William R. Dubin

Pharmacotherapy of psychiatric emergencies

The psychiatric emergency service has become a major provider of psychiatric care over the past decade. Concomitant with this growth has been an emphasis on pharmacological treatment. While rapid tranquilization is the best known and most frequently used intervention, a growing diagnostic awareness has led to a variety of other chemotherapeutic approaches. The current reviews of pharmacologic intervention in the psychiatric emergency service do not detail the variability of treatment approaches or examine alternative treatment approaches. The goal of this article is to critically review current pharmacologic treatments and address areas in which there is no consensus in treatment approach. From this review the authors suggest guidelines for pharmacotherapy of psychiatric emergencies. The authors discuss rapid tranquilization, the treatment of alcohol and drug intoxication and withdrawal, and anxiety disorders.

Geriatric Psychiatry in the Emergency Department: Characteristics of Geriatric and Non-geriatric Admissions

A study was made of the Emergency Department records of 49 elderly (65 years old or older) and 49 middle‐aged (40–64 years old) patients seen in an urban hospitals psychiatric emergency service. The data were compared for demographic and admission information, psychiatric treatment history, presenting complaints, symptoms, diagnoses, and final disposition status. For the elderly patients, the referral was more likely to be their first contact with psychiatric treatment, and they were more likely to be referred (accompanied) by family or friends than to be self‐referred. Among the middle‐aged patients, “substance abuse” (e.g., drugs, alcohol) disorders and schizophrenic disorders were more common. The elderly, however, were much more likely to be regarded as having an organic brain syndrome of unspecified cause (34.7 per cent vs 0). Access to treatment was fairly consistent for both groups as measured by the hospitals priority code, total time spent in the emergency department, and final disposition. These results raise important issues concerning the unique psychosocial characteristics and psychiatric treatment needs of elderly patients. This applies particularly to the emergency‐department medical clearance of elderly patients with symptoms of organic brain syndrome.

The Efficacy and Safety of Maintenance ECT in Geriatric Patients

lectroconvulsive therapy (ECT) is commonly prescribed for older patients. After acute treatment E with ECT, some patients are continued in maintenance ECT (M-ECT) treatment because of drug refractoriness or inability to tolerate drug side effects. Some M-ECT patients are in partial or full remission from their depressive illness and receive ECT once or twice a month to prevent relapse or recurrence. Most M-ECT’-9 studies have not specifically addressed the issue of efficacy and safety in patients over 75 years of age. We havP previously reported on the efficacy and safety of M-ECT in an older (average age 68 years) population.’ Here we present data on the eight patients over the age of 75 from this earlier study who were successfully and safely treated with M-ECT. Four cases are reported in detail.

Geriatric Psychiatry in the Emergency Department, II: Evaluation and Treatment of Geriatric and Nongeriatric Admissions

The records of a hospital psychiatric emergency department were reviewed for elderly and middle‐aged patients who were diagnosed with organic brain syndrome (OBS) or psychiatric disorder. These records were then compared with those of elderly patients from the medical emergency department. While elderly medical patients received routine physical evaluations and laboratory testing, elderly psychiatric patients with behavioral symptoms were often referred to psychiatry before they received tests necessary to differentiate physical disorders from functional psychiatric disorders. When tests were administered to psychiatric patients, many abnormal results were apparent, indicating the possible presence of physical disease. It is recommended that all elderly patients with psychiatric symptoms undergo adequate medical evaluations to screen for physical causes of the psychiatric symptoms.