Why Are You Here Today?

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.

Summary

Investigators at a private, nonprofit psychiatric facility in Rhode Island that is affiliated with a medical school studied whether there was significant misuse of their psychiatric emergency service (PES), which is available around the clock. Studies have shown inappropriate use of medical emergency departments (EDs), but few studies have dealt with the use--or misuse--of the PES.

Of about 400 persons who used the PES in a summer month in 2003, 82 patients filled out a brief survey at the time of presentation; of these, 27% did so anonymously. Of the 82 patients, 35% reported being depressed or suicidal and 15% said that they had drug or alcohol abuse problems. Affective disorder was the diagnosis in 62%, substance use disorder in 16%, and psychotic disorder in 11%. Forty-three patients were admitted to the inpatient or day hospital, while 15 patients were discharged home.

Services considered appropriate to the PES included admission to an inpatient unit or day hospital, crisis counseling, detoxification, diagnostic evaluation, and treatment recommendations. Mismatched services included prescriptions, family therapy, referral to outpatient providers, and tests. Forty-five percent of patients had at least one mismatched service request.

The investigators concluded that use of the PES was generally appropriate, but because of the 45% of patients who had an inappropriate request for service, they concluded that there was a need to improve public education on the availability of mental health services.

Commentary

This is an interesting effort to understand factors related to PES service demand, particularly service recipients' "true need" to be seen in the PES. Many PES clinicians recognize that patients present for a variety of purposes, along a continuum from severe suicide attempts/first break psychosis/delirium on one end to a desire for "3 hots and a cot" on the other end.

Unfortunately, reliance on patient self-report makes interpretation of what is really going on complex, to say the least. Unlike emergency medicine, in which laboratory tests and imaging studies can provide an objective benchmark of the severity of the illness that is causing ED presentation, psychiatry is less precise. Relying on patient self-report about the need for PES services is a bit like putting the fox in charge of the chicken coop. If asked, most patients who either make the effort to get to an ED or are willing to complete a survey about their current PES presentation will say that they need to be there. Perhaps the other 300-odd patients who did not complete the survey had a different "take" on their experience.

As an example, borderline patients often present with deliberate self-injury, which may not place them in the same category of acute risk as patients who make a suicide attempt in the context of severe depression. Both types of patients may say they need PES services. The difficulty arises when service providers do not necessarily agree. It would be helpful to develop objective measures of patient acuity and service need before embarking on a study such as this, and to employ these measures either in a chart review or in a prospective manner. Another opportunity would be to compare staff and patient perception of PES service appropriateness. Finally, we have almost no idea which aspects of PES treatment are most helpful for a given patient type. Studies of the "active ingredient" in PES care are now under way. There is more to come in the near future.

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