Use of restraints and pharmacotherapy in academic psychiatric emergency services

Abstract

Psychiatric emergency services (PES) are an increasingly important component of mental health services. To assess the type and scope of services delivered in the PES setting, the American Association for Emergency Psychiatry sponsored an Expert Consensus Panel Survey of these services in 1999. The questionnaire was mailed to medical directors of PES facilities with 91% (n = 51) responding. More than 90% of the respondents were teaching sites. Restraints were reportedly used in a mean of 8.5% of presentations for a mean of 3.3 h per episode. Restraint utilization correlated with the percentage of psychotic patients treated, but not with a wide variety of other patient and service variables. Involuntary medications were used in 16% of cases, though in oral form in 29% of those cases. A large majority (94%) endorsed mild sedation permitting further assessment as the appropriate endpoint and rejected sleep or heavy sedation as an endpoint (82%). Benzodiazepines received the strongest endorsements and 82% indicated it would be appropriate to administer a benzodiazepine alone for agitation first and initiate antipsychotic treatment subsequently if appropriate. When there is no history of prior antipsychotic exposure, 60% favored a benzodiazepine alone. However, given a history of previous antipsychotic treatment, only 8% endorsed this strategy. Most respondents (78%) preferred to use oral medication for treating behavioral emergencies, whenever possible but 70.3% reported regular use of an IM combination of a benzodiazepine and high-potency typical neuroleptic when necessary. In addition to managing emergencies, 82% of services initiated standing medications for patients being admitted to hospital settings and 70% initiated regular medication treatments for patients being released to the community. Of patients started on oral antipsychotics, 42% received an atypical antipsychotic. Reflecting medication characteristics of particular importance in emergency settings, most respondents (92%) cited selective serotonin reuptake inhibitors as the preferred type of antidepressant, and divalproex or related compounds (90%) for treatment of bipolar disorder in the PES.

Introduction

In recent years, psychiatric emergency services (PES) have become a major point of entry into the mental health system and a principal treatment site for many patients with chronic and severe mental illness [1], [2]. This shift towards treatment rather than triage in crisis settings represents a relatively new phenomenon. In the early 1980s, a comprehensive review of services provided in psychiatric crisis response systems found that many emergencies were handled by walk-in crisis centers, and the staff of these centers did not typically prescribe medications [3]. Particularly before Diagnostic and Statistical Manual of Mental Disorders (DSM)-III and -IV, assessment was often limited. As a result, diagnosis in emergency rooms tended to be imprecise [4], and medication initiation was usually deferred to inpatient treatment providers. The medications available at that time were also more toxic and required greater premedication medical assessment. At that stage in PES development, the scope of services was limited to crisis intervention and disposition [1], [5], [6]. This has been described as the triage model [7].

Since that time, the philosophical, legal, and financial environment has changed, and one major goal of emergency services is now diversion from hospital admission, whenever possible. To accommodate this broader mandate, PESs are now complex, organizationally unique services with a variety of resources that can include outreach teams, observation beds, and community-based crisis and residential beds. Reliability of psychiatric diagnosis in emergency settings has been shown to be moderate to excellent for many diagnostic categories [8], [9]. This approach to emergency services, characterized by more precise diagnosis, initiation of treatment in the emergency setting, and transfer to a lower level of care, has been described as the treatment model [2]. This model is in part possible because of the introduction of safer, more tolerable psychotropic drugs (including new antidepressants, mood stabilizers, and atypical antipsychotics), which require less intensive premedication assessment, titration, and monitoring. Although originally driven by necessity, this approach also has many benefits. Immediate initiation of treatment may promote more rapid symptom control, reduce use of restraint and seclusion, and shorten length of stay for those patients who are admitted [2].

While the role of the PES in the system of care has evolved, no systematic assessment of modern PES settings or practices has been conducted. To characterize such services, we report results of a survey of PES directors conducted under the auspices of the American Association for Emergency Psychiatry (AAEP), the subspecialty organization for emergency psychiatry. The goal of this detailed survey was to describe PES settings, staffing, and clinical practices, including the pharmacologic and nonpharmacologic strategies used in common emergency presentations. A companion article has described the settings, staffing, scope of practice, etc. [10]. This report focuses on data related to physical restraint and pharmacologic treatments.