Jagoda Pasic

The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia.

anagement of behavioral disturbances Mand psychosis associated with dementia is a clinical and, in some cases, a medicolegal and ethical challenge for clinicians, caregivers, and health care settings. These medications are associated with multiple adverse outcomes, including serious adverse effects, such as increased risk for cerebrovascular events and mortality. At the same time, clinicians feel pressure from caregivers, acute inpatient staff, and long-term care settings to safely manage psychotic and aggressive behaviors in this population. The incidence and prevalence of dementia and associated behavioral disturbances in the adult population is on the rise. There is a lack of consistent practices and guidance to manage these behaviors as well as an upto-date review of the existing effectiveness literature, and these are much needed. Thus, the recent publication of the American Psychiatric Associations (APAs) practice guidelines on the use of antipsychotics to treat agitation or psychosis in patients with dementia comes at a most opportune time. Practice guidelines are unique in that they have the potential to positively impact behavior of practicing clinicians. They are also likely to be used as standard of care by insurance companies and in lawsuits or other litigation. It is thus important that practice guidelines provide a thorough, balanced, accurate, and current review of available treatments based on medical and scientific literature. The APAs most recent practice guideline on antipsychotic treatment in patients with dementia appears to have done just that. The practice guideline is organized into two main sections. The first section is broken up into four main categories: an introduction and overview of the guidelines, the guidelines themselves and how they were implemented based on current evidence in literature, quality measurement considerations, and the guideline development process. The second section is an appendix that provides a comprehensive review of available evidence and the results of expert opinion survey data. The authors also included a list of acronyms and abbreviations used in the guidelines, glossary of terms, list

Methamphetamine Users in the Psychiatric Emergency Services: A Case-Control Study

The purpose of this study is to examine the sociodemographic, clinical, and service use characteristics of patients with positive methamphetamine (MA) urine toxicology and compare with non-MA users seen in an urban Psychiatric Emergency Services (PES). One hundred twenty patient charts were extracted for demographics, mode of arrival, clinical information, medication treatment of MA-intoxication, and disposition. Compared with non-MA patients, MA patients were significantly younger, male, referred by police, with cardiac symptoms, psychosis, dysphoria, past substance use, and were less likely to have a diagnosis of Schizophrenia, a past psychiatric history/hospitalization, and a history of suicide attempts. Subsequent hospitalization rates did not differ. MA patients treated with medications more readily accepted the referral to chemical dependency treatment. This study shows that hypertension and tachycardia upon arrival to the PES, symptoms of dysphoria and psychosis, past substance use and not having the diagnosis of Schizophrenia are all related to methamphetamine use.

Risk for physical restraint or seclusion in the psychiatric emergency service (PES)

OBJECTIVE We describe risk factors associated with patients experiencing physical restraint or seclusion in the psychiatric emergency service (PES). METHODS We retrospectively reviewed medical records, nursing logs and quality assurance data for all adult patient encounters in a PES over a 12-month period (June 1, 2011-May 31, 2012). Descriptors included demographic characteristics, diagnoses, laboratory values, and clinician ratings of symptom severity. χ(2) and multivariate logistic regression analyses were performed. RESULTS Restraint/seclusion occurred in 14% of 5335 patient encounters. The following characteristics were associated with restraint/seclusion: arrival to the PES in restraints; referral not initiated by the patient; arrival between 1900 and 0059 hours; bipolar mania or mixed episode; and clinician rating of severe disruptiveness, psychosis or insight impairment. Severe suicidality and a depression diagnosis were associated with less risk of restraint or seclusion. CONCLUSION Acute symptomatology and characteristics of the encounter were more likely to be associated with restraint/seclusion than patient demographics or diagnoses. These findings support recent guidelines for the treatment of agitation and can help clinicians identify patients at risk of behavioral decompensation.

The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder

Victor I. Reus, M.D., Laura J. Fochtmann, M.D., M.B.I., Oscar Bukstein, M.D., M.P.H., A. Evan Eyler, M.D., M.P.H., Donald M. Hilty, M.D., Marcela Horvitz-Lennon, M.D., M.P.H., Jane Mahoney, Ph.D., R.N., PMHCNS-B.C., Jagoda Pasic, M.D., Ph.D., Michael Weaver, M.D., Cheryl D. Wills, M.D., Jack McIntyre, M.D. (Consultant), Jeremy Kidd, M.D. (Consultant), Joel Yager, M.D. (Systematic Review), Seung-Hee Hong (Systematic Review)

Who's Boarding in the Psychiatric Emergency Service?

Introduction When a psychiatric patient in the emergency department requires inpatient admission, but no bed is available, they may become a “boarder.” The psychiatric emergency service (PES) has been suggested as one means to reduce psychiatric boarding, but the frequency and characteristics of adult PES boarders have not been described. Methods We electronically extracted electronic medical records for adult patients presenting to the PES in an urban county safety-net hospital over 12 months. Correlative analyses included Student’s t-tests and multivariate regression. Results 521 of 5363 patient encounters (9.7%) resulted in boarding. Compared to non-boarding encounters, boarding patient encounters were associated with diagnoses of a primary psychotic, anxiety, or personality disorder, or a bipolar manic/mixed episode. Boarders were also more likely to be referred by family, friends or providers than self-referred; arrive in restraints; experience restraint/seclusion in the PES; or be referred for involuntary hospitalization. Boarders were more likely to present to the PES on the weekend. Substance use was common, but only tobacco use was more likely associated with boarding status in multivariate analysis. Conclusion Boarding is common in the PES, and boarders have substantial psychiatric morbidity requiring treatment during extended PES stays. We question the appropriateness of PES boarding for seriously ill psychiatric patients.

Clinical Prevalence and Correlates of Substance Use in Adolescent Psychiatric Emergency Patients

Objectives: This study used clinical and administrative data to describe the clinical prevalence and correlates of substance use disorders (SUDs) in 622 adolescents aged 12 to 17 years who were evaluated with 1 or more psychiatric diagnoses after presenting to an urban psychiatric emergency service. Methods: Clinical and administrative data including demographics, diagnosis, psychiatric severity, suicidality, treatment history, treatment disposition, social support, and overall functioning were retrospectively obtained from patient records. These data were used to describe the prevalence and correlates of SUDs in this sample of adolescents with psychiatric disorders. Results: Twenty-eight percent of youth had an SUD. Marijuana and alcohol use disorders were the most common. The diagnosis of SUD was not associated with specific psychiatric diagnostic categories (mood, anxiety, and psychotic), psychiatric symptom severity, or suicidality, in the overall sample. There was limited evidence for a mediating/moderating effect of sex on the correlation between psychiatric measures and SUD diagnosis. Older age, SUD treatment history, and role dysfunction (ie, poor school functioning) were independently associated with any SUD diagnosis or a drug use disorder when accounting for sex. Older age and history of SUD treatment were independently correlated with alcohol use disorders. Twenty-three percent of youth with SUDs were referred for SUD treatment. Conclusions: Substance use disorders were prevalent in this population, and the rate of SUD treatment disposition was lower than anticipated. Substance use disorders were associated with lower functioning but not independently correlated with psychiatric diagnostic categories or symptom severity. This study supports the need for improved screening, intervention, and referral options for SUDs in this setting.

The Peregrinating Psychiatric Patient in the Emergency Department.

Many emergency department (ED) psychiatric patients present after traveling. Although such travel, or peregrination, has long been associated with factitious disorder, other diagnoses are more common among travelers, including psychotic disorders, personality disorders, and substance abuse. Travelers’ intense psychopathology, disrupted social networks, lack of collateral informants, and unawareness of local resources complicate treatment. These patients can consume disproportionate time and resources from emergency providers. We review the literature on the emergency psychiatric treatment of peregrinating patients and use case examples to illustrate common presentations and treatment strategies. Difficulties in studying this population and suggestions for future research are discussed.

Acute Withdrawal: General Principles

Patients with substance use disorders are frequent utilizers of medical and psychiatric services in the emergency department. Recognition of common withdrawal syndromes is essential in formulating a differential diagnosis and providing appropriate medical care. In the DSM-5, withdrawal syndromes are uniquely defined for each substance class but share core features in that, (1) they occur after cessation of heavy and prolonged drug use, (2) the cause significant distress or impairment in social, occupational or interpersonal function and, (3) the symptoms cannot be better attributed to another mental or medical disease. In this section the major substance withdrawals include alcohol, benzodiazepine, barbiturate, cannabis, opioid and stimulant (amphetamine-type substances and cocaine). While abrupt cessation of other substances listed in the DSM-5, such as tobacco, can lead to withdrawal, focus has been placed on the most common withdrawal syndromes that can lead to medical concerns.