Gabrielle J. Melin, MD, MS

CASE: A ‘high utilizer’

Ms. Y, a 49-year-old intensive care registered nurse, is admitted to the psychiatric hospital for suicidal ideation for the eighth time in 1 year. Ms. Y has chronic suicidal ideation with multiple attempts and has been on disability for 3 years for treatment of severe depression. She has been hospitalized for depression with suicide ideation 49 times since her divorce 6 years ago. She is prescribed fluoxetine, 60 mg/d, quetiapine, 400 mg/d, and clonazepam, 2 mg/d.

Ms. Y reports the same series of events that preceded her previous hospitalizations: severe insomnia led to a worsening of her other depressive symptoms, including intense suicidal ideation. In an attempt to sleep, she took “a couple” of extra clonazepam. She called her therapist, who was alarmed by her slurred speech and pleas for help. A friend drove Ms. Y to the hospital, where she was directly admitted without being evaluated in the emergency room (ER).

The authors’ observations

Ms. Y possesses 7 of the 11 characteristics of a high utilizer of psychiatric services (Table 1),^1,2 defined as a patient who is:

• 2 standard deviations above the mean number of visits to an urban psychiatric emergency service in 6 months or
  
• has 4 inpatient admissions in a quarter or 6 inpatient admissions in 1 year.
  

Ms. Y always is directly admitted because she refuses to go through the ER for evaluation. She seems to know just how much medication to take to remain medically stable. She receives special treatment—she can call her therapist, ask for admission, and have her request granted. Until now, Ms. Y’s care providers have condoned her entitlement.

Table 1

Common characteristics of high utilizers* of psychiatric services

Homelessness
Developmental delays
Enrolled in a mental health plan
History of voluntary and involuntary hospitalization
Personality disorders
Likely to be uncooperative
Substance abuse or dependence (or history)
History of incarceration
Unreliable social support
Young Caucasian women
* Defined as having either 2 standard deviations above the mean number of visits to an urban psychiatric emergency service in 6 months or 4 inpatient admissions in a quarter or 6 inpatient admissions in 1 year
Source: References 1,2

The author’s observations

Because previous hospitalizations and courses of ECT have provided Ms. Y with only minimal, short-lived improvement, the treatment team decides to reconsider her diagnosis and treatment plan. Ms. Y’s first psychiatrist diagnosed her with major depressive disorder. After thoroughly interviewing Ms. Y and reviewing her history, the hospital psychiatrist determines that she meets criteria for borderline personality disorder (BPD) in addition to major depression. The psychiatrist explains this diagnosis to Ms. Y, provides her with education and support, and recommends dialectical behavioral therapy (DBT) and case management. She rejects the new diagnosis and treatment plan and pleads for help establishing treatment with a new psychiatrist.

The team at the psychiatric hospital feels Ms. Y needs to receive ongoing treatment from a psychiatrist. In the hope that she will be able to establish a therapeutic alliance with a new psychiatrist and therapist, they decide to continue working with Ms. Y if she accepts the BPD diagnosis and agrees to undergo DBT.

EVALUATION: A troubling pattern

Before Ms. Y’s husband divorced her, she had not received psychiatric care and had no psychiatric diagnosis. During the contentious divorce, she experienced depressive symptoms that later intensified, and she was unable to return to her previous high level of functioning.

Ms. Y became suicidal and was hospitalized for the first time shortly after the divorce was finalized and her ex-husband remarried. She began treatment with a psychiatrist, whom she idealized and saw for 5 years.

When this psychiatrist—who had been one of the few stable relationships in Ms. Y’s life—moved to another state, Ms. Y experienced a rapid recurrence of depression. She began treatment with 3 other psychiatrists but fired them because they “never understand me” like her first psychiatrist did, and she never felt she received the consistent, supportive care she deserved. She become suicidal and again required psychiatric hospitalization. This pattern continued up to her current admission.

The authors’ observations

Ms. Y briefly returns to work between hospitalizations but is not able to tolerate the stress. At one point she was admitted to an out-of-state facility; after this 2-month stay, she remained out of the local psychiatric hospital for 6 months but then became unable to function and was readmitted to the local psychiatric hospital.

 

When interviewed, Ms. Y describes feeling hopeless, empty, and alone each time 2 of her 3 children return to college after summer break. Her youngest child lives at home but is involved in extracurricular high school activities, and doesn’t seem to need her. Ms. Y is estranged from both parents. Her social support is unreliable because she tends to push others away and isolate herself.

Her children report that in recent months Ms. Y’s functioning has deteriorated and they are frustrated with her. Ms. Y repeatedly takes more clonazepam than prescribed but adamantly justifies her actions, saying she takes extra doses to sleep or relax. She seems to “run to the hospital” each time she faces a challenge or has a responsibility to fulfill. Many of her hospitalizations coincided with special occasions, such as her children’s birthdays, graduations, and holidays.

The authors’ observations

Because she has no history of mania, Ms. Y does not meet criteria for bipolar affective disorder. Her multidisciplinary treatment team feels she is too fragile to transfer care to new providers or to foster care, so we schedule a care conference and carefully compose a 6-month contract to formally articulate limits and boundaries within which we will continue to treat her.

The contract specifies that Ms. Y will participate in DBT, take her medications exactly as prescribed, and not receive any early refills of her prescriptions. We arrange with Ms. Y’s health plan to have a home healthcare agency provide her medications weekly. This benefit was not available to other health plan members. Ms. Y signs the contract.

TREATMENT: Contract violation

Ms. Y complies with the contract for 2 months, then abruptly fires her long-term therapist, whom she claims violated confidentiality by giving false information to another provider. At her next session, Ms. Y will not provide details about the alleged incident, and the issue never is resolved. She admits she did not start DBT and is not taking her medications as prescribed.

Ms. Y expresses her disagreement with the terms of the contract. She becomes very upset and asks for her care to be transferred to another psychiatrist. She demands to be followed at the current clinic because “I was born here.” She denies being actively suicidal and terminates the session early. That afternoon, she calls 1 of the inpatient psychiatrists and asks if he would treat her. She also calls the first psychiatrist she had seen to enlist help in obtaining care.

The authors’ observations

In Groves’ description of 4 types of “hateful patients,” Ms. Y represents a combination of an entitled demander and a manipulative help-rejecter. The behaviors and personality disorders associated with these types of patients—and effective management strategies—are listed in (Table 2).³ (Table 3) offers tips for successfully dealing with high utilizers of psychiatric services. High utilizers of medical services other than psychiatry are more likely than patients who are not high utilizers to have a psychiatric disorder (Box).^4-9

Box

Ms. Y’s entitlement interferes with her treatment—she has been allowed to dictate her treatment for years and, therefore, has not been managed effectively. She received resources that other patients did not, such as having weekly medication set up by a home healthcare nurse. Rules were bent to help Ms. Y, but allowing her to dictate treatment has made her so dependent that she worsened over time. Knowing that she was receiving special treatment appears to have strengthened her pathologic sense of entitlement.

Some members of our treatment team began to experience countertransference, which also interfered with Ms. Y’s treatment. They viewed her behavior as entitled, demanding, and manipulative and dreaded caring for her. Failing to recognize such defenses can lead to consequences such as malignant alienation—a progressive deterioration in the patient’s relationship with others that includes loss of sympathy and support from staff members—which can put a patient at high risk for suicide.¹⁰

 

After a lengthy discussion among several psychiatrists, therapists, nurses, and attorneys, the treatment team decided to terminate outpatient care for Ms. Y at our facility because of her chronic nonadherence to treatment recommendations. Ms. Y had manipulated numerous providers in our department, called multiple doctors in our facility to ask them to care for her, and asked her ex-husband to contact the department administration on her behalf. Her behavior bordered on harassment. In addition, the interventions we provided were making her worse, not better. Factors that influenced our decision included:

• fear of Ms. Y committing suicide
  
• fear of setting limits
  
• fear of being reported to the Medical Board
  
• fear of a lawsuit.
  

The team sent Ms. Y a registered letter explaining the reasons for the termination and providing referrals for other providers in the area. She was told that she retains access to the ER and can receive inpatient psychiatric care, provided she first is evaluated in the ER.

Table 2

Strategies for helping 4 types of ‘hateful patients’

Dependent clinger
Behaviors	Shows extreme gratitude with flattery
Associated personality traits/disorders	Codependent
Management strategies	As early and as tactfully as possible, set firm limits on the patient’s expectations for an intense doctor-patient relationship. Tell the patient that you have limits not only on knowledge and skill but also on time and stamina
Entitled demander
Behaviors	Intimidates, devalues, induces guilt, may try to control with threats; terrified of abandonment
Associated personality traits/disorders	Narcissistic, borderline personality disorder
Management strategies	Try to rechannel your patient’s feelings of entitlement into a partnership that acknowledges his or her entitlement not to unrealistic demands but to good medical care. Help your patient stop directing anger at the healthcare team
Manipulative help-rejecter
Behaviors	Resists treatment; may seem happy with treatment failures
Associated personality traits/disorders	Psychopathy, paranoia, borderline personality disorder, negativistic, passive/aggressive
Management strategies	Diminish your patient’s notion that losing the symptom or illness implies losing the doctor by ‘sharing’ your patient’s pessimism. Tell your patient that treatment may not cure the illness. Schedule regular follow-up visits
Self-destructive denier
Behaviors	Denial helps them survive
Associated personality traits/disorders	Borderline personality disorder, histrionic, schizoid, schizotypal
Management strategies	Recognize that this type of patient can make clinicians wish the patient would die and that the chance of helping a self-destructive denier is minimal. Lower unrealistic expectations of delivering perfect care. Evaluate the patient for a treatable mental illness, such as depression, anxiety, etc.
Source: Reference 3

Table 3

Tips for managing high utilizers

Establish a collaborative treatment plan with firm limits and expectations Document the treatment plan and encourage the patient to actively contribute Provide the patient with a copy of the plan Have the patient sign release of information for other care providers and have active contact with them for continuity and accountability Specify that the patient can obtain prescriptions or have medication dosages changed only by a psychiatrist or primary care provider Document an emergency department treatment plan to prevent unnecessary medication changes, obtaining narcotics or benzodiazepines if the patient has chemical dependency issues, etc. Involve the patient’s family
Acknowledge your feelings and countertransference Have regular contact with a mentor or colleague for consultation Ask yourself: Are you working harder than the patient? Is the patient capable of working harder or complying? Keep in mind the difference between mental illness and bad behavior
Explore your patient’s expectations and commitment to treatment by asking: ‘What do you consider as barriers to compliance or improvement?’ (Share your thoughts with the patient) ‘What are you willing to commit to in order to get better?’ ‘If I had a magic wand that I could wave and fix1 thing in your life right now, what would it be?’ or ‘What is the number 1 area in your life that is causing distress?’
Practice safely and proactively Determine if the patient has an undiagnosed psychiatric disorder Provide a phone call reminder for appointments Call if the patient does not show up for an appointment Document, document, document

OUTCOME: The pattern continues

Ms. Y continues to receive treatment with a different outpatient psychiatrist and therapist in the area. She has not been hospitalized for almost 2 years but her financial state has deteriorated and she has had a recurrence of depression. Ms. Y’s psychiatrist recently called the hospital to ask for direct admission on the patient’s behalf, stating that Ms. Y did not want to wait hours to be seen in the ER. Hospital staff explained that she needs to first come to the ER for evaluation. Ms. Y refused to come to the ER and was not admitted. About 1 month later, Ms. Y’s psychiatrist called again, and she was directly admitted to the psychiatric hospital.

 

Related resource

• National Suicide Prevention Lifeline. 1-800-273-TALK (8255). www.suicidepreventionlifeline.org.
  

Drug brand names

• Clonazepam • Klonopin
  
• Fluoxetine • Prozac
  
• Quetiapine • Seroquel
  

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or manufacturers of competing products.

CASE: A ‘high utilizer’

Ms. Y, a 49-year-old intensive care registered nurse, is admitted to the psychiatric hospital for suicidal ideation for the eighth time in 1 year. Ms. Y has chronic suicidal ideation with multiple attempts and has been on disability for 3 years for treatment of severe depression. She has been hospitalized for depression with suicide ideation 49 times since her divorce 6 years ago. She is prescribed fluoxetine, 60 mg/d, quetiapine, 400 mg/d, and clonazepam, 2 mg/d.

Ms. Y reports the same series of events that preceded her previous hospitalizations: severe insomnia led to a worsening of her other depressive symptoms, including intense suicidal ideation. In an attempt to sleep, she took “a couple” of extra clonazepam. She called her therapist, who was alarmed by her slurred speech and pleas for help. A friend drove Ms. Y to the hospital, where she was directly admitted without being evaluated in the emergency room (ER).

The authors’ observations

Ms. Y possesses 7 of the 11 characteristics of a high utilizer of psychiatric services (Table 1),^1,2 defined as a patient who is:

• 2 standard deviations above the mean number of visits to an urban psychiatric emergency service in 6 months or
  
• has 4 inpatient admissions in a quarter or 6 inpatient admissions in 1 year.
  

Ms. Y always is directly admitted because she refuses to go through the ER for evaluation. She seems to know just how much medication to take to remain medically stable. She receives special treatment—she can call her therapist, ask for admission, and have her request granted. Until now, Ms. Y’s care providers have condoned her entitlement.

Table 1

Common characteristics of high utilizers* of psychiatric services

Homelessness
Developmental delays
Enrolled in a mental health plan
History of voluntary and involuntary hospitalization
Personality disorders
Likely to be uncooperative
Substance abuse or dependence (or history)
History of incarceration
Unreliable social support
Young Caucasian women
* Defined as having either 2 standard deviations above the mean number of visits to an urban psychiatric emergency service in 6 months or 4 inpatient admissions in a quarter or 6 inpatient admissions in 1 year
Source: References 1,2

The author’s observations

Because previous hospitalizations and courses of ECT have provided Ms. Y with only minimal, short-lived improvement, the treatment team decides to reconsider her diagnosis and treatment plan. Ms. Y’s first psychiatrist diagnosed her with major depressive disorder. After thoroughly interviewing Ms. Y and reviewing her history, the hospital psychiatrist determines that she meets criteria for borderline personality disorder (BPD) in addition to major depression. The psychiatrist explains this diagnosis to Ms. Y, provides her with education and support, and recommends dialectical behavioral therapy (DBT) and case management. She rejects the new diagnosis and treatment plan and pleads for help establishing treatment with a new psychiatrist.

The team at the psychiatric hospital feels Ms. Y needs to receive ongoing treatment from a psychiatrist. In the hope that she will be able to establish a therapeutic alliance with a new psychiatrist and therapist, they decide to continue working with Ms. Y if she accepts the BPD diagnosis and agrees to undergo DBT.

EVALUATION: A troubling pattern

Before Ms. Y’s husband divorced her, she had not received psychiatric care and had no psychiatric diagnosis. During the contentious divorce, she experienced depressive symptoms that later intensified, and she was unable to return to her previous high level of functioning.

Ms. Y became suicidal and was hospitalized for the first time shortly after the divorce was finalized and her ex-husband remarried. She began treatment with a psychiatrist, whom she idealized and saw for 5 years.

When this psychiatrist—who had been one of the few stable relationships in Ms. Y’s life—moved to another state, Ms. Y experienced a rapid recurrence of depression. She began treatment with 3 other psychiatrists but fired them because they “never understand me” like her first psychiatrist did, and she never felt she received the consistent, supportive care she deserved. She become suicidal and again required psychiatric hospitalization. This pattern continued up to her current admission.

The authors’ observations

Ms. Y briefly returns to work between hospitalizations but is not able to tolerate the stress. At one point she was admitted to an out-of-state facility; after this 2-month stay, she remained out of the local psychiatric hospital for 6 months but then became unable to function and was readmitted to the local psychiatric hospital.

 

When interviewed, Ms. Y describes feeling hopeless, empty, and alone each time 2 of her 3 children return to college after summer break. Her youngest child lives at home but is involved in extracurricular high school activities, and doesn’t seem to need her. Ms. Y is estranged from both parents. Her social support is unreliable because she tends to push others away and isolate herself.

Her children report that in recent months Ms. Y’s functioning has deteriorated and they are frustrated with her. Ms. Y repeatedly takes more clonazepam than prescribed but adamantly justifies her actions, saying she takes extra doses to sleep or relax. She seems to “run to the hospital” each time she faces a challenge or has a responsibility to fulfill. Many of her hospitalizations coincided with special occasions, such as her children’s birthdays, graduations, and holidays.

The authors’ observations

Because she has no history of mania, Ms. Y does not meet criteria for bipolar affective disorder. Her multidisciplinary treatment team feels she is too fragile to transfer care to new providers or to foster care, so we schedule a care conference and carefully compose a 6-month contract to formally articulate limits and boundaries within which we will continue to treat her.

The contract specifies that Ms. Y will participate in DBT, take her medications exactly as prescribed, and not receive any early refills of her prescriptions. We arrange with Ms. Y’s health plan to have a home healthcare agency provide her medications weekly. This benefit was not available to other health plan members. Ms. Y signs the contract.

TREATMENT: Contract violation

Ms. Y complies with the contract for 2 months, then abruptly fires her long-term therapist, whom she claims violated confidentiality by giving false information to another provider. At her next session, Ms. Y will not provide details about the alleged incident, and the issue never is resolved. She admits she did not start DBT and is not taking her medications as prescribed.

Ms. Y expresses her disagreement with the terms of the contract. She becomes very upset and asks for her care to be transferred to another psychiatrist. She demands to be followed at the current clinic because “I was born here.” She denies being actively suicidal and terminates the session early. That afternoon, she calls 1 of the inpatient psychiatrists and asks if he would treat her. She also calls the first psychiatrist she had seen to enlist help in obtaining care.

The authors’ observations

In Groves’ description of 4 types of “hateful patients,” Ms. Y represents a combination of an entitled demander and a manipulative help-rejecter. The behaviors and personality disorders associated with these types of patients—and effective management strategies—are listed in (Table 2).³ (Table 3) offers tips for successfully dealing with high utilizers of psychiatric services. High utilizers of medical services other than psychiatry are more likely than patients who are not high utilizers to have a psychiatric disorder (Box).^4-9

Box

Ms. Y’s entitlement interferes with her treatment—she has been allowed to dictate her treatment for years and, therefore, has not been managed effectively. She received resources that other patients did not, such as having weekly medication set up by a home healthcare nurse. Rules were bent to help Ms. Y, but allowing her to dictate treatment has made her so dependent that she worsened over time. Knowing that she was receiving special treatment appears to have strengthened her pathologic sense of entitlement.

Some members of our treatment team began to experience countertransference, which also interfered with Ms. Y’s treatment. They viewed her behavior as entitled, demanding, and manipulative and dreaded caring for her. Failing to recognize such defenses can lead to consequences such as malignant alienation—a progressive deterioration in the patient’s relationship with others that includes loss of sympathy and support from staff members—which can put a patient at high risk for suicide.¹⁰

 

After a lengthy discussion among several psychiatrists, therapists, nurses, and attorneys, the treatment team decided to terminate outpatient care for Ms. Y at our facility because of her chronic nonadherence to treatment recommendations. Ms. Y had manipulated numerous providers in our department, called multiple doctors in our facility to ask them to care for her, and asked her ex-husband to contact the department administration on her behalf. Her behavior bordered on harassment. In addition, the interventions we provided were making her worse, not better. Factors that influenced our decision included:

• fear of Ms. Y committing suicide
  
• fear of setting limits
  
• fear of being reported to the Medical Board
  
• fear of a lawsuit.
  

The team sent Ms. Y a registered letter explaining the reasons for the termination and providing referrals for other providers in the area. She was told that she retains access to the ER and can receive inpatient psychiatric care, provided she first is evaluated in the ER.

Table 2

Strategies for helping 4 types of ‘hateful patients’

Dependent clinger
Behaviors	Shows extreme gratitude with flattery
Associated personality traits/disorders	Codependent
Management strategies	As early and as tactfully as possible, set firm limits on the patient’s expectations for an intense doctor-patient relationship. Tell the patient that you have limits not only on knowledge and skill but also on time and stamina
Entitled demander
Behaviors	Intimidates, devalues, induces guilt, may try to control with threats; terrified of abandonment
Associated personality traits/disorders	Narcissistic, borderline personality disorder
Management strategies	Try to rechannel your patient’s feelings of entitlement into a partnership that acknowledges his or her entitlement not to unrealistic demands but to good medical care. Help your patient stop directing anger at the healthcare team
Manipulative help-rejecter
Behaviors	Resists treatment; may seem happy with treatment failures
Associated personality traits/disorders	Psychopathy, paranoia, borderline personality disorder, negativistic, passive/aggressive
Management strategies	Diminish your patient’s notion that losing the symptom or illness implies losing the doctor by ‘sharing’ your patient’s pessimism. Tell your patient that treatment may not cure the illness. Schedule regular follow-up visits
Self-destructive denier
Behaviors	Denial helps them survive
Associated personality traits/disorders	Borderline personality disorder, histrionic, schizoid, schizotypal
Management strategies	Recognize that this type of patient can make clinicians wish the patient would die and that the chance of helping a self-destructive denier is minimal. Lower unrealistic expectations of delivering perfect care. Evaluate the patient for a treatable mental illness, such as depression, anxiety, etc.
Source: Reference 3

Table 3

Tips for managing high utilizers

Establish a collaborative treatment plan with firm limits and expectations Document the treatment plan and encourage the patient to actively contribute Provide the patient with a copy of the plan Have the patient sign release of information for other care providers and have active contact with them for continuity and accountability Specify that the patient can obtain prescriptions or have medication dosages changed only by a psychiatrist or primary care provider Document an emergency department treatment plan to prevent unnecessary medication changes, obtaining narcotics or benzodiazepines if the patient has chemical dependency issues, etc. Involve the patient’s family
Acknowledge your feelings and countertransference Have regular contact with a mentor or colleague for consultation Ask yourself: Are you working harder than the patient? Is the patient capable of working harder or complying? Keep in mind the difference between mental illness and bad behavior
Explore your patient’s expectations and commitment to treatment by asking: ‘What do you consider as barriers to compliance or improvement?’ (Share your thoughts with the patient) ‘What are you willing to commit to in order to get better?’ ‘If I had a magic wand that I could wave and fix1 thing in your life right now, what would it be?’ or ‘What is the number 1 area in your life that is causing distress?’
Practice safely and proactively Determine if the patient has an undiagnosed psychiatric disorder Provide a phone call reminder for appointments Call if the patient does not show up for an appointment Document, document, document

OUTCOME: The pattern continues

Ms. Y continues to receive treatment with a different outpatient psychiatrist and therapist in the area. She has not been hospitalized for almost 2 years but her financial state has deteriorated and she has had a recurrence of depression. Ms. Y’s psychiatrist recently called the hospital to ask for direct admission on the patient’s behalf, stating that Ms. Y did not want to wait hours to be seen in the ER. Hospital staff explained that she needs to first come to the ER for evaluation. Ms. Y refused to come to the ER and was not admitted. About 1 month later, Ms. Y’s psychiatrist called again, and she was directly admitted to the psychiatric hospital.

 

Related resource

• National Suicide Prevention Lifeline. 1-800-273-TALK (8255). www.suicidepreventionlifeline.org.
  

Drug brand names

• Clonazepam • Klonopin
  
• Fluoxetine • Prozac
  
• Quetiapine • Seroquel
  

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or manufacturers of competing products.

CASE: A ‘high utilizer’

Ms. Y, a 49-year-old intensive care registered nurse, is admitted to the psychiatric hospital for suicidal ideation for the eighth time in 1 year. Ms. Y has chronic suicidal ideation with multiple attempts and has been on disability for 3 years for treatment of severe depression. She has been hospitalized for depression with suicide ideation 49 times since her divorce 6 years ago. She is prescribed fluoxetine, 60 mg/d, quetiapine, 400 mg/d, and clonazepam, 2 mg/d.

Ms. Y reports the same series of events that preceded her previous hospitalizations: severe insomnia led to a worsening of her other depressive symptoms, including intense suicidal ideation. In an attempt to sleep, she took “a couple” of extra clonazepam. She called her therapist, who was alarmed by her slurred speech and pleas for help. A friend drove Ms. Y to the hospital, where she was directly admitted without being evaluated in the emergency room (ER).

The authors’ observations

Ms. Y possesses 7 of the 11 characteristics of a high utilizer of psychiatric services (Table 1),^1,2 defined as a patient who is:

• 2 standard deviations above the mean number of visits to an urban psychiatric emergency service in 6 months or
  
• has 4 inpatient admissions in a quarter or 6 inpatient admissions in 1 year.
  

Ms. Y always is directly admitted because she refuses to go through the ER for evaluation. She seems to know just how much medication to take to remain medically stable. She receives special treatment—she can call her therapist, ask for admission, and have her request granted. Until now, Ms. Y’s care providers have condoned her entitlement.

Table 1

Common characteristics of high utilizers* of psychiatric services

Homelessness
Developmental delays
Enrolled in a mental health plan
History of voluntary and involuntary hospitalization
Personality disorders
Likely to be uncooperative
Substance abuse or dependence (or history)
History of incarceration
Unreliable social support
Young Caucasian women
* Defined as having either 2 standard deviations above the mean number of visits to an urban psychiatric emergency service in 6 months or 4 inpatient admissions in a quarter or 6 inpatient admissions in 1 year
Source: References 1,2

The author’s observations

Because previous hospitalizations and courses of ECT have provided Ms. Y with only minimal, short-lived improvement, the treatment team decides to reconsider her diagnosis and treatment plan. Ms. Y’s first psychiatrist diagnosed her with major depressive disorder. After thoroughly interviewing Ms. Y and reviewing her history, the hospital psychiatrist determines that she meets criteria for borderline personality disorder (BPD) in addition to major depression. The psychiatrist explains this diagnosis to Ms. Y, provides her with education and support, and recommends dialectical behavioral therapy (DBT) and case management. She rejects the new diagnosis and treatment plan and pleads for help establishing treatment with a new psychiatrist.

The team at the psychiatric hospital feels Ms. Y needs to receive ongoing treatment from a psychiatrist. In the hope that she will be able to establish a therapeutic alliance with a new psychiatrist and therapist, they decide to continue working with Ms. Y if she accepts the BPD diagnosis and agrees to undergo DBT.

EVALUATION: A troubling pattern

Before Ms. Y’s husband divorced her, she had not received psychiatric care and had no psychiatric diagnosis. During the contentious divorce, she experienced depressive symptoms that later intensified, and she was unable to return to her previous high level of functioning.

Ms. Y became suicidal and was hospitalized for the first time shortly after the divorce was finalized and her ex-husband remarried. She began treatment with a psychiatrist, whom she idealized and saw for 5 years.

When this psychiatrist—who had been one of the few stable relationships in Ms. Y’s life—moved to another state, Ms. Y experienced a rapid recurrence of depression. She began treatment with 3 other psychiatrists but fired them because they “never understand me” like her first psychiatrist did, and she never felt she received the consistent, supportive care she deserved. She become suicidal and again required psychiatric hospitalization. This pattern continued up to her current admission.

The authors’ observations

Ms. Y briefly returns to work between hospitalizations but is not able to tolerate the stress. At one point she was admitted to an out-of-state facility; after this 2-month stay, she remained out of the local psychiatric hospital for 6 months but then became unable to function and was readmitted to the local psychiatric hospital.

 

When interviewed, Ms. Y describes feeling hopeless, empty, and alone each time 2 of her 3 children return to college after summer break. Her youngest child lives at home but is involved in extracurricular high school activities, and doesn’t seem to need her. Ms. Y is estranged from both parents. Her social support is unreliable because she tends to push others away and isolate herself.

Her children report that in recent months Ms. Y’s functioning has deteriorated and they are frustrated with her. Ms. Y repeatedly takes more clonazepam than prescribed but adamantly justifies her actions, saying she takes extra doses to sleep or relax. She seems to “run to the hospital” each time she faces a challenge or has a responsibility to fulfill. Many of her hospitalizations coincided with special occasions, such as her children’s birthdays, graduations, and holidays.

The authors’ observations

Because she has no history of mania, Ms. Y does not meet criteria for bipolar affective disorder. Her multidisciplinary treatment team feels she is too fragile to transfer care to new providers or to foster care, so we schedule a care conference and carefully compose a 6-month contract to formally articulate limits and boundaries within which we will continue to treat her.

The contract specifies that Ms. Y will participate in DBT, take her medications exactly as prescribed, and not receive any early refills of her prescriptions. We arrange with Ms. Y’s health plan to have a home healthcare agency provide her medications weekly. This benefit was not available to other health plan members. Ms. Y signs the contract.

TREATMENT: Contract violation

Ms. Y complies with the contract for 2 months, then abruptly fires her long-term therapist, whom she claims violated confidentiality by giving false information to another provider. At her next session, Ms. Y will not provide details about the alleged incident, and the issue never is resolved. She admits she did not start DBT and is not taking her medications as prescribed.

Ms. Y expresses her disagreement with the terms of the contract. She becomes very upset and asks for her care to be transferred to another psychiatrist. She demands to be followed at the current clinic because “I was born here.” She denies being actively suicidal and terminates the session early. That afternoon, she calls 1 of the inpatient psychiatrists and asks if he would treat her. She also calls the first psychiatrist she had seen to enlist help in obtaining care.

The authors’ observations

In Groves’ description of 4 types of “hateful patients,” Ms. Y represents a combination of an entitled demander and a manipulative help-rejecter. The behaviors and personality disorders associated with these types of patients—and effective management strategies—are listed in (Table 2).³ (Table 3) offers tips for successfully dealing with high utilizers of psychiatric services. High utilizers of medical services other than psychiatry are more likely than patients who are not high utilizers to have a psychiatric disorder (Box).^4-9

Box

Ms. Y’s entitlement interferes with her treatment—she has been allowed to dictate her treatment for years and, therefore, has not been managed effectively. She received resources that other patients did not, such as having weekly medication set up by a home healthcare nurse. Rules were bent to help Ms. Y, but allowing her to dictate treatment has made her so dependent that she worsened over time. Knowing that she was receiving special treatment appears to have strengthened her pathologic sense of entitlement.

Some members of our treatment team began to experience countertransference, which also interfered with Ms. Y’s treatment. They viewed her behavior as entitled, demanding, and manipulative and dreaded caring for her. Failing to recognize such defenses can lead to consequences such as malignant alienation—a progressive deterioration in the patient’s relationship with others that includes loss of sympathy and support from staff members—which can put a patient at high risk for suicide.¹⁰

 

After a lengthy discussion among several psychiatrists, therapists, nurses, and attorneys, the treatment team decided to terminate outpatient care for Ms. Y at our facility because of her chronic nonadherence to treatment recommendations. Ms. Y had manipulated numerous providers in our department, called multiple doctors in our facility to ask them to care for her, and asked her ex-husband to contact the department administration on her behalf. Her behavior bordered on harassment. In addition, the interventions we provided were making her worse, not better. Factors that influenced our decision included:

• fear of Ms. Y committing suicide
  
• fear of setting limits
  
• fear of being reported to the Medical Board
  
• fear of a lawsuit.
  

The team sent Ms. Y a registered letter explaining the reasons for the termination and providing referrals for other providers in the area. She was told that she retains access to the ER and can receive inpatient psychiatric care, provided she first is evaluated in the ER.

Table 2

Strategies for helping 4 types of ‘hateful patients’

Dependent clinger
Behaviors	Shows extreme gratitude with flattery
Associated personality traits/disorders	Codependent
Management strategies	As early and as tactfully as possible, set firm limits on the patient’s expectations for an intense doctor-patient relationship. Tell the patient that you have limits not only on knowledge and skill but also on time and stamina
Entitled demander
Behaviors	Intimidates, devalues, induces guilt, may try to control with threats; terrified of abandonment
Associated personality traits/disorders	Narcissistic, borderline personality disorder
Management strategies	Try to rechannel your patient’s feelings of entitlement into a partnership that acknowledges his or her entitlement not to unrealistic demands but to good medical care. Help your patient stop directing anger at the healthcare team
Manipulative help-rejecter
Behaviors	Resists treatment; may seem happy with treatment failures
Associated personality traits/disorders	Psychopathy, paranoia, borderline personality disorder, negativistic, passive/aggressive
Management strategies	Diminish your patient’s notion that losing the symptom or illness implies losing the doctor by ‘sharing’ your patient’s pessimism. Tell your patient that treatment may not cure the illness. Schedule regular follow-up visits
Self-destructive denier
Behaviors	Denial helps them survive
Associated personality traits/disorders	Borderline personality disorder, histrionic, schizoid, schizotypal
Management strategies	Recognize that this type of patient can make clinicians wish the patient would die and that the chance of helping a self-destructive denier is minimal. Lower unrealistic expectations of delivering perfect care. Evaluate the patient for a treatable mental illness, such as depression, anxiety, etc.
Source: Reference 3

Table 3

Tips for managing high utilizers

Establish a collaborative treatment plan with firm limits and expectations Document the treatment plan and encourage the patient to actively contribute Provide the patient with a copy of the plan Have the patient sign release of information for other care providers and have active contact with them for continuity and accountability Specify that the patient can obtain prescriptions or have medication dosages changed only by a psychiatrist or primary care provider Document an emergency department treatment plan to prevent unnecessary medication changes, obtaining narcotics or benzodiazepines if the patient has chemical dependency issues, etc. Involve the patient’s family
Acknowledge your feelings and countertransference Have regular contact with a mentor or colleague for consultation Ask yourself: Are you working harder than the patient? Is the patient capable of working harder or complying? Keep in mind the difference between mental illness and bad behavior
Explore your patient’s expectations and commitment to treatment by asking: ‘What do you consider as barriers to compliance or improvement?’ (Share your thoughts with the patient) ‘What are you willing to commit to in order to get better?’ ‘If I had a magic wand that I could wave and fix1 thing in your life right now, what would it be?’ or ‘What is the number 1 area in your life that is causing distress?’
Practice safely and proactively Determine if the patient has an undiagnosed psychiatric disorder Provide a phone call reminder for appointments Call if the patient does not show up for an appointment Document, document, document

OUTCOME: The pattern continues

Ms. Y continues to receive treatment with a different outpatient psychiatrist and therapist in the area. She has not been hospitalized for almost 2 years but her financial state has deteriorated and she has had a recurrence of depression. Ms. Y’s psychiatrist recently called the hospital to ask for direct admission on the patient’s behalf, stating that Ms. Y did not want to wait hours to be seen in the ER. Hospital staff explained that she needs to first come to the ER for evaluation. Ms. Y refused to come to the ER and was not admitted. About 1 month later, Ms. Y’s psychiatrist called again, and she was directly admitted to the psychiatric hospital.

 

Related resource

• National Suicide Prevention Lifeline. 1-800-273-TALK (8255). www.suicidepreventionlifeline.org.
  

Drug brand names

• Clonazepam • Klonopin
  
• Fluoxetine • Prozac
  
• Quetiapine • Seroquel
  

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or manufacturers of competing products.

Ms. S, age 34, is a hard-working, single mother of two who works full-time at a local factory. She has recurrent major depression and has been struggling for 2 months. As you write the script to increase her fluoxetine dosage, she asks, “Hey, Doc, can you sign this form so I can have some time off work?”

If you feel uncomfortable signing work forms, approach your patients’ employment issues as you would any medical problem. Your job is to assess capacity to work, and the employer—based on restrictions you write in the medical report—decides if an accommodation can be made.

By answering five questions (Table 1), you can make informed decisions about your patients’ ability to work while:

• minimizing recovery time
  
• maintaining their daily structure and functioning
  
• reducing risk of chronic disability.
  

Table 1

Can a mentally ill patient work? 5 questions to consider

What is the employee’s diagnosis?
What work can the employee do today?
To reduce risk of medical harm, what work should the employee not do?
Does an impairment prevent the employee from performing essential job functions?
What must occur to get the patient back to work?

QUESTION 1: What is the employee’s diagnosis?

Diagnosis gives you a framework to understand what an employee can and cannot do on the job. Because Ms. S’ diagnosis is major depressive disorder, she may have low mood, low energy, decreased concentration, slowed movement, and disturbed sleep.

But diagnosis alone does not mean she is unable to work. Being separated from work can destabilize a person’s life (Box),^1-4 and debilitating depressive symptoms can change from day to day.

QUESTION 2: What work can the employee do today?

Four capacities are needed to function in the workplace:

• understanding and memory
  
• sustained concentration and persistence
  
• social interaction
  
• adaptation.⁵
  

When assessing your patient’s ability to work, match these capacities with an analogous set of eight psychiatric work functions (Table 2).⁶ Start by determining what the patient does at work. Ask her to describe her work or—even better—to provide a written job description.

A mildly depressed custodian could follow instructions, perform repetitive tasks, and keep pace on a daily shift. A depressed school principal, on the other hand, might lack the decision-making and social skills to relate to teachers, students, and parents. If she can follow instructions and perform simple tasks, however, she might be able to return to work and catch up on paperwork. She could postpone meetings and appointments until she feels well enough resume her full duties.

For almost any job, an employee must have understanding and memory to follow instructions and perform simple tasks.

Table 2

Can your patient work? Assess work functions by required capacities

Work function*	Capacity required to perform work function†
Comprehend and follow instructions	Understanding and memory
Perform simple and repetitive tasks	Understanding and memory
Maintain a work pace appropriate to a given workload	Sustained concentration and persistence
Perform complex or varied tasks	Understanding and memory; adaptation
Relate to other people beyond giving and receiving instructions	Social interaction; adaptation
Influence people	Social interaction; adaptation
Make generalizations, evaluations, or decisions without immediate supervision	Understanding and memory; adaptation
Accept and carry out responsibility for direction, control, and planning	Understanding and memory; adaptation
*Defined by the California Division of Industrial Accidents.
†Analogous capacities developed by the American Medical Association and Social Security Administration
Source: References 5 and 6

Case continued: assessing capacity

To assess ability to comprehend and follow instructions, you could ask Ms. S to:

• take the yellow book off the bookshelf with her right hand
  
• turn to page 23
  
• set the book down on your desk.
  

Most people—even with debilitating depressive symptoms—could complete that task.

To assess ability to perform simple tasks, you might ask Ms. S to describe what she does on a typical day. If she brushes her teeth, makes meals, does laundry, and buys groceries, she can probably do similar tasks at work. If she’s lying on the couch, staring at the wall, and neglecting self care, she might not have the motivation or concentration to complete simple tasks.

It might help to know how Ms. S arrived to see you. Driving is a more complicated task than having a friend or family member bring her. Ms. S’ story may include inconsistencies, and ideally you would have her sign releases to obtain collateral history from family, friends, or perhaps her supervisor.

Watching Ms. S leave can offer information about her functioning. Does she talk to anyone? Does she look the same as when she was in the office? Did she appear slowed when you saw her, yet could easily walk to the car and drive off?

 

QUESTION 3: To reduce risk of medical harm, what work should the patient not do?

A suicidal or homicidal patient may need to be hospitalized and should not go to work. Someone who is neglecting self care—such as eating—probably does not belong at work and could be at risk for harm.

Symptoms such as decreased concentration, psychomotor slowing, and decreased alertness are absolute contraindications for hazardous jobs that require sustained concentration and quick decisions—such as driving fork lifts or operating heavy machinery.

If potential exists for harm, recommend that the employee be treated before you re-evaluate return to work. Ideally, a case manager from the employer’s occupational health provider would check with the employee during treatment to reassess safety factors and facilitate a smooth return to work.

If medical harm is unlikely, recommending time off work becomes “medical discretion” and is not necessarily “medically required.”⁷

QUESTION 4: Does an impairment prevent the patient from performing essential job functions?

Impairment—a medical term—is often confused with disability, an administrative term:

• Impairment is “a loss, loss of use, or derangement of a body part, organ system, or organ function.”
  
• Disability is “an alteration of an individual’s capacity to meet personal, social, or occupational demands because of an impairment.”⁵
  

Even severe impairment does not necessarily mean a person is disabled. For example, a person who becomes blind in one eye has permanently impaired vision but can do many jobs and has no social limitations. But an airline pilot who loses sight in one eye becomes permanently disabled from that occupation because monocular blindness disqualifies pilots from flying.

Box

Essential job functions are fundamental duties of an employment position⁸ that cannot be passed off to anyone else. Without these duties, the position would not exist or would be different.

An employee who can perform essential job functions despite an impairment should stay at work. If he or she cannot do those functions, clearly state the impairment—such as decreased concentration, problems with persistence and pace—on the medical form so that the employer can decide if an accommodation can be made.

If essential job functions are high-order—such as air traffic control—even slight impairment could prevent the employee from safely doing the job. An impaired air traffic controller probably could do less-complex activities, however, such as clerical work.

Medical discretion. Most depressed patients can follow instructions and complete simple tasks, but many cannot keep up with the usual work pace because of low energy and slowed thinking and movements. Using medical discretion to recommend a short time off might help a depressed person return to full productivity more quickly if intensive treatment is available.

Limit discretionary time off to short periods when a treatment program is available. When blanket restrictions are written, the patient too often sits idle at home, getting worse and not better. At least excuse your patient from work to attend medical appointments and engage in depression treatment.

QUESTION 5: What must occur to get the patient back to work?

Returning to work as soon as possible can be therapeutic. Having a regular routine and daily structure gives the depressed person a sense of normalcy not found while sitting at home. Beyond stating the impairment on the medical form, suggest possible accommodations the employer could make to expedite return to work.

For your depressed patient, you could suggest reduced work hours (to accommodate low energy) or allowing more time to complete tasks. Whatever the diagnosis, addressing conflict in the workplace often helps. Strategies include:

• working individually with your patient
  
• alerting the patient to the employer’s conflict resolution policies and employee assistance programs.
  

CASE RESOLUTION: WORK AS THERAPY

Ms. S shows good eye contact, is appropriately dressed, shows no psychomotor abnormalities, and is not suicidal or homicidal. Mental status exam is normal. You determine that she can follow instructions, perform tasks, and keep up with her workload. She can probably do her job but initially might have difficulties because of depression’s effects on socialization and executive functioning.

 

You encourage Ms. S to return to work for the therapeutic benefits of a daily routine, but you suggest she postpone big projects or major decisions until she feels better.

Reassure your patient when you find no compelling reason why she cannot return to work. Explain that feeling ambivalent about maintaining function at work is normal, and staying at work is crucial to confidence and self-esteem.

Recognize the potential attraction of secondary gain—such as attention from family and medical providers and financial incentives to stay off work—but also normalize the experience for your patient. Help her regain her independence and start thinking about how she can improve her work situation.

Related resources

• Academy of Organizational and Occupational Psychiatry. www.aoop.org.
  
• National Partnership for Workplace Mental Health. www.workplacementalhealth.org
  
• Talmage JB, Melhorn JM (eds). A physician’s guide to return to work. Chicago: AMA Press; 2005.
  

Drug brand names

• Fluoxetine • Prozac
  

Disclosures

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Ms. S, age 34, is a hard-working, single mother of two who works full-time at a local factory. She has recurrent major depression and has been struggling for 2 months. As you write the script to increase her fluoxetine dosage, she asks, “Hey, Doc, can you sign this form so I can have some time off work?”

If you feel uncomfortable signing work forms, approach your patients’ employment issues as you would any medical problem. Your job is to assess capacity to work, and the employer—based on restrictions you write in the medical report—decides if an accommodation can be made.

By answering five questions (Table 1), you can make informed decisions about your patients’ ability to work while:

• minimizing recovery time
  
• maintaining their daily structure and functioning
  
• reducing risk of chronic disability.
  

Table 1

Can a mentally ill patient work? 5 questions to consider

What is the employee’s diagnosis?
What work can the employee do today?
To reduce risk of medical harm, what work should the employee not do?
Does an impairment prevent the employee from performing essential job functions?
What must occur to get the patient back to work?

QUESTION 1: What is the employee’s diagnosis?

Diagnosis gives you a framework to understand what an employee can and cannot do on the job. Because Ms. S’ diagnosis is major depressive disorder, she may have low mood, low energy, decreased concentration, slowed movement, and disturbed sleep.

But diagnosis alone does not mean she is unable to work. Being separated from work can destabilize a person’s life (Box),^1-4 and debilitating depressive symptoms can change from day to day.

QUESTION 2: What work can the employee do today?

Four capacities are needed to function in the workplace:

• understanding and memory
  
• sustained concentration and persistence
  
• social interaction
  
• adaptation.⁵
  

When assessing your patient’s ability to work, match these capacities with an analogous set of eight psychiatric work functions (Table 2).⁶ Start by determining what the patient does at work. Ask her to describe her work or—even better—to provide a written job description.

A mildly depressed custodian could follow instructions, perform repetitive tasks, and keep pace on a daily shift. A depressed school principal, on the other hand, might lack the decision-making and social skills to relate to teachers, students, and parents. If she can follow instructions and perform simple tasks, however, she might be able to return to work and catch up on paperwork. She could postpone meetings and appointments until she feels well enough resume her full duties.

For almost any job, an employee must have understanding and memory to follow instructions and perform simple tasks.

Table 2

Can your patient work? Assess work functions by required capacities

Work function*	Capacity required to perform work function†
Comprehend and follow instructions	Understanding and memory
Perform simple and repetitive tasks	Understanding and memory
Maintain a work pace appropriate to a given workload	Sustained concentration and persistence
Perform complex or varied tasks	Understanding and memory; adaptation
Relate to other people beyond giving and receiving instructions	Social interaction; adaptation
Influence people	Social interaction; adaptation
Make generalizations, evaluations, or decisions without immediate supervision	Understanding and memory; adaptation
Accept and carry out responsibility for direction, control, and planning	Understanding and memory; adaptation
*Defined by the California Division of Industrial Accidents.
†Analogous capacities developed by the American Medical Association and Social Security Administration
Source: References 5 and 6

Case continued: assessing capacity

To assess ability to comprehend and follow instructions, you could ask Ms. S to:

• take the yellow book off the bookshelf with her right hand
  
• turn to page 23
  
• set the book down on your desk.
  

Most people—even with debilitating depressive symptoms—could complete that task.

To assess ability to perform simple tasks, you might ask Ms. S to describe what she does on a typical day. If she brushes her teeth, makes meals, does laundry, and buys groceries, she can probably do similar tasks at work. If she’s lying on the couch, staring at the wall, and neglecting self care, she might not have the motivation or concentration to complete simple tasks.

It might help to know how Ms. S arrived to see you. Driving is a more complicated task than having a friend or family member bring her. Ms. S’ story may include inconsistencies, and ideally you would have her sign releases to obtain collateral history from family, friends, or perhaps her supervisor.

Watching Ms. S leave can offer information about her functioning. Does she talk to anyone? Does she look the same as when she was in the office? Did she appear slowed when you saw her, yet could easily walk to the car and drive off?

 

QUESTION 3: To reduce risk of medical harm, what work should the patient not do?

A suicidal or homicidal patient may need to be hospitalized and should not go to work. Someone who is neglecting self care—such as eating—probably does not belong at work and could be at risk for harm.

Symptoms such as decreased concentration, psychomotor slowing, and decreased alertness are absolute contraindications for hazardous jobs that require sustained concentration and quick decisions—such as driving fork lifts or operating heavy machinery.

If potential exists for harm, recommend that the employee be treated before you re-evaluate return to work. Ideally, a case manager from the employer’s occupational health provider would check with the employee during treatment to reassess safety factors and facilitate a smooth return to work.

If medical harm is unlikely, recommending time off work becomes “medical discretion” and is not necessarily “medically required.”⁷

QUESTION 4: Does an impairment prevent the patient from performing essential job functions?

Impairment—a medical term—is often confused with disability, an administrative term:

• Impairment is “a loss, loss of use, or derangement of a body part, organ system, or organ function.”
  
• Disability is “an alteration of an individual’s capacity to meet personal, social, or occupational demands because of an impairment.”⁵
  

Even severe impairment does not necessarily mean a person is disabled. For example, a person who becomes blind in one eye has permanently impaired vision but can do many jobs and has no social limitations. But an airline pilot who loses sight in one eye becomes permanently disabled from that occupation because monocular blindness disqualifies pilots from flying.

Box

Essential job functions are fundamental duties of an employment position⁸ that cannot be passed off to anyone else. Without these duties, the position would not exist or would be different.

An employee who can perform essential job functions despite an impairment should stay at work. If he or she cannot do those functions, clearly state the impairment—such as decreased concentration, problems with persistence and pace—on the medical form so that the employer can decide if an accommodation can be made.

If essential job functions are high-order—such as air traffic control—even slight impairment could prevent the employee from safely doing the job. An impaired air traffic controller probably could do less-complex activities, however, such as clerical work.

Medical discretion. Most depressed patients can follow instructions and complete simple tasks, but many cannot keep up with the usual work pace because of low energy and slowed thinking and movements. Using medical discretion to recommend a short time off might help a depressed person return to full productivity more quickly if intensive treatment is available.

Limit discretionary time off to short periods when a treatment program is available. When blanket restrictions are written, the patient too often sits idle at home, getting worse and not better. At least excuse your patient from work to attend medical appointments and engage in depression treatment.

QUESTION 5: What must occur to get the patient back to work?

Returning to work as soon as possible can be therapeutic. Having a regular routine and daily structure gives the depressed person a sense of normalcy not found while sitting at home. Beyond stating the impairment on the medical form, suggest possible accommodations the employer could make to expedite return to work.

For your depressed patient, you could suggest reduced work hours (to accommodate low energy) or allowing more time to complete tasks. Whatever the diagnosis, addressing conflict in the workplace often helps. Strategies include:

• working individually with your patient
  
• alerting the patient to the employer’s conflict resolution policies and employee assistance programs.
  

CASE RESOLUTION: WORK AS THERAPY

Ms. S shows good eye contact, is appropriately dressed, shows no psychomotor abnormalities, and is not suicidal or homicidal. Mental status exam is normal. You determine that she can follow instructions, perform tasks, and keep up with her workload. She can probably do her job but initially might have difficulties because of depression’s effects on socialization and executive functioning.

 

You encourage Ms. S to return to work for the therapeutic benefits of a daily routine, but you suggest she postpone big projects or major decisions until she feels better.

Reassure your patient when you find no compelling reason why she cannot return to work. Explain that feeling ambivalent about maintaining function at work is normal, and staying at work is crucial to confidence and self-esteem.

Recognize the potential attraction of secondary gain—such as attention from family and medical providers and financial incentives to stay off work—but also normalize the experience for your patient. Help her regain her independence and start thinking about how she can improve her work situation.

Related resources

• Academy of Organizational and Occupational Psychiatry. www.aoop.org.
  
• National Partnership for Workplace Mental Health. www.workplacementalhealth.org
  
• Talmage JB, Melhorn JM (eds). A physician’s guide to return to work. Chicago: AMA Press; 2005.
  

Drug brand names

• Fluoxetine • Prozac
  

Disclosures

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Ms. S, age 34, is a hard-working, single mother of two who works full-time at a local factory. She has recurrent major depression and has been struggling for 2 months. As you write the script to increase her fluoxetine dosage, she asks, “Hey, Doc, can you sign this form so I can have some time off work?”

If you feel uncomfortable signing work forms, approach your patients’ employment issues as you would any medical problem. Your job is to assess capacity to work, and the employer—based on restrictions you write in the medical report—decides if an accommodation can be made.

By answering five questions (Table 1), you can make informed decisions about your patients’ ability to work while:

• minimizing recovery time
  
• maintaining their daily structure and functioning
  
• reducing risk of chronic disability.
  

Table 1

Can a mentally ill patient work? 5 questions to consider

What is the employee’s diagnosis?
What work can the employee do today?
To reduce risk of medical harm, what work should the employee not do?
Does an impairment prevent the employee from performing essential job functions?
What must occur to get the patient back to work?

QUESTION 1: What is the employee’s diagnosis?

Diagnosis gives you a framework to understand what an employee can and cannot do on the job. Because Ms. S’ diagnosis is major depressive disorder, she may have low mood, low energy, decreased concentration, slowed movement, and disturbed sleep.

But diagnosis alone does not mean she is unable to work. Being separated from work can destabilize a person’s life (Box),^1-4 and debilitating depressive symptoms can change from day to day.

QUESTION 2: What work can the employee do today?

Four capacities are needed to function in the workplace:

• understanding and memory
  
• sustained concentration and persistence
  
• social interaction
  
• adaptation.⁵
  

When assessing your patient’s ability to work, match these capacities with an analogous set of eight psychiatric work functions (Table 2).⁶ Start by determining what the patient does at work. Ask her to describe her work or—even better—to provide a written job description.

A mildly depressed custodian could follow instructions, perform repetitive tasks, and keep pace on a daily shift. A depressed school principal, on the other hand, might lack the decision-making and social skills to relate to teachers, students, and parents. If she can follow instructions and perform simple tasks, however, she might be able to return to work and catch up on paperwork. She could postpone meetings and appointments until she feels well enough resume her full duties.

For almost any job, an employee must have understanding and memory to follow instructions and perform simple tasks.

Table 2

Can your patient work? Assess work functions by required capacities

Work function*	Capacity required to perform work function†
Comprehend and follow instructions	Understanding and memory
Perform simple and repetitive tasks	Understanding and memory
Maintain a work pace appropriate to a given workload	Sustained concentration and persistence
Perform complex or varied tasks	Understanding and memory; adaptation
Relate to other people beyond giving and receiving instructions	Social interaction; adaptation
Influence people	Social interaction; adaptation
Make generalizations, evaluations, or decisions without immediate supervision	Understanding and memory; adaptation
Accept and carry out responsibility for direction, control, and planning	Understanding and memory; adaptation
*Defined by the California Division of Industrial Accidents.
†Analogous capacities developed by the American Medical Association and Social Security Administration
Source: References 5 and 6

Case continued: assessing capacity

To assess ability to comprehend and follow instructions, you could ask Ms. S to:

• take the yellow book off the bookshelf with her right hand
  
• turn to page 23
  
• set the book down on your desk.
  

Most people—even with debilitating depressive symptoms—could complete that task.

To assess ability to perform simple tasks, you might ask Ms. S to describe what she does on a typical day. If she brushes her teeth, makes meals, does laundry, and buys groceries, she can probably do similar tasks at work. If she’s lying on the couch, staring at the wall, and neglecting self care, she might not have the motivation or concentration to complete simple tasks.

It might help to know how Ms. S arrived to see you. Driving is a more complicated task than having a friend or family member bring her. Ms. S’ story may include inconsistencies, and ideally you would have her sign releases to obtain collateral history from family, friends, or perhaps her supervisor.

Watching Ms. S leave can offer information about her functioning. Does she talk to anyone? Does she look the same as when she was in the office? Did she appear slowed when you saw her, yet could easily walk to the car and drive off?

 

QUESTION 3: To reduce risk of medical harm, what work should the patient not do?

A suicidal or homicidal patient may need to be hospitalized and should not go to work. Someone who is neglecting self care—such as eating—probably does not belong at work and could be at risk for harm.

Symptoms such as decreased concentration, psychomotor slowing, and decreased alertness are absolute contraindications for hazardous jobs that require sustained concentration and quick decisions—such as driving fork lifts or operating heavy machinery.

If potential exists for harm, recommend that the employee be treated before you re-evaluate return to work. Ideally, a case manager from the employer’s occupational health provider would check with the employee during treatment to reassess safety factors and facilitate a smooth return to work.

If medical harm is unlikely, recommending time off work becomes “medical discretion” and is not necessarily “medically required.”⁷

QUESTION 4: Does an impairment prevent the patient from performing essential job functions?

Impairment—a medical term—is often confused with disability, an administrative term:

• Impairment is “a loss, loss of use, or derangement of a body part, organ system, or organ function.”
  
• Disability is “an alteration of an individual’s capacity to meet personal, social, or occupational demands because of an impairment.”⁵
  

Even severe impairment does not necessarily mean a person is disabled. For example, a person who becomes blind in one eye has permanently impaired vision but can do many jobs and has no social limitations. But an airline pilot who loses sight in one eye becomes permanently disabled from that occupation because monocular blindness disqualifies pilots from flying.

Box

Essential job functions are fundamental duties of an employment position⁸ that cannot be passed off to anyone else. Without these duties, the position would not exist or would be different.

An employee who can perform essential job functions despite an impairment should stay at work. If he or she cannot do those functions, clearly state the impairment—such as decreased concentration, problems with persistence and pace—on the medical form so that the employer can decide if an accommodation can be made.

If essential job functions are high-order—such as air traffic control—even slight impairment could prevent the employee from safely doing the job. An impaired air traffic controller probably could do less-complex activities, however, such as clerical work.

Medical discretion. Most depressed patients can follow instructions and complete simple tasks, but many cannot keep up with the usual work pace because of low energy and slowed thinking and movements. Using medical discretion to recommend a short time off might help a depressed person return to full productivity more quickly if intensive treatment is available.

Limit discretionary time off to short periods when a treatment program is available. When blanket restrictions are written, the patient too often sits idle at home, getting worse and not better. At least excuse your patient from work to attend medical appointments and engage in depression treatment.

QUESTION 5: What must occur to get the patient back to work?

Returning to work as soon as possible can be therapeutic. Having a regular routine and daily structure gives the depressed person a sense of normalcy not found while sitting at home. Beyond stating the impairment on the medical form, suggest possible accommodations the employer could make to expedite return to work.

For your depressed patient, you could suggest reduced work hours (to accommodate low energy) or allowing more time to complete tasks. Whatever the diagnosis, addressing conflict in the workplace often helps. Strategies include:

• working individually with your patient
  
• alerting the patient to the employer’s conflict resolution policies and employee assistance programs.
  

CASE RESOLUTION: WORK AS THERAPY

Ms. S shows good eye contact, is appropriately dressed, shows no psychomotor abnormalities, and is not suicidal or homicidal. Mental status exam is normal. You determine that she can follow instructions, perform tasks, and keep up with her workload. She can probably do her job but initially might have difficulties because of depression’s effects on socialization and executive functioning.

 

You encourage Ms. S to return to work for the therapeutic benefits of a daily routine, but you suggest she postpone big projects or major decisions until she feels better.

Reassure your patient when you find no compelling reason why she cannot return to work. Explain that feeling ambivalent about maintaining function at work is normal, and staying at work is crucial to confidence and self-esteem.

Recognize the potential attraction of secondary gain—such as attention from family and medical providers and financial incentives to stay off work—but also normalize the experience for your patient. Help her regain her independence and start thinking about how she can improve her work situation.

Related resources

• Academy of Organizational and Occupational Psychiatry. www.aoop.org.
  
• National Partnership for Workplace Mental Health. www.workplacementalhealth.org
  
• Talmage JB, Melhorn JM (eds). A physician’s guide to return to work. Chicago: AMA Press; 2005.
  

Drug brand names

• Fluoxetine • Prozac
  

Disclosures

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Police officers bring Mr. A, age 25, to the emergency department (ED) in handcuffs after an alleged assault at work. He is calm but will provide no information about himself. ED staff don’t know if he has been using illicit substances, is on medications, or has any medical conditions.

Mr. A says the FBI is after him, but he makes no threats to ED staff. He talks about milking cows on a farm and of hearing animal sounds, though he lives in the city. After about 30 minutes, he consents to a lab draw and provides a urine sample.

Because no charges are pending and Mr. A is semi-cooperative, police remove his handcuffs and leave him in the care of two ED security officers. He is given something to eat and drink and seems fairly content. He asks how long he will need to stay in the room but does not demand to leave.

In a fast-paced ED, physicians might not notice signs of psychiatric illness, such as Mr. A’s paranoid and delusional thinking. By being familiar with techniques to manage patients’ psychiatric emergencies, you can help your ED colleagues:

• establish working psychiatric diagnoses and medical causes of psychiatric symptoms in the fast-paced ED
• maintain a safe ED environment for patients and clinicians.

What ed patients want

To understand how ED patients feel, put yourself in Mr. A’s shoes. You were at work and began to hallucinate. You believed your boss was out to harm you, and in fear you made comments perceived as threatening.

The next thing you know, you’re in a police car with handcuffs on. All of your coworkers witnessed your embarrassment. Now you are in a small ED room, wondering what’s going to happen next. Are you going to be put in a straight jacket and a padded room?

Patients may experience anxiety-provoking thoughts whether they come to the ED voluntarily or involuntarily. Fear and confusion can affect their behavior in the ED, and how providers respond to patients in crisis can escalate or de-escalate an already-difficult situation.

Psychiatric illness in the ed

Mr. A may have a psychiatric disorder, as do at least 3% of patients seen in EDs.¹ This figure may be low, however:

• Kunen et al² asserted that EDs are underdiagnosing psychiatric disorders, given a U.S. Department of Health and Human Services 1999 estimate that 20% to 28% of Americans have psychiatric illnesses. Using ED discharge records across 6 months in three emergency departments, the authors found the psychiatric diagnosis rate to be 5.27% in 33,000 ED visits.
• Another study, done in a university teaching hospital ED, showed that ED physicians trained to focus on patients’ presenting problems often missed comorbid medical or psychiatric illnesses.

In the randomized, controlled trial by Schriger et al,³ 218 patients with nonspecific complaints suggesting occult psychiatric illness (such as chronic headache, abdominal pain, or back pain) completed the Primary Care Evaluation of Mental Disorders (PRIME-MD) questionnaire. This 27-item self-report asks questions about mood, alcohol use, obsessive-compulsive symptoms, phobias, and somatoform symptoms.

Participants were then randomly assigned to “report” or “nonreport” groups, depending on whether or not ED physicians received their PRIME-MD scores. Even when informed of patients’ psychiatric symptoms, ED physicians rarely diagnosed or treated psychiatric disorders. Lack of mental status documentation and psychiatric interviews was apparent, the authors noted.

Case continued: a toxic cocktail

Mr. A’s urine drug screen and lab results are positive for benzodiazepines, methamphetamines, and cannabis. The staff decide Mr. A will require further observation and detoxification, and he is told this. A bed is not available at the hospital, however, and calls to nearby facilities find no empty beds.

As time passes, Mr. A shows signs of agitation and arousal. He paces the examination room—his jaw clenched and his face flushed—and begins raising his voice, asking to be discharged.

Recommendations. Unpleasantness is sometimes unavoidable, but no one in the ED has tried to create an alliance with Mr. A (Box). Try to make patients’ ED experiences as positive as possible. Make it clear that you share a common goal: to help the patient feel better. In fact, psychiatric patients and emergency psychiatrists have similar ideas about what constitutes quality ED care. When surveyed,⁴ ED patients said they preferred:

• verbal interventions compared with medications
• a collaborative approach with ED physicians
• having medications selected for their specific problems, medication experiences, and choices
• benzodiazepines rather than conventional antipsychotics such as haloperidol.

Box

 

A pragmatic workup

Medical illnesses such as delirium, stroke, drug toxicity, or urinary tract infections can trigger or worsen psychiatric illness (Table 1).⁵ Comorbidities such as diabetes, hypertension, obesity, and heart disease are common in patients with psychiatric disorders, and psychotropics can cause or exacerbate these conditions.

In the high-pressure ED, a sufficient workup for complicated medical conditions lies somewhere between extensive/unnecessary and inadequate. Thus, determining an exact diagnosis is not as important as establishing a diagnostic category to guide emergency treatment.

Think of psychiatric disorders as they are organized in DSM-IV-TR—mood, anxiety, psychotic, substance use/withdrawal/intoxication, cognitive, adjustment, somatoform, and personality disorders—and whether they are primary or secondary to a general medical condition or substance use. For example:

• Anxiety disorder secondary to a general medical condition means the history, physical exam, or lab reports suggest a medical condition is the direct physiologic cause of the mood disturbance.
• Methamphetamine-induced psychotic disorder would be the diagnosis if methamphetamines are presumed to be causing a patient’s psychotic symptoms.

Hospitalization. ED staff often develop a treatment plan based on a patient’s clinical picture and a working diagnosis. The plan hinges on deciding if the patient needs to be admitted to the hospital. Admission may be warranted for life-threatening medical conditions or safety issues, such as threats to self or others or inability to care for oneself at home. Other issues come into play—such as starting or changing medications and follow-up to ensure continuity of care—if you decide to discharge the patient.

Even after medical clearance, patients in the psychiatric emergency service may have underlying medical illnesses (Table 2).⁶

Table 1

Medical disorders that can cause psychiatric symptoms

Medical/toxic disorders	Examples
Alcohol and drugs of abuse	Amphetamines (including methamphetamine), cocaine, heroin, Jimson weed, ketamine, marijuana, MDMA (‘Ecstasy’), LSD, PCP
Prescription drugs	Antibiotics, anticholinergics, anticonvulsants, antihypertensives, benzodiazepines, chemotherapeutic agents, cimetidine, corticosteroids, digitalis, narcotics, propranolol, sleep medications, tricyclic antidepressants
CNS disease	Hypertensive encephalopathy, intracranial aneurysm, metastases, normal pressure hydrocephalus, postictal nonconvulsive status, primary CNS infection, seizure disorders, stroke, subdural hematoma, tumor
Infections	Acute rheumatic fever, diphtheria, malaria, Legionnaires’ disease, pneumonia, Rocky Mountain spotted fever, sepsis, syphilis, typhoid fever, urinary tract infection
Metabolic/endocrine disorders	Adrenal disease, diabetic ketoacidosis, hepatic encephalopathy, hypoglycemia, pituitary dysfunction, renal disease, serum electrolyte imbalances (sodium, potassium, calcium), thyroid disease, vitamin deficiencies, Wilson’s disease
Cardiopulmonary disease	Arrhythmias, congestive heart failure, COPD/asthma, myocardial infarction, pulmonary embolism
Miscellaneous	Anemia, lupus, multiple sclerosis, temporal arteritis, vasculitis
Source: Reprinted with permission from Williams ER, Shepherd SM. Medical clearance of psychiatric patients. Emerg Med Clin North Am 2000;18(2):185-90. Copyright 2000, Elsevier.

Table 2

Reasonable medical assessment in psychiatric emergencies

DO
Obtain a medical history, the best determinant of medical need
Listen to patients. If they say they have a medical condition, believe them; if they say they don’t, try to believe them
Thoroughly check vital signs
Conduct a focused physical examination
Maintain a high index of suspicion
Be selective with laboratory testing. Check: thyroid-stimulating hormone in those with known thyroid disease electrolyte levels in volume-depleted patients or those in withdrawal lead levels in high-risk youth urine in elderly patients with acute mental status changes
DON’T
Order blanket laboratory screening
Order an ECG in healthy young patients in the absence of clinical findings
Order chest radiography in the absence of known disease/exposure/symptoms
Source: Reprinted from Currier GW. Medical assessment on the psychiatric emergency service. Psychiatric Issues in Emergency Care Settings 2004;3(July):17, with permission from Cliggott Publishing Group of CMP Healthcare Media. Copyright 2004.

Overwhelming demand

In the study of ED patient preferences,⁴ one-fifth of patients said they went to the ED because they lacked access to routine mental health care. Therefore, besides psychiatric conditions caused by medical illnesses, ED physicians can see patients with any primary psychiatric diagnosis, including mood and anxiety disorders and psychosis.

Under pressures of time and limited collateral information, ED staff must:

• individualize psychiatric treatment
• consider use of medications and/or restraints
• rule out life-threatening causes for psychiatric symptoms
• stabilize patients and prevent injury to self and others.

These tasks are becoming increasingly difficult as more and more patients present to emergency rooms. Nationally, ED visits increased from 19 million in 1992 to 108 million in 2000, according to the U.S. Department of Health and Human Services.¹

Psychiatric patients are seeking ED care in greater numbers, and the number of those staying longer than anticipated (“boarding”) also has increased, according to a 2004 survey of 340 physicians by the American College of Emergency Physicians, American Psychiatric Association, National Mental Health Association, and National Alliance for the Mentally Ill. Surveyed physicians blamed inadequate Medicaid funding and bed shortages for the increasing ED visits.⁷

In crowded emergency rooms, where patients wait longer and longer to be seen, the influx of acutely ill psychiatric patients increases the risks of agitation, violence, and injury, as well as litigation.⁸

 

Case continued: going up in smoke

Recognizing Mr. A’s arousal, ED staff tries to reassure him and offers him food, something to drink, a phone Call, and a magazine. When these attempts fail to de-escalate his agitation, staff offers to make him more comfortable by giving oral lorazepam, which he adamantly refuses. He is told again that he must stay until a transfer facility is found for him.

Mr. A then demands to go outside “for a smoke.” When he is told ED patients cannot leave to smoke and is offered nicotine replacement, he begins to scream and lunges at one of the security officers. He is extremely strong, and additional officers are summoned. He retreats inside the room, slams the door, shatters the door window with a chair, and begins punching the broken glass. He slides to the floor in a vasovagal reaction at the sight of his bleeding hands but soon becomes combative again.

Staff give Mr. A IM haloperidol, 10 mg, and lorazepam, 2 mg, to manage his extreme agitation and place him in physical restraints to protect him and others. Within 25 to 30 minutes he is calm, and a safe environment has been re-established. The lacerations on his hands are sutured, and he is admitted to an inpatient psychiatric hospital for further stabilization and treatment.

No place for complacency

Mr. A’s experience illustrates how situations can become dangerous when precautions are not taken. Five steps can help you prepare and protect yourself when evaluating patients in the ED:

• seek the patient history
• evaluate the context in which the patient is being assessed
• identify arousal states (fear, anger, confusion, and humiliation)
• structure the interview for safety
• keep your guard up during the clinical encounter.⁹

Risk is high when law enforcement officers bring a patient to the ED. Be on guard, even if the patient is 80 years old and in a wheelchair. Complacency has no place in the ED; prepare as much as you can before interviewing the patient.

When restraints are needed. Involuntary medication and/or restraints may be necessary when reasonable interventions have failed, the patient will not cooperate, and he or she is exhibiting behavior/symptoms that could result in injury. Approximately 10% to 20% of psychiatric patients require physical or chemical restraint in the ED.¹⁰

Expert consensus guidelines suggest starting with verbal intervention, voluntary medication, and show of force, although emergency medication may be a reasonable first treatment (Algorithm).¹¹ Offer oral medication first; IM medications carry risks including acute dystonia and akathisia, although these can be treated.

Lorazepam, 1 to 2 mg oral/IM, combined with haloperidol, 2 to 5 mg oral/IM, is a reasonable start in most cases. If the patient remains extremely agitated, the same medications and dosages can be repeated 30 to 60 minutes after the initial administration.¹²

Conventional oral/IM agents are usually more readily available in the ED than atypical antipsychotics, which must be ordered from the pharmacy. Recent FDA black-box warnings also emphasize that atypical antipsychotics are approved only for treating schizophrenia, acute manic and mixed episodes of bipolar I disorder, and for maintenance treatment in bipolar disorder. When compared with placebo, atypical antipsychotics have been associated with:

• increased risk for cerebrovascular events in elderly patients with dementia
• death in elderly patients with dementia-related psychosis.

Atypicals may be more appropriate than conventional antipsychotics for emergency treatment of agitation and aggression in some patients with complicating medical conditions or histories. For example, avoid high-potency conventional antipsychotics in patients with a history of extrapyramidal side effects and in those with mental retardation/developmental delay.¹¹ Similarly, avoid benzodiazepines in patients with chronic obstructive pulmonary disease (COPD) or a history of drug-seeking behavior or drug abuse.

Of course not all psychiatric interventions in the ED are involuntary. For example, the ED physician may start an antidepressant for a patient diagnosed with mild to moderate depression for whom hospitalization is not indicated. Characteristics of patients who may be good candidates for starting antidepressants in the ED include a clear diagnosis, no substance abuse, low suicide risk, no psychosis or agitation, available social supports, clear follow-up plan, desire to begin treatment, and ability to pay for and obtain medications.¹³

Algorithm Consensus guideline for treating a behavioral emergency

Related resources

• Allen MH, Currier GW, Hughes DH, et al. The Expert Consensus Guideline Series: Treatment of behavioral emergencies. Postgrad Med 2001;May(Spec No):1-88.
• American College of Emergency Physicians. www.acep.org
• National Alliance on Mental Illness. www.nami.org

Drug brand names

• Fluoxetine • Prozac
• Haloperidol • Haldol
• Lorazepam • Ativan

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Police officers bring Mr. A, age 25, to the emergency department (ED) in handcuffs after an alleged assault at work. He is calm but will provide no information about himself. ED staff don’t know if he has been using illicit substances, is on medications, or has any medical conditions.

Mr. A says the FBI is after him, but he makes no threats to ED staff. He talks about milking cows on a farm and of hearing animal sounds, though he lives in the city. After about 30 minutes, he consents to a lab draw and provides a urine sample.

Because no charges are pending and Mr. A is semi-cooperative, police remove his handcuffs and leave him in the care of two ED security officers. He is given something to eat and drink and seems fairly content. He asks how long he will need to stay in the room but does not demand to leave.

In a fast-paced ED, physicians might not notice signs of psychiatric illness, such as Mr. A’s paranoid and delusional thinking. By being familiar with techniques to manage patients’ psychiatric emergencies, you can help your ED colleagues:

• establish working psychiatric diagnoses and medical causes of psychiatric symptoms in the fast-paced ED
• maintain a safe ED environment for patients and clinicians.

What ed patients want

To understand how ED patients feel, put yourself in Mr. A’s shoes. You were at work and began to hallucinate. You believed your boss was out to harm you, and in fear you made comments perceived as threatening.

The next thing you know, you’re in a police car with handcuffs on. All of your coworkers witnessed your embarrassment. Now you are in a small ED room, wondering what’s going to happen next. Are you going to be put in a straight jacket and a padded room?

Patients may experience anxiety-provoking thoughts whether they come to the ED voluntarily or involuntarily. Fear and confusion can affect their behavior in the ED, and how providers respond to patients in crisis can escalate or de-escalate an already-difficult situation.

Psychiatric illness in the ed

Mr. A may have a psychiatric disorder, as do at least 3% of patients seen in EDs.¹ This figure may be low, however:

• Kunen et al² asserted that EDs are underdiagnosing psychiatric disorders, given a U.S. Department of Health and Human Services 1999 estimate that 20% to 28% of Americans have psychiatric illnesses. Using ED discharge records across 6 months in three emergency departments, the authors found the psychiatric diagnosis rate to be 5.27% in 33,000 ED visits.
• Another study, done in a university teaching hospital ED, showed that ED physicians trained to focus on patients’ presenting problems often missed comorbid medical or psychiatric illnesses.

In the randomized, controlled trial by Schriger et al,³ 218 patients with nonspecific complaints suggesting occult psychiatric illness (such as chronic headache, abdominal pain, or back pain) completed the Primary Care Evaluation of Mental Disorders (PRIME-MD) questionnaire. This 27-item self-report asks questions about mood, alcohol use, obsessive-compulsive symptoms, phobias, and somatoform symptoms.

Participants were then randomly assigned to “report” or “nonreport” groups, depending on whether or not ED physicians received their PRIME-MD scores. Even when informed of patients’ psychiatric symptoms, ED physicians rarely diagnosed or treated psychiatric disorders. Lack of mental status documentation and psychiatric interviews was apparent, the authors noted.

Case continued: a toxic cocktail

Mr. A’s urine drug screen and lab results are positive for benzodiazepines, methamphetamines, and cannabis. The staff decide Mr. A will require further observation and detoxification, and he is told this. A bed is not available at the hospital, however, and calls to nearby facilities find no empty beds.

As time passes, Mr. A shows signs of agitation and arousal. He paces the examination room—his jaw clenched and his face flushed—and begins raising his voice, asking to be discharged.

Recommendations. Unpleasantness is sometimes unavoidable, but no one in the ED has tried to create an alliance with Mr. A (Box). Try to make patients’ ED experiences as positive as possible. Make it clear that you share a common goal: to help the patient feel better. In fact, psychiatric patients and emergency psychiatrists have similar ideas about what constitutes quality ED care. When surveyed,⁴ ED patients said they preferred:

• verbal interventions compared with medications
• a collaborative approach with ED physicians
• having medications selected for their specific problems, medication experiences, and choices
• benzodiazepines rather than conventional antipsychotics such as haloperidol.

Box

 

A pragmatic workup

Medical illnesses such as delirium, stroke, drug toxicity, or urinary tract infections can trigger or worsen psychiatric illness (Table 1).⁵ Comorbidities such as diabetes, hypertension, obesity, and heart disease are common in patients with psychiatric disorders, and psychotropics can cause or exacerbate these conditions.

In the high-pressure ED, a sufficient workup for complicated medical conditions lies somewhere between extensive/unnecessary and inadequate. Thus, determining an exact diagnosis is not as important as establishing a diagnostic category to guide emergency treatment.

Think of psychiatric disorders as they are organized in DSM-IV-TR—mood, anxiety, psychotic, substance use/withdrawal/intoxication, cognitive, adjustment, somatoform, and personality disorders—and whether they are primary or secondary to a general medical condition or substance use. For example:

• Anxiety disorder secondary to a general medical condition means the history, physical exam, or lab reports suggest a medical condition is the direct physiologic cause of the mood disturbance.
• Methamphetamine-induced psychotic disorder would be the diagnosis if methamphetamines are presumed to be causing a patient’s psychotic symptoms.

Hospitalization. ED staff often develop a treatment plan based on a patient’s clinical picture and a working diagnosis. The plan hinges on deciding if the patient needs to be admitted to the hospital. Admission may be warranted for life-threatening medical conditions or safety issues, such as threats to self or others or inability to care for oneself at home. Other issues come into play—such as starting or changing medications and follow-up to ensure continuity of care—if you decide to discharge the patient.

Even after medical clearance, patients in the psychiatric emergency service may have underlying medical illnesses (Table 2).⁶

Table 1

Medical disorders that can cause psychiatric symptoms

Medical/toxic disorders	Examples
Alcohol and drugs of abuse	Amphetamines (including methamphetamine), cocaine, heroin, Jimson weed, ketamine, marijuana, MDMA (‘Ecstasy’), LSD, PCP
Prescription drugs	Antibiotics, anticholinergics, anticonvulsants, antihypertensives, benzodiazepines, chemotherapeutic agents, cimetidine, corticosteroids, digitalis, narcotics, propranolol, sleep medications, tricyclic antidepressants
CNS disease	Hypertensive encephalopathy, intracranial aneurysm, metastases, normal pressure hydrocephalus, postictal nonconvulsive status, primary CNS infection, seizure disorders, stroke, subdural hematoma, tumor
Infections	Acute rheumatic fever, diphtheria, malaria, Legionnaires’ disease, pneumonia, Rocky Mountain spotted fever, sepsis, syphilis, typhoid fever, urinary tract infection
Metabolic/endocrine disorders	Adrenal disease, diabetic ketoacidosis, hepatic encephalopathy, hypoglycemia, pituitary dysfunction, renal disease, serum electrolyte imbalances (sodium, potassium, calcium), thyroid disease, vitamin deficiencies, Wilson’s disease
Cardiopulmonary disease	Arrhythmias, congestive heart failure, COPD/asthma, myocardial infarction, pulmonary embolism
Miscellaneous	Anemia, lupus, multiple sclerosis, temporal arteritis, vasculitis
Source: Reprinted with permission from Williams ER, Shepherd SM. Medical clearance of psychiatric patients. Emerg Med Clin North Am 2000;18(2):185-90. Copyright 2000, Elsevier.

Table 2

Reasonable medical assessment in psychiatric emergencies

DO
Obtain a medical history, the best determinant of medical need
Listen to patients. If they say they have a medical condition, believe them; if they say they don’t, try to believe them
Thoroughly check vital signs
Conduct a focused physical examination
Maintain a high index of suspicion
Be selective with laboratory testing. Check: thyroid-stimulating hormone in those with known thyroid disease electrolyte levels in volume-depleted patients or those in withdrawal lead levels in high-risk youth urine in elderly patients with acute mental status changes
DON’T
Order blanket laboratory screening
Order an ECG in healthy young patients in the absence of clinical findings
Order chest radiography in the absence of known disease/exposure/symptoms
Source: Reprinted from Currier GW. Medical assessment on the psychiatric emergency service. Psychiatric Issues in Emergency Care Settings 2004;3(July):17, with permission from Cliggott Publishing Group of CMP Healthcare Media. Copyright 2004.

Overwhelming demand

In the study of ED patient preferences,⁴ one-fifth of patients said they went to the ED because they lacked access to routine mental health care. Therefore, besides psychiatric conditions caused by medical illnesses, ED physicians can see patients with any primary psychiatric diagnosis, including mood and anxiety disorders and psychosis.

Under pressures of time and limited collateral information, ED staff must:

• individualize psychiatric treatment
• consider use of medications and/or restraints
• rule out life-threatening causes for psychiatric symptoms
• stabilize patients and prevent injury to self and others.

These tasks are becoming increasingly difficult as more and more patients present to emergency rooms. Nationally, ED visits increased from 19 million in 1992 to 108 million in 2000, according to the U.S. Department of Health and Human Services.¹

Psychiatric patients are seeking ED care in greater numbers, and the number of those staying longer than anticipated (“boarding”) also has increased, according to a 2004 survey of 340 physicians by the American College of Emergency Physicians, American Psychiatric Association, National Mental Health Association, and National Alliance for the Mentally Ill. Surveyed physicians blamed inadequate Medicaid funding and bed shortages for the increasing ED visits.⁷

In crowded emergency rooms, where patients wait longer and longer to be seen, the influx of acutely ill psychiatric patients increases the risks of agitation, violence, and injury, as well as litigation.⁸

 

Case continued: going up in smoke

Recognizing Mr. A’s arousal, ED staff tries to reassure him and offers him food, something to drink, a phone Call, and a magazine. When these attempts fail to de-escalate his agitation, staff offers to make him more comfortable by giving oral lorazepam, which he adamantly refuses. He is told again that he must stay until a transfer facility is found for him.

Mr. A then demands to go outside “for a smoke.” When he is told ED patients cannot leave to smoke and is offered nicotine replacement, he begins to scream and lunges at one of the security officers. He is extremely strong, and additional officers are summoned. He retreats inside the room, slams the door, shatters the door window with a chair, and begins punching the broken glass. He slides to the floor in a vasovagal reaction at the sight of his bleeding hands but soon becomes combative again.

Staff give Mr. A IM haloperidol, 10 mg, and lorazepam, 2 mg, to manage his extreme agitation and place him in physical restraints to protect him and others. Within 25 to 30 minutes he is calm, and a safe environment has been re-established. The lacerations on his hands are sutured, and he is admitted to an inpatient psychiatric hospital for further stabilization and treatment.

No place for complacency

Mr. A’s experience illustrates how situations can become dangerous when precautions are not taken. Five steps can help you prepare and protect yourself when evaluating patients in the ED:

• seek the patient history
• evaluate the context in which the patient is being assessed
• identify arousal states (fear, anger, confusion, and humiliation)
• structure the interview for safety
• keep your guard up during the clinical encounter.⁹

Risk is high when law enforcement officers bring a patient to the ED. Be on guard, even if the patient is 80 years old and in a wheelchair. Complacency has no place in the ED; prepare as much as you can before interviewing the patient.

When restraints are needed. Involuntary medication and/or restraints may be necessary when reasonable interventions have failed, the patient will not cooperate, and he or she is exhibiting behavior/symptoms that could result in injury. Approximately 10% to 20% of psychiatric patients require physical or chemical restraint in the ED.¹⁰

Expert consensus guidelines suggest starting with verbal intervention, voluntary medication, and show of force, although emergency medication may be a reasonable first treatment (Algorithm).¹¹ Offer oral medication first; IM medications carry risks including acute dystonia and akathisia, although these can be treated.

Lorazepam, 1 to 2 mg oral/IM, combined with haloperidol, 2 to 5 mg oral/IM, is a reasonable start in most cases. If the patient remains extremely agitated, the same medications and dosages can be repeated 30 to 60 minutes after the initial administration.¹²

Conventional oral/IM agents are usually more readily available in the ED than atypical antipsychotics, which must be ordered from the pharmacy. Recent FDA black-box warnings also emphasize that atypical antipsychotics are approved only for treating schizophrenia, acute manic and mixed episodes of bipolar I disorder, and for maintenance treatment in bipolar disorder. When compared with placebo, atypical antipsychotics have been associated with:

• increased risk for cerebrovascular events in elderly patients with dementia
• death in elderly patients with dementia-related psychosis.

Atypicals may be more appropriate than conventional antipsychotics for emergency treatment of agitation and aggression in some patients with complicating medical conditions or histories. For example, avoid high-potency conventional antipsychotics in patients with a history of extrapyramidal side effects and in those with mental retardation/developmental delay.¹¹ Similarly, avoid benzodiazepines in patients with chronic obstructive pulmonary disease (COPD) or a history of drug-seeking behavior or drug abuse.

Of course not all psychiatric interventions in the ED are involuntary. For example, the ED physician may start an antidepressant for a patient diagnosed with mild to moderate depression for whom hospitalization is not indicated. Characteristics of patients who may be good candidates for starting antidepressants in the ED include a clear diagnosis, no substance abuse, low suicide risk, no psychosis or agitation, available social supports, clear follow-up plan, desire to begin treatment, and ability to pay for and obtain medications.¹³

Algorithm Consensus guideline for treating a behavioral emergency

Related resources

• Allen MH, Currier GW, Hughes DH, et al. The Expert Consensus Guideline Series: Treatment of behavioral emergencies. Postgrad Med 2001;May(Spec No):1-88.
• American College of Emergency Physicians. www.acep.org
• National Alliance on Mental Illness. www.nami.org

Drug brand names

• Fluoxetine • Prozac
• Haloperidol • Haldol
• Lorazepam • Ativan

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Police officers bring Mr. A, age 25, to the emergency department (ED) in handcuffs after an alleged assault at work. He is calm but will provide no information about himself. ED staff don’t know if he has been using illicit substances, is on medications, or has any medical conditions.

Mr. A says the FBI is after him, but he makes no threats to ED staff. He talks about milking cows on a farm and of hearing animal sounds, though he lives in the city. After about 30 minutes, he consents to a lab draw and provides a urine sample.

Because no charges are pending and Mr. A is semi-cooperative, police remove his handcuffs and leave him in the care of two ED security officers. He is given something to eat and drink and seems fairly content. He asks how long he will need to stay in the room but does not demand to leave.

In a fast-paced ED, physicians might not notice signs of psychiatric illness, such as Mr. A’s paranoid and delusional thinking. By being familiar with techniques to manage patients’ psychiatric emergencies, you can help your ED colleagues:

• establish working psychiatric diagnoses and medical causes of psychiatric symptoms in the fast-paced ED
• maintain a safe ED environment for patients and clinicians.

What ed patients want

To understand how ED patients feel, put yourself in Mr. A’s shoes. You were at work and began to hallucinate. You believed your boss was out to harm you, and in fear you made comments perceived as threatening.

The next thing you know, you’re in a police car with handcuffs on. All of your coworkers witnessed your embarrassment. Now you are in a small ED room, wondering what’s going to happen next. Are you going to be put in a straight jacket and a padded room?

Patients may experience anxiety-provoking thoughts whether they come to the ED voluntarily or involuntarily. Fear and confusion can affect their behavior in the ED, and how providers respond to patients in crisis can escalate or de-escalate an already-difficult situation.

Psychiatric illness in the ed

Mr. A may have a psychiatric disorder, as do at least 3% of patients seen in EDs.¹ This figure may be low, however:

• Kunen et al² asserted that EDs are underdiagnosing psychiatric disorders, given a U.S. Department of Health and Human Services 1999 estimate that 20% to 28% of Americans have psychiatric illnesses. Using ED discharge records across 6 months in three emergency departments, the authors found the psychiatric diagnosis rate to be 5.27% in 33,000 ED visits.
• Another study, done in a university teaching hospital ED, showed that ED physicians trained to focus on patients’ presenting problems often missed comorbid medical or psychiatric illnesses.

In the randomized, controlled trial by Schriger et al,³ 218 patients with nonspecific complaints suggesting occult psychiatric illness (such as chronic headache, abdominal pain, or back pain) completed the Primary Care Evaluation of Mental Disorders (PRIME-MD) questionnaire. This 27-item self-report asks questions about mood, alcohol use, obsessive-compulsive symptoms, phobias, and somatoform symptoms.

Participants were then randomly assigned to “report” or “nonreport” groups, depending on whether or not ED physicians received their PRIME-MD scores. Even when informed of patients’ psychiatric symptoms, ED physicians rarely diagnosed or treated psychiatric disorders. Lack of mental status documentation and psychiatric interviews was apparent, the authors noted.

Case continued: a toxic cocktail

Mr. A’s urine drug screen and lab results are positive for benzodiazepines, methamphetamines, and cannabis. The staff decide Mr. A will require further observation and detoxification, and he is told this. A bed is not available at the hospital, however, and calls to nearby facilities find no empty beds.

As time passes, Mr. A shows signs of agitation and arousal. He paces the examination room—his jaw clenched and his face flushed—and begins raising his voice, asking to be discharged.

Recommendations. Unpleasantness is sometimes unavoidable, but no one in the ED has tried to create an alliance with Mr. A (Box). Try to make patients’ ED experiences as positive as possible. Make it clear that you share a common goal: to help the patient feel better. In fact, psychiatric patients and emergency psychiatrists have similar ideas about what constitutes quality ED care. When surveyed,⁴ ED patients said they preferred:

• verbal interventions compared with medications
• a collaborative approach with ED physicians
• having medications selected for their specific problems, medication experiences, and choices
• benzodiazepines rather than conventional antipsychotics such as haloperidol.

Box

 

A pragmatic workup

Medical illnesses such as delirium, stroke, drug toxicity, or urinary tract infections can trigger or worsen psychiatric illness (Table 1).⁵ Comorbidities such as diabetes, hypertension, obesity, and heart disease are common in patients with psychiatric disorders, and psychotropics can cause or exacerbate these conditions.

In the high-pressure ED, a sufficient workup for complicated medical conditions lies somewhere between extensive/unnecessary and inadequate. Thus, determining an exact diagnosis is not as important as establishing a diagnostic category to guide emergency treatment.

Think of psychiatric disorders as they are organized in DSM-IV-TR—mood, anxiety, psychotic, substance use/withdrawal/intoxication, cognitive, adjustment, somatoform, and personality disorders—and whether they are primary or secondary to a general medical condition or substance use. For example:

• Anxiety disorder secondary to a general medical condition means the history, physical exam, or lab reports suggest a medical condition is the direct physiologic cause of the mood disturbance.
• Methamphetamine-induced psychotic disorder would be the diagnosis if methamphetamines are presumed to be causing a patient’s psychotic symptoms.

Hospitalization. ED staff often develop a treatment plan based on a patient’s clinical picture and a working diagnosis. The plan hinges on deciding if the patient needs to be admitted to the hospital. Admission may be warranted for life-threatening medical conditions or safety issues, such as threats to self or others or inability to care for oneself at home. Other issues come into play—such as starting or changing medications and follow-up to ensure continuity of care—if you decide to discharge the patient.

Even after medical clearance, patients in the psychiatric emergency service may have underlying medical illnesses (Table 2).⁶

Table 1

Medical disorders that can cause psychiatric symptoms

Medical/toxic disorders	Examples
Alcohol and drugs of abuse	Amphetamines (including methamphetamine), cocaine, heroin, Jimson weed, ketamine, marijuana, MDMA (‘Ecstasy’), LSD, PCP
Prescription drugs	Antibiotics, anticholinergics, anticonvulsants, antihypertensives, benzodiazepines, chemotherapeutic agents, cimetidine, corticosteroids, digitalis, narcotics, propranolol, sleep medications, tricyclic antidepressants
CNS disease	Hypertensive encephalopathy, intracranial aneurysm, metastases, normal pressure hydrocephalus, postictal nonconvulsive status, primary CNS infection, seizure disorders, stroke, subdural hematoma, tumor
Infections	Acute rheumatic fever, diphtheria, malaria, Legionnaires’ disease, pneumonia, Rocky Mountain spotted fever, sepsis, syphilis, typhoid fever, urinary tract infection
Metabolic/endocrine disorders	Adrenal disease, diabetic ketoacidosis, hepatic encephalopathy, hypoglycemia, pituitary dysfunction, renal disease, serum electrolyte imbalances (sodium, potassium, calcium), thyroid disease, vitamin deficiencies, Wilson’s disease
Cardiopulmonary disease	Arrhythmias, congestive heart failure, COPD/asthma, myocardial infarction, pulmonary embolism
Miscellaneous	Anemia, lupus, multiple sclerosis, temporal arteritis, vasculitis
Source: Reprinted with permission from Williams ER, Shepherd SM. Medical clearance of psychiatric patients. Emerg Med Clin North Am 2000;18(2):185-90. Copyright 2000, Elsevier.

Table 2

Reasonable medical assessment in psychiatric emergencies

DO
Obtain a medical history, the best determinant of medical need
Listen to patients. If they say they have a medical condition, believe them; if they say they don’t, try to believe them
Thoroughly check vital signs
Conduct a focused physical examination
Maintain a high index of suspicion
Be selective with laboratory testing. Check: thyroid-stimulating hormone in those with known thyroid disease electrolyte levels in volume-depleted patients or those in withdrawal lead levels in high-risk youth urine in elderly patients with acute mental status changes
DON’T
Order blanket laboratory screening
Order an ECG in healthy young patients in the absence of clinical findings
Order chest radiography in the absence of known disease/exposure/symptoms
Source: Reprinted from Currier GW. Medical assessment on the psychiatric emergency service. Psychiatric Issues in Emergency Care Settings 2004;3(July):17, with permission from Cliggott Publishing Group of CMP Healthcare Media. Copyright 2004.

Overwhelming demand

In the study of ED patient preferences,⁴ one-fifth of patients said they went to the ED because they lacked access to routine mental health care. Therefore, besides psychiatric conditions caused by medical illnesses, ED physicians can see patients with any primary psychiatric diagnosis, including mood and anxiety disorders and psychosis.

Under pressures of time and limited collateral information, ED staff must:

• individualize psychiatric treatment
• consider use of medications and/or restraints
• rule out life-threatening causes for psychiatric symptoms
• stabilize patients and prevent injury to self and others.

These tasks are becoming increasingly difficult as more and more patients present to emergency rooms. Nationally, ED visits increased from 19 million in 1992 to 108 million in 2000, according to the U.S. Department of Health and Human Services.¹

Psychiatric patients are seeking ED care in greater numbers, and the number of those staying longer than anticipated (“boarding”) also has increased, according to a 2004 survey of 340 physicians by the American College of Emergency Physicians, American Psychiatric Association, National Mental Health Association, and National Alliance for the Mentally Ill. Surveyed physicians blamed inadequate Medicaid funding and bed shortages for the increasing ED visits.⁷

In crowded emergency rooms, where patients wait longer and longer to be seen, the influx of acutely ill psychiatric patients increases the risks of agitation, violence, and injury, as well as litigation.⁸

 

Case continued: going up in smoke

Recognizing Mr. A’s arousal, ED staff tries to reassure him and offers him food, something to drink, a phone Call, and a magazine. When these attempts fail to de-escalate his agitation, staff offers to make him more comfortable by giving oral lorazepam, which he adamantly refuses. He is told again that he must stay until a transfer facility is found for him.

Mr. A then demands to go outside “for a smoke.” When he is told ED patients cannot leave to smoke and is offered nicotine replacement, he begins to scream and lunges at one of the security officers. He is extremely strong, and additional officers are summoned. He retreats inside the room, slams the door, shatters the door window with a chair, and begins punching the broken glass. He slides to the floor in a vasovagal reaction at the sight of his bleeding hands but soon becomes combative again.

Staff give Mr. A IM haloperidol, 10 mg, and lorazepam, 2 mg, to manage his extreme agitation and place him in physical restraints to protect him and others. Within 25 to 30 minutes he is calm, and a safe environment has been re-established. The lacerations on his hands are sutured, and he is admitted to an inpatient psychiatric hospital for further stabilization and treatment.

No place for complacency

Mr. A’s experience illustrates how situations can become dangerous when precautions are not taken. Five steps can help you prepare and protect yourself when evaluating patients in the ED:

• seek the patient history
• evaluate the context in which the patient is being assessed
• identify arousal states (fear, anger, confusion, and humiliation)
• structure the interview for safety
• keep your guard up during the clinical encounter.⁹

Risk is high when law enforcement officers bring a patient to the ED. Be on guard, even if the patient is 80 years old and in a wheelchair. Complacency has no place in the ED; prepare as much as you can before interviewing the patient.

When restraints are needed. Involuntary medication and/or restraints may be necessary when reasonable interventions have failed, the patient will not cooperate, and he or she is exhibiting behavior/symptoms that could result in injury. Approximately 10% to 20% of psychiatric patients require physical or chemical restraint in the ED.¹⁰

Expert consensus guidelines suggest starting with verbal intervention, voluntary medication, and show of force, although emergency medication may be a reasonable first treatment (Algorithm).¹¹ Offer oral medication first; IM medications carry risks including acute dystonia and akathisia, although these can be treated.

Lorazepam, 1 to 2 mg oral/IM, combined with haloperidol, 2 to 5 mg oral/IM, is a reasonable start in most cases. If the patient remains extremely agitated, the same medications and dosages can be repeated 30 to 60 minutes after the initial administration.¹²

Conventional oral/IM agents are usually more readily available in the ED than atypical antipsychotics, which must be ordered from the pharmacy. Recent FDA black-box warnings also emphasize that atypical antipsychotics are approved only for treating schizophrenia, acute manic and mixed episodes of bipolar I disorder, and for maintenance treatment in bipolar disorder. When compared with placebo, atypical antipsychotics have been associated with:

• increased risk for cerebrovascular events in elderly patients with dementia
• death in elderly patients with dementia-related psychosis.

Atypicals may be more appropriate than conventional antipsychotics for emergency treatment of agitation and aggression in some patients with complicating medical conditions or histories. For example, avoid high-potency conventional antipsychotics in patients with a history of extrapyramidal side effects and in those with mental retardation/developmental delay.¹¹ Similarly, avoid benzodiazepines in patients with chronic obstructive pulmonary disease (COPD) or a history of drug-seeking behavior or drug abuse.

Of course not all psychiatric interventions in the ED are involuntary. For example, the ED physician may start an antidepressant for a patient diagnosed with mild to moderate depression for whom hospitalization is not indicated. Characteristics of patients who may be good candidates for starting antidepressants in the ED include a clear diagnosis, no substance abuse, low suicide risk, no psychosis or agitation, available social supports, clear follow-up plan, desire to begin treatment, and ability to pay for and obtain medications.¹³

Algorithm Consensus guideline for treating a behavioral emergency

Related resources

• Allen MH, Currier GW, Hughes DH, et al. The Expert Consensus Guideline Series: Treatment of behavioral emergencies. Postgrad Med 2001;May(Spec No):1-88.
• American College of Emergency Physicians. www.acep.org
• National Alliance on Mental Illness. www.nami.org

Drug brand names

• Fluoxetine • Prozac
• Haloperidol • Haldol
• Lorazepam • Ativan

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.