Psychiatric emergencies: challenges and vicissitudes

EDITORIAL

Psychiatric emergency: challenges and vicissitudes

Cristina Marta Del-Ben^I; Chei Tung Teng^II

^IDivision of Psychiatry, Departament of Neurosciences and Behavioral Sciences, Faculdade de Medicina de Ribeirão Preto (FMRP), Universidade de São Paulo (USP), São Paulo, SP, Brasil

^IIDepartament of Psychiatry, Faculdade de Medicina de São Paulo, Universidade de São Paulo (USP), São Paulo, SP, Brasil

The delivery of psychiatric care in the emergency room is a relatively recent practice in the Brazilian context. Its implementation is closely related to the restructuration of mental health care policies, whose basic guidelines are essentially aimed at the de-hospitalization of psychiatric patients and the replacement of large psychiatric hospitals by different healthcare delivery options, including psychiatric emergency services.

The effective integration of a psychiatric emergency service with the other mental health care services available in a given area is a crucial factor for the proper functioning of the emergency unit and of the psychiatric care system as a whole. Within an articulated mental health services network, psychiatric emergency has a significant role in taking decisions related to the definition of the adequate treatment for each case, simultaneously performing the function of triaging new cases and allocating them in the network of available services, and the function of providing support to the other services, in the case of patients already included in the mental health care network. This support can include the treatment and assessment of acute behavior alterations and of general medical conditions associated with the psychiatric condition, hospitalization support, medication adjustment, coverage during periods in which other services are unavailable, short-term followup, and reallocation to the services of origin after the management of the acute episode.¹

The excessive demand and the high rotation - inherent to emergency services - can cause emergency care to sound unappealing to health professionals and even less attractive for the development of activities related to research and education. Conversely, the variety of cases with such distinct clinical presentations, complexity, and evolution is also a feature of emergency services, constituting a unique and valuable material for research and education.

The greatest challenge faced by psychiatric emergency is the management of its limitations in order to achieve its goals of effectively performing its functions within a network of integrated mental health care services, providing evidence-based care and, at the same time, creating minimally adequate conditions for teaching practices and for the development of quality research projects to assess the efficacy and efficiency of interventions in emergency contexts.

This supplement has the objective of presenting articles related to updates in emergency psychiatry practices in a somewhat broader sense, including the concept of acute care psychiatry that involves, in addition to the management of the emergency situation itself, the intensive care delivered during the acute episode and its reoccurrence, the performance of differential diagnosis, and the implementation of the initial therapeutic conduct. There is little evidence-based information in this area and routines are usually decided according to the opinions of specialists based on individual experiences. It is a goal of this supplement to promote an effective integration between scientific evidence and clinical experience that can provide the reader of the Revista Brasileira de Psiquiatria with a scientific base on which to direct his clinical practice in psychiatric emergency.

This compilation of review articles is intent on showing that it is possible to deliver psychiatric care maintaining the quality of the work based on scientific evidence even in apparently unfavorable situations. The current scenario in our area concerning the integration between psychiatric emergency services and the health care network is examined in the article "Psychiatric emergency services and their relationships with mental health network in Brazil".The article "Differential diagnosis of first episode psychosis: importance of optimal approach in psychiatric emergencies" discusses the relevance of the use of operational diagnostic criteria and assessment instruments to perform diagnoses in emergency contexts.

The leading reason underlying the search for psychiatric emergency care - psychomotor agitation/aggressiveness² - is widely discussed in the article "Management of the violent or agitated patient". Although suicide rates in Brazil are lower than in other countries, the national indicators have significantly increased over the past years,³ and this important public health problem is examined in the article "Detecting suicide risk at psychiatric emergency services". The issue of the high prevalence of disorders related to the use of psychoactive substances⁴is surveyed in the article "Management of patients with substance use illnesses in psychiatric emergency department". Lastly, due to the increasing numbers of children and adolescents seen in emergency situations and the scarce knowledge existing in this regard, this topic is explored in the article "Psychiatric emergencies in childhood and adolescence".

There exists an evident need to establish guidelines for the structural and technical improvement of psychiatric emergency services based on scientific evidence and applicable to the Brazilian reality. Nevertheless, the Brazilian scientific production on this topic is still incipient. A search performed in the Medline database on August 1, 2010, using the Mesh term "emergency services, psychiatry" and with no limits returned 1.861 matches; however, when the term "Brazil" was included in the search, only 13 articles were selected. Therefore, this supplement has the additional purpose of demonstrating how fruitful psychiatric emergency services can be for the conduction of methodologically sound scientific investigations in the hope that this may encourage the Brazilian scientific community to produce knowledge in this field.

"Call me crazy, but I enjoy emergency psychiatry". ⁵

Referências

• 1. Kates N, Eaman S, Santone J, Didemus C, Steiner M, Craven M. An integrated regional emergency psychiatry service. Gen Hosp Psychiatry 1996;18(4):251-6.
• 2. Santos ME, do Amor JA, Del-Ben CM, Zuardi AW. Psychiatric emergency service in a university general hospital: a prospective study. Rev Saude Publica 2000;34(5):468-74.
• 3. Lovisi GM, Santos SA, Legay L, Abelha L, Valencia E. Epidemiological analysis of suicide in Brazil from 1980 to 2006. Rev Bras Psiquiatr 2009;31(Suppl 2):S86-94.
• 4. Barros RE, Marques JM, Carlotti IP, Zuardi AW, Del-Ben CM. Short admission in an emergency psychiatry unit can prevent prolonged lengths of stay in a psychiatric institution. Rev Bras Psiquiatr 2010;32(2):6.
• 5. Strauss GD. Emergency psychiatry and its vicissitudes. Psychiatr Serv 2003;54(8):1099-100.

Publication Dates

• Publication in this collection
  26 Nov 2010
• Date of issue
  Oct 2010