Psych Patients, Take by Amb. or Police?

[Asysin2leads]

Third of all, and the post about all EDP's being cuffed really surprises me, being crazy isn't against the law. EDP's are mentally ill, they are sick. Yes, I like to have a nice police officer take the ride with me, in case Mr. Mentally Ill person decides to get rowdy, but really Rid, if a 16 year old girl breaks up with her boyfriend and in the midst of her angst she threatens suicide and her parents panic and call 911, they slap the cuffs on her and throw her in the back of a squad car? Wow, as if she didn't have problems before, huh?

[PRPGfirerescuetech]

One of the services I work for is perpetually arguing this fact. Regardless of circumstance, every psych call puts EMS between a rock and a hard place. How each job is handled is completely intrinsic on the local PD, the preferences of the EBH crisis center, the policies of your local EBH intake unit, and local hospital preferences.

A suggestion to all.

-Find out if your local EBH intake unit requires medical evaluation prior to admission. Some do. Some dont. This variant will answer many questions of the transport means of your psych patient.

-Find out your local police Departments policies.

-Many emergency rooms are more equipped than others in dealing with psych patients. Know where to go.

Most importantly, know your behavioral health laws. Many are rather complicated in nature. Know your rights and responsibilities. These vary state by state.

Please remember this. EMS providers can do nothing for psych patients more than any police officer can do. Err on the side of caution, and DOCUMENT heavily. These calls are a high level of concern by many administrators, due to the level of liability invoked by the service, and most specifically, the provider.

If your service doesnt have a policy regarding these matters, talk to your boss. Talk to their boss. Arm yourself with information, you are only helping yourself.

...and if all else fails, dart em' like a rhino and hope for the best.

Be safe to all,

PRPG

[AnthonyM83]

I just learned about a new service they're putting in place here for EDP calls:

http://www.co.sanmateo.ca.us/smc/departmen...9831632,00.html

There will be a special AMR vehicle for behavioral code 2 transports, taking care of the paper work.

For emergency psychiatric holds, officers will still do that themselves, but now they have another option for Code 2 holds and (hopefully) won't have to wait forever on-scene for the one BLS ambulance sometimes available on the other side of the county.

[Para-Medic]

Third of all, and the post about all EDP's being cuffed really surprises me, being crazy isn't against the law. EDP's are mentally ill, they are sick. Yes, I like to have a nice police officer take the ride with me, in case Mr. Mentally Ill person decides to get rowdy, but really Rid, if a 16 year old girl breaks up with her boyfriend and in the midst of her angst she threatens suicide and her parents panic and call 911, they slap the cuffs on her and throw her in the back of a squad car? Wow, as if she didn't have problems before, huh?

I thought committing harm against ones self is a crime. Plus, wouldn't a person who is threatening to harm themselves be more likely to harm others too?

[PRPGfirerescuetech]

I thought committing harm against ones self is a crime. Plus, wouldn't a person who is threatening to harm themselves be more likely to harm others too?

Committing harm is. Threatening to committ harm is not. Second statement is invalid, law and medicine should not, and can not act on what a psych patient "might" do. If we do, we'd hog tie everybody, "snow" them, and bring them in at gun-point.

Obviously has to be boundaries.

[Richard B the EMT]

If some "proper authority" like an EMS crew-person, or a LEO, feels that a suspected or confirmed EDP is a potential threat to either the patient's own self, their family or bystanders at the location, or to the Emergency Responders, have the LEOs restrain (handcuff, at the minimum) the patient. The patient is not under arrest, but placed into "Protective Custody" for everyone's protection.

(Semantics! Use them, learn them, love them!)

[webby2525]

As far as I know here, if anyone gets in the backseat of a LEO's car, they must be handcuffed, or so they say is the local dept's policy. As Richard said, not "under arrest" per say. Most transports here were done by PD when the hospital had a small psych area where they would temp. hold pts for a max of 24 hours I believe until they can determine if the pt is a harm to themslves or others. Now that the local hospital has no facility, I am not too sure. Only reason EMS would be called as was said earlier if the pt downed some pills or cut themselves already.

[Just Plain Ruff]

Here is my take on this whole psych thing

They are one of my most dreaded calls - I hate them due to their unpredictability BUT that being said

I always transport the patient. The main reason is that you never know what that person has taken and not told you about. I'd hate to go out on a psych call and let them refuse or do a no transport and the patient actually have taken a overdose of a med that is making them act this way. The liabliity is just too great.

I'm being paid to transfer or not to transfer, so I just go ahead and transfer.

These patients are people too and deserve our care even if we don't like that type of call.

Did I ever tell you the time I transported Jesus Christ? His family said he took no meds prior to the psych event, he denied taking any meds. It turns out he had taken a pharmacopea of meds that all interacted with one another causing an intense psychiatric episode. I had a feeling he took something and the ER did a drug/tox screen(it was one of those sendouts that comes back a week later) and it came back with over 20 meds that came up on it. The patient survived without deficits and once the drugs were out of the system he had no further episodes.

We did a tad bit of praying together when we were on the drive to the hospital. Thank god he didn't think he could fly.

[Ace844]

Here is my take on this whole psych thing

They are one of my most dreaded calls - I hate them due to their unpredictability BUT that being said

I always transport the patient. The main reason is that you never know what that person has taken and not told you about. I'd hate to go out on a psych call and let them refuse or do a no transport and the patient actually have taken a overdose of a med that is making them act this way. The liabliity is just too great.

I'm being paid to transfer or not to transfer, so I just go ahead and transfer.

These patients are people too and deserve our care even if we don't like that type of call.

Did I ever tell you the time I transported Jesus Christ? His family said he took no meds prior to the psych event, he denied taking any meds. It turns out he had taken a pharmacopea of meds that all interacted with one another causing an intense psychiatric episode. I had a feeling he took something and the ER did a drug/tox screen(it was one of those sendouts that comes back a week later) and it came back with over 20 meds that came up on it. The patient survived without deficits and once the drugs were out of the system he had no further episodes.

We did a tad bit of praying together when we were on the drive to the hospital. Thank god he didn't think he could fly.

"TommyGavin: You know how people, like religious people, are always saying stuff like, "have you found Jesus?"

Mikey: Yeah?

Tommy: Guess what. I found him.

Mikey: Oh, yeah. Where has he been for the last 2000 years?

Tommy: Apparently my new apartment "

[Ace844]

(Establishing evidence-based standards of practice for suicidal patients in emergency medicine. Stacey Bennett @ James Daly, John Kirkwood, Cathy McKain and Jolynne Swope.

Topics in Emergency Medicine 28.2 (April-June 2006): p138(6).

Full Text :COPYRIGHT 2006 Lippincott/Williams & Wilkins)

Suicidality is an ever-rising societal issue in today's world. Thousands of people seek safety and treatment for their self-injurious thoughts and behaviors every year in the United States. As a result, emergency departments are being bombarded with patients with suicidal ideation or suicide attempts. Once in the emergency department, these patients are subject to being labeled a "psychiatric patient," and therefore do not receive the same standard of care a medically compromised patient would. In an effort to provide appropriate treatment for these patients, many changes are called for, including educating emergency department nurses in identifying patients who are at highest risk, developing a system of triaging these patients within an appropriate length of time, and providing a safe environment while promptly making arrangement for evaluation and transfer to the proper level of treatment. Key words: documentation, risks, suicide, treatment, triage

**********

CASE STUDY

Mary is a 24-year-old single female who currently works 2 jobs to support herself. At work, she experiences difficulty with her coworkers as weil as her boss. Recently, her sister was incarcerated for drug charges and her mother, her only support, was also recently diagnosed with a chronic, debilitating illness. To make matters worse, Mary's longtime boyfriend broke up with her a week ago, and because of financial difficulties, she had to return home to live with her mother.

On this day, Mary is at her breaking point. With recent thoughts of self-harm, she has devised a plan and is contemplating ending her life with an overdose of her mother's pain medication. With the pills in her hand, Mary is interrupted by her mother unexpectedly walking into the bathroom. Her mother convinces Mary to go to the local emergency department for treatment.

Upon arrival, Mary has second thoughts of going to the emergency department because of the high volume of people waiting ahead of her. Mary reluctantly signs in at the nurse's desk and takes a seat in the waiting room. Approximately 2 hours later, her name is called and she follows a nurse to a small triage area where she is questioned about her complaint. When Mary tells the nurse that she is having thoughts of hurting herself, she is placed on a gurney in the hallway. The nursing staff reassures Mary that she will be seen by the physician shortly.

As time passes, Mary becomes irritable and disgruntled with the process in which she is engaged. She begins to regret her agreement to seek treatment. Her thoughts reflect to wishing she "would have taken those pills because no one cares anyhow." At this time, Mary verbalizes her desire to leave, but agrees to stay at her mother's insistence. A short time later, Mary is transferred to a room within the emergency department.

Staff attempts to make Mary comfortable by offering her food, drink, and a trip to the bathroom. She accepts these offerings and again verbalizes her desire to harm herself. Mary's mother also begins to express her frustration over the amount of time they have been waiting.

In total, Mary and her mother spent 12 hours in the emergency department, at which time, Mary was seen by the attending psychiatrist and deemed appropriate for admission to the inpatient unit.

INTRODUCTION

Mental health issues and mental disorders have been present in the society for thousands of years. However, the societal view of persons suffering with these ailments has changed little over time. Persons seeking treatment for suicidal ideation or other mental health issue, often face a stigma in society as well as from the health professionals they encounter. With the correct education, intervention, and treatment, suicide can be prevented.

The Pennsylvania Department of Health identifies suicidal behavior as a focus area for reform, as outlined in the Healthy People 2010 campaign. (1) In 2003, 10.5 persons per 100,000 successfully committed suicide) It has been reported that approximately 500,000 people require emergency department treatment as a result of a suicide attempt per year in the United States. (2) Of this statistic, many individuals do not have a significant psychiatric history, indicating that acute life events and daily stressors are playing an enormous role in this process.

BACKGROUND

As depicted in the case study, the care suicidal patients receive in the emergency department is often inadequate. Many times, patients with mental illness do not have a safe environment in which to inhabit while waiting to be seen by a physician. Many emergency departments do not have a designated area in which to keep these patients safely. When attempts are made to renovate medical rooms to accommodate suicidal patients, this practice poses great risk. Rooms furnished with medical equipment provide suicidal patients ample opportunity in which to injure themselves. In addition, most of the times these patients do not have their belongings or their person searched for items that can be used for self-harm.

When a suicidal patient seeks treatment at an emergency department, time is of the utmost importance. Patients should be triaged promptly to ensure their safety. Historically, triage, the concept of sorting patients secondary to their clinical urgency, was developed as a medical practice. (3) As a result, standard guidelines to adequately triage patients with mental illness were not created.

STATEMENT OF PROBLEM

For most individuals, suicide is difficult to discuss as the outcome is extreme and definitive. As a small portion of society carries out the act of suicide, many more individuals contemplate it during times of intense stress. Those who commit suicide often do so as a result of a planned, deliberate action, although others die as a result of impulsivity and severe emotional distress. (4)

When an individual seeks treatment for suicidal ideation, often times, mixed feelings are presented about the decision to end his or her life. Many do not verbalize a desire to commit suicide during the triage process, rather they complain of feelings of hopelessness, depression, or the desire for medication changes. As a result, the need for emergency department nurses to be educated in identifying those most at risk is paramount.

Once the need for treatment is identified, the patient must be placed in a safe environment while the assessment and the initial stages of treatment occur. Prolonged delays in this process can cause disruptive behavior, agitation, elopement, or an attempt at suicide by the patient. Thus, the staff is required to observe the patient and possibly have a staff member with the individual at all times.

IDENTIFYING HIGHEST RISK PATIENTS

With the climate of managed care and de-institutionalization, many emergency departments are often faced with the challenge of treating the same individuals, or "frequent flyers," in a short period. As a result, emergency department nurses must be educated on the importance of identifying each patient's need and taking it seriously every time. The literature presents conflicting viewpoints on the type of patient who is most at risk. The American Psychiatric Association (APA) reports that while suicidal behavior is directly related to depression, many individuals who complete the act do not have a psychiatric history. (4) Conversely, it is reported that individuals identified as having prior suicidal attempts or thoughts and who have an established plan are at most risk for self-harm. (5)

As a result, there are many factors associated with suicide that persons encounter in their daily lives. How the individual copes with their everyday life contributes to his or her suicide risk. Stressors associated with suicide include sex, age, life transitions, family history of suicide, unsatisfactory relationships, and unstable lifestyle. (4) As a point of fact, the APA reports that while women attempt suicide more often, men have a higher rate of completion (4). In addition, the following factors are indicators that an individual is considered at a high risk of attempting suicide (Box 1).

Box 1.

Indicators of High Risk*

* Excessive substance use/abuse

* Severe disturbance of mood/thought/

behavior

* Chronic medical issues

* Frequent, intense, prolonged suicidal

ideation

* Multiple, planned suicide attempts

* Unambiguous wish to die, hopelessness

* Chosen method lethal and available to

patient

* Poor insight and controlled affect

* Poor rapport with others, social isolation,

weak family relationships

*Adapted from Collaborative Care Protocols

and Pathways. (5)

TRIAGING PATIENTS

The most important factor in the treatment of a suicidal patient is access to care. In the emergency department, this process begins with the initial patient triage. It is imperative that this process occurs promptly as these patients are in a state of crisis. The APA affirms that acute suicidal behavior is considered to be a psychiatric emergency, and therefore should be assessed and treated immediately. (4) In addition, a study conducted by Smart et al (3) stated that the triage time for a patient who is suicidal or self-injurous is to be limited to within 10 minutes.

Although suicidal ideation is psychiatric in nature, it is important that the patient receive medical clearance, including a toxicology screening. As part of the risk assessment, the emergency department nurse should inquire about the recent use of any drugs or alcohol as comorbid drug and alcohol use is prevalent in this population. In support, the APA reports that "alcohol use is part of many attempted and successful suicides". (4) As intoxication can intensify feelings of hopelessness, it also lowers the patient's impulse control mechanisms. For this reason, all suicidal patients should receive a toxicology screening during the initial phase of treatment in the emergency department. Furthermore, depending on state law, voluntary or involuntary commitment status may be considered invalid if it is performed while the patient's blood alcohol level is above the legal limit.

In addition to identifying the level of illicit drugs and alcohol in the patient's blood, the toxicology report should also include acetaminophen levels. Acetaminophen is now the most commonly used drug in attempted suicide. (6) It is important to review these results regardless of whether the patient information supports the suspicion of drug use as patients may be unable to give an accurate history because of decreased concentration or neurological impairment. However, in some instances, patients with a strong urge to commit suicide may purposefully misrepresent information related to drug use. Box 2 outlines the results that should be obtained as part of the medical clearance for a suicidal patient.

Box 2.

Results Required in addition to

Standard Medical Clearance:

* Drug toxicology

* Blood alcohol level

* Acetaminophen level

* Urine pregnancy test

As an added component of the triage process, an initial suicide risk assessment should be completed. This assessment should include the duration of the suicidal ideation, any history of previous suicide attempts, the existence of a plan, and access to means to complete the plan. (4) The registered nurse caring for the patient should be performing this task as part of the behavioral assessment. As a point of note, a psychiatrist is not needed to complete this assessment as the responses received from the patient will indicate the immediate level of safety precautions needed.

In response to the information attained in the risk assessment, the patient should be placed on suicide precautions. As the results of the evaluation indicate, emergency department staff should place the individual on a corresponding level of safety observation. The patient can either be placed on a 1:1 continuous observation, a close continuous observation, or 15-minute suicide checks. (5) Patients assessed to be in imminent suicidal danger or who are considered to be highly impulsive, should be placed on the 1:1 continuous observation. This level of care indicates a staff member must be within arms reach of the patient at all times. A patient in need of close continuous observation requires a staff member to have the patient within eye contact at all times. However, during this time, the assigned staff member should be near the patient, if needed for assistance. When a patient is observed on 15-minute suicide checks, the assigned staff member is required to visually assess the patient for safety every 15 minutes. These levels of observation do not require completion by a registered nurse. In some institutions, this care is provided by either a nursing aide or hospital security.

ENVIRONMENT

Once the patient has been triaged, and the risk to self has been identified, the next factor in treatment is the immediate environmental safety of the patient. The individual should be taken to a private room for observation. One of the initial steps in aiding the patient to regain control is to decrease external stimuli. In a busy emergency department atmosphere, relocating the patient to a quiet, secluded area is crucial.

The contents of the observation room are of primary importance. For the patient that has no obvious medical complications and does not require the use of restraints to maintain safety, a room with seating arrangement for the patient and the monitoring staff is sufficient. Care should be taken as this room should not provide the patient with access to sharp objects, cords, plastic bags, glass items, string, or other things that can be easily broken or thrown. Box 3 describes the idem environment of an observation room.

Box 3.

Characteristics of an Observation

Room

* Private

* Direct access for visualization by staff

* Absence of cords, string, plastic bags,

sharp objects, or other objects that could

be broken or thrown

* Doors should be easily unlocked from

both sides to prevent possible barricading

* All windows should be shatter proof

* All hardware should be breakaway

An additional important safety precaution is to determine whether individuals have implements with which to hurt themselves, either on their person or in their belongings. With the patients in the observation room and their privacy maintained, a search for sharp objects, medications, or other dangerous items should be completed. At this time, depending on the level of risk determined, the patient should either be placed in a hospital gown or be asked to remove any belts or shoe laces.

DISCUSSION

It is important that nursing staff involved with the care and treatment of a suicidal patient receives proper training related to crisis management. This training should also include education on suicide risk assessment and on the importance of being nonjudgmental and empathetic, in an effort to establish rapport with the patient and the family. (5) Providing education on proper interviewing techniques as well as the importance of meeting the physical needs of a suicidal patient should also be discussed. Furthermore, the nurse needs to be familiar with the law and hospital policy regarding involuntary hospitalization, the use of seclusion and restraints, and the patient's rights. (4)

Documentation of the patient's behavior and the staff interventions is of high importance. It is paramount that all steps during the triage and observation of a suicidal patient be accurately recorded. As in the medical arena of healthcare, if a case is later reviewed in court, the charted record reflects the "story" of the hospital encounter. While the suggestions discussed are meant to minimize the risk to the individual, great consideration must be taken at all times when caring for a suicidal patient. As a point of fact, according to the Joint Commission on Accreditation of Healthcare Organizations, suicide was the number one sentinel event reported by the hospitals in December 2005. (7) Box 4 outlines the highlights of proper documentation.

Box 4.

Documentation Highlights

* Clear

* Concise

* Chronological

* Objective information only

* Standardized forms for universal staff utilization

Emergency departments across the country are witnessing a rise in psychiatric visits. It is our role as clinicians to ensure that every patient is seen in a timely manner, and pro vided a safe, comfortable environment while in our care. When establishing a safe environment for psychiatric patients in emergency medicine, the following guidelines should be followed:

* Become familiar with the guiding principles set forth by the hospital's governing agency.

* Include the expertise of the hospital's psychiatric service when creating policy and procedure for the emergency department.

* Educate emergency department nursing personnel how to accurately assess for suicidal ideation and how to institute the safety precautions as indicated.

* Establish proper documentation guidelines related to behavioral assessment and monitoring.

* Establish an efficient system for psychiatric intervention and treatment.

Psychiatric patients pose a unique risk to the already challenging emergency department environment. As a result, the needs of these individuals are often overlooked. It is common to discover that many emergency departments lack specific guidelines for the care and treatment of psychiatric patients. As this population increases, it is imperative to provide the needed education, awareness, and skills to the emergency department staff in order to adequately meet the needs of these patients.

REFERENCE

(1.) Healthy People 2010. Available at: http://www.dsf. Health.state.pa.us.html. Accessed March 9, 2006

(2.) Screening for suicidal risk: a systematic evidence review for the United state Preventive Services Task Force. 2004. Available at: http://www.ahrq.gov/clinic/ uspstfix.htm. Accessed March 15, 2006.

(3.) Smart D, Pollard C, Walpole B. Mental health triage in emergency medicine. Aust NZJ Psychiatry 1999; 33:57-66.

(4.) American Psychiatric Association. Psychiatric emergencies: conditions that are life-threatening-suicide. 2006. Available at: http://www.nurscce.com/online courses/9225P2.html. Accessed March 7, 2006.

(5.) Wayne State University School of Medicine. WSU Project C.A.R.E. Collaborative care protocols and pathways. 2003. Available at: http://www.med.wayne. edu/wsuprojectcare/Deliverables/Collaborative%20 Care%20Pmtocols%20and%20Pathways.pdf. Accessed March 26, 2006.

(6.) Suicidal behavior. 2004. Available at: http://merck. corrt/mmhe/sec07/chl02a.html. Accessed March 25, 2006.

(7.) Joint Commission on Accreditation of Healthcare Organizations. Sentinel event statistic update. Available at: http://www.jointcommission.org/Library/ JCAHOnline/jo_12_05.htm. Accessed March 17, 2006.

Stacey Bennett, RN, BSW; James Daly, RN, C; John Kirkwood, BA, RN, C; Cathy McKain, RN, C; Jolynne Swope, BA

From the Department of Psychiatry, Penn State Milton S. Hershey Medical Center, Hershey, Pa.

Corresponding author: Stacey Bennett, BSW, RN, Department of Psychiatry, Penn State Milton S. Hershey Medical Center, 500 University Dr, PO Box 850, Hershey, PA 17033 (e-mail: sbennett@psu.edu).

(Should Emergency Medicine Physicians Screen for Psychiatric Disorders?(Disease/Disorder overview). Seth Kunen.

Psychiatric Times (March 1 @ 2006): p33.

Subjects

Full Text :COPYRIGHT 2006 All rights reserved. No part of this information my be reproduced, republished or redistributed without prior written consent of CMP Media Inc.

Byline: Seth Kunen, PhD, PsyD, and Cris V. Mandry, MD)

Emergency department (ED) visits have increased substantially from 89 million in 1992 to over 110 million visits in 2002, while during the same period, the number of EDs decreased by about 15% (McCaig, 1994; McCaig and Burt, 2004). An estimated 1.7 million people rely entirely on EDs for all their health care needs (Walls et al., 2002). The demand for emergency services continues to increase while the availability of inpatient hospital beds and alternative sources of urgent care have decreased, resulting in widespread overcrowding (American Academy of Pediatrics Committee on Pediatric Emergency Medicine, 2004; Brewster et al., 2001; Derlet and Richards, 2000). Consequences of overcrowding include increased ambulance diversion, longer hours of patient boarding in the ED, and increased numbers of patients who leave either before being evaluated or against medical advice (Yamane, 2003). We suspect that another consequence of ED overcrowding is an increased tendency to ignore or disregard psychiatric problems, especially if the psychiatric problem is not the chief complaint.

Psychiatric Diagnoses

The annual rate of psychiatric problems in the U.S. population is estimated to be about 20% (28% if substance use disorders are included) for both children (Shaffer et al., 1996) and adults (USDHHS, 1999). When the rates of specific mental disorders are studied among ED patients, the psychiatric rates are often much higher than the respective national rates (Meldon et al., 1997; Schriger et al., 2001; Zane et al., 2003), so it is reasonable to assume that the overall psychiatric rate among ED patients is at least 20% to 28%.

In a Centers for Disease Control and Prevention (CDC) survey of EDs, it was reported that 3.3% of patients received a psychiatric diagnosis as the primary diagnosis (McCaig and Burt, 2004). However, since McCaig and Burt (2004) did not report the percentage of all patients receiving a psychiatric diagnosis, we analyzed the CDC data and found that across all ages, 6.24% received at least one psychiatric diagnosis, and 1.27% received two or more psychiatric diagnoses. Among patients 15 years and older, 7.5% received at least one psychiatric diagnosis, and 1.51% had two or more psychiatric diagnoses. The 6.24% rate is similar to what we have found in an independent study of three EDs that included all ICD-9 diagnoses (Kunen et al., 2005). These comorbidity rates are about one-third the 3% comorbidity rate found in the National Comorbidity Study (Kessler et al., 1994).

We also compared the psychiatric rates of Caucasians and African-Americans in the CDC data. With all ages included, the psychiatric rate of Caucasians (mean=6.14) and African-Americans (mean=6.24) did not differ, x2 (1; n=33,235) < 1, p < 0.50. With patients 15 years and older, the psychiatric rate of Caucasians (mean=7.20) and African-Americans (mean=7.95) did not differ, x2 (1; n=26,443)=2.94, p < 0.10.

The finding that only 6.24% of all patients received a psychiatric diagnosis clearly indicates that most psychiatric disorders among ED patients are missed or ignored. However, it could be argued that the 6.24% rate is reasonable if it primarily represents diagnoses of the more serious psychiatric disorders, since ED physicians may not have the time to screen for the less serious psychiatric disorders. To determine if ED physicians are principally screening for the more serious psychiatric disorders, we examined the psychiatric rates of the following three psychiatric categories in the CDC data: 1) schizophrenia, 2) substance use disorders and 3) mood disorders.

The annual rate of mood disorders is estimated to be about 9%, the rate of substance use disorders is approximately 9.5%, and the annual schizophrenia rate is about 1.3% (Grant et al., 2005; USDHHS, 1999). In the CDC data, 1.92% of all patients received a mood disorder diagnosis (versus 9% annual rate in the United States). The substance use disorder rate in the CDC data, with substance use disorder-related psychoses (e.g., alcohol psychosis) included, was 2.76% (versus prevalence rate of 9.5%). The substance use disorder rate without substance use disorder-related psychoses was 2.55%. The schizophrenia rate in the CDC data was 0.57%, which is less than half of the national prevalence rate of approximately 1.3%. The argument that the psychiatric rate of 6.24% primarily reflects diagnoses of the more serious disorders is not supported by the data.

In our experience, the argument offered most frequently by ED physicians to justify the exclusion of psychiatric disorders that are not the chief presenting complaint is that the scope of practice of emergency medicine should include only acute or urgent injuries and physical illnesses. However, adherence to the model that emergency medicine should be exclusively concerned with acute or urgent injuries or illnesses is no longer tenable, since approximately half of all emergency department visits are neither acute nor urgent (McCaig and Burt, 2004). It is also important to note that many patients who are experiencing health threatening problems, such as battered wives, sexually abused children, homicidal patients, depressed and suicidal patients, substance abusing patients, HIV/AIDS patients, and psychotic individuals who are relapsing or actively experiencing hallucinations, are often reluctant to volunteer information about their problems because of fears of negative consequences (e.g., further abuse, legal charges, civil commitment, or loss of insurance) (Klitzman and Greenberg, 2002; Magura and Kang, 1997; Morrison and Downey, 2000; Rew and Esparza, 1990). These groups of patients may not disclose their problems without encouragement from their physicians. The failure to initiate inquiries into psychosocial and psychiatric issues can have lethal consequences for some patients (Williams, 1995).

We also have found that many ED physicians believe that mental disorders, in general, are relatively minor threats to health. However, this view is not supported by public health research, which has shown that psychiatric illness, and depression in particular, is a major cause of lost years of productive life, and in fact is second only to the number of years of productive life lost to cardiovascular disease (Murray and Lopez, 1996). The view that psychiatric disorders are relatively minor threats to health is a perspective not shared by The Emergency Medicine Core Content Task Force (EMTALA), which published a "Model of the Clinical Practice of Emergency Medicine" (Hockberger et al., 2001).

In this model, the Task Force listed the levels of acuity of common conditions presenting to EDs. The three levels of acuity listed were:

1. Critical: life-threatening illness or injury with a high probability of mortality if not treated;

2. Emergent: illness or injury that may progress in severity or result in complications with a high probability of morbidity if left untreated; and

3. Lower Acuity: illness or injuries that have a low probability of progression to more serious complications.

Eighteen categories of medical conditions were described, and one of those areas, psycho-behavioral disorders, deals with psychiatric conditions. Of the 35 individual psycho-behavioral disorders listed in these categories, 20 (57%) were designated as either emergent or critical problems.

The provisions of EMTALA (1986) are relevant to the issue of whether emergency medicine should include psychiatric issues within its scope of practice. The Task Force prevents hospitals from dumping unwanted patients and guarantees all emergency patients the right to a medical screening exam to determine if a medical emergency exists and stabilization before transfer. As shown below, EMTALA specifically includes psychiatric problems and substance abuse as part of the definition of a medical emergency (bold face text added):

In the case of a hospital that has an emergency department, if any individual (whether or not eligible for Medicare benefits and regardless of ability to pay) comes by himself or herself or with another person to the emergency department and a request is made on the individual's behalf for examination or treatment of a medical condition by qualified medical personnel (as determined by the hospital in its rules and regulations), the hospital must provide for an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examinations must be conducted by individuals determined qualified by hospital bylaws or rules and regulations and who meet the requirements of 482.55 concerning emergency services personnel and direction. ...

Emergency medical condition means ... [a] medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in ... [p]lacing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.

The central issue here is whether it is legal or ethical for ED physicians to routinely ignore significant psychiatric issues that are not the chief presenting complaint. As an example, consider the following clinical case.

A 65-year-old retired Caucasian male presents to the ED with a fractured metatarsal as a result of a single motor vehicle accident. The ED physician appropriately diagnoses and treats the fracture, gives the patient pain medication, and sets up an orthopedic appointment. Just prior to discharge, the physician asks the patient how he is feeling, and the patient says he has been feeling "somewhat down and tired for a while." When asked about the pain in his foot, the patient says the pain medication seems to be working. The patient arranges a ride home and the physician then discharges the patient. The physician did not ask anything further about the nature of the accident or what the patient meant by "somewhat down and tired for a while," and the patient did not volunteer any additional information.

Later that night, the patient commits suicide. If the physician had asked the patient about the circumstances surrounding the accident, the physician would have learned that the patient had been drinking heavily recently because of an emotionally troubling divorce and that the patient was in fact depressed and having suicidal thoughts. Moreover, the demographic and social characteristics of this patient (i.e., age 65 years old, Caucasian race, divorced, depressed, excessive alcohol use and retired) are, collectively, strong indicators of potential suicide (Minino et al., 2002; O'Connell et al., 2004).

Has the physician violated EMTALA? Is the physician guilty of medical malpractice? Would the physician be found not culpable because the patient did not initiate a discussion of psychiatric issues? We believe the answer to these questions is the EMTALA requirement noted above that the hospital must provide for an appropriate medical screening examination to determine if an emergency medical condition exists. We believe that an appropriate medical exam should have included additional questions about the patient's emotional status, and because the physician "transferred" the patient home while the patient was still experiencing an "unstabilized" psychiatric crisis, the physician placed the hospital at risk for having violated EMTALA and the physician increased his risk of being subject to a medical malpractice suit.

Issues of Comorbidity

Another major problem with ignoring psychiatric disorders that are not the chief complaint is that psychiatric disorders frequently co-occur with serious health problems and can complicate or slow recovery if left untreated (Ramirez and House, 1997). Patients with significant medical illnesses have twice the rate of psychiatric disorders found in the non-medically ill population (House et al., 1995), and the rate of medical disorders among persons with severe psychiatric illnesses is significantly higher than the rate of medical disorders among persons without severe psychiatric illnesses (Dickey et al., 2002). Two of the most common psychiatric disorders found among the seriously medically ill are substance use disorders and depression (House et al., 1995).

In a National Institutes of Health publication on depression (Strock, 2000), it was noted:

In recent years, researchers have shown that physical changes in the body can be accompanied by mental changes as well. Medical illnesses such as stroke, a heart attack, cancer, Parkinson's disease, and hormonal disorders can cause depressive illness, making the sick person apathetic and unwilling to care for his or her physical needs, thus prolonging the recovery period.

Depression is not only a frequent sequela of coronary heart disease (CHD), but it is also a risk factor for CHD in both men and women and a risk factor for increased CHD mortality among men (Ferketich et al., 2000). In our analysis of the CDC data, we found that cardiac related problems (e.g., myocardial infarction, hypertensive heart disease, congestive heart failure) were present in 5.71% of patients (this percentage likely reflects more than 5 million patient visits each year to EDs). The percentage of these cardiac patients diagnosed with depression was 0.81%. In contrast, other studies indicate that the depression rate among patients with MI is probably closer to 40% (Cheok et al., 2003).

It is also important to note that there are significant correlations among depressive disorders, substance use disorders, serious medical illness and suicide (Angst et al., 1999; Dickey et al. 2002; House et al., 1995). Suicide was the 11th leading cause of death in 2000 in the United States, and it accounts for more deaths each year than homicides (Minino et al., 2002). As many as 500,000 patients each year are treated in EDs for injuries associated with attempted suicides (McCaig and Stussman, 1997), and more than 90% percent of people who kill themselves have a major mental disorder such as depression or SUDS (Conwell and Brent, 1995; Moscicki, 1997).

Missed Diagnosis

Many factors contribute to the low psychiatric rate among ED patients. These factors include overcrowding, physician beliefs about the scope of practice of emergency medicine, and physician attitudes that psychiatric problems are relatively minor threats to health. Another factor worth noting involves countertransference reactions of physicians to patients. Countertransference refers to an emotional reaction of the physician to a patient that is generally a reflection of the physician's unresolved intrapsychic conflicts, but countertransference also may be a reaction to the patient's behavior.

In one of Freud's earliest discussions of countertransference, he considered countertransference to be an unconscious interference with the physician's ability to understand patients (Freud, 1910). The concept of countertransference has been significantly enlarged since Freud (e.g., Gabbard, 2001), and it is recognized today that skilled psychotherapists can use their countertransference reactions as a source of valuable information about the patient and the therapeutic alliance (Abend, 1989; Hunt and Issacharoff, 1977; Racker, 1957). However, among physicians not trained to recognize countertransference reactions, such reactions may go unnoticed and may interfere with the medical care of the patient.

Countertransference is now recognized as having a significant impact on patient care in many different areas (Schwartz and Wendling, 2003). Patient populations, such as violent patients (Tardiff, 1988), battered women (Butterfield et al., 1999; Keller, 1996), uncooperative patients and patients with psychosis (Adler and Griffith, 1991), patients with dual diagnoses (Shaffer and Costikyan, 1988), suicidal patients (Gabbard, 2003) and patients with personality disorders (McIntyre and Schwartz,1998) may elicit strong countertransference reactions such as premature discharge, envy, masochism (excessive use of restraint, seclusion and medication), denial, misdiagnosis, anger, hate, rescue fantasies and helplessness. Patients who are poor, unkempt, illiterate, nonadherent and of different racial and ethnic groups also can elicit countertransference reactions that interfere with accurate psychiatric diagnosis and appropriate medical care. It is incumbent upon all health care professionals to monitor their countertransference reactions to ensure that each patient receives the highest quality health care possible.

There are significant social consequences associated with the underdiagnosis of psychiatric problems among ED patients. The national psychiatric rates of Caucasians and African-Americans are approximately equal (about 20%; with substance abuse about 28%) (USDHHS, 1999), and the psychiatric rates among Caucasians and African-Americans in the CDC study, while significantly lower than the national rates, are also approximately equal. Given that African-Americans are twice as likely as Caucasians to attend EDs (McCaig and Burt, 2004), and given that African-Americans are more likely than Caucasians to seek mental health care in EDs (USDHHS, 2001), the psychiatric underdiagnosis in ED patients will differentially increase the unmet mental health burdens of African-Americans, who experience significant disparities in access to and utilization of most health care services compared to Caucasians (Smedley et al., 2003). In the Surgeon General's report on minority mental health (USDHHS, 2001), it was noted:

Racial and ethnic minorities collectively experience a greater disability burden from mental illness than do whites. This higher level of burden stems from minorities receiving less care and poorer quality of care, rather than from their illnesses being inherently more severe or prevalent in the community.

Another reason to address psychiatric problems in the ED is that it has the potential to reduce ED use by some high-frequency ED patients. High-frequency ED patients with psychiatric disorders disproportionately utilize all types of health care services and have higher median financial charges per ED visit than low-frequency ED users (Arfken et al., 2004; Byrne et al., 2003; Curran et al., 2003; Hansagi et al., 1990; Kennedy and Ardagh, 2004; Williams et al., 2001). The identification and management (either through treatment or referral for treatment) of disorders such as depression, substance use disorder and panic disorder among high-frequency ED users has the potential to increase the operating efficiency of EDs while reducing pain and suffering, unnecessary medical expenses, and unnecessary return visits.

For example, Okin et al. (2000) found that case management of high-frequency ED users with psychosocial problems produced substantial benefits in several areas:

1. There was a 60% decrease in the median number of ED visits in the subsequent year;

2. Median ED costs decreased 53% (from $4,124 to $2,195);

3. Median inpatient costs decreased from 66% from $8,330 to $2,786;

4. Homelessness decreased by 57%;

5. Drug and alcohol use decreased by 24%;

6. Primary care service use increased 74%.

Okin and colleagues found that for every dollar invested in case management, there was a $1.44 reduction in hospital costs.

Screening Tools

There are several quick tests that busy ED physicians and nurses can use to help screen for psychiatric disorders. For example, some frequently used tests for screening depression are the Beck Depression Inventory (BDI) (Beck et al., 1961), the Center for Epidemiologic Studies Depression Scale (CES-D) (Radloff, 1977) and the Zung Depression Scale (Zung, 1965). Depression screening, particularly among elders, can be done quickly and efficiently by using a three-item depression screen (Fabacher et al., 2002).

Although many physicians are opposed to the idea of giving antidepressants to patients with mood disorders in the ED, reasonable arguments can be made in favor of starting some patients with depression on antidepressant medication in the ED. For example, Glick and colleagues (Glick, 2004; Glick and Ghaemi, 2000), point out that the newer selective serotonin reuptake inhibitor antidepressants are much safer than the older generation antidepressants and that depressed ED patients who do not have the motivation to comply with recommendations to seek mental health care services may be more likely to comply if antidepressant therapy is initiated in the ED.

Several brief screening instruments are available to screen for alcohol and drug abuse problems (Cherpitel and Bazargan, 2003; Cherpitel and Borges, 2004). While it should be recognized that the predictive ability of most suicide scales is limited, two useful suicide-screening inventories are the Beck Hopelessness Scale (Beck et al., 1974) and the Child Hopelessness Scale (a derivative of the Beck Hopelessness Scale) (Kazdin et al., 1986).

Physicians interested in screening for psychotic symptoms may find it useful to employ short screening instruments such as the Brief Psychiatric Rating Scale (Overall and Gorham, 1962), the Mini-Mental State Exam (Folstein et al., 1975), or the Severity and Acuity of Psychiatric Illness Scales (Lyons, 1998). This latter scale requires several hours of training to administer, but can be completed in approximately five minutes by interviewing collaterals.

Conclusion

While the focus of this article has been on the neglect of psychiatric problems among ED patients, we also should note that as a specific psychiatric disorder increasingly becomes the diagnostic focus, the tendency to ignore underlying medical problems may increase (Hall et al., 1981, 1978; Riba and Hale, 1990; Tintinalli et al., 1994). A thorough history and physical exam (H & PE), including vital signs, will help the ED physician avoid missing underlying organic conditions, since the H & PE has been shown to have both high specificity and sensitivity in identifying medical problems among ED psychiatric patients (Olshaker et al., 1997). In fact, the H & PE has been found to be superior to laboratory tests alone (e.g., blood chemistries, urinalysis) in detecting medical disorders (Olshaker et al., 1997).

It is important to keep in mind that an organic basis is present in approximately 20% of patients presenting with an acute psychosis (Richards and Gurr, 2000), and that altered mental status, which is one of the prominent signs of a psychiatric disorder, may in fact be more frequently associated with neurological problems, toxicity or trauma than with purely psychological factors (Kanich et al., 2002). Patients presenting with altered mental status who have histories of mental disorders may be too quickly assumed to be experiencing an exacerbation of their psychiatric problems (Reeves et al., 2000).

Many other medical conditions can mimic psychiatric disorders. For example, thyroid disease can present as depression, anxiety, agitation and confusion, while cardiopulmonary disease can present as anxiety and confusion (Williams and Shepard, 2000). Incomplete cervical spinal cord injury cases can be misdiagnosed as hysteria or conversion disorders (Bicknell and Fielder, 1992). The possibility of an underlying organic etiology for symptoms suggesting psychosis (e.g., hallucinations, delusions), depression, anxiety, altered mental status and somatization disorder should always be considered (Reeves et al., 2000).

Should ED physicians screen for psychiatric disorders? It would be sound medical practice for ED physicians to routinely screen for psychiatric disorders such as substance abuse and depression (and suicidal ideation), particularly among their seriously medically ill and injured patients. Enlarging the scope of practice of emergency medicine to include psychiatric disorders has the potential to significantly improve the quality of the services provided by the public health care safety net, particularly for those patients who rely on EDs for most of their health care needs.

Mr. Kunen is a clinical psychologist and director of research in the Louisiana State University Emergency Medicine Residency Program in Baton Rouge, La.

Dr. Mandry is trained in both emergency medicine and internal medicine at the Louisiana State University and serves as founding emergency medicine residency director of the Emergency Medicine Program in Baton Rouge, La.

Mr. Kunen and Dr. Mandry have indicated they have nothing to disclose.

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