteworthy, and the rate of outpatient follow-up care adherence is remarkably high.

Deciding whether to initiate treatment with medication in a person whom you are not going to see in follow-up is always tricky, and I am unaware of any formal guidelines in this regard. Safety is an overriding concern; therefore, the potential for overdose after PES discharge, abuse liability, drug-drug interactions, and worsenening physical or mental well-being are key considerations. The extent to which dose titration is needed after PES discharge and how quickly the person can be seen at the next point along the care continuum are other considerations. It would certainly be less troublesome to simply defer any medication decisions until the person is seen by the (ongoing) treating psychiatrist. However, such a stance may be inconsistent with the patient's need and his or her seeking of help at a time of crisis.

As in all medical interactions, the emergency department (ED) clinician must make an appraisal of the potential benefits versus potential disadvantages of starting medication there and then. The input of family members, if available in the ED, can be a real asset in this decision- making process.

Peter F. Buckley, MD

Professor and Chairman

Department of Psychiatry

Medical College of Georgia

Augusta