Behavioral emergencies are a common and serious problem for consumers, their families and communities, and the healthcare providers on whom they rely for help. In recent years, serious concerns about the management of behavioral and psychiatric emergencies—in particular, the misapplication and overuse of physical and chemical restraints and seclusion—have become a focus of attention for mental health professionals and policy makers as well as for the lay public, the media, and patient advocacy organizations. Policy leaders and clinicians are searching for ways to balance the rights of consumers with considerations of safety and good care in an area in which it is difficult to conduct research. A survey of mental health professionals who are experts on the treatment of psychiatric and behavioral emergencies identified consumer input and collaboration between patient and clinician whenever possible as being extremely important in achieving the best short-term and particularly the best long-term outcomes for patients. The survey of consumer perspectives described in this article was undertaken in response to the need to better understand consumer experiences and preferences. The authors describe four emergency services forums conducted in 2002, which involved a total of 59 consumers. Each forum involved a written consumer survey as well as a workshop to develop and prioritize recommendations for improving psychiatric emergency care. The authors present the results of the consumer survey and summarize the top recommendations from the workshops. In both the survey and the workshops, the consumers repeatedly stressed the importance of having staff treat them with respect, talk to them, listen to them, and involve them in treatment decisions. There were a number of important areas of agreement between the recommendations of the consumer panel and those of the experts in emergency psychiatry surveyed for the Expert Consensus Guidelines on the Treatment of Behavioral Emergencies. These include the desirability of verbal interventions, the use of a collaborative approach, and the use of oral medications guided by the individual consumer’s problems, medication experiences, and preferences. The majority of the consumer panel reported adverse experiences with general hospital emergency rooms and, in fact, called for the development of specialized psychiatric emergency services such as those recommended in the Expert Consensus Guidelines. One-fifth of the consumer panel attributed their emergency contact to lack of access to more routine mental health care. The consumers clearly do not reject medications categorically. Almost half indicated that they wanted medications and a similar number indicated benefit from medications, although many complained of forced administration and unwanted side effects. The consumer panel preferred benzodiazepines and ranked haloperidol as a least preferred option. Among their key recommendations for improving psychiatric emergency care, the consumer panel stressed the development of alternatives to traditional emergency room services, the increased use of advance directives, more comfortable physical environments for waiting and treatment, increased use of peer support services, improved training of emergency staff to foster a more humanistic and person-centered approach, increased collaboration between practitioners and patients, and improved discharge planning and post-discharge follow-up. The implications of these findings for improving psychiatric emergency care are considered.
ALLEN: University of Colorado School of Medicine; CARPENTER: Comprehensive NeuroScience, Inc.; SHEETS: Mental Health Services Design Consultant, Syracuse NY; MICCIO: People, Inc., Poughkeepsie, NY; and ROSS: Ross Editorial.
Please send correspondence and reprint requests to: Michael H. Allen, MD, University of Colorado Hospital, University North Pavillion, 4455 East 12th Ave., Denver, CO 80220.
Acknowledgment: This project was conducted by Comprehensive NeuroScience, Inc., with the support of an educational grant from Janssen Pharmaceutica, L.P. We want to thank all the consumers who participated in the psychiatric emergencies forums for sharing their experiences and valuable insights. We also acknowledge the following individuals and organizations for their help in making these forums a reality: Scott Ebner, Vocational Services Coordinator for Onondaga County in Syracuse, NY; Lisa McChesney, Director of Unique Perspectives, a consumer advocacy agency in Syracuse, NY; Brian Philips, Coordinator of the Peer Networking Group, an upstate NY regional consumer advocacy network; Harvey Rosenthal, Director, and Matthew Mathai, Assistant Director, of the New York Association of Psychiatric Rehabilitation Services (NYAPRS), headquartered in Albany NY; Grace Nichols, Supervisor of the NYAPRS Advance Directive Training Program; Magellan Behavioral Care of Iowa and their Consumer Advocate, Miriam Righter, in Des Moines, Iowa; and Jessica Martinez, Patients Rights Advocate with the Patients Rights Office of the Los Angeles County Department of Mental Health in Los Angeles, CA. The authors also thank the Advance Directive Trainers of the NYAPRS Advance Directives Regional Education Program, Grace Nichols, Kate Dellis-Stover, Ann Marie Casey, and Derrell Hennings, for their valuable help in developing the survey instrument used in this study. We acknowledge Paola Vega for coordinating survey data entry and thank Richard Pulice, PhD, for his helpful comments on the manuscript.