This brief overview of emergency psychiatry is the
21st in the Review of Psychiatry series published by American Psychiatric
Publishing Inc. The series is aimed at practicing clinicians, and Emergency Psychiatry presents ‘the
latest thinking of psychiatrists experienced in emergency work’ (p. xiii). Its
target audience is general and intensivists working in different psychiatric
specialties, although the back cover note extends the intended readership to
all mental health workers. The book is divided into five chapters, which can be
read individually, as each is an overview of a specific area of emergency care.

The first chapter discusses models of psychiatric
emergency services. A range of emergency mental health services is reviewed,
although the chapter focuses primarily on hospital based psychiatric emergency
services. A limitation of this focus, acknowledged by the authors, is that such
centers are staff intensive and therefore expensive. They require a up to 3000
visits a year to justify their cost, making this model untenable outside major
urban centers. The chapter contains a review of the goals of emergency care,
and discusses some of the common service level issues of emergency services.
These include limitations of space, the role of time in de-escalating
psychiatric emergencies, and the limitations of space in traditional medical
emergency departments. The consultation model of service is discussed, and
found to be limited compared to the comprehensive service offered by specialist
hospital based centers. There is a long discussion of the potential conflict
between the clinical imperatives of clinicians and those of funders,
particularly managed care organizations. The chapter is a useful introduction
to service level issues of emergency psychiatry.

Chapter two covers assessment, perhaps the core
skill of psychiatric emergency services. The first part of the chapter is given
to an extended discussion of the role of psychiatrists in providing medical
care for patients seen in psychiatric emergencies. While acknowledging the
limited experience of psychiatrists in general medicine, the authors
nevertheless argue strongly that medical care is a function of psychiatric
services. Several reasons for this position are advanced. They are; the high
rates of undetected physical illness in psychiatric patients, the contribution
of organic factors to psychiatric presentations, the side effects and potential
complications of commonly used psychotropic medications, and problems
experienced by mentally ill patients in accessing primary care services.
Despite this, the issue of the appropriate setting for medical care of psychiatric
patients is not settled, and the role of psychiatrists in providing medical
care is therefore not always clear. The chapter contains a brief discussion of
triage, and reviews the place of diagnosis in predicting disposition decisions.
The latter part of the chapter is given to psychosocial and cognitive
assessment, meaning that psychiatric evaluation, the systematic observation of
the patient at interview, history taking, and weighing up diagnostic
considerations were, for me, lightly addressed.

Attempted suicide, one of the most commonly
presenting psychiatric emergencies, is discussed in Chapter Three. Rates of
suicide increased in western countries in the second half of the twentieth
century, and many countries now have national suicide prevention strategies. In
psychiatric emergencies, assessment of suicide risk is a fundamental skill, and
the outline of risk factors, intervention strategies and modifiable
contributors to suicide is a useful guide to management of suicidal
individuals. While there is an understandable concern to focus on suicide
prevention in emergency psychiatry, the process of differentiating recurring
deliberate self-harm from suicide attempts is only briefly covered. Much of the
coverage of non-suicidal self-harm is focused on self-harm as a predictor of
suicide. This means that management of self-harm related to emotional
dysregulation seen in borderline personality disorder is not covered. This
chapter also contains some statements that are difficult to justify, for
example, that "it is generally accepted that 90% of individuals who commit
suicide have a serious mental disorder" (p. 87), and "suicide is
almost always the result of inadequately treated mental illness" (p. 105).
However there are also some useful pointers to clinicians. There is evidence
that the intensity of suicidal thoughts at their worst point in a patient’s
life is a better predictor of risk than current suicidality, and a reminder
that access to means, especially guns, is another strong predictor of completed
suicide. The authors recommend that well managed risk in the community is a
more therapeutic option than hospitalization, despite the common perception
that more restrictive care is advisable in case of legal action. They state
that a well-documented, effective plan of care, especially one that involves
review of decisions with another clinician, can provide substantial protection
against legal action. The commonly used ‘no-suicide contract’ is rightly
dismissed in favor of thorough assessment and establishment of a therapeutic
alliance. The chapter contains guidance for clinicians in managing the
professional risks involved in treating vulnerable patients.

Chapter Four covers agitation and aggression, common
problems in psychiatric emergencies. There is an extensive discussion of the
pathophysiology of these behaviors, which I found a distraction from the focus
on understanding their immediate precipitants and effective interventions.
Violence is a common sequel of agitation, and the section on assessment covers
the range of factors known to be associated with violence. If there was one
aspect of this section I would like to have seen covered in more depth it is
the role of substance abuse in violence, and the implications for treatment.
The chapter reviews the options of treatment settings, and provides some
sensible advice on verbal and behavioral interventions, including restraint and
seclusion. The final section of the chapter considers pharmacological
interventions, with the authors favoring benzodiazepines as the pharmacological
agents of choice for reducing arousal.

The final chapter on psychosocial interventions is a
welcome inclusion. The chapter takes the view, consistent with the literature
on crisis intervention, that a psychiatric emergency is an opportunity for
change, even if that change does not occur in the current period of contact.
The authors contrast procedural and process approaches to the psychiatric
interview, emphasizing that with appropriate attention to the immediate and
medium-term needs of the patient, the objectives of both can be met. The
interview can achieve the dual function of obtaining necessary information
about risk, as well establish a therapeutic alliance that will contribute to
greater engagement and, ultimately, to improved outcome. Models of psychosocial
intervention are outlined and illustrated with short vignettes demonstrating
the responses that typify each approach. The limitations of using cognitive,
psychodynamic, and behavioral approaches are acknowledged, and their
application to psychiatric emergencies is discussed in terms of the likely
barriers to their use caused by clinical features of presenting problems. This
makes this section practically useful, although effective use of any of these
models requires some background in the theory and practice particular to each
of them. The chapter takes a realistic approach to the constraints under which
psychiatric emergency work takes place. Sense of coercion, agitation and
anxiety, and aspects of the physical environment are all acknowledged as
limitations on how much therapeutic interpersonal work can be achieved in the
emergency setting. Nevertheless the emergency is regarded as an opportunity to
begin the task of change with the important objective of preventing future
presentations.  

In a book which aims to provide an overview there
will inevitably be omissions. The needs of specific populations such as
children and adolescents, older people, and those whose primary problems derive
from substance misuse are not specifically covered. The book is written in
plain language, and in a readable style. It is very well referenced, providing
adequate opportunity to readers to pursue issues of particular concern in
greater depth. The focus on psychiatric assessment and diagnosis is balanced by
discussion of psychological and social factors, and there is a concern
throughout to provide care to the least restrictive standard.  For a clinician new to psychiatric emergency
work, or a generalist clinician wishing to broaden their understanding of
psychiatric emergencies it is a useful introduction; experienced clinicians may
want a more in-depth coverage. The book is recommended to mental health
workers, and especially to students and especially to those new to psychiatric
emergency work. It would be a useful resource in libraries for students of
health and medical studies.

© 2003 Tony O’Brien

Tony O’Brien, Senior Lecturer, School of
Nursing, University Auckland, New Zealand.

Categories: MentalHealth