Until the 1950s, most ill psychiatric patients were admitted into state-supported hospitals for long-term care. With advances in medications to moderate the behavior of acutely ill and decompensated chronic patients, the doors to the state hospitals were unlocked and patients were transitioned into the community, usually through a halfway house. These patients now turned to general hospitals when help was needed, and emergency rooms (now called emergency departments, or EDs) were the usual point of entry. As a result, local communities began bearing more of the costs of care. The Community Mental Health Center (CMHC) Act in the 1960s provided an alternative to the ED because emergency care from CMHCs was a federally funded and mandated service. The staff of the state hospitals also transitioned into the community, many to serve either in the ED or the CMHC (1).

As one who lived through this evolution, I felt that the services left much upon which to improve. When I was a psychiatric resident, I brought a relative into the emergency department for evaluation of psychiatric symptoms. The staff ignored his medical conditions and downplayed his psychiatric symptoms. If the doctor had talked to me or the other relatives present, he would have known he was evaluating a patient who had diabetes, a history of alcohol abuse, and a heart condition as well as an acute behavioral change—thinking the radio was making demands upon him personally. The patient’s despair was palpable to us, his relatives. He had even tried to drag his wife into the car in the closed garage to “save her and himself” from having to endure another moment of torment on earth as part of a murder-suicide he had planned. Fortunately, his wife had struggled free and called some family members for assistance. It took us 2 hours to convince him to go to the local ED. (There was no 911 back then.)

The doctor saw him as “a nice old man who must smoke his pipe a lot” because his teeth and fingers were stained. My relative had convinced the doctor that he was just feeling sad because Christmas was coming, which reminded him of his deceased parents, and that he’d be over his sadness by tomorrow. We asked the nurse, “Who is discharging our relative?” and inquired whether we could please speak to the doctor to tell him why we were so worried about our relative today. We were told the doctor had gone on to see another patient, so we were “done.” There were no resources we knew of or were told about except a private psychiatric hospital 40 minutes away.

Our relative declared himself “well” because the doctor hadn’t found anything wrong. It took 2 more hours before he relented enough for us to get a second opinion from the private hospital. I’d called ahead this time and provided the doctor there with a summary of our concerns. Sure enough, once we arrived and our relative was evaluated, the psychiatrist confirmed a psychotic depression. He agreed to admit him and promised to collaborate with our relative’s regular doctor about his medical conditions. After a month of treatment, he returned home in a happier frame of mind.

In my own training, it became obvious that emergency psychiatric cases were managed either by a doctor with no specialty training in psychiatry rotating onto ED coverage or by the least trained—residents or others at the beginnings of their careers who were assigned to the front lines. These doctors manning the medical EDs often had little understanding of what the patients’ psychiatric problems were conceptually or how to manage them if they did diagnose them adequately. The EDs and
CMHCs initially had separate emergency ser-vices and different staffing patterns. Both centered on a basic question: Is the patient safe to release, or does he or she need to be stabilized and/or sequestered (1)?

With observations I’d made by the 1970s in training and afterward, I asked the American Psychiatric Association (APA) to form a task force on emergency psychiatric care. It was unfair for patients to be treated in a helter-skelter fashion while enduring a psychiatric emergency. I rallied some very knowledgeable people, all psychiatrists from the APA, to plot a strategy to make psychiatric emergency care a legitimate activity. These task force members included Andrew Slaby from the National Institute of Mental Health (NIMH) Staff College, who had taught emergency psychiatry principles; Clotilde Bowen, a colonel in the army who had worked with the alcohol and drug abuse issues of Vietnam soldiers; Betsy Comstock, who ran Ben Taub’s huge psychiatric ED service in Houston; John Petrich from Harbor View Hospital ED staff in Portland, Oregon, who was frustrated with the low level of training with which the staff came to him; Paul McClelland from the Maryland State Department of Mental Health, who was stymied by the lack of urgent services for the mentally ill in his state; and a resident, Rohn Friedman. Beverly Fauman joined us later on and was a link, as was I, to emergency medicine, another fledgling field.

The initial APA task force met and hashed out a consensus definition for a psychiatric emergency: “An acute disturbance of thought, behavior or social relationship that requires an immediate intervention as defined by the patient, the family or the community” (2). With this definition as our basis, we went on to develop, through a Delphi process, standards, educational modules, optimal staffing, architectural considerations, and relationships within and beyond the emergency department. We then met to mock up tentative principles. These were tested on invited conferees at a conference set up in Lansing, Michigan, to focus on emergency psychiatry. We were then ready to send these principles to a network we had identified as legitimate owners of a piece of the emergency psychiatry action because of their leadership positions at their home bases. These extenders of the task force held local conferences around the country. These conferences spun off to a wider audience to train conferees about the proposed standards for psychiatric emergency care and stimulated discussions on how to import and institute the standards back home, as well as give us feedback to fine-tune the standards to be widely useful and applicable (3,4,5,6).

The standards that the task force developed went through continuous development and included more consultants and organizations adding their input (1,3,4,5,6). The additional consultants were Marion Fane, Michael Fauman, Judith Jacobs, Lucy Ozarin, Kenneth Pitts, and resident Raul Gomez. Even though the task force met only from 1978 to 1983, its efforts continued with the American College of Emergency Physicians (ACEP) and the American Association for Emergency Psychiatry (AAEP). The Standards Committee of AAEP met from 1990 to 1993, with myself as chair and members Joe Parks, Janet Richmond, Andrew Slaby, Douglas Puryear, and Michael Tueth to provide cogent comments. Organizations that made official comments to the effort expanded to include the ACEP, the Michigan Psychiatric Society Task Force on Emergency Psychiatry Issues, the Michigan Department of Mental Health, and the Emergency Department Nurses Association.

The standards required an answered 24-hour telephone line, quick response once a patient arrived at the ED, continuity of care by coordinating emergency care with ongoing therapists, and sharing information if the patient was discharged back to the community. They also made recommendations about staff requirements, training modalities, and administrative structure. The standards addressed space issues, disaster planning, unique patient presentations, and considerations for settings other than the ED. A special consideration was to address the emergency medical system (EMS) for EMS categorization because
paramedics and emergency departments were using this graded system for designating the level of care that a patient required.

We held regional conferences sponsored by the American Psychiatric Association’s division on psychiatric services, the American College of Emergency Physicians, and paramedic training groups. We held conferences at the University of Michigan; Dartmouth Medical School in Hanover, New Hampshire; Ben Taub in Texas; and Harbor Medical on the West Coast.

Much of the education of professionals staffing the psychiatric emergency had been and often still is experiential—seeing and then doing. Now that there are continuing medical education requirements for psychiatrists and emergency department doctors and continuing education requirements for social work and psychology, ongoing specific topical emergency conferences are offered with great regularity. Because specialty board questions were being generated, first by task force members and then by the networked larger body, it became important to be up-to-date in emergency psychiatry. Trainees such as social work students, medical students, and psychiatry residents are encouraged, and often required, to serve psychiatric emergencies with experienced staff supervising them and helping them refine their knowledge and expertise. Also, the task force developed a training curriculum for distribution (7,8), and many task force members wrote textbooks, chapters, and articles on emergency psychiatry (1,3,4,6,7,9,10,11,12,13,14,15,16,17,18,19). We also developed tools of evaluation (6,13,16,20,21

Stay updated, free articles. Join our Telegram channel

Join