Emergency Psychiatry
It is a testament to the coming of age of emergency psychiatry that a text of this caliber can be produced. Michael H. Allen, the editor of Emergency Psychiatry, assembled national experts in the field of emergency psychiatry to concisely write about the acute evaluation and care of psychiatric patients. This text, which is part of American Psychiatric Publishing's "Review of Psychiatry" series, will be valuable to both inpatient units and emergency services, because the topics it covers are germane to both. For example, the focus on managing patients' aggression is timely for both settings because of current efforts by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration) to decrease the use of physical and chemical restraints. The authors provide a practical review of acute psychopharmacology and behavioral intervention techniques to assist the clinician in this endeavor.
The text is divided into five chapters and is succinct. All the chapters are well written. In the first chapter, "Structure and Function of Psychiatric Emergency Services," Richard E. Breslow enumerates the multiple existing and evolving delivery models for emergency psychiatric care—consultation, specialized psychiatric services, crisis hospitalization, and mobile units. The staffing of these various models is also diverse. The second chapter, by Glenn W. Currier and coauthors, explores medical, psychiatric, and cognitive assessment in the psychiatric emergency service. The authors note the high incidence of comorbid medical illness among patients in the psychiatric emergency service—50 percent of the patients have major medical illnesses—and review the literature to determine how to best assess for these illnesses in the acute care setting. These authors also comment on the Accreditation Council on Graduate Medical Education's scant four-month general medical requirement for psychiatric residents, suggesting that residents may be poorly equipped to handle even routine medical problems.
The book's final chapter, "Psychosocial Interventions in the Psychiatric Emergency Service: A Skills Approach," by Ronald C. Rosenberg and Kerry J. Sulkowicz, rather than offering a reductionistic view that presents the patient's out-of-control behaviors as a product of neurochemical processes, emphasizes the complexity of the patient's internal world, the importance of ongoing familial interactions, and the patient's accrued experiences and psychological processes. The authors offer several therapeutic models for working with these patients. They accurately portray the psychiatric emergency service environment and its limitations: "The milieu of the PES is noisy, with minimal privacy and overlapping staff roles that can be confusing to the patient. Referrals to the PES typically have a coercive component…. There is little time for the building of therapeutic relationships; nor is there always consistency of approach among staff…nevertheless, …some aspect of virtually every therapeutic approach can be useful in the PES, particularly if the clinician remains flexible and has modest goals."
Given the current prominence of emergency psychiatry, it is easy to forget that this field is still in its infancy; nearly all its founders are still vital and productive. Emergency Psychiatry will serve as valuable documentation of the current state of the field for those of us who are employed by inpatient units, psychiatric emergency services, and medical emergency departments.
Dr. Hughes is vice-chair in the department of psychiatry of Boston Medical Center.
