Glenn W. Currier

The Columbia-suicide severity rating scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults

OBJECTIVE Research on suicide prevention and interventions requires a standard method for assessing both suicidal ideation and behavior to identify those at risk and to track treatment response. The Columbia-Suicide Severity Rating Scale (C-SSRS) was designed to quantify the severity of suicidal ideation and behavior. The authors examined the psychometric properties of the scale. METHOD The C-SSRSs validity relative to other measures of suicidal ideation and behavior and the internal consistency of its intensity of ideation subscale were analyzed in three multisite studies: a treatment study of adolescent suicide attempters (N=124); a medication efficacy trial with depressed adolescents (N=312); and a study of adults presenting to an emergency department for psychiatric reasons (N=237). RESULTS The C-SSRS demonstrated good convergent and divergent validity with other multi-informant suicidal ideation and behavior scales and had high sensitivity and specificity for suicidal behavior classifications compared with another behavior scale and an independent suicide evaluation board. Both the ideation and behavior subscales were sensitive to change over time. The intensity of ideation subscale demonstrated moderate to strong internal consistency. In the adolescent suicide attempters study, worst-point lifetime suicidal ideation on the C-SSRS predicted suicide attempts during the study, whereas the Scale for Suicide Ideation did not. Participants with the two highest levels of ideation severity (intent or intent with plan) at baseline had higher odds for attempting suicide during the study. CONCLUSIONS These findings suggest that the C-SSRS is suitable for assessment of suicidal ideation and behavior in clinical and research settings.

The psychopharmacology of agitation: consensus statement of the American association for emergency psychiatry project BETA psychopharmacology workgroup.

Agitation is common in the medical and psychiatric emergency department, and appropriate management of agitation is a core competency for emergency clinicians. In this article, the authors review the use of a variety of first-generation antipsychotic drugs, second-generation antipsychotic drugs, and benzodiazepines for treatment of acute agitation, and propose specific guidelines for treatment of agitation associated with a variety of conditions, including acute intoxication, psychiatric illness, delirium, and multiple or idiopathic causes. Pharmacologic treatment of agitation should be based on an assessment of the most likely cause of the agitation. If agitation results from a delirium or other medical condition, clinicians should first attempt to treat the underlying cause instead of simply medicating with antipsychotics or benzodiazepines.

Behavioural Manifestations of Anabolic Steroid Use

The use of anabolic androgenic steroids (AAS) for gains in strength and muscle mass is relatively common among certain subpopulations, including athletes, bodybuilders, adolescents and young adults.Adverse physical effects associated with steroid abuse are well documented, but more recently, increased attention has been given to the adverse psychiatric effects of these compounds. Steroids may be used in oral, 17α-alkylated, or intramuscular, 17β-esterified, preparations. Commonly, steroid users employ these agents at levels 10- to 100-fold in excess of therapeutic doses and use multiple steroids simultaneously, a practice known as ‘stacking’. Significant psychiatric symptoms including aggression and violence, mania, and less frequently psychosis and suicide have been associated with steroid abuse. Long-term steroid abusers may develop symptoms of dependence and withdrawal on discontinuation of AAS.Treatment of AAS abusers should address both acute physical and behavioural symptoms as well as long-term abstinence and recovery. To date, limited information is available regarding specific pharmacological treatments for individuals recovering from steroid abuse. This paper reviews the published literature concerning the recognition and treatment of behavioural manifestations of AAS abuse.

Pharmacological treatment of psychotic agitation.

The presentation of agitated psychotic patients to psychiatric emergency services is a common occurrence. The traditionally accepted treatment for such patients involves the use of a typical antipsychotic, generally haloperidol. More recently benzodiazepines, such as lorazepam, have been used in combination with antipsychotics due to their sedative properties and relatively benign adverse effect profiles. Standard clinical protocol at many institutions involves the intramuscular administration of 5 to 10mg of haloperidol and 1 to 2mg of lorazepam.Atypical antipsychotics have gained acceptance as first-line treatments for psychotic disorders. These drugs are seen as an improvement over traditional antipsychotics because of their increased efficacy and reduced extrapyramidal effects. The utility of atypical antipsychotics in the emergency setting has been relatively unexplored because slow titration schedules or dose-limiting adverse effects for some members of the class have made this form of treatment impractical. However, the recent availability of oral liquid and rapidly dissolving tablet preparations of some atypical agents has provided useful alternatives in some cases. Nevertheless, for many patients a parenteral drug is the only desirable or feasible treatment option. Intramuscular preparations of the atypical antipsychotics olanzapine and ziprasidone have been developed, and are close to launch in the US. The availability of a rapid-acting intramuscular preparation of an atypical antipsychotic could represent a significant advancement in the treatment of agitation associated with psychosis.

Fatalities associated with therapeutic use and overdose of atypical antipsychotics

Since 1989, several novel antipsychotic drugs have become available for use including clozapine, risperidone, olanzapine, quetiapine and ziprasidone. These agents represent a substantial improvement in the treatment of schizophrenia and related disorders and are considered to have a favourable adverse effect profile relative to traditional antipsychotics. Nonetheless, in rare cases, people have died as a result of taking atypical antipsychotic drugs at therapeutic and supratherapeutic doses. Toxic doses of atypical antipsychotics are highly variable: some patients have died while taking therapeutic doses and others have survived massive overdoses. Toxicity may be increased by coingestion of other agents, particularly drugs with similar metabolic pathways. Atypical antipsychotics are metabolised predominantly by cytochrome P450 (CYP) isoenzymes, particularly CYP1A2 (clozapine and olanzapine), CYP3A4 (clozapine, quetiapine and ziprasidone) and CYP2D6 (olanzapine and risperidone). Concurrent prescription of other drugs that inhibit these isoenzymes may increase the probability of adverse events in patients taking atypical antipsychotics. Deaths due to atypical antipsychotic toxicity are often related to cardiovascular complications, but pulmonary, neurological, endocrine and gastrointestinal complications have also caused fatalities. Prevention and management of atypical antipsychotic overdose are of increased clinical relevance as prescription of these drugs increases

Treatment of behavioral emergencies: a summary of the expert consensus guidelines.

Objectives. Behavioral emergencies are a common and serious problem for consumers, their communities, and the healthcare settings on which they rely, but there is little research to guide provider responses to this challenge. Key constructs such as agitation have not been adequately operationalized so that the criteria defining a behavioral emergency are vague. A significant number of deaths of patients in restraint has focused government and regulators on these issues, but a consensus about key elements in the management of behavioral emergencies has not yet been articulated by the provider community. The authors assembled a panel of 50 experts to define the following elements: the threshold for emergency interventions, the scope of assessment for varying levels of urgency and cooperation, guiding principles in selecting interventions, and appropriate physical and medication strategies at different levels of diagnostic confidence and for a variety of etiologies and complicating conditions. Method. A written survey with 808 decision points was completed by 50 experts. A modified version of the RAND Corporation 9-point scale for rating appropriateness of medical decisions was used to score options. Consensus on each option was defined as a non-random distribution of scores by chi-square “goodness-of-fit” test. We assigned a categorical rank (first line/preferred choice, second line/ alternate choice, third line/usually inappropriate) to each option based on the 95% confidence interval around the mean rating. Guideline tables were constructed describing the preferred strategies in key clinical situations. Results. The expert panel reached consensus on 83% of the options. The relative appropriateness of emergency interventions was ascertained for a continuum of behaviors. When asked about the frequency with which emergency interventions (parenteral medication, restraint, seclusion) were required in their services, 47% of the experts reported that such interventions were necessary for 1%–5% of patients seen in their services and 32% for 6%–20%. In general, the consensus of this panel lends support to many elements of recent regulations from the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services), including the timing of clinician assessment and reassessment and the intensity of nursing care. However, the panel did not endorse the concept of “chemical restraint,” instead favoring the idea that medications are treatments for target behaviors in behavioral emergencies even when the causes of these behaviors are not well understood. Control of aggressive behavior emerged as the highest priority during the emergency; however, preserving the physician-patient relationship was rated a close second and became the top priority in the long term. Oral medications, particularly concentrates, were clearly preferred if it is possible to use them. Benzodiazepines alone were top rated in 6 of 12 situations. High-potency conventional antipsychotics used alone never received higher ratings than benzodiazepines used alone. A combination of a benzodiazepine and an antipsychotic was preferred for patients with suspected schizophrenia, mania, or psychotic depression. There was equal support for high-potency conventional or atypical antipsychotics (particularly liquids) in oral combinations with benzodiazepines. Droperidol emerged in fourth place in some situations requiring an injection. Conclusions. To evaluate many of the treatment options in this survey, the experts had to extrapolate beyond controlled data. Within the limits of expert opinion and with the expectation that future research data will take precedence, these guidelines provide some direction for addressing common clinical dilemmas in the management of psychiatric emergencies and can be used to inform clinicians in acute care settings regarding the relative merits of various strategies.

An Emergency Department-Based Brief Intervention for Veterans at Risk for Suicide (SAFE VET)

Reducing deaths from veteran suicide is a public health priority for veterans who receive their care from the Department of Veterans Affairs (VA) and those who receive services in community settings. Emergency departments frequently function as the primary or sole point of contact with the health care system for suicidal individuals; therefore, they represent an important venue in which to identify and treat veterans who are at risk for suicide. We describe the design, implementation and initial evaluation of a brief behavioral intervention for suicidal veterans seeking care at VA emergency departments. Initial findings of the feasibility and acceptability of the intervention suggest it may be transferable to diverse VA and non-VA settings, including community emergency departments and urgent care centers.

Orally versus intramuscularly administered antipsychotic drugs in psychiatric emergencies.

High utilization of emergency services by patients at increased risk for agitation and aggression makes the determination of effective therapy a major concern of psychiatric care. Agitated and aggressive behavior needs to be treated rapidly and effectively to minimize the risk to both patients and staff. Traditionally, short-acting intramuscular (IM) formulations of conventional antipsychotic drugs have been preferred in the emergency setting due to their rapid onset of action and the ability to administer them to uncooperative patients. IM injections, however, may not always be the preferred option. Recently, orally administered second generation (atypical) antipsychotics have been shown to be at least as effective in managing acute agitation as conventional antipsychotic drugs, with a superior tolerability profile. The current review evaluates pharmacokinetic parameters, formulation options, and clinical efficacy data for the treatment of acute agitation or aggressive behavior with antipsychotic medications. A synthesis of data from individual clinical trials, meta-analyses, review articles, and expert consensus recommendations is used to develop a working clinical algorithm for the acute management of aggression and agitation.

Organization and function of academic psychiatric emergency services

Psychiatric emergency services (PES) are evolving as freestanding, parallel components of emergency departments at many tertiary care medical centers in the U.S. While PES facilities provide an increasing percentage of first-line care for patients with psychiatric crises, the services they provide and their interactions with medical emergency services have not been systematically assessed. The purpose of this study was to examine PES structure, care processes, patient characteristics and relationship with medical emergency services by surveying PES directors with a 70-item questionnaire about PES facilities in 1998. This report presents information about staffing adequacy, medical evaluation and other procedures, length of stay, and aftercare. The response rate was 91% (n=51), and most sites (>90%) were academic training sites. A large percentage (92%) of PES sites were open 24 h a day, 7 days a week, and 94% had an attending psychiatrist present at least 8 h daily. PES psychiatrists performed initial medical evaluation at 55% of sites and were often responsible for medical clearance. Pharmacologic therapy was routinely initiated for patients being admitted in 92% of facilities and for patients being released in 70% of facilities. Mean (SD) length of stay in the PES was 9.0 (11.3) hours. The PES facilities were effective at referring patients to aftercare, and 51% of PES sites provided follow-up care. However, 69% of respondents reported inadequate referral options for patients with substance abuse. The mean recidivism rate was 18%, primarily attributed to substance abuse and medication noncompliance. The results of this survey show that PES facilities are organizationally complex units in which staff routinely perform medical clearance, initiate treatment, and coordinate aftercare. Our findings highlight the importance of adequate medical training for PES psychiatrists, the need for improved aftercare programming, and better access to substance abuse treatment for discharged patients.

Consumer and family experiences in the emergency department following a suicide attempt

Objective. To understand the separate experiences of consumers (patients) and family members in the Emergency Department (ED) following a suicide attempt. Methods. Separate anonymous surveys were created for two groups: 1) consumers (n = 465) who had made a suicide attempt and been to the ED, and 2) others (referred to here as family members; n = 254) who had a close friend or relative treated in an ED due to suicidal behavior. Surveys were available on the National Alliance on Mental Illness (NAMI) website (www.nami.org) for 2 months. Results. Almost half of consumers were accompanied by a family member to the ED following their suicide attempt. Over half of consumers and family members felt that staff treated them with respect and addressed ethnic and cultural issues appropriately. However, fewer than 40% of consumers felt that staff listened to them, described the nature of treatments to them, or took their injury seriously. Family members were more likely than consumers to feel heard or to receive information about treatment. More than half of consumers and almost a third of family members felt directly punished or stigmatized by staff. Consumers and family members also reported negative experiences involving a perception of unprofessional staff behavior, feeling the suicide attempt was not taken seriously, and long wait times. Conclusions. Individuals who visited the NAMI website reported a range of negative experiences in EDs following visits for suicide attempts. The effects of these experiences on retention in care and subsequent self-injurious behavior are largely unexplored. A greater understanding of these effects may inform development of interventions to increase the satisfaction of consumers and their families and friends and improve outcomes that result from emergency care of suicidal patients and their families.