aaep summer newsletter 2012
DESCRIPTION
AAEP Summer Newsletter 2012TRANSCRIPT
Inside this issue
AAEP Annual Meeting ................. 3
Topics in Emergency Psychiatry .. 4
Calling All Authors ....................... 4
Behavioral Emergencies Seminars Update ........................................ 5
Engaging Patients at the Front Door ............................................ 6-9
Several Faces of Philadelphia ...... 10
Project BETA Update ................... 11
Member Announcements ........... 11
AAEP Goes to New York City ....... 12
American Association For
Emergency Psychiatry
Newsletter Summer Issue 2012
Letter from the President
Salutations! I am honored to be writing to you as the new president of the AAEP. I will try to advance our efforts to treat psychiatric emergencies. I will try to responsibly steward our organization through these two years. And, I will try not to bore you. A few ongoing AAEP projects and problems deserve attention:
Dissemination of the Project BETA recommendations
Collaboration with APA and other professional organizations
Development of standards for emergency psychiatric facilities and clinicians
Expansion of our journal
Stabilization of our finances First, our finances; we are running at a loss. It is not a big one. We have reserves. Our situation improved a bit thanks to our past president, Dr. Scott Zeller and his negotiations around the publication of Project BETA. Our organizational staff has found ways to reduce expenditures. Still, we can only continue along this path for a few more years. Membership dues are our main source of income. If you have not yet paid your 2012 membership dues, do so today! There is also money from webinars. Years past, there have been pharmaceutical company grants. And, in the past, we have been paid for course material presented for the Veterans Administration Hospitals. Now, for various reasons, funding is limited. However, the AAEP membership is the authority on emergent evaluation and treatment of psychiatric conditions. We believe AAEP has valuable knowledge, and not just to its own members. We are open to suggestions about revitalizing any of those sources of income. We are open to suggestions about new income sources. It would be nice to list our journal as a source of revenue, but that would be untrue. Much as we value professional publications, it is an expense at this juncture. To generate revenues requires a much larger and more frequent publication. Please write and submit a paper for publication. Encourage your colleagues to submit, even if they are not members. (Then encourage them to join.) In the meantime, we will continue our current format and circulate issues when submissions warrant. Practice standards are another hallmark of a professional organization, an important developmental phase after establishing regular meetings and a publication. Project BETA, and Dr. Zun's Annual National Update on Behavioral Emergencies, have moved AAEP along far enough to begin tackling this change. Board members are exploring our options, lead by Dr. Jagoda Pasic and Janet Richmond, MSW. We can dream eventually for formal
(Continued on page 2)
Seth Powsner, MD
President 2012-2014
"board" recognition, but it is more realistic to set standards for training and excellence of practitioners and facilities. Project BETA is still quite active. It is being actively disseminated. It is available online through the Western Journal of Emergency Medicine. Dr. Zeller has made a PowerPoint presentation available for AAEP members who would like to present in their own practice community. I encourage members to join this effort. It will improve patient care while advancing the AAEP. Looking forward, I personally am struck by the challenge of collaboration. Our colleagues, our facilities, and our related professional organizations have only limited resources with which to face of a surplus of legitimate demands. We are all sorely tempted to exclaim "not my problem, not in my job description." But mental illness is not going out of business, despite the economic meltdown. The patients, the crises remain. Either we as professionals hang together, or we hang separately, i.e., work ourselves to death. AAEP is having some success engaging other organizations: the APA annual spring meeting now reliably includes an AAEP course or seminar, and the IPS annual fall meeting now reliably includes various AAEP presentations. This fall (for the second time) the APM annual meeting (C-L Psychiatry's Academy of Psychosomatic Medicine) will include a joint AAEP - APM presentation. For the first time, the APM will also include a Special Interest Group for Emergency Psychiatry, with a number of joint AAEP - APM members. And, the National Suicide Prevention Lifeline with our past president Dr Tony Ng is starting to review possible projects with AAEP. The AAEP is working towards more formal relationships with the professional Emergency Medicine organizations. There are some ongoing efforts around medical clearance and there have been joint presentations with NAEMSP -- National Association of Emergency Medical Service Physicians. We hope we can work together with ambulance staff through NAEMSP or another relevant organization. I personally serve as volunteer faculty to our local EMS training program, giving lectures on psychiatry to new trainees. I urge you to connect and to collaborate. Participate in AAEP list serve discussions. Encourage your colleagues to become members and join the discussions, if they have not already. Talk with your trainees and younger colleagues about Emergency Psychiatry. You may be pleasantly surprised by the number who are attracted to the excitement and change of pace it offers. Most of all, I urge you to listen to your colleagues. While it is easy to feel like the most embattled, the most burdened, the most abused grunts in the war on mental illness, it is not a "good place" from which to discuss collaboration. Few on the front lines enlisted for the battle in which they are now engaged. Very few have any energy or inclination to work harder to relieve our emergency services. However, there may be small changes that can reduce efforts for both sides, like pre-arranged clinical staff contacts, fax machines, or secure email. These will not eliminate overcrowding and emergency department boarders, but they are start. A small start is way better than a small argument.
Seth Powsner, MD
President
Letter from the President (continued)
2
AAEP Member Announcements
What’s going on with your
Emergency Psychiatry facility, with
you and your staff? We’d like to
know and share it with other AAEP
members in our informal
newsletter. Has your program
moved to a new building? Did you
or one of your attendings publish
an article related to Emergency
Psychiatry? Have you, your staff, or
your program recently been
honored? Is there a new
educational or training process you
are using that you believe could
help your peers? We welcome you
to share any news relevant to
Emergency Psychiatry with your
fellow members. Please send your
announcements to us either by
email or see the attached
Announcement Form and send
your news to:
3
Upcoming Events
Institute on Psychiatric Services
October 4-7, 2012
New York, NY
Emergency Psychiatry: A
Contemporary Paradigm from
Theory to Practice
Thursday, October 4
8:00 a.m.—12 noon
Sheraton New York Hotel & Towers
Empire West ballroom, 2nd Floor
Recovery Oriented Practices in
Emergency Psychiatry
Friday, October 5
8:00 a.m.—9:30 a.m.
Sheraton New York Hotel & Towers
Conference H, Lower Lobby
AAEP Board of Directors Meeting
Friday, October 5
10:00 a.m.—2:00 p.m.
Sheraton New York Hotel & Towers
AAEP Site Visit
Friday, October 5
2:30 p.m.—4:30 p.m.
Bellevue Psychiatric Hospital
Advance Registration required
See page 4 for details
AAEP Member Reception
Friday, October 5
5:00 p.m.—6:30 p.m.
Location TBD
Advance Registration required
See page 4 for details
Avoiding Psychiatric Inpatient
Hospitalizations via Emergency
Outpatient Alternatives
Saturday, October 6
3:30 p.m.—5:00 p.m.
Sheraton New York Hotel & Towers
Conference K, Lower Lobby
Third Annual National Update on
Behavioral Emergencies
December 5 - 7, 2012
Flamingo Las Vegas Hotel
AAEP Annual Meeting May 2012, Philadelphia, PA
The American Association for Emergency Psychiatry recently met in Philadelphia, PA for its
Annual Meeting. Members shared taxis from the Convention Center where the APA’ Annual
meeting was held to Temple University Hospital Department of Psychiatry. Neil Sanuck,
member of AAEP and Attending at Temple, took the above pictured members of the AAEP on a
tour of his facilities.
The Crisis Response Center (PES) at Temple University Hospital has a 6-bed, 23-hour
observation area in the back of the unit. They use those beds for patients with psychiatric
complaints who are intoxicated or using substances, in order to rule out substance-induced
mood/psychotic disorders. The city agency that acts as the HMO for behavioral health for
Medicaid patients pays Temple for up to 23 hours of observation in such cases, and has found
that it greatly reduces the number of unnecessary acute admissions.
Following the site visit, members returned to downtown Philadelphia for a casual reception
and the AAEP Annual Business Meeting. This year’s recipient of the AAEP Resident Award was
Chrisantha E. Anandappa, M.D. of Ann Arbor, MI. See page ## for an article written by him on
his experience.
As part of this meeting, the AAEP also gave a round of applause to the outgoing President, Dr.
Scott Zeller for all of his accomplishments and years of service to the AAEP.
The AAEP is currently planning its fall events and we hope to see you in New York for what
promises to be an excellent meeting.
The American Association for Emergency Psychiatry would like to invite all members and colleagues in the field of Emergency Psychiatry to submit a manuscript or book review for publication in the AAEP Journal, Emergency Psychiatry.
This Journal is intended to be a forum for the exchange of multidisciplinary ideas. Manuscripts are welcomed that deal with the interfaces of emergency psychiatry. This includes psychiatric evaluation of indi-viduals in the emergency room setting,
education and training in the field and re-search into causes, and treatment of be-havioral problems. Manuscripts are evalu-ated for style, clarity, consistency, and suitability.
Submit manuscripts or queries electroni-cally to: Jacquilyn Davis, Administrative Assistant, at: [email protected]. Include the address, telephone number, and email address for the corresponding author on all manuscripts.
Calling All Authors!
Mental health professionals working in emergency settings face pressure to quickly,
efficiently and appropriately assess, treat, and triage patients. This series will provide the
opportunity for distance learning on the most critical psychiatric emergency topics.
Risk Issues in Emergency Psychiatry
Issues in Emergency Psychiatry: Supporting Patient Safety and Reducing Professional
Liability Risk
No Force First: Crisis and Recovery
Settling Disputes about Medical Clearance:
Psychiatrists and Emergency Physicians Agree on Some Rules
Debriefing and Psychoeducation Following Seclusion and Restraint
Interviewing with the End in Mind
Each presentation will be one hour in length and can be viewed live from the comfort of
your home or office computer. Participants are given time at the end of each presentation
for a question and answer session. We encourage all participants to take advantage of this
opportunity to discuss the topic material with the speaker and fellow registrants.
Participants may register under a single or group rate. Group rates are perfect for
classroom settings and we recommend using a speaker phone and projection screen. All
conference rates allow the use of one telephone line and one Internet connection. If you
require the use of additional lines, be sure to send payment for each line you plan to
utilize.
For more information and to register for one or the entire above conferences click here.
Special Thanks to our Sponsor:
Professional Risk Management Services, Inc. is a proud
sponsor of the AAEP’s 2012 Topics in Emergency
Psychiatry Web Conference Series. We are grateful for
their continued support and invite you to view their
website at www.prms.com. Conferences from 2012
have been archived as a member benefit and can be viewed under the members only
section.
Topics in Emergency Psychiatry 2012 Series
4
Topics in Emergency Psychiatry Web Conference Series
July 31, 2012 – 1:00 pm eastern
Issues in Emergency Psychiatry:
Supporting Patient Safety and Reducing Professional Liability Risk
Presented by: Charles D. Cash, JD, LLM
August 21, 2012 - 1:00 pm eastern
No Force First: Crisis and Recovery
Presented by: Kenneth Thompson, MD
September 25, 2012 - 1:00 pm eastern
Settling Disputes about Medical Clearance: Psychiatrists and Emergency Physicians Agree on Some Rules
Presented by Michael Allen, MD; Eric Anderson, MD; and Michael Wilson, MD, PhD
October 23, 2012 - 1:00 pm eastern
Debriefing and Psychoeducation Following Seclusion and Restraint
Presented by Maryann Popiel
Nov 27, 2012 - 1:00 pm eastern
Interviewing with the End in Mind
Presented by Jon Berlin, MD
Register Today!
Members-only Listserv
AAEP has recently created a listserv
discussion group that is available via
invitation to members in good
standing only. This will be a great
opportunity to discuss pressing
issues, diagnostic dilemmas and
treatment approaches in Emergency
Psychiatry, and obtain consultation
from your fellow experts on difficult
cases. Please accept the invitation
and join us today!
There is nothing to fear, it will be
very easy to unsubscribe if you
choose to do so at a later time.
If you have misplaced or did not
received your invitation email, please
contact Jacquilyn Davis at:
5
The Sinai Health System in collaboration
with Rosalind Franklin University of
Medicine and Science/Chicago Medical
School is presenting the “Third Annual
National Update on Behavioral
Emergencies” on December 5th through
7th at the Flamingo Las Vegas Hotel. This
is the only conference in the country to
address the behavioral emergencies in the
acute care setting including emergency department and PESs.
The purpose of this conference is to increase the knowledge and collaboration among care
givers in the emergency, PES and acute care settings for patients who present with
psychiatric symptoms. The target audience includes emergency physicians, psychiatrists,
psychologists, nurses, nurse practitioners, mental health workers, social workers, and
physician assistants.
There is an impressive array of presentations and speakers this year. The titles of this year’s
presentations include Psychiatric Boarders in the Emergency Department, Pediatric
Emergency Psychiatric Issues, Behavioral Aspects of Head Trauma, New Drugs of Abuse,
Disaster Psychology, Transfer and EMTALA Regulations, Difficult Patient Presentations,
Recovery and Self-Management, Eating Disorder and Use of Ketamine in the ED. The
speakers are national and international experts in the field.
This year’s conference has many enhancements from last year. In order to ensure that all
the pertinent topics are included in the conference, we have added a new pre-conference
session in the afternoon on the basics to complement the competency examination. The
second pre-conference session sponsored by the Institute for Behavioral Healthcare
Improvement is an all day seminar on Systems Change for Better Emergency Department
Care for Behavioral Health Clients is scheduled the day before the conference on December
5th. This workshop will provide methods for evaluating and improving the current system
of care for behavioral health clients in emergency departments and examples of successful
improvement projects at selected hospitals.
For those interested in the scientific paper session, investigators are invited to submit an
abstract of original research in the area of behavioral emergencies such as the evaluation
and treatment of psychiatric patients in the emergency setting. The abstracts must not
have been presented elsewhere, limited to 300 words and need to be in a format that
includes title, objectives, methods, results, and conclusion. The scientific committee
composed of psychiatrists and emergency physicians encourages submission from
residents in emergency medicine and psychiatric training programs. The deadline for
submission is October 1, 2011 and should be emailed to Dr Leslie Zun at [email protected].
Please join us for this exciting conference. For more information regarding the conference,
go to www.behavioralemergencies.com or contact Trena Burke, conference coordinator at
1-773-257-6589 or [email protected]. For additional information regarding the IBHI
pre-conference seminar, please contact Peter Brown at [email protected] or at 518 732-7178.
Behavioral Emergencies Seminars Update By: Leslie Zun, M.D.
Call for Abstracts
3rd Annual National Update
on Behavioral Emergencies
Conference
Las Vegas
December 5-7, 2012
Contact Dr Zun at [email protected]
Call for Abstracts
3rd Annual National Update
on Behavioral Emergencies
Conference
Las Vegas
December 5-7, 2012
Contact Dr Zun at [email protected]
Conceptualization drives practice. One of the obstacles to better handling of acute agitation in the modern emergency department (ED) that deserves more attention is the characterization of the psychological process itself. This becomes possible as more trained practitioners get involved at the beginning of a case and observe their own practice. [1] We ask ourselves: How am I to think about what I’m doing when I intervene with an unknown person in such an extreme state? Is it management, diagnosis, treatment, a combination or something else entirely? The part of this question traditionally referred to as “biological” is easily answered. When every attempt at verbal de-escalation with an ill and combative person has failed and we reluctantly move on to the last resort, that of forced medication, we resist the unfortunate, non-medical term “chemical restraint” in favor of “involuntary emergency medication.” Were someone to challenge us with the observation that our preferred, medical-sounding term implies the existence of a diagnosis, and asks how is it possible to diagnose a stranger in need of emergency intervention within minutes of admission, we readily supply the answer that psychiatry, like all of medicine, is an iterative process, with repeated cycles of data gathering, synthesis of data into a formulation, and intervention. In the case of high psychiatric acuity and dangerousness requiring immediate attention, we may be forced to start out with a readily apparent, intermediate diagnosis, which we then treat with a round of stabilizing treatment that sets the stage for refinement of diagnosis and treatment. When appropriately decided upon and administered, stabilizing medication is treatment. But is the same true for the start of the psychological interaction? A review of the literature on brief psychotherapy might suggest it is not. For example, one of the main potential contraindications to brief therapy is poor understanding or insight:
Brief therapy tends to be most helpful for patients who have a clear understanding of their problems and a strong motivation to address these. In situations in which people’s readiness to change is low…they enter therapy denying the need for change, being unclear about the changes they need to make, or having ambivalence over the need for change. As a result, they may require many weeks of exploratory therapy and self-discovery… [2]
This is one of six potential contraindications to brief psychotherapy listed in a new textbook on the subject, and the other five often apply to our typical agitated person equally as well: persistent illness, severe illness, significant history of abuse and neglect, high complexity with dual diagnosis, and poor social support. At the end of this list, the authors note “clients who are particularly sensitive to interpersonal loss may find it impossible to tolerate a therapy in which a working bond is quickly dissolved.” From this perspective, agitated patients may seem the antithesis of a good candidate for short-term therapy. This is enough to dampen the therapeutic enthusiasm of any a newcomer to emergency psychiatry and make him likely to hang back, allowing others to take the lead. But let us examine actual modern practice more closely. The most challenging cases of agitation with a psychiatric dimension occur when the individual is initially opposed to helpful intervention. It is this avoidance of engagement that most distinguishes persons that must be seen in a specialized emergency setting from those that might possibly be managed successfully without emergency detention in less
(Continued on page 7)
Engaging Patients at the Front Door: Theoretical Considerations in the Psychology of Agitation and De-escalation By: Jon Berlin, MD
6
Interested in writing for the Newsletter?
All members of AAEP are invited to
submit articles for publication the
Newsletter. We welcome articles
relevant to the field of Emergency
Psychiatry from all perspectives:
from psychiatrists working in a PES
to social workers, nurses, students,
or physicians in the field.
Newsletters are sent to the
Membership electronically on a
quarterly basis.
For deadlines and additional
information on how you can
contribute to the Newsletter,
please contact Jacquilyn Davis at
888-945-5430 or email
“How am I to think about what I’m doing when I intervene with an unknown person in such an extreme state? Is it management, diagnosis, treatment, a combination or something else entirely?”
7
intensive settings, such as a crisis line, residence, clinic, community- based crisis center, or voluntary psychiatric hospital unit. Some agitated individuals are interested in being helped, and crisis practitioners have learned to be mobile and adaptable, intervening early and in a setting that is most welcoming and expedient. This brief report addresses those agitated individuals who must be forced to get help and who cannot be engaged without brief containment, skill and sensitivity. Psychological aspects of engagement and de-escalation in this situation are highlighted. While a patient’s poor insight, distrust, and low motivation on some level must have as much of a biological basis as his or her psychiatric illness, they are also ideally suited to psychological and interpersonal approaches, and the fact that these approaches sometimes do work indicates that experiential interventions should be better characterized. Likewise, while we now know that psychological treatment operates at the level of neurobiology, we are in the earliest stages of knowing the precise details. It is still instructive to examine it as a psychological process. A word about evidence base: by definition, we are talking about a subset of individuals who are not amenable to consenting to any kind of a research protocol. Studies on the efficacy of medication for agitation, for example, are limited to the subset of agitation that has not extinguished the ability to cooperate. Given our present state of technology, such things as remote brain imaging and biochemical analysis of the psychological processes of both patient and practitioner from the moment they encounter one another in the ED or psychiatric emergency service (PES) exist only in the realm of futuristic science. Therefore, we must rely on clinical descriptions. Fortunately, of late, a consensus of opinion among psychiatric and medical emergency practitioners has begun to emerge [3] and we can speak with some confidence about the most effective techniques. In particular, evidence is accumulating that individuals can often be helped to de-escalate without coercion, beyond the minimum amount required to bring them to the PES or ED in the first place. At times, the agitated individual resistant to engagement is disoriented, confused, and exhibiting a fluctuating level of consciousness, in which case delirium is suspected and engagement is a virtual impossibility. A medical emergency department to address a serious medical condition is the preferred destination. At other times, the individual is so emotionally and psychiatrically inflamed, or under the influence of some substance, or both, that any approach by any person for any reason is considered an unwelcome advance. Engagement is often futile here as well. However, there are also instances where the outcome is uncertain: the individual could go either way. This is the subject of our present discussion. For the most part, the clinical techniques started out as improvisations. However, even innovations are rooted in scientific precedent. This preliminary report draws upon five well established conceptual frameworks: 1) the Triage versus Treatment Models of emergency psychiatry; 2) the Stages of Change Model, grounded in the process and outcomes literature on psychotherapy; 3) Motivational Interviewing; 4) Solution Focused Therapy; and 5) Psychological First Aid and Trauma-Informed Care. In the following material, a fairly typical case of non-coercive de-escalation may be thought of as, among other things, a piece of ultra-brief psychotherapy. CASE VIGNETTE A bright, verbal, middle-aged woman came into our PES on an emergency detention. She had threatened some family members with bodily harm and aggressively shoved the police when they arrived on the scene. She presented with pressured speech, flight of ideas, extreme irritability, and psychomotor agitation. She sat in the triage booth but refused vital signs. The triage nurse could not make any headway with her on any subject and sought my
(Continued on page 8)
Engaging Patients at the Front Door (continued)
For the most part, the clinical techniques started out as improvisations. However, even innovations are rooted in scientific precedent. This preliminary communication is based on report draws upon five well established conceptual frameworks:
1) the Triage versus Treatment Models of emergency psychiatry;
2) the Stages of Change Model, grounded in the process and outcomes literature on psychotherapy;
3) Motivational Interviewing;
4) Solution Focused Therapy; and
5) Psychological First Aid and Trauma-Informed Care.
assistance. When I went out to greet her, I found her still seated but gesticulating violently with her arms and expounding loudly and sarcastically to no one in particular. She eyed me suspiciously. She would give no history, and I had no old chart to review or family to question. However, she was clearly suffering from acute agitation and some type of manic psychosis. She appeared to be on the verge of losing control, and I was afraid for the physical safety of those around her. Nonetheless, she had yet to do anything untoward that required physical intervention. I thought we had a small opening. I had many questions about her underlying biopsychosocial assessment, but I wanted her to be an active participant in the assessment process. I deliberately formulated the goals of engagement and non-coercive de-escalation. Next, I checked to see that security and nursing were on the alert and approached her cautiously, sitting down in a chair on rollers with a built-in desk between us. I scanned this woman’s face, head and body for any signs of an emergency medical condition. I did not see any. She was hostile to this approach and I felt her dissecting me mentally. I broke into her tirade to introduce myself and ask what I could do for her. She ignored this. (In retrospect, I might have explained what I was looking for and included her in the process.) Over a five-minute period of time, I was only able to break in a few times. I asked what I could do for her, and she replied that I could get her a black doctor. I said I was sorry, there wasn’t one on duty. I asked if there was anything else I could get her. She replied that she wanted someone with some [blanking] commonsense. I said I thought I had that but it didn’t seem to be working. There was no response. Finally, I asked her what she needed. At this, she abruptly stood up, pointed an accusatory finger at me, and said she needed to get the [blank] out of here. I stood up too. Despite the escalation, I thought there might be something here I could work with. I said, “Excellent, that’s my job, to jump-start the process of your getting out of here. Can we sit down to discuss it?” She looked at me skeptically, but I said, “No, really, I want to work with you on that. What we need is to be able to show people that it’s safe for you to go.” This got her attention. When she asked how long that would take, I said I didn’t know, but I then pressed the question, “What works for you when you feel like this? What do you need?” Suddenly, she paused to study my face. She slowly took a breath and said, “I suppose I could take some [blanking] lithium.” I confirmed with her that she had found it effective. I turned to get her some, but stopped and turned back around to face her and said, “You know, lithium is good but it usually takes a week to work. We usually recommend adding something to speed things up.” I started to list some of the medications to consider but she immediately cut me off and said, “And some [blanking] Zyprexa,” whereupon she accepted appropriate doses of lithium and meltable olanzapine and de-escalated quickly. At that point, the nurse and I were able to complete our intake assessments, including collateral history. The patient had a seriously decompensated bipolar condition that needed 24-hour care. She was admitted to the hospital without incident. DISCUSSION Cases that go as well as this are starting to become routine. Clearly, quick action and topic focus are key to keep them from rapidly deteriorating to the point of physical interaction. We are in stormy seas and must have a star to sail by. We avoid argument and confrontation, instead finding a common goal to motivate the patient. Usually, it is the idea of freedom and discharge or release in return for enough demonstrated self-control to reassure people that he or she is safe to go. By stating our intention at the outset to work toward a specific goal the person has that we can endorse, we signal our intention to be a true ally. We also offer relief from psychic distress, in the form of assurance of physical
(Continued on page 9)
Engaging Patients at the Front Door (continued)
8
References
Currier GW, Allen MH. Emergency Psychiatry: Physical and Chemical Restraint in the Psychiatric Emergency Service. Psychiatric Services, VOL 51, No. 6, June 01, 2000.
Dewan MJ, Steenbarger BN, Greenberg RP, The Art and Science of Brief Psychotherapies: an Illustrated Guide. p. 5. American Psychiatric Publishing, Arlington VA. 2012.
Richmond JS, Berlin JS, Fishkind AB, Holloman GH, Wilson MP, Rifai MA, Ng AT, Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. Western Journal of Emergency Medicine. Vol. XIII, No. 1: 17-25: Feb 2012.
9
safety, active listening, comfort measures or appropriate voluntary medication. All of it derives from psychological and interactive therapy, ideally from the moment the person arrives on our doorstep. All staff must be trained to dispel paranoia and be helpful in any way they can. We offer hope and ways to help an individual increase personal mastery. The emphasis is on being useful and motivating the person to work with us. Significantly, the passage about brief therapy I quoted from at the beginning includes the statement that patients with very poor insight may “benefit from a course of Motivational Interviewing… before they are motivated to make a commitment to more action-oriented, short-term approaches.” In this case, I tried to keep from being the one to bring up medicine. I postponed until later questions about her diagnosis or why she had stopped taking her medication. I was very comfortable making the judgment call that the benefits of giving her the lithium she offered to take greatly outweighed the risk of administering one dose without a lithium level and other baseline studies. I knew that she ultimately might be prescribed different medication that she would like better. Her intermediate diagnosis was obvious, and I preferred a treatment-oriented, engaging approach, combined with psychological first aid, trauma informed care, directness about the bottom line of safety for discharge, and a focus on the solution. I wanted her to choose something that would help. Elements of several brief psychotherapies were combined to effect a striking psychological change that no doubt one day will be characterized as a neurobiological event. There is every reason to think that the psychological process of de-escalation is therapy. Moreover, if the psychological treatment of severe and persistent illness is conceptualized as a puzzle made up of many small pieces assembled over time, then we can think of de-escalation as a piece of brief therapy, even though many of the potential contraindications to brief therapy may be present. Cases of agitation in the moment are often daunting, and clinical staff need to be motivated too. It helps to remind them of the benefits of non-coercive de-escalation. It reduces the risk of injury to patient and staff. It is a timely object lesson we role model for the patient in how to push oneself to resolve conflict without getting physical. It counteracts iatrogenic escalation intrinsic to emergency settings. It reduces mental trauma and alienation from clinical relationships, potentially enhancing outpatient therapy and reducing recidivism. It is an important quality indicator for accrediting agencies. Finally, ED and PES staff who face psychiatric patient backups and boarding due to a shortage of psychiatric beds will appreciate that, if a person such as our manic lady can be helped to avoid restraints and involuntary medication, transfer to a non-safety net hospital will be much easier, and the length of stay in the ED/PES much briefer. In some cases, the patient can return home, and it will become possible to avoid admission altogether. A treatment mindset is key, and a view of emergency work oriented only to triage and diagnosis or chemical restraint will miss this golden opportunity.
Jon Berlin Milwaukee, WI
Engaging Patients at the Front Door (continued)
AAEP Resident Award
The American Association of Emergency Psychiatry (AAEP) is pleased to announce an award for residents demonstrating excellence in emergency psychiatry. Psychiatry residents at all levels of training are eligible for the award. Criteria for the award are expertise and excellence in emergency psychiatry as demonstrated by outstanding clinical skills, administrative responsibilities, and educational activities. Each residency program may nominate one resident for the award.
Eligibility: Applicants must be in good standing in an approved US/Canadian psychiatry residency training program. Each program may nominate one resident.
Prize: $250, plus paid expenses (two nights hotel and airfare) to attend the AAEP spring meeting (San Francisco, CA May 18-22)
Criteria: Demonstrated interest and excellence in emergency and/or acute care psychiatry. Excellence may be in the area(s) of clinical work, research, administration or teaching.
Application Process: Program Directors should send entire packet to include 5 copies each of:
Resident’s CV
Resident’s essay on interest in emergency psychiatry
Letter of support from Department Chair/Program Director or designee
Letter of support from Psychiatry Emergency Director or designee
Due Date: All materials are due by March 1, 2013
Send to:
AAEP Resident Award Selection Committee One Regency Drive P.O. Box 30 Bloomfield, CT 06002
As a fourth-year Psychiatry resident at the University of Michigan, I felt I had experienced a wide variety of patients and diagnoses after training in our Psychiatric Emergency Services (PES). However, thanks to the generosity and the planning of the AAEP, I was able to obtain several new perspectives in psychiatry and emergency psychiatric training during my trip to the 2012 APA Conference in Philadelphia, Pennsylvania. My transportation and accommodations were provided by the AAEP as part of receiving the 2012 Resident Award, and it was an honor just to be nominated by my institution.
As this was my inaugural visit to the APA, I was amazed to see the variety of classes, lectures and symposia offered to the multitude of psychiatrists from all over the world. I listened to fascinating lectures on community mental health, group psychotherapy for ADHD, value-based psychiatric treatment and treatment-resistant depression. I also was able to see Dr. Otto Kernberg discuss his latest book and give a brief demonstrative talk as part of Dr. Philip Resnick’s presentation on how to deliver engaging psychiatry lectures. Along with the informational sessions, I reviewed a variety of posters on numerous mental health subjects by psychiatrists from all over the globe. I even enjoyed the Members-In-Training discounts from all the booksellers in the main exhibition hall.
As this was my first APA conference, I expected to see anti-psychiatry demonstrations but I was quite surprised (and a bit startled) to experience the cacophonous protest rally organized by CCHR. Despite their dubious representation of our profession, it did little to dampen my inaugural APA experience. In fact, one of the most memorable activities during APA 2012 was taking part in the AAEP member tour of Temple University’s Crisis Response Center, or CRC, which is an expanded psychiatric emergency service located on the Episcopal Campus of Temple University Hospital. Although I had traveled to Philadelphia on numerous occasions—and my older sister had lived in the area for several years—I had never ventured into the region served by Temple University Hospital.
During our visit, we learned that the CRC is one of five such centers in the City of Philadelphia that serve individuals in crisis with psychiatric and/or substance-related needs. According to our generous PGY2 Resident host, “Ben,” and his Attending psychiatrist, those needs continue to be quite strong. The AAEP members had the opportunity to see how the CRC patients were triaged and listened to how such a moderately-sized staff were able to assess and treat several hundred patients per month. The tough demographics of the North Philadelphia neighborhoods served by Temple reflected many of the social problems regularly seen in the CRC. Although I was no stranger to the types of cases seen at Temple, I was impressed by the CRC team’s spirit and fortitude in treating such a large volume of society’s most vulnerable patients.
After our tour, the event was capped by a very pleasant and informal reception at Fado Irish Pub back in Center City. I was able to meet the outgoing and incoming AAEP presidents and hear more of what the AAEP hoped to bring to the practice and training of emergency psychiatry. While enjoying the fellowship of the gathered AAEP members, including my PES attendings, Drs. Rachel Glick and Deepika Sastry, we shared our impressions of Temple’s CRC and resolved to bring their unflagging enthusiasm back home to Ann Arbor. Many thanks to the amazing staff of Temple’s CRC for sharing their dedicated service with us!
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Several Faces of Philadelphia... By: Chrisantha E. Anandappa, M.D.
Have you paid your 2012 Dues?
Go to:
www.EmergencyPsychiatry.org
today to remit your membership
dues payment online using a Visa
or MasterCard
Or mail payment to:
AAEP
One Regency Drive
P.O. Box 30
Bloomfield, CT 06002
Need an invoice? Contact the AAEP
Office at 888-945-5430 or email
to request a copy.
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AAEP Member Announcements
Comprehensive Psychiatric Emergency Programs provide relief to crowded EDs
http://www.bartonassociates.com/2012/06/06/comprehensive-psychiatric-
emergency-programs-provide-relief-to-crowded-eds/
U-M resident physician honored with emergency psychiatry award
http://ummentalhealth.info/2012/03/20/u-m-resident-physician-honored-with-
emergency-psychiatry-award
Scott Zeller, MD, Immediate Past President is a finalist for the San Francisco
Business Times Healthcare Heroes Awards. Winners will be announced on
Wednesday, July 25 at the San Francisco Marriott Marquis from 7:30 a.m.-10:00 a.m.
Each of the finalists will be profiled in a special publication which will appear in the
July 27 edition of the San Francisco Business Times. Send your announcements to
Last night I attend the quarterly journal club meeting of the emergency medicine department a large teaching hospital in the Bay Area (not my center). They had chosen to do the BETA articles for their meeting and invited me to participate. What a great experience! The docs (about 40 in attendance) were really positive about the information and it looks like they plan to adopt most of the recommendations. They were especially high on the de-escalation paper; the doc who presented it is known as their guy who typically "tears articles to shreds" when he presents, but he gushed during his detailed report and finished with "I can't find anything to criticize in this."
The meeting, scheduled to go from 7pm to 9pm, went until after 10:30 and there were people still talking on the way out to the cars. This only confirmed my belief that our colleagues in emergency medicine are very eager to discuss strategies for these often difficult cases and definitely appreciate the fresh perspective that BETA brings. If your ED has a journal club or similar educational meeting I encourage you to suggest the BETA articles to them and join in the conversation.
Also, Psychiatric Times repeatedly reported that their piece on Project BETA is one of their most emailed articles. Even two months after the article was published, it has to be searched for on their website (as it is far too old to be on the front page). BETA topped the charts.
We continue to get a lot of feedback from EDs and PES facilities from around the country and even foreign sites who are saying they wish to implement the BETA guidelines in their shops.
I have been doing a 50-minute synopsis PowerPoint presentation on BETA for Northern California EDs and psychiatric hospitals, and people have been very positive. If any of you wish to present the BETA information in your area I am happy to share the slides with you.
Project BETA Update By: Scott Zeller, M.D.
Click the above image to read
the Project BETA articles
published in West JEM
AAEP Board Roster
President
Seth Powsner, MD
President-Elect
Kimberly D. Nordstrom, MD
Immediate Past President
Scott Zeller, MD
Board of Directors:
Leslie Zun, MD, MBA
Jagoda Pasic, MD, PhD
Daryl Knox, MD
Jack Rozel, MD
Social Work Liaison
Janet Richmond, MSW
Director, Emergency Psychiatry
Research
Michael P. Wilson, MD, PhD
Director, Emergency Psychiatry
Standards and Guidelines
Garland H. Holloman, Jr., MD
AAEP Executive Office Staff:
Executive Director
Jacquelyn Coleman, CAE
Administrative Assistant
Jacquilyn Davis
American Association for Emergency Psychiatry One Regency Drive
P.O. Box 30 Bloomfield, CT 06002 Phone: 888-945-5430
Fax: 860-286-0787 Email: [email protected]
Website: www.EmergencyPsychiatry.org
AAEP Goes to New York City—IPS 2012 Members of the AAEP are invited to attend the Fall Social Event October 5, 2012 in New
York City. Members will travel from the Sheraton New York Hotel & Towers at 811
Seventh Avenue (at 53rd Street) to Bellevue Hospital Center located at 462 First Avenue
for what promises to be an informative and memorable site visit.
Bellevue Hospital Center is the oldest public hospital in the United States and was
named New York's #1 hospital in Emergency Care by New York Magazine. Bellevue’s
Comprehensive Psychiatric Emergency Program (CPEP) consists of 4 core
components: an Extended Observation Unit, a Mobile Crisis Unit, an Interim Crisis Clinic,
and a Crisis Residence. In addition, the CPEP Forensic Evaluation Service was opened in
October, 2011 and provides incarcerated patients with the same high quality
emergency psychiatric evaluation afforded to all other patients seen in CPEP. The CPEP
sees close to 13,000 patients annually and admits patients to the Psychiatry inpatient
service with 335 beds distributed among 13 units. CPEP is a core training site for
Bellevue Hospital and the New York University School of Medicine. It is a primary
training site for NYU medical students, NYU psychiatry residents, Emergency Medicine
residents, Neurology residents, Bellevue Psychology Interns, and visiting residents.
Following the site visit, members are invited to attend a casual reception at a location to
be announced shortly.
Advance registration for the site visit and reception are required. To register for these
events, please contact Jacquilyn Davis at [email protected] or call 888-
945-5430.
Additional details on the above events will be sent to all members via email in the
coming weeks. We hope to see you all in New York!