Psychiatric Emergency Services in a Canadian City: II. Clinical Characteristics and Patients' Disposition* L.K. OYEWUMI, B.Sc., M.B.B.S. I, O. ODEnDE, M.D. 2 AND S.S. KAZARIAN, Ph.D.3
The clinical characteristics ofpatients seen at the psychiatric emergency facilities in a Canadian city and the determinants of decisions regarding their treatment were investigated. A total of 544 patients who sought psychiatric emergency services from the three hospitals in Saskatoon during a three month period were studied. Cognitive disturbance, pastpsychiatric history, previous psychiatric hospitalization and diagnoses of substance use disorders, affective disorders, anxiety disorders and schizophrenic disorders were associated with psychiatric emergencies. Psychiatric diagnoses and availability of social support were significantly associated with disposition. The implications ofthese findings for psychiatric emergency services are discussed.
or not to hospitalize is a crucial but complex one that is influenced by a number of factors (5,6). In our previous paper (7), the prevalence and patterns of use of psychiatric emergency services in Saskatoon were reported. The aim of this report is to examine the clinical characteristics of individuals using pschiatric emergency services and to explore the determinants of decisions made at theses facilities.
Method Patients who visited one of the four psychiatric emergency services (described in the earlier paper (7» in Saskatoon between July and September of 1987 were studied. For the purposes of this report, the data on the 32 patients from the Saskatoon Crisis Intervention Service (SCIS) were excluded because of the methods of data collection at the SCIS and the fact that it is not a hospital. Data on the remaining 544 patients (who made 717 visits to the three psychiatric emergency facilities) were considered in this report. Two experienced research assistants collected sociodemographic, clinical and dispositional information from the medical records of identified patients. The research assistants were supervised by two of the researchers (L.K.O. and A.O.O.), who met regularly with them to discuss their progress. This ensured accurate, consistent and complete gathering of information. The data obtained were coded and subjected to chi-square analyses for categorical measures (for example, sex) and t-test statistics for continuous measures (for example, age).
O
ver the past two decades, psychiatric emergency services have become the prime entry point for individuals into mental health services (1,2). A variety of psychosocial problems and psychiatric syndromes have been recognized in such individuals (1,3). Although the services were initially designed as an entry point for acutely ill patients, recent studies have revealed that they are being used more often by chronic patients (1,3,4). This clinical group, described as "chronic crisis patients" make repeat visits, are relatively young and present with complex psychosocial problems (1,3). An understanding ofthe clinical characteristics of patients using psychiatric emergency services is important for adequate planning of such facilities. Also, the decision whether
Results
'This project received funding from the Clinical Teaching and Research Grant of the University of Saskatchewan and contributions from the three hospitals and Saskatoon Mental Health Services. Manuscript received August 1990, revised May 1991. IDirector, Clinical Evaluation Unit, London Psychiatric Hospital; Associate Professor of Psychiatry, University of Western Ontario, London, Ontario; formerly, Chief of Psychiatry, Saskatoon City Hospital and Associate Professor, University of Saskatchewan, Saskatoon, Saskatchewan. 2Visiting Associate Professor of Psychiatry, University of Saskatchewan, Saskatoon, Saskatchewan; Professor and Head, Department of Psychiatry, University of Ibadan, Ibadan, Nigeria. 3Director, Psychology Department, London Psychiatric Hospital; Clinical Associate Professor, Departments of Psychology (Adjunct) and Psychiatry (Part-Time), University of Western Ontario, London, Ontario. Addressreprintrequeststo: Dr. L.K.O. Oyewumi, Director, Clinical Evaluation Unit, London Psychiatric Hospital, London, Ontario N6A 4Hl
The Population Of the 544 patients, 262 were male and 282 were female. Their mean age was 38.7 years. Approximately one-half (50.5%) had never been married. The majority (52.8%) had a history of psychiatric illness, and 61.2% received no social support. Approximately one-third (35.8%) were unemployed.
Clinical Variables Presenting Complaints The most prevalent presenting complaint was cognitive disturbance (38.0%), mainly difficulty concentrating and/or remembering. Other complaints included somatic symptoms of aches and pains, crawling sensations (27.6%); sleep distur-
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March,1992
PSYCHIATRIC EMERGENCY SERVICES
bances (10.6%), abnormal behaviour (8.0%); alcohol withdrawal or intoxication (3.7%); and fear of self-harm (6.4%). The rates of presenting complaints at the three hospitals varied and closely reflected the patterns of psychopathology identified at each institution. Consciousness on Arrival The overall rate of unconscious arrivals to the emergency facilities was 2.66%. Saskatoon City Hospital (SCH) had the highest rate (4.25%) followed by St. Paul's Hospital (SPH) (2.12%) and University Hospital (UH) (1.64%). Of the unconscious arrivals, 89.5% (17 patients) were diagnosed with substance use disorders. A large proportion (68%) had drug or alcohol overdoses, 16% were unconscious as a result of suicide attempts using means other than overdoses, while the remaining 16% were unconscious as a result of unspecified injuries. The proportions of those unconscious because of overdose were similar in the three hospitals. Overdoses were caused most often by benzodiazepines (26%), street drugs such as cocaine or glue (28%), analgesics (20%), alcohol (eight percent), antidepressants (eight percent), barbiturates and other hypnosedatives (eight percent). In only one instance (one percent) was the overdose caused by major tranquilizers. Most of the drugs causing overdoses were obtained from family physicians (58%), over the counter (32%), or from friends (seven percent). In only a few cases was the drug obtained from a specialist physician (two percent) or a relative (two percent). Sixty-one cases of attempted suicide were recorded during the three month study period. These were made by 58 patients, three of whom made two attempts each. Eleven (18%) of these 61 had also attempted suicide during the previous 12 months. The common diagnoses among these patients were substance use disorder (82.8%), affective disorder (8.6%), and adjustment disorder (8.6%). Psychiatric History Over one-half of the patients (52.8%) had a history of psychiatric illness. They accounted for 61% of all psychiatric emergency visits made during the period of study. Forty-four percent of them had never been hospitalized for psychiatric illness. Thirty-seven percent of them had been admitted once or twice to a psychiatric facility; 13.4% had been admitted between three and five times, while 6.3% had been hospitalized on more than five occasions. The most common diagnostic categories for patients who had been previously hospitalized were affective disorders (35%), schizophrenic disorders (25%), substance use disorders (21 %), and anxiety disorders (nine percent). Most of the patients seen at UH (60.4%) and SCH (60.6%) had been previously hospitalized. Forty-two point three percent of the patients had a history of drug dependence: 74% used alcohol, 20.4% used street drugs such as cocaine and amphetamines, 2.6% used cannabis, while 0.9% used solvents and 0.4% used analgesics.
97
Physical Examination The findings on physical examinations were reported in 7.5% of cases (n = 54). The major physical problems were gastrointestinal (37%), bruises and lacerations (18.5%), CNS abnormality (14.8%), respiratory and genito-urinary (5.6% each) and other (18.5%). There was no difference in the physical findings among the patients seen at the various institutions. DSM-lll Diagnoses The patients were diagnosed by the emergency room physicians or the psychiatrist who saw them in consultation. Patients who were diagnosed by the emergency room physicians or those who received no diagnosis were reviewed and diagnosed according to DSM-III criteria by two psychiatrists (LKO and AOO). The common diagnostic categories were substance use disorders (29.0%), anxiety disorders (24.8%), affective disorders (23.6%), schizophrenic disorders (9.20%), adjustment disorders (6.7%), personality disorders (1.5%) and organic mental disorders (1.8%). Other less common diagnoses were panic disorders (1.1%), paranoid disorders (0.7%), psychosexual disorders (0.1%) and other disorders (1.9%). Referralfor Psychiatric Consultation Psychiatric consultations were sought for 50.1 % of the patients. Psychiatric consultations were sought more frequently at UH (77%) than at SCH (33%) and SPH (7.1%). The emergency room physicians at SCH and SPH tended to see more patients themselves and made only few referrals to the psychiatrists. Pattern ofMedication Prescription Patients were given medication at 254 (35.3%) of the emergency visits. Of these, 207 (81.5%) received stat medication only, 31 (12.2%) received regular medication only, while 16 (6.3%) were given combination of stat and regular medication. The administration of medication alone or a combination of stat and regular medication did not differ among the three hospitals. However, SCH and SPR each administered 38% of the stat medication while UR administered only 24%. The most common medications prescribed as stat or regular medications were benzodiazepines and hypnosedatives (62.6%) and antipsychotics (13.9%). The most commonly prescribed stat and regular antipsychotics were chlorpromazine (54.5% stat and 46.7% regular) and haloperidol (27.3% stat and 20.0% regular). Patients'Disposition One hundred and twenty-six (17.6%) of the 717 visits resulted in admission to hospital. The majority of the patients admitted to hospital were diagnosed with substance use disorders (46.8%), followed by affective disorders (24.2%) and schizophrenic disorders (14.5%). Fifty-one percent were admitted to UR, and 24% to SCH and 24% to SPR. Fifty percent of admissions were to the psychiatric wards while 40% were
98
Vol. 37, No.2
CANADIAN JOURNAL OF PSYCHIATRY
Table I Factors Associated with the Outcome of the Visit to a Psychiatric Emergency Facility Admitted
Discharged
(n=126)
(n=591)
Mean age
38.8
38.6
SD
16.9
17.0
Sex • Male Previous psychiatric inpatient treatment
47.2%
• Yes Diagnosis
59.6%
• Affective disorder • Adjustment disorder
Chi-square or t*
Level
0.00
>0.99
0.02
>0.90
1.07
>0.30
47.8% 53.1%
24.2%
24.4%
5.6%
7.1%
• Schizophrenic disorder
14.5%
8.2%
• Substance use disorder
46.8%
26.0%
• Anxiety disorder
2.4%
29.1%
• Organic mental disorder
4.8%
1.2%
• Personality disorder
0.8%
1.7%
• Other disorder
0.8%
2.3%
53.7%
35.4%
46.3%
64.6%
Social support • Yes ·No
Significance
58.20
< 0.0001
11.10
The clinical characteristics ofpatients seen at the psychiatric emergency facilities in a Canadian city and the determinants of decisions regarding their treatment were investigated. A total of 544 patients who sought psychiatric emergency services from the three hospitals in Saskatoon during a three month period were studied. Cognitive disturbance, pastpsychiatric history, previous psychiatric hospitalization and diagnoses of substance use disorders, affective disorders, anxiety disorders and schizophrenic disorders were associated with psychiatric emergencies. Psychiatric diagnoses and availability of social support were significantly associated with disposition. The implications ofthese findings for psychiatric emergency services are discussed.
or not to hospitalize is a crucial but complex one that is influenced by a number of factors (5,6). In our previous paper (7), the prevalence and patterns of use of psychiatric emergency services in Saskatoon were reported. The aim of this report is to examine the clinical characteristics of individuals using pschiatric emergency services and to explore the determinants of decisions made at theses facilities.
Method Patients who visited one of the four psychiatric emergency services (described in the earlier paper (7» in Saskatoon between July and September of 1987 were studied. For the purposes of this report, the data on the 32 patients from the Saskatoon Crisis Intervention Service (SCIS) were excluded because of the methods of data collection at the SCIS and the fact that it is not a hospital. Data on the remaining 544 patients (who made 717 visits to the three psychiatric emergency facilities) were considered in this report. Two experienced research assistants collected sociodemographic, clinical and dispositional information from the medical records of identified patients. The research assistants were supervised by two of the researchers (L.K.O. and A.O.O.), who met regularly with them to discuss their progress. This ensured accurate, consistent and complete gathering of information. The data obtained were coded and subjected to chi-square analyses for categorical measures (for example, sex) and t-test statistics for continuous measures (for example, age).
O
ver the past two decades, psychiatric emergency services have become the prime entry point for individuals into mental health services (1,2). A variety of psychosocial problems and psychiatric syndromes have been recognized in such individuals (1,3). Although the services were initially designed as an entry point for acutely ill patients, recent studies have revealed that they are being used more often by chronic patients (1,3,4). This clinical group, described as "chronic crisis patients" make repeat visits, are relatively young and present with complex psychosocial problems (1,3). An understanding ofthe clinical characteristics of patients using psychiatric emergency services is important for adequate planning of such facilities. Also, the decision whether
Results
'This project received funding from the Clinical Teaching and Research Grant of the University of Saskatchewan and contributions from the three hospitals and Saskatoon Mental Health Services. Manuscript received August 1990, revised May 1991. IDirector, Clinical Evaluation Unit, London Psychiatric Hospital; Associate Professor of Psychiatry, University of Western Ontario, London, Ontario; formerly, Chief of Psychiatry, Saskatoon City Hospital and Associate Professor, University of Saskatchewan, Saskatoon, Saskatchewan. 2Visiting Associate Professor of Psychiatry, University of Saskatchewan, Saskatoon, Saskatchewan; Professor and Head, Department of Psychiatry, University of Ibadan, Ibadan, Nigeria. 3Director, Psychology Department, London Psychiatric Hospital; Clinical Associate Professor, Departments of Psychology (Adjunct) and Psychiatry (Part-Time), University of Western Ontario, London, Ontario. Addressreprintrequeststo: Dr. L.K.O. Oyewumi, Director, Clinical Evaluation Unit, London Psychiatric Hospital, London, Ontario N6A 4Hl
The Population Of the 544 patients, 262 were male and 282 were female. Their mean age was 38.7 years. Approximately one-half (50.5%) had never been married. The majority (52.8%) had a history of psychiatric illness, and 61.2% received no social support. Approximately one-third (35.8%) were unemployed.
Clinical Variables Presenting Complaints The most prevalent presenting complaint was cognitive disturbance (38.0%), mainly difficulty concentrating and/or remembering. Other complaints included somatic symptoms of aches and pains, crawling sensations (27.6%); sleep distur-
Can. J. Psychiatry Vol. 37, March 1992
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March,1992
PSYCHIATRIC EMERGENCY SERVICES
bances (10.6%), abnormal behaviour (8.0%); alcohol withdrawal or intoxication (3.7%); and fear of self-harm (6.4%). The rates of presenting complaints at the three hospitals varied and closely reflected the patterns of psychopathology identified at each institution. Consciousness on Arrival The overall rate of unconscious arrivals to the emergency facilities was 2.66%. Saskatoon City Hospital (SCH) had the highest rate (4.25%) followed by St. Paul's Hospital (SPH) (2.12%) and University Hospital (UH) (1.64%). Of the unconscious arrivals, 89.5% (17 patients) were diagnosed with substance use disorders. A large proportion (68%) had drug or alcohol overdoses, 16% were unconscious as a result of suicide attempts using means other than overdoses, while the remaining 16% were unconscious as a result of unspecified injuries. The proportions of those unconscious because of overdose were similar in the three hospitals. Overdoses were caused most often by benzodiazepines (26%), street drugs such as cocaine or glue (28%), analgesics (20%), alcohol (eight percent), antidepressants (eight percent), barbiturates and other hypnosedatives (eight percent). In only one instance (one percent) was the overdose caused by major tranquilizers. Most of the drugs causing overdoses were obtained from family physicians (58%), over the counter (32%), or from friends (seven percent). In only a few cases was the drug obtained from a specialist physician (two percent) or a relative (two percent). Sixty-one cases of attempted suicide were recorded during the three month study period. These were made by 58 patients, three of whom made two attempts each. Eleven (18%) of these 61 had also attempted suicide during the previous 12 months. The common diagnoses among these patients were substance use disorder (82.8%), affective disorder (8.6%), and adjustment disorder (8.6%). Psychiatric History Over one-half of the patients (52.8%) had a history of psychiatric illness. They accounted for 61% of all psychiatric emergency visits made during the period of study. Forty-four percent of them had never been hospitalized for psychiatric illness. Thirty-seven percent of them had been admitted once or twice to a psychiatric facility; 13.4% had been admitted between three and five times, while 6.3% had been hospitalized on more than five occasions. The most common diagnostic categories for patients who had been previously hospitalized were affective disorders (35%), schizophrenic disorders (25%), substance use disorders (21 %), and anxiety disorders (nine percent). Most of the patients seen at UH (60.4%) and SCH (60.6%) had been previously hospitalized. Forty-two point three percent of the patients had a history of drug dependence: 74% used alcohol, 20.4% used street drugs such as cocaine and amphetamines, 2.6% used cannabis, while 0.9% used solvents and 0.4% used analgesics.
97
Physical Examination The findings on physical examinations were reported in 7.5% of cases (n = 54). The major physical problems were gastrointestinal (37%), bruises and lacerations (18.5%), CNS abnormality (14.8%), respiratory and genito-urinary (5.6% each) and other (18.5%). There was no difference in the physical findings among the patients seen at the various institutions. DSM-lll Diagnoses The patients were diagnosed by the emergency room physicians or the psychiatrist who saw them in consultation. Patients who were diagnosed by the emergency room physicians or those who received no diagnosis were reviewed and diagnosed according to DSM-III criteria by two psychiatrists (LKO and AOO). The common diagnostic categories were substance use disorders (29.0%), anxiety disorders (24.8%), affective disorders (23.6%), schizophrenic disorders (9.20%), adjustment disorders (6.7%), personality disorders (1.5%) and organic mental disorders (1.8%). Other less common diagnoses were panic disorders (1.1%), paranoid disorders (0.7%), psychosexual disorders (0.1%) and other disorders (1.9%). Referralfor Psychiatric Consultation Psychiatric consultations were sought for 50.1 % of the patients. Psychiatric consultations were sought more frequently at UH (77%) than at SCH (33%) and SPH (7.1%). The emergency room physicians at SCH and SPH tended to see more patients themselves and made only few referrals to the psychiatrists. Pattern ofMedication Prescription Patients were given medication at 254 (35.3%) of the emergency visits. Of these, 207 (81.5%) received stat medication only, 31 (12.2%) received regular medication only, while 16 (6.3%) were given combination of stat and regular medication. The administration of medication alone or a combination of stat and regular medication did not differ among the three hospitals. However, SCH and SPR each administered 38% of the stat medication while UR administered only 24%. The most common medications prescribed as stat or regular medications were benzodiazepines and hypnosedatives (62.6%) and antipsychotics (13.9%). The most commonly prescribed stat and regular antipsychotics were chlorpromazine (54.5% stat and 46.7% regular) and haloperidol (27.3% stat and 20.0% regular). Patients'Disposition One hundred and twenty-six (17.6%) of the 717 visits resulted in admission to hospital. The majority of the patients admitted to hospital were diagnosed with substance use disorders (46.8%), followed by affective disorders (24.2%) and schizophrenic disorders (14.5%). Fifty-one percent were admitted to UR, and 24% to SCH and 24% to SPR. Fifty percent of admissions were to the psychiatric wards while 40% were
98
Vol. 37, No.2
CANADIAN JOURNAL OF PSYCHIATRY
Table I Factors Associated with the Outcome of the Visit to a Psychiatric Emergency Facility Admitted
Discharged
(n=126)
(n=591)
Mean age
38.8
38.6
SD
16.9
17.0
Sex • Male Previous psychiatric inpatient treatment
47.2%
• Yes Diagnosis
59.6%
• Affective disorder • Adjustment disorder
Chi-square or t*
Level
0.00
>0.99
0.02
>0.90
1.07
>0.30
47.8% 53.1%
24.2%
24.4%
5.6%
7.1%
• Schizophrenic disorder
14.5%
8.2%
• Substance use disorder
46.8%
26.0%
• Anxiety disorder
2.4%
29.1%
• Organic mental disorder
4.8%
1.2%
• Personality disorder
0.8%
1.7%
• Other disorder
0.8%
2.3%
53.7%
35.4%
46.3%
64.6%
Social support • Yes ·No
Significance
58.20
< 0.0001
11.10
