EDITORIAL
Psychiatric emergency services: a key part of the healthcare network
Marco Antonio Alves Brasil
Psychiatry and Medical Psychology Service, Hospital Universitário Clementino Fraga Filho (HUCFF), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brasil Departament of Psychiatry and Legal Medicine, Faculdade de Medicina, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brasil
Psychiatric emergency (PE), although seen as a necessary component of psychiatric care, is not traditionally a relevant topic in the psychiatric literature. However, with the reduction of hospitalization periods, the need for alternatives in healthcare delivery, and the growing number of patients in acute episodes, PE has been increasingly recognized as a central part of the healthcare network. For an expanding number of patients, emergency services act as the entrance door to the healthcare system and as essential healthcare units, sometimes being the only option available.
Conversely, psychiatrists working in emergency services need knowledge and skills that are not contemplated in the general psychiatric training. Techniques to establish quick rapport and obtain essential information, to manage agitated patients, to quickly assess the risk of suicide, and to make proper referrals to other sources of healthcare delivery are requirements that constitute the daily practice of psychiatrists in emergency services.
The authors of the articles included in this supplement of the Revista Brasileira de Psiquiatria examine some of the essential components of the state of the art of PE, its role and importance within the integrated psychiatric care network, as well as the particularities of the diagnosis and management of patients admitted in this context.
Régis Barros, Teng Chei Tung, and Jair Mari, performing literature reviews and entitled by their broad knowledge and experience on the topic, show that PE services are central for the proper functioning of mental health networks, due both to their role in managing emergency situations and regulating the network that they are a part of. The authors emphasize that these services should occupy a special place in Brazilian public health policies for their enhancement and effectiveness.
Célia Mantovani, Marcelo Migon, Flávio Alheira, and Cristina Del-Benhighlight the importanceof non-pharmacological measures in the adequate management of agitated or aggressive patients and emphasize that the main objective of the pharmacological treatment is rapid tranquilization, aimed at reducing symptoms without inducing intense or prolonged sedation, keeping the patient calm but fully or partially responsive.
Cristina Del-Ben, Armanda Rufino, João Marques, and Paulo Menezes warn that characteristics intrinsic to emergency care - single and brief cross-sectional assessment with little information available - may hamper the diagnostic process. These limitations can be circumvented by the application of operational diagnostic criteria, the use of standardized interviews and scales, and minimum observation periods.
José Manoel Bertolote, Carolina de Mello-Santos, and Neury Botega offer excellent guidelines for health professionals to identify risk and protective factors in the management of patients at risk of suicide. The authors emphasize the importance of the clinical interview and, although they recognize that there is no way to foresee who is going to attempt suicide, they point out that it is possible to assess the individual risk for each patient by means of a thorough and empathic investigation.
Sandra Scivoletto, Miguel Boarati, and Gizela Turkiewicz deal with the most relevant clinical aspects in the emergency psychiatric assessment of children and adolescents and the guidelines for the initial conduct in this context. The most frequent causes of psychiatric emergencies in childhood and adolescence, as well as the management strategies recommended for each situation, are discussed in detail.
Ricardo do Amaral, André Malbergier, and Arthur Guerra present and discuss current evidence on the management of substance intoxication and abstinence. They demonstrate that the use of substances constitutes, in itself, a prevalent problem in our country, in addition to being related to other health risks. They warn about the need for specialized services and professionals in the field, which must be placed among the major concerns of public health professionals in the organization of emergency services.
The initiative to publish a supplement on Psychiatric Emergencies is opportune. In the context of PE, one can observe and confirm how false the dichotomy between body and mind is. Almost five centurys ago, Francis Bacon stated that "nature is more diverse in her operations than man in his conceptions, and nowhere can this be better seen than in the history of the mind-body dualism, a human artifact" [Free translation]. Nevertheless, body and mind are still treated in separate spaces, and this contributes for the stigmatization of mental disorders and the confirmation of this false dichotomy. PE has a crucial role in the improvement of the integration of psychiatric care and general medical care. A public healthcare network in which psychiatric patients can be treated in a space that is shared or integrated with general clinical care is increasingly necessary. The patient with mental disorders should be seen as a patient of the general healthcare system, but unfortunately this is not what happens in our country. We have few PE services and psychiatric hospitalization units integrated with general hospitals, regardless of all the evidence showing that this is an absolute requirement.
A significant portion of psychiatric patients suffer from undiagnosed somatic disorders that may be related to the etiology or exacerbation of their mental disorders, with over 50% of older patients with psychiatric disorders having some clinical (somatic) condition that contributes to their behavioral alterations.1
People with severe mental disorders die 25 years earlier in average as compared with the general population; 60% of early deaths in schizophrenia patients are due to such causes as cardiovascular and pulmonary diseases, as well as infectious diseases. This excessive morbidity resulting in early deaths is partly due to difficulties in the access to healthcare and the lack of communication between the mental and general health systems.1,2
I congratulate the authors of this supplement. The reader has in his hands high-quality reviews of the relevant literature made by people with great experience and familiarity with the topics examined. Enjoy the reading.
References
- 1. Griswold KS, Pastore PA, Homish GG, Henke A. Access to primary care: are mental health peers effective in helping patients after a psychiatric emergency? Primary Psychiatry 2010;17(6):42-5.
- 2. Slaby AE, Trujillo M. Emergency psychiatry in the twenty-first century. Primary Psychiatry. 2009;16(9):35-6.
Publication Dates
-
Publication in this collection
06 Dec 2010 -
Date of issue
Oct 2010
