aaep spring 2013 newsletter
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AAEP Spring 2013 NewsletterTRANSCRIPT
Inside this issue
Members Only Listserv ............ ....2
Calling All Authors ................... ....3
Change of AAEP Staff ............... ….4
National Updates on Behavioral Emergencies ............................ ….4
A Place at the Medical Center.. 5-9
Institute on Psychiatric Services...7
Topics in Emergency Psychiatry 2013 Series .............................. 11
American Association For
Emergency Psychiatry
Newsletter Spring Issue 2013
Got Hobby?
Most of us don't dwell on questions, at least not interview and mental
status exam questions. We may dwell at times on existential or
economic questions as the stock market goes up and down. But,
informal observations of colleagues and trainees reveals mostly a
repetition of well-worn queries learned in school or clinical rotations.
Local vernacular provides variations like anyone trying to do you dirt
from one colleague in pursuit of paranoid thoughts. And, a few of us
ask patients to spell earth or globe backwards rather than world. There
is mundo for Spanish speakers and monde for Francophones. Falling
back to four letters reveals that people have more trouble with exit
than stop, though both appear frequently in the American scene.
Asking patients to spell live backwards is unhelpful.
There seems to be more variety among opening questions: What brings
you here? or Why did the police bring you here? or a patient centered
What can we do for you today? It is not evident that any one is any
better than another. Cogent arguments can be made that patients do
not attend to opening questions any more than we attend to common
greetings like Hello, how are you? All are uttered in service of a social
task, breaking the ice. Many patients would do fine with Hello, I'm
doctor Smirtz. Mumble, mumble, mumble followed by a facial
expression of concerned attention.
I have no citations to support all of this. I will only paraphrase Yogi
Bera: you can learn a lot just by listening.
Questions in the middle of the interview, the second quarter, are the
trickiest. We are in pursuit of our patient's story. We want to know why
this day is different from every previous day. And it is their story, not
the checkboxes on our form, which will yield the clearest insight into
diagnosis and treatment. Anyone who has listened to AAEP Past
President Dr. Jon Berlin’s lecture on interviewing and engaging a
patient in crisis, knows what I mean. Unfortunately, there is no simple
(Continued on page 2)
Seth Powsner, MD
President 2012-2014
Letter from the President
formula for enticing a person to share the facts of their life (though the
CIA and its competitors are working on it).
What about the third quarter of an interview? What are good questions
to explore those possibilities we feel compelled to check, whether or not
they seem relevant to a case? I was taught to ask something like Have
you had any thoughts of killing yourself? I asked this during my oral
board exam of a talkative, manic patient. She did not answer directly, she
just continued rambling. However, my examiners judged that I had
discharged my responsibility to check for suicide risk. Years later, while
revising a form for trainees, I was inspired to try some alternatives. Now I
ask, Is there any reason anyone would think your were out to hurt
yourself (or anyone else)? The results have been rewarding. No one
glares back at me and exclaims How dare you suggest such a thing-- I'm a
very religious person and would never contemplate suicide. Most patients
simply say NO, or No, I don't believe so. Some are suicidal, and they
answer the underlying question with I keep thinking of ways to end my
life. And, every now and then someone says, No, I'd never kill myself, but
the way I've been acting/drinking/yelling, my family is probably worried
about me. Win-win! Fewer bad feelings, more information, just for slight
change of wording.
What about Adam Lanza, the shooter at Sandy Hook Elementary School?
If he had come to psychiatric attention, would he have told anyone
anything about his plans? Probably not. Recent news leaks suggest years
of quiet planning with an aim to raise the score, set a new record for
deaths in one shooting event. No violence checklist asks do you make
long spread sheets? (Luckily, he did not seem to have studied the Bath,
Michigan School Disaster of 1927 which killed 38 young children, 6
adults, and injured another 58 according to Wikipedia.)
But, assuming he had come to our attention, perhaps for threatening
someone at a bar, or a shooting range, what question might have been
yielded a clue? We could ask if he intended to hurt anyone. He might be
insulted if he took it to indicate we believed he was foolish enough to
reveal his careful plans. Or, he might take our query as pro-forma, if he
believed we recognized him as a smart young man, but that we were
obliged to ask 'cause it was on some form.
So assuming he'd talk at all, what might draw him out? My fallback is
something like: I've never met you before. Where are you from, where did
you grow up? What was it like? What did your parents do for a living?
Most people answer at length. Some talk because they enjoyed their
childhood, some because they hated it, and either way, they hope I'll
take their side. Unfortunately, Adam Lanza might only have described a
common childhood story of divorced parents and trouble finding a
suitable major in college.
(Continued on page 3)
Letter from the President (continued)
2
Members-only Listserv
AAEP has recently created a listserv
discussion group that is available via
invitation to members in good
standing only. This will be a great
opportunity to discuss pressing
issues, diagnostic dilemmas and
treatment approaches in Emergency
Psychiatry, and obtain consultation
from your fellow experts on difficult
cases. Please accept the invitation
and join us today!
There is nothing to fear, it will be
very easy to unsubscribe if you
choose to do so at a later time.
If you have misplaced or did not
received your invitation email, please
contact Marie Westlake at:
3
Upcoming Events
APA Annual Meeting
San Francisco, CA
May 18-22, 2013
AAEP Board Meeting
May 20, 2013
1:00 p.m.—5:00 p.m.
Westin St. Francis
Victorian Room
(Second Floor)
AAEP Annual Business
Meeting and Reception
May 20, 2013
6:30 p.m.—8:00 p.m.
Westin St. Francis
Victorian Room
(Second Floor)
IPS Conference
Philadelphia, PA
October 10-13, 2013
4th Annual National Update on
Behavioral Emergencies
Orlando, FL
December 11-13, 2013
Calling All Authors!
What about hobbies? Some will say they can't afford a hobby in today's
economy. Some will reveal potentially significant exposure to solvents or
poisons. Some will mention their guns or swords-- they are much more
inclined to talk about them as a collector's fancy rather than as a risk factor.
I had a fascinating discussion of assault weapons with an aficionado who
made it clear he saw no reason for any civilian to own one that actually
fired automatically. Sober, he went on at length about the history and
specifications of military weapons. We were only talking because he had
said something stupid at a bar.
Should hobbies be the appropriate focus of serious psychiatric attention,
like delusional thinking? They seem a little frivolous. And perhaps that's the
point: people will often drop their guard a bit on the subject of hobbies and
sports. It's just a hobby. It's just a game. Likewise with humor (a tricky tool
in psychiatry). But all of these give clues about what matters and what
doesn't matter to a person. Hitler liked to paint, but it is said that his
paintings didn't include many people.
What might Adam Lanza have said about his hobbies? He might simply have
opined something about the merits of Xbox over PlayStation. Then again,
maybe he would have really gotten into it. We will probably never know.
Still, it is an interesting question.
Letter from the President (continued)
The American Association for Emergency Psychiatry would like to invite all members
and colleagues in the field of Emergency Psychiatry to submit a manuscript or book
review for publication in the AAEP Journal, Emergency Psychiatry.
This Journal is intended to be a forum for the exchange of multidisciplinary ideas.
Manuscripts are welcomed that deal with the interfaces of emergency psychiatry. This
includes psychiatric evaluation of individuals in the emergency room setting, educa-
tion and training in the field and research into causes, and treatment of behavioral
problems. Manuscripts are evaluated for style, clarity, consistency, and suitability.
Submit manuscripts or queries electronically to: Marie Westlake, Executive Assistant,
at: [email protected]. Include the address, telephone number, and
email address for the corresponding author on all manuscripts.
Dear AAEP Members,
As we work on this newsletter and prepare for the San Francisco meeting, my co-
workers and I are already missing our friend Jacqui Davis. As you know, Jacqui has
moved on to serve as Executive Assistant to the CEO of the Girl Scouts of
Connecticut. We wish her the best and know that she will succeed and excel in
this new endeavor. They are lucky to have her.
I have worked with the AAEP in various positions since 2003. In addition to
training new staff members, I have worked on the website and have assisted on-
site at several of the Annual Meetings. I now look forward to assuming the
responsibilities of the AAEP’s Executive Assistant and meting and working with
you all.
Regarding my professional background, I have been with S & S Management
Services for approximately fifteen years and have worked with several medical
associations over those years. Previous to this, I worked for many years at
Hartford Hospital/Connecticut Children's Medical Center, where I started out as
Office Manager in the Department of Psychiatry and later served as Graduate and
Postgraduate Medical Education Coordinator in the Department of Pediatrics.
On a personal note, I live in Suffield, Connecticut, with my husband, Bill. In my
spare time, I serve on the Executive Board of Wildfire Farms Equine Rescue where
our own two rescued quarter horses, Jack and Annie, live. Horses have always
been my passion and working with the Rescue is an incredibly rewarding
experience for me.
Please contact me any time by phone (888-945-5430) or email
([email protected]) if I can answer questions or assist you in any way. I
hope to see you in San
Francisco!
4
AAEP Member Announcements
What’s going on with your
Emergency Psychiatry facility, with
you and your staff? We’d like to
know and share it with other AAEP
members in our informal
newsletter. Has your program
moved to a new building? Did you
or one of your attendings publish
an article related to Emergency
Psychiatry? Have you, your staff, or
your program recently been
honored? Is there a new
educational or training process you
are using that you believe could
help your peers? We welcome you
to share any news relevant to
Emergency Psychiatry with your
fellow members. Please send your
announcements to us by email to:
Please join us this year for the 4th Annual
National Update on Behavioral Emergencies in
Orlando December 11-13. For further
information, go to
www.behavioralemergencies.com, or contact
Dr. Les Zun at [email protected].
Change of AAEP Office Staff By: Marie L. Westlake
Jack & Annie
5
A Place at the Medical Center: Evolving Paradigms and Their Effect on Emergency Psychiatry By: Jon S. Berlin, M.D.
Most if not all of the best Psychiatric Emergency Services (PES’s) and
Comprehensive Psychiatric Emergency Programs (CPEP’s) are located in a medical
center. Are there intrinsic reasons for this and should the relationship continue or
are there other good locations to consider? Evolving paradigms in psychiatry and
medicine require that we periodically re-examine our conceptualization of
psychiatric emergencies with open-minded pragmatism. What are the high
volume, high risk and problem prone cases, and what are the tools that we as
emergency practitioners need to treat them?
Since the Community Mental Health Act of 1963, the trend in psychiatric
treatment for severe and persistent disorders in the U.S. has been a shift in the
locus of care away from the hospital and toward the community. Emergency
(Continued on page 6)
Interested in writing for the Newsletter?
All members of AAEP are invited to
submit articles for publication the
Newsletter. We welcome articles
relevant to the field of Emergency
Psychiatry from all perspectives:
from psychiatrists working in a PES
to social workers, nurses, students,
or physicians in the field.
Newsletters are sent to the
Membership electronically on a
quarterly basis.
For deadlines and additional
information on how you can
contribute to the Newsletter,
please contact Marie Westlake at
888-945-5430 or email
psychiatry has followed suit. Just as the ground-breaking program of assertive
community treatment (ACT) in the 1970s significantly expanded our notion of
ambulatory care (1), innovations in crisis service such as mobile outreach,
neighborhood crisis houses and in-home treatment broadened our view of
emergency care, extending it beyond the bricks-and-mortar emergency
department (ED) and PES (2).
A series of significant developments in psychological therapy accompanied this
expanded crisis service model. Our field has established a strong systems and
family perspective that catches crises early in their course. Weaving together
different theoretical strands, state-of-the-art crisis care aspires to an approach
that is trauma-informed, non-coercive (3), strengths-based, motivational, solution
-focused, patient-centered, and recovery-oriented.
The biological movement in psychiatry, symbolized by the 1990-2000 “Decade of
the Brain,” has been another major trend. This rests on the foundation of the
biopsychosocial model and recognizes the surging investigation into the genetic,
anatomic, and neurophysiological bases of severe mental illness. It continues to
exert profound influence on the field. New medications have led to a quantum
leap in our effectiveness. Functional brain imaging studies are increasingly
illuminating. Not only do they hold great promise for breakthroughs in research,
but they are also headed for routine use in clinical diagnosis and monitoring of
treatment.
Fifty years after the Mental Health Act, another paradigm shift in psychiatry has
moved front and center: complete integration with primary care and medical
specialties coupled with the 2010 Accountable Care Act’s (ACA’s)
pressing emphasis on a system of payment that is based on outcomes and cost
containment. To mention just a few of the indications of this rapidly burgeoning
movement: the project at the Mayo Clinic co-locating ambulatory psychiatry and
medicine (4), Oregon’s state-wide Coordinated Care Organization experiment (5),
emergency medicine’s efforts to reinvigorate its emergency psychiatry capability
(6), and current statements about philosophy coming out of the AMA (7) and the
American Psychiatric Association (8). These new directions* are not necessarily
incompatible with the general migration of psychiatric services to the community,
but they definitely add layers of complexity and raise questions about the best
way to format crisis services.
Not coincidentally, emergency patients today are sicker than ever before and
healthcare policy makers and politicians around the country are facing some of
their toughest budget decisions in years. Inevitably, they will be forced to re-
examine all of their emergency services anew and ask familiar questions with a
new intensity: What’s the best use of scarce mental health resources? Can we get
by with small crisis centers in the community? Do we really need a PES or CPEP?
(A CPEP is PES integrated with an observation/treatment area and community-
based crisis services.) How much access do our crisis clients need to medical
(Continued on page 7)
A Place at the Medical Center (continued)
6
References
1 Test MA & Stein LI Practical guidelines for the community treatment of markedly impaired patients. Community Mental Health Journal, 1976, 12, 72-82.
2 Hughes DH. Trends and treatment models in emergency psychiatry. Hosp Community Psychiatry, 1993; 44:927-928.
3 Richmond JS, Berlin JS, Fishkind AB, Holloman GH, Zeller SL, Wilson MP, Rifai MA, Ng AT. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry BETA De-escalation Workgroup. Western Jour of Emerg Med, 2012 Feb; XIII(1):17-25.
4 Williams M, Angstman K, Johnson I, Katzelnick D. Implementation of a care management model for depression at two primary care clinics. J Ambul Care Manage, 2011 Apr-Jun; 34(2):163-73.
5 Kitzhaber J. Oregon bets on coordinated care. Interview with Hayden Bush. Hosp Health Netw, 2013 Jan; 87(1):32-3, 1.
6 Zun L, Chepenik LG, Mallory MS. Behavioral Emergencies for the Emergency Physician. Cambridge University Press, 2013.
7
A Place at the Medical Center (continued)
ED’s? What about new technologies? Do we need to be located at a medical
center? Is there any added value of an academic medical center?
The PES Perspective
In certain respects, the community-based crisis approach redefines our idea of
emergency care. But anyone who has manned the battle stations in PES has seen
first-hand an irreducible subset of the emergency population that does not fit the
alternative treatment models: individuals with high degrees of dangerousness or
impairment or sexual misconduct who are antipathetic to therapeutic
engagement or non-responsive to treatment. They are the raison d’etre of the
PES, and the alternative crisis response centers would flounder quite literally
without PES there to back them up. It is crucial to recognize this reality.
Moreover, there will probably always be police officers and ED personnel and
others with minimal mental health training who cannot make more modern triage
decisions and who need a one-stop shop. Consequently, for large urban areas,
there is a consensus that PES retains its indispensable role as the nerve center and
clearinghouse of the emergency mental health system (9, 10).
The advent of universal healthcare coverage will not substantively alter this
situation. We look forward to the day when PES will be relieved of its inefficient
safety net role for the uninsured. But lack of a funding source is not the only
obstacle to transitioning certain individuals into private hospitals or community-
based treatment settings.
Accordingly, the public sector hospital also retains its place in the spectrum of
care for individuals with acute undiagnosed illness or the most severe and
disruptive disorders. Despite PES having supplanted its triage function with an
(Continued on page 8)
7 Moran M. AMA president calls for shift in values to integrated care. Psychiatric News. Amer Psychiatric Assoc, Dec 07, 2012; 47(23): 1-9.
8 Brink, D. Integrative care is the future of psychiatric care. Clinical Psychiatry News. International Medical News Group, LLC. Mar 05, 2013.
9 Allen MH. Level I psychiatric emergency services: the tools of the crisis sector. Psychiatric Clin North Am, 1999; 22:713-734.
10 Lee TS Renaud EF, Hills OF. Emergency psychiatry: an emergency treatment hub-and-spoke model for psychiatric emergency services. Psychiatric Serv. 2003; 54(12): 1590-1591, 1594.
11 Forster P, King J. Definitive treatment of patients with severe mental disorder in an emergency service. Part I. Hosp Community Psychiatry, 1994; 45:867-869.
12 Koran LM et al. Medical disorders among patients admitted to a public-sector psychiatric inpatient unit. Psychiatric Serv, 2002 Dec; 53(12): 1623-5.
13 Mirin S, Summergrad P. The evolving academic health center: challenges and opportunities for psychiatry. Acad Psychiatry, 2011; 35:89-95.
Save the Date!
65th Institute on Psychiatric Services Philadelphia, PA
October 10-13, 2013
Theme: Transforming Psychiatric Practice,
Reforming Health Care Delivery
A Place at the Medical Center (continued)
active treatment function (11), it cannot turn everyone around. Some people
need more time. It is also a given that the more dangerous an individual has been
in the community, the longer it takes the community to accept him back. There is
still a need for the PES observation unit, the crisis stabilization unit, and the
hospital.
Doctors, nurses, social workers and others working in PES see high degrees of
medical acuity. There are serious medical problems such as delirium with a
pseudo-mental health presentation, and there is a disproportionate amount co-
morbid medical illness in the psychiatric population (12). There are patients on
complicated medication regimens with the potential for serious side effects and
drug-drug interactions. PES patients are referred every day to the ED for medical
evaluation and stabilization. Some of them are rushed to an ED for life-
threatening emergencies. Some of them that originated in an ED are returned to
the referring ED to address occult medical problems that were missed the first
time.
A Place at the Medical Center
Once the essence of PES is distilled, its preferred location at a medical center
becomes apparent. There are number of reasons for this. Additional benefits
accrue from its being in an academic medical center with strong psychiatry and
emergency departments:
Medical Safety: The prevalence and severity of medical problems in the
emergency psychiatry population warrants close physical proximity to
emergency medical services. Since a PES cannot ensure viability without
guaranteed throughput to some of its own beds at the back end, there
will inevitably be a sizable number of patients with ongoing medical
needs for continuous primary and specialty care, as well as unplanned
emergency care.
Integrated Care: Co-location of psychiatry with all of the medical specialties
at a medical center creates new opportunities for cost containment and
better medical and psychiatric outcomes. It also supports the biological
element of psychiatry.
Credibility and Legitimacy: Locating a PES at a medical center gives it
significant credibility and legitimacy. Psychiatric patients and their
caregivers are constantly at risk for being marginalized. This is
particularly true for the PES population. Architectural symbolism is
important. Situating a PES in a center of higher learning and specialty
care is the single most powerful thing that committed policy makers can
do to combat the stigma of mental illness.
Intellectual Resources: At its best, an academic medical center is a university
(Continued on page 9)
8
AAEP Board Roster
President
Seth Powsner, MD
President-Elect
Kimberly D. Nordstrom, MD
Immediate Past President
Scott Zeller, MD
Board of Directors:
Leslie Zun, MD, MBA
Jagoda Pasic, MD, PhD
Daryl Knox, MD
Jack Rozel, MD
Social Work Liaison
Janet Richmond, MSW
Director, Emergency Psychiatry
Research
Michael P. Wilson, MD, PhD
Director, Emergency Psychiatry
Standards and Guidelines
Garland H. Holloman, Jr., MD
AAEP Executive Office Staff:
Executive Director
Jacquelyn T. Coleman, CAE
Executive Assistant
Marie L. Westlake
American Association for Emergency Psychiatry One Regency Drive
P.O. Box 30 Bloomfield, CT 06002 Phone: 888-945-5430
Fax: 860-286-0787 Email: [email protected]
Website: www.EmergencyPsychiatry.org
of scientists, leaders and humanitarians at the cutting edge of their field.
Physical proximity and spontaneous interaction fosters intellectual cross-
fertilization and a deep bench of mutual support.
Research: By definition, the types of illnesses found in the PES population are the
hardest to treat, residing at the edges of our scientific knowledge. They
represent the clinical frontier that an academic medical center has the
mission to study and to treat.
Recruitment: The quality of staff is the most important determinant of quality
care. The practice of emergency psychiatry clearly requires a sub-specialty
level of skill, and recruitment and retention of good staff is perhaps the
biggest challenge facing the PES medical director. All of the preceding reasons
for having a PES located at a medical center are selling points when
attempting to recruit and retain staff. Location of the PES adjacent to a
medical school facilitates the training of psychiatry residents in this specialty.
Resident rotations and moonlighting in PES also afford the opportunity to
scout out talent and attract excellent residents to this line of work.
Public Health Mission: It is good for an academic medical center to have a PES
(13). PES’s are living examples of the commitment to public health and faith in
a population that has been stigmatized and marginalized. The PES is also a
bellwether and barometer of the functionality of the broader mental health
system. The better the system functions, the lower the volume and acuity in
PES. Schools of public health have much to learn and then contribute by
studying demographic and other characteristics of the PES population.
Very serious psychiatric emergencies are a fact of life. Patients, staff, police and other
stakeholders welcome the availability of a specialty service to care for them. There are
excellent reasons to have an array of community-based crisis services. But a good PES
is a prized component of a health care system, and there are enduring reasons for the
nexus of the safety net to be rooted in a crucible of expertise and innovation.
*These directions are not brand new. For years, the community psychiatry movement
has promoted integration of any and all the programs with a mental health
connection, including primary care, substance abuse, correctional mental health, social
services, child-protective services, adult services, and vocational rehabilitation. For the
most part, however, these still remain in silos. The treatment model of the ACA is of
course a new, improved version of the original capitated HMO concept.
A Place at the Medical Center (continued)