Mark Schechter

Patient- and Practice-Related Determinants of Emergency Department Length of Stay for Patients With Psychiatric Illness

STUDY OBJECTIVE To identify patient and clinical management factors related to emergency department (ED) length of stay for psychiatric patients. METHODS This was a prospective study of 1,092 adults treated at one of 5 EDs between June 2008 and May 2009. Regression analyses were used to identify factors associated with ED length of stay and its 4 subcomponents. Secondary analyses considered patients discharged to home and those who were admitted or transferred separately. RESULTS The overall mean ED length of stay was 11.5 hours (median 8.2 hours). ED length of stay varied by discharge disposition, with patients discharged to home staying 8.6 hours (95% confidence interval 7.7 to 9.5 hours) and patients transferred to a hospital outside the system of care staying 15 hours (95% confidence interval 12.7 to 17.6 hours) on average. Older age and being uninsured were associated with increased ED length of stay, whereas race, sex, and homelessness had no association. Patients with a positive toxicology screen result for alcohol stayed an average of 6.2 hours longer than patients without toxicology screens, an effect observed primarily in the periods before disposition decision. Diagnostic imaging was associated with an average 3.2-hour greater length of stay, prolonging both early and late components of the ED stay. Restraint use had a similar effect, leading to a length of stay 4.2 hours longer than that of patients not requiring restraints. CONCLUSION Psychiatric patients spent more than 11 hours in the ED on average when seeking care. The need for hospitalization, restraint use, and the completion of diagnostic imaging had the greatest effect on postassessment boarding time, whereas the presence of alcohol on toxicology screening led to delays earlier in the ED stay. Identification and sharing of best practices associated with each of these factors would provide an opportunity for improvement in ED care for this population.

Common factors in empirically supported treatments of borderline personality disorder.

In this article, we examine the manuals of empirically supported psychotherapies for borderline personality disorder (BPD) by comparing their common and specific treatment strategies. We compare these treatments using a previously constructed scale of treatment interventions. Individual psychotherapies for BPD have several common strategies: clear treatment framework, attention to affect, focus on treatment relationship, an active therapist, and exploratory and change-oriented interventions. Use of interpretations, supportive interventions, designating treatment targets, attention to patient functioning, multimodal treatment, and support for therapies varied across the psychotherapies. We discuss these findings in the context of clusters of BPD symptoms, reports regarding overlap in treatment interventions used by various psychotherapies, and the effectiveness of specific treatment strategies.

Strategies in treatment of suicidality: identification of common and treatment-specific interventions in empirically supported treatment manuals.

OBJECTIVE Many reports of treatments for suicidal patients claim effectiveness in reducing suicidal behavior but fail to demonstrate which treatment interventions, or combinations thereof, diminish suicidality. In this study, treatment manuals for empirically supported psychological treatments for suicidal patients were examined to identify which interventions they had in common and which interventions were treatment-specific. METHOD Empirically supported treatments for suicidality were identified through a literature search of PsychLit and MEDLINE for the years 1970-2007, employing the following search strategy: [suicide OR parasuicide] AND [therapy OR psychotherapy OR treatment] AND [random OR randomized]. After identifying the reports on randomized controlled studies that tested effectiveness of different treatments, the reference list of each report was searched for further studies. Only reports published in English were included. To ensure that rated manuals actually correspond to the delivered and tested treatments, we included only treatment interventions with explicit adherence rating and scoring and with adequate adherence ratings in the published studies. Five manualized treatments demonstrating efficacy in reducing suicide risk were identified and were independently evaluated by raters using a list of treatment interventions. RESULTS The common interventions included a clear treatment framework; a defined strategy for managing suicide crises; close attention to affect; an active, participatory therapist style; and use of exploratory and change-oriented interventions. Some treatments encouraged a multimodal approach and identification of suicidality as an explicit target behavior, and some concentrated on the patient-therapist relationship. Emphasis on interpretation and supportive interventions varied. Not all methods encouraged systematic support for therapists. CONCLUSION This study identified candidate interventions for possible effectiveness in reducing suicidality. These interventions seem to address central characteristics of suicidal patients. Further studies are needed to confirm which interventions and which combinations thereof are most effective.

Suicide Fantasy as a Life-Sustaining Recourse

The suicide literature tends to lump all suicidal ideation together, thereby implying that it is all functionally equivalent. However obvious the claim that suicidal ideation is usually a prelude to suicidal action, some suicidal daydreaming tends to inhibit suicidal action. How are we to distinguish between those daydreams that augur an impending attempt from those that help patients calm down?

Traumatic subjective experiences invite suicide

The overwhelming events that lead to posttraumatic stress disorders and similar states are commonly understood to arise from noxious external events. It is however the unmasterable subjective experiences such events provoke that injure the mind and ultimately the brain. Further, traumatic over-arousal may arise from inner affective deluge with minimal external stimulation. Affects that promote suicide when sufficiently intense are reviewed; we propose that suicidal crises are often marked by repetitions (flashbacks) of these affects as they were originally endured in past traumatic experiences. Further, recurrent overwhelming suicidal states may retraumatize patients (patients who survive suicide attempts survive attempted murders, albeit at their own hands). We propose that repeated affective traumatization by unendurable crises corrodes the capacity for hope and erodes the ability to make and maintain loving attachments.

The patient's experience of validation in psychoanalytic treatment.

The importance of the patients experience of validation is not a new one in psychoanalytic thinking, and can be traced throughout the literature. However, its role as an essential aspect of the psychoanalytic process, particularly in working with intrapsychic conflict, has traditionally been underappreciated. It is argued that validating interventions have an important role in psychoanalytic treatment, and that they often serve to open up, rather than foreclose, the analysis of transference. Marsha Linehans conceptualization of the role of validation in Dialectical Behavioral Therapy provides a unifying framework for a more extensive psychoanalytic consideration of validation. After a review of the psychoanalytic literature, a number of conceptual issues are discussed that have complicated thinking about validation from a psychoanalytic perspective. Two clinical examples are presented, one from the authors psychoanalytic practice and one from his own analysis. Both illustrate how active validation by the analyst can play an essential facilitating role in the psychoanalytic process.

Comparison of Journals of Suicidology

BACKGROUND Three English-language journals deal explicitly with suicide phenomena. To the best of our knowledge, no previous study has analyzed the subject content of these three journals. AIMS To review the abstracts of the three suicide-related journals in order to clarify the subjects of the papers. METHODS We examined all abstracts of every paper published in Crisis: The Journal of Crisis Intervention and Suicide Prevention, Archives of Suicide Research, and Suicide and Life-Threatening Behavior for the 5 years between 2006 and 2010, and categorized each paper by subject. RESULTS We found that the journals were similar with respect to subject allocation. Most papers dealt with epidemiological issues (32.7-40.1% of abstracts); prevention (5.8%-15.3%) and research (8.3%-10.6%) were next best represented subjects. Clinical papers comprised from 2.8% to 8.2% of the studies published. CONCLUSIONS English-language suicide journals publish a preponderance of epidemiological studies. Clinical studies are relatively underrepresented.

Case Management for Frequent Emergency Department Users

To the Editor: Repeated emergency department utilization reflects unmet clinical need, is costly, and contributes to emergency department overcrowding. Mental health and substance use disorders are common among these patients, prompting proposals for greater use of emergency department– based case management. The literature on this intervention is limited, and studies have yielded mixed results in terms of efficacy and cost-effectiveness (1). Here we describe our experience with patient engagement in this intensive intervention from a pilot program conducted in 2009 and 2010 at two emergency departments. Adults (N5297) with primary mental health or substance use diagnoses and evidence of high emergency department utilization (four or more emergency department visits in the prior year or two or more visits in the past 30 days) were invited to participate in the case management program. Participants were recruited via a mixture of direct engagement, letter, or phone call and received a restaurant gift card (

Self-Harming Behavior and Suicidality: Suicide Risk Assessment

20 value) after completing the enrollment interview. At enrollment, participants completed the Addiction Severity Index Lite (ASI Lite) (2) and the Schwartz Outcome Scale (SOS-10), a measure of self-reported psychological distress (possible scores range from 1 to 60, with lower scores reflecting greater psychological distress) (3). Institutional review board approval for this study was obtained, and written informed consent was obtained from all participants. We defined “engagement” as at least one additional contact with the case manager up to 12 months after the baseline interview. “Unengaged” participants did not follow up with scheduled in-person case management visits and were either unreachable by phone or did not return outreach attempts at phone contact. Of the 297 eligible patients invited, 127 (43%) agreed to participate and completed written informed consent. Of the 127 enrolled patients, ten later withdrew consent and four died of causes unrelated to the study. Thus the final study sample was 113 participants who completed baseline data. Fifty-seven percent (N563 of 111 for whom data were available) were male, 86% (N594 of 109) were Caucasian, and 92% (N5101 of 110) were single or divorced. The mean6SD age was 41.2612.5 years, and the mean education level was 10.364.7 years. Sixty-eight percent of the participants engaged with the case manager. Unengaged patients had higher scores than the engaged patients on the psychiatric health domain of the ASI Lite (.656.21 versus .566.23, p5.04), indicative of greater baseline symptom severity (possible scores on this domain range from 0 to 1). Similarly, unengaged participants reported greater degrees of baseline psychological distress on the SOS-10, compared with participants who engaged with the case manager (28.0614.1 versus 35.86 13.3, p5.01). Overall, we found that only 26% (N577 of 297) of the eligible highutilizing population ultimately engaged with this service and that patients who exhibited greater psychiatric severity and psychological distress were less likely to engage with case management. These findings are consistent with prior studies on the difficulties of engaging and retaining patients with psychiatric conditions who are recruited from the emergency department (4). The findings also suggest that baseline illness severity and self-rated quality of life, which were previously found to be associated with early termination from outpatient case management (5), may be helpful in identifying patients at greater risk of dropout from emergency department– based case management. Targeted retention techniques may therefore be necessary for this vulnerable population. Anthony Weiss, M.D., M.B.A. Mark Schechter, M.D. Grace Chang, M.D., M.P.H.

Postdischarge suicide: A psychodynamic understanding of subjective experience and its importance in suicide prevention

The patient who is discussed in this article represents some of the difficulties regularly faced by clinicians dealing with suicidal patients, such as how to assess the real risks involved when a patient denies any plans to kill herself. The case consultants emphasize the importance of a thorough suicide risk assessment, and the importance of considering a broad overview of the patient’s presentation. Protective factors, such as the patient’s stated reasons for living, which are usually ties to loved ones or work, are not enough. Similarly, the patient’s denial of current suicidal ideation does not necessarily mean that there is no further risk for suicide. The complexity of this evaluation and the tensions that it balances require knowledge, training, skill, and time. Short circuiting this process leads to unnecessary risk taking with potentially lethal consequences. Modern psychiatric inpatient stays put pressure on the clinician to discharge patients in a very short period of time, often prematurely. Consideration of the points raised by these consultants can help in this complicated assessment.