Practicing Emergency Psychiatry Requires Different Way of Thinking
Abstract
Emergency psychiatrists tend to agree that their field presents formidable challenges that make it appealing to some psychiatrists but not others.
If you ask emergency psychiatrists in North America where the field is going, you’ll get different answers. But one thing they tend to agree on is that emergency psychiatry has distinct characteristics that often separate it from the way office-based psychiatry is practiced.
In most cases, “we practice more similarly [to other types of psychiatrists] than differently,” Scott Simpson, M.D., a fourth-year resident at the University of Washington who plans on making emergency psychiatry his career, said during an interview with Psychiatric News. “But in emergency psychiatry, I think we are more at the forefront in dealing with decompensating mental illness, substance intoxication, acute withdrawal, and medical complications. So for me, it’s like seeing patients when their disease is very acute, and they are frankly in a lot of trouble.”
Jodi Lofchy, M.D., director of emergency psychiatry at University Health Network—a four-hospital conglomerate in Toronto, Canada—agreed. “In the emergency room, you can encounter psychosis, intoxication, the police, and drama. It’s a far cry from seeing patients over an extended time period and having a relaxed, calm type of relationship.”
The pace of work in emergency psychiatry settings differs considerably from that common in other psychiatry settings, two past presidents of the American Association of Emergency Psychiatry pointed out. They are Rachel Glick, M.D., an associate chair for clinical and administrative affairs in the Department of Psychiatry at the University of Michigan, and Jon Berlin, M.D., an associate clinical professor of psychiatry and emergency medicine at the Medical College of Wisconsin.
Also, “We are seeing more and more complicated patients,” Berlin reported, “patients with dual diagnoses, patients with problematic past experiences with treatment, and patients who are in treatment but not getting all of their treatment through their current treatment plan.”
Uniqueness Presents Multiple Hurdles
Such idiosyncrasies impose some daunting challenges.
“You have to be able to act quickly on the basis of not a lot of information, maybe just a small bit of key information,” Berlin stated.
“You have to sort out who’s medically ill and who’s psychiatrically ill very quickly to make sure that you have the right teams working on them,” Lofchy remarked.
“The biggest challenge is unpredictability,” Michael Allen, M.D., a professor of psychiatry and emergency medicine at the University of Colorado, noted. “Care must vary quite a bit depending on the time and resources available, which means that emergency psychiatrists are constantly using judgment about how much can and must be done in some cases or would be futile or impossible in others. Sometimes no amount of work makes any difference, and in other cases a little more time and attention, a little treatment, or a phone call completely changes the outcome.”
“Sometimes it’s tough finding a hospital bed for people who need to be hospitalized,” Berlin said. “We have responded to that challenge by creating some alternatives, such as an in-house observation unit that we man ourselves, and crisis-care management in the community as an alternative to hospitalization.” Another hurdle, he added, is calming agitated patients. During the past several years, the American Association of Emergency Psychiatry has been encouraging emergency psychiatrists to involve agitated patients in the calming process, rather than acting autocratically, he said.
“It is very trying working with a lot of young patients who are having new psychiatric symptoms—their first episodes of depression, suicidality, or psychosis,” Simpson pointed out. “Often patients will come with their families, and cultural and language differences may come into play.”
“Another challenge American emergency psychiatrists face,” Glick said, “is the broken health care system in this country. We sort of become the providers of last resort.”
Emergency Psychiatry Not for Faint of Heart
And because of the unique aspects of emergency psychiatry and the demands they entail, it’s probably not surprising that it takes a special kind of psychiatrist to do emergency psychiatry over the long term.
“I think it has more to do with personality than anything,” Glick suggested. “I don’t sit still well. I like to move around a lot. I like variety. I like to say that the youngest patient I ever saw in the emergency room was 2 and the oldest 102. And being able to spend just a few minutes with a patient versus a long time, I like that variability…. We [also] get people who are quite agitated, who are aggressive or assaultive, who are scary. But that is what I like about it.”
The emergency room is also a setting for psychiatrists “who are very comfortable multitasking,” Lofchy said. “If you can’t juggle a few balls in the air at the same time, then the emergency room is not for you.”
“I would say that you have to be very good at engaging people who may be angry about being there,” said Berlin. “Oftentimes people are brought to us who are very acute and don’t recognize their need for help.”
But when psychiatrists are well matched to emergency psychiatry, it can lead to professional gratification, those who practice it say.
“I love the patients, I love trying to make an oftentimes scary experience comforting,” Simpson asserted. “And I love working in fast-paced, very tense environments with specialized nurses, social workers, chemical-dependency counselors, and other team members.”
“As is often the case, an opportunity is the other side of a threat,” Allen said. “The high stakes and stress of an emergency are all the more rewarding when the emergency psychiatrist is able to bring all of the knowledge of people and systems to bear, solve a knotty problem, and help the person in the middle with that problem.”
“You are in a powerful position to make people’s introduction to psychiatry and psychiatric illness a positive one,” Lofchy declared. “And ultimately that can lead to better adherence to medication and compliance with treatment. . . . Another reward is helping people at risk of harming themselves. We aren’t very good at predicting suicide, but we are very good at acting when people are explicitly at risk.”
“A good psychiatric emergency service is the nerve center of the mental health system,” Berlin emphasized. “It is a key component of the emergency medicine delivery system. In 2009 the Centers for Disease Control and Prevention reported that 136 million Americans went to emergency rooms, and we know that anywhere from 5 to 10 percent of those were psych-related. This is like 7 to 13 million psych visits in American emergency settings each year. So those of us who work in this setting believe that we are performing difficult but valuable services.” ■
More information about this topic is posted at http://www.emergencypsychiatry.org.
“One of the things that is distinct about our psychiatry emergency service is that we are on a college campus,” Rachel Glick, M.D., associate chair for clinical and administrative affairs in the Department of Psychiatry at the University of Michigan, told Psychiatric News. “We see a lot of personality disorders and a lot of adjustment disorders, where patients come in because of some crisis in their lives. We also get patients who have somatoform disorders or somatic symptoms that we think are psychiatric in nature—for example, chest pain that might indicate a panic attack.” And once in a while, she said, they see someone with a conversion disorder.
A few years ago, for example, a student who couldn’t walk was brought to their emergency service in a wheelchair. Glick and her colleagues talked with her and learned that she had recently moved in with a boyfriend against her parents’ wishes, and things were not going well. It looked as if she wanted to return home, but was reluctant to admit to herself, and to her parents, that she had made a mistake, and “this anxiety probably drove the conversion reaction,” Glick said.
So what Glick and her team said to the student was this: “We can’t find a reason why you can’t walk, but we wonder whether part of it has to do with the fact that you’re really struggling with how to admit to yourself, and then to your parents, that you made a mistake. After all, your mind and your body are connected even though you’re not faking it. We know that you believe that you can’t walk right now. But we actually think that you probably can.” After a few hours, the student was able to get up and walk to the bathroom, and “we were able to discharge her to her family,” Glick said.
Jon Berlin, M.D., an associate clinical professor of psychiatry and emergency medicine at the Medical College of Wisconsin, described the case of a man with severe mood and substance abuse disorders who wasn’t responding to hospitalization or detoxes and kept returning to Berlin’s emergency psychiatry service with suicidal crises, panic episodes, or severe intoxication. During the patient’s visits, Berlin got to know him and “we kind of hit it off,” Berlin said. “He asked me whether he could see me in my office as a private patient. I said yes. He now faithfully keeps appointments and no longer visits the emergency room. He is doing tons better.”
Psychological crises can occur on cruise ships. People often travel with their families and are squeezed together in a confined space, which can lead to conflicts. So can the heavy consumption of alcohol. Passengers sometimes forget to bring their psychotropic medications with them on the ship. And once in a while, passengers attempt suicide.
Yet there is psychiatric help for people in such situations via a company called JSA Health Telepsychiatry. It was founded in 2007 by Avrim Fishkind, M.D., a Houston emergency psychiatrist; Scott Zeller, M.D., an emergency psychiatrist in Oakland, Calif.; and Jon Berlin, M.D., an emergency psychiatrist in Milwaukee, Wis.
“We serve basically anybody who might need an emergency psychiatrist,” Fishkind explained in an interview. “Typically they would be in underserved areas where there aren’t enough psychiatrists. It could be rural or urban. For example, we serve people not just on cruise ships, but in shelters, community mental health centers, general hospital floors and intensive care units, schools, residential treatment facilities, freestanding crisis centers, and crisis-stabilization units. And soon we will be starting forensics, working with courts and restoration-to-competency programs.”
“We are up to 60,000 patient contacts a year,” he noted. “Over 30 full-time and part-time psychiatrists and nurse practitioners work for the company. They are all over Texas. We have one in California. We have one in Rocky Mountain National Park in Colorado. We have one in Maine. And we have one coming on board from London, England. So as long as they have a Texas license and a reliable connection, we can consider them for work with the company.”
When asked what he would like to see the company accomplish over the next five or 10 years, Fishkind replied: “I would like us to continue to prove that telepsychiatry can be used in virtually any environment—say, helping people on the space station if anything [involving a mental health crisis] ever happens.”
There is only one other telepsychiatry company in the United States that provides emergency psychiatry services that are as comprehensive as those of JSA Health Telepsychiatry, Fishkind said. It is called InSight Telepsychiatry and was founded in 2008 by James Varrell, M.D., a psychiatrist in Marlton, N.J. “There are other telepsychiatry companies [that offer emergency psychiatry services], but not with such a wide reach,” Fishkind said.
