Patterns of Psychiatric Emergency at Tertiary Referral Psychiatric Hospital Saber A

Original article 121

Patterns of psychiatric emergency at tertiary referral psychiatric hospital Saber A. Mohameda, Yasser M. Rayaa,b, Dalia Khalila and Usama M. Youssefa aDepartment of Psychiatry, Faculty of Medicine, Background Zagazig University, Zagazig, Egypt and bDepartment Psychiatry, Faculty of Medicine, Qassim University, Psychiatric emergency has been extensively studied over years with different Qassim, Kingdom of Saudi Arabia transcultural presentations.

Correspondence to Saber A. Mohamed, MD, Objective Department of Psychiatry, Faculty of Medicine, Zagazig The aim of the study was to assess sociodemographic aspects and clinical diagnoses of University, 44522 Zagazig, Egypt Tel: + 0552330699; e-mail: [email protected] psychiatric emergency cases attending emergency room (ER) at tertiary referral mental hospital and to study some of the clinical contributions of admitted patients through ER. Patients and methods Received 27 March 2013 During 3-month period, 3666 attendants to psychiatric ER were submitted for this Accepted 16 January 2014 cohort study. Patients were submitted to medical assessment and psychiatric Middle East Current Psychiatry evaluation by semistructured clinical interview. Of them, 283 were admitted and further 2014, 21:121–126 submitted to Mini–Mental State Examination, Brief Psychiatric Rating Scale, and Crisis Triage Rating Scale at ward. Results A total of 3666 patients (2352 male and 1314 female) who were aged 33.44 ± 11.5 years, age range of 8–70 years, with psychiatric emergency attended Al Taif Psychiatric Hospital ER, KSA. The most prevalent psychiatric diagnoses were schizophrenia-related disorders in 30.4%, mood disorders in 28.8%, substance- related disorders in 21.4%, anxiety in 9.6%, developmental disorders (MR) in 3.2%, personality disorders in 0.6%, somatoform disorders in 0.14%, and neurological disorders in 2.2%, whereas 3.3% of ER attendants had no formal psychiatric disorder. The main cause for attending ER was refill of medicine in 31%, followed by natural exacerbation of illness in 26%, then familial conflict in 16%, and finally social problem in 15% of patients. The hospitalization rate was found to be 7.7%; most admitted patients were alert. Hospitalized male patients were found to be more severe and had less social support with little cooperativeness from their families than female patients. Conclusion Psychiatric emergency constitutes a significant route for providing service for mentally ill patients. Family education and early detection of psychiatric disorders minimize the burden of psychiatric illness.

Keywords: emergency room, hospital, psychiatric emergency

Middle East Curr Psychiatry 21:121–126 & 2014 Institute of Psychiatry, Ain Shams University 2090-5408

emergencies are frequently seen by emergency physicians Introduction who face the challenge of assessing and managing patients Psychiatric emergency has been extensively studied over presenting with psychosis, severe depression, agitation, years with different transcultural presentations. The suicidalintent,andsubstanceabuse.Oneoftheimportant pressure on inpatient capacity in acute care wards attracts factors considered in evaluation of psychiatric patient in attention of healthcare providers about the emergency this setting is exclusion of organicity that may mimic room (ER) route to psychiatric services. Psychiatric psychiatric condition particularly in elderly [3]. emergencies are classified as major psychiatric emergencies, which represent a threat to life – for example, suicidal, During the past 25 years, there has been a shift away from overdose, homicidal, agitated, and severe adverse drug institutionalizing mentally ill patients toward reliance on reaction, and minor psychiatric emergencies, which are community services. Psychiatric emergencies facilities are severely distressing but not a threat to life – for example, often the only source of treatment and support for many of grief, panic attacks, and rape [1]. the chronically disabled people living in the community [4]. Psychiatric emergency may be defined as any disturbance in thought, feelings, or actions for which immediate Some authors reported that, during the past 15 years, therapeutic intervention is necessary [2]. Psychiatric there has been a rapid increase in the growth and

2090-5408 & 2014 Institute of Psychiatry, Ain Shams University DOI: 10.1097/01.XME.0000444070.24436.8e

Copyright © Middle East Current Psychiatry. Unauthorized reproduction of this article is prohibited. 122 Middle East Current Psychiatry utilization of psychiatric emergencies facilities in the skull and chest radiography and computed tomography of USA. The psychiatric emergency service is now the main the brain if indicated in selected patients – for example, entry point into the network of mental health service for patients with suspected organicity, catatonic features, people in need of help [5]. history of head trauma, or first break psychoses, and routine laboratory tests, including liver function tests, The total volume of emergency department visits by complete blood profile, renal function tests, hepatitis patients with mental and substance use disorders has markers (B and C and HIV), pregnancy test for women, been increasing more rapidly than the number of visits by HIV, and urinary drug screening for amphetamine, other patients [6–9] – a trend that may intensify cannabis, benzodiazepines, and alcohol. administrative burdens and add to the costs of emergency department care. Increased patient volume coupled with Those admitted patients were further submitted to a reduced number of emergency departments may psychometric evaluation by the following: exacerbate chronic shortages of specialty mental healthcare providers and services, which exist in many US (1) Mini–Mental State Examination: It is designed by communities [10,11]. Some authors found that the Folstein et al. [15] from Baltimore (Arabic version) duration of emergency department visits made by as the most widely used and studied screening patients presenting with mental health complaints and measure of cognitive impairment. It has the advan- visits made by all other patients increased at similar tages of brevity, ease of administration, and high rates [12]. In Egyptian study, it was found that inter-rater reliability. It can be easily incorporated psychiatric emergency use is more often in low socio- into routine clinical practice. It is not useful for the economic classes and in female individuals more than detection of focal cognitive deficits and is insensitive male individuals, and hospitalized patients were more to frontal lobe disorders. A score of less than 24 was severe and had less social support with little coopera- initially suggested for distinguishing between im- tiveness than nonhospitalized ones [13]. Some recent paired and normal individuals with a reasonably high studies reported that frequent visitors to a French degree of specificity and sensitivity. It has been psychiatric emergency service were more likely to be clearly established that the Mini–Mental State single and homeless and to have diagnostic variability, Examination is very vulnerable to the effects of age, substance use disorders, and personality disorders [14]. education, and socioeconomic status. It takes an average of 5–10 min to be completed. (2) Brief Psychiatric Rating Scale [16]: It has been widely recognized and used for both routine follow-up and Aim of the study research assessment of psychiatric patients. Theaimofthestudywastoassessthesociodemographic (3) Crisis Triage Rating Scale [17]: It is used to expedite aspects of psychiatric emergency patients attending ER at the rapid screening of emergency psychiatric patients tertiary referral mental hospital and to study some of the who require hospital admission and who are suitable clinical contributions of patients admitted through ER. for outpatient crisis intervention treatment. It is applied within the first 24 h of admission of the patients. It has three dimensions: dangerousness, Patients and methods support system, and motivation and ability to cooperate. A simple sum of the three scores provides Procedure the cognitive triage rating scale (CTRS). Early trails After approval of ethical committe: all medical files of on this CTRS indicated that most of those with scores attendants to ER over 3-month period were reviewed for of 8 or lower were referred for admission, whereas medical and psychiatric evaluation, which was performed those with scores of 10 or high tended to be suitable by specialist and resident psychiatrists in a descriptive for outpatient crisis intervention treatment. Those study. Those who were admitted were further assessed, who were admitted to hospital were considered to be after obtaining informed consent from patient or relative, more severe, have less social support, and scored using specially designed formula including semistruc- lower on the CTRS than those who were discharged. tured clinical interview derived from Al Taif Psychiatric Hospital sheet at ER. It covers, mainly, sociodemographic data, personal history, past history, medical history, family Data management and statistical methods history, premorbid personality, medical and psychiatric The data were coded and entered on an IBM-compatible examination, psychiatric diagnosis according to the DSM- personal computer using the statistical package SPSS IV diagnostic criteria, differential diagnosis, investigations ver. 13. The data were summarized using the mean and recommendations, special notes, and initial treatment SD for continuous type, whereas percentage was used for plan at ER. Those admitted patients were further the qualitative type. The differences between groups assessed, at acute inpatient ward, by medical team were tested using the Student t-test and analysis of consisting of consultant and six specialists, two resident variance for continuous data. The w2-test was used for psychiatrists, medical specialist, social worker, psycholo- qualitative data. The correlation between two continuous gist, and registered nurse for final medical and psychiatric groups was assessed using the Pearson correlation test. management. All admitted patients were routinely The level of significance for all above-mentioned tests subjected to radiologic examination, including routine was at P value less than 0.05 [18].

Results without ability to wait for the out patient department Over 3-month period, 3666 consecutive referral psychiatric appointment. The hospitalization rate was found to be 7.7%; patients [2352 male patients (64%) and 1314 female most admitted patients were alert (81%) and only 15.5% patients (36%)] who were aged 33.44 ± 11.5 years, with were drowsy, whereas 3.5% were stuporous and there were age range of 8–70 years and peak at 20–30 years (31%) no reported comatosed patients (Table 5). Hospitalized (Table 1), with psychiatric emergency attended Al Taif male patients were found to be more severe and have less Psychiatric Hospital ER, KSA. Most of the patients were social support with little cooperativeness from their families single (76%), had low education level (39.9%), and 59% were than hospitalized female patients (Table 6). In all, 72% of unemployed (Table 2). The most prevalent psychiatric inpatients were found to have illness for more than 5 years, diagnoses, in descending chronological manner, were schizo- whereas10%hadlessthan1yearandin18%psychiatric phrenia-related disorders (schizophrenia, brief psychotic illness ranged from 1 to 5 years (Table 7). A total of 23.5% of disorder, psychosis not otherwise specified, schizoaffective, inpatients scored 41–50 by Brief Psychiatric Rating Scale, delusional, and schizophreniform) in 30.4%, mood disorders whereas only 12% scored more than 70 (Table 8). (bipolar disorder manic and depressive subtypes, depression) in 28.8%, substance-related disorders (substance abuse Table 3 Prevalence of psychiatric emergencies according to mainly cannabis and amphetamine, substance-induced DSM-IV TR psychoses, and substance-induced mood disorders) in Diagnosis n (%) 21.4%, anxiety (generalized anxiety disorder, social anxiety, obssesive compulsive disorder, post traumatic stress disorder, Schizophrenia 1115 (30.4) Mood disorder 1057 (28.8) and phobic) in 9.6%, developmental disorders (MR) in 3.2%, Substance-related disorders 783 (21.4) personality disorders in 0.6%, delirium and dementia in 0.4%, Anxiety disorders 353 (9.6) somatoform disorders in 0.14%, and neurological disorders Developmental disorders MR 118 (3.2) Normal 119 (3.3) (migraine and epilepsy) in 2.2%, whereas 3.3% of ER Migraine and epilepsy 81 (2.2) attendants had no formal psychiatric disorder (Table 3). The Personality disorder 22 (0.6) main causes for attending ER were refill of medicine in 31%, Dementia and delirium 13 (0.4) Somatoform disorders 5 (0.14) followed by natural exacerbation of mental illness in 26%, then familial conflict in 16%, and finally social problem in 15% of patients (Table 4). The policy of refill medicine at Table 4 Precipitating factors to emergency the ER is allowed for selected patients for social reasons – for example, run out of medicine without available appointment n (%) at out patient department, patients from far remote areas Familial 578 (16) Social 550 (15) Marital 183 (5) Table 1 Age distribution Work 110 (3) School 37 (1) Age (years) n (%) Natural exacerbation 953 (26) Refill 1136 (31) o10 36 (1) No cause 110 (3) 10–20 550 (15) 20–30 1137 (31) 30–40 1064 (29) 40–50 476 (13) Table 5 Mini–Mental State Examination in hospitalized patients 50–60 293 (8) 460 110 (3) Items n (%)

Alert 229 (81) Table 2 Sex, marital status, residency, education, and Drowsy 44 (15.5) occupation of emergency room attendants Stupor 10 (3.5) Coma 0 (0) Items n (%)

Sex Male 2352 (64) Table 6 CTRS in hospitalized patients Female 1314 (36) Marital status CTRS n (%) Married 606 (16.5) Single 2790 (76) 3 9 (3.2) Divorced 270 (7.5) 4 19 (6.7) Residency 5 25 (8.8) Urban 1723 (47) 6 40 (14.1) Rural 1943 (53) 7 31 (10.9) Education 8 71 (25.1) o6 years 1443 (39.3) 9 65 (22.9) 6–12 years 1353 (37) 10 8 (2.8) 412 years 870 (23.7) 11 6 (2.1) Occupation 12 7 (2.5) Not working 2160 (59) 13 2 (0.7) Students 260 (7) 14 0 (0) Semiskilled 1045 (28.5) 15 0 (0) Skilled 201 (5.5) CTRS, cognitive triage rating scale.

Table 7 Duration of illness marital disturbance, educational troubles, and others. Duration n (%) However, Eferakeya and colleagues [24,25] distinguished mental illness as the major precipitating factor followed o1 year 28 (10) by situational factors. 1–5 years 50 (18) 45 years 204 (72) One important finding in our study was the relatively high hospitalization rate (7.7%), which is very close to the study by Pajonk et al. [26] (9.2%), whereas at the same time the rate was higher than that reported by Khashaba et al. [13] Table 8 Brief Psychiatric Rating Scale of inpatients (1.7%) in Egyptian study and by Adityanjee et al. [22] (2%). BPRS score % We think that the relatively high rate of hospitalization may be in part due to the nature of the mental hospital as it is o20 1 tertiary referral hospital in a very big catchment area and 21–30 14.5 31–40 21.5 the prevalent psychiatric diagnoses of schizophrenia, mood- 41–50 23.5 related disorders, and substance-related disorders; because 51–60 16.5 most patients were brought by police or red crescent 61–70 11 470 12 involuntary because of their violence, abnormal behavior, or social conflicts; and at last due to the poor compliance of BPRS, Brief Psychiatric Rating Scale. patients at maintenance treatment. One interesting finding in our study was the more common prevalence in male patients (64%) than in Discussion female patients (36%) attending ER and seeking The main findings of this study were the chronological order psychiatric service. It might be explained in part by the of psychiatric disorders as a cause of admission and as a nature of the surrounding culture and traditions. It is in causative factor in attending patients in emergency, the accordance with the study by Okasha [27] who reported modest rate of hospitalization to psychiatric ward, higher that male patients (57.4%) are more common than female percentage in male patients than in female patients, and patients (42.4%) in ER. However, it is in contradiction to singles, less educated, and unemployed patients were more the study by Larkin and colleagues [8,11]. Some prone to come in emergency. The major causes for attending authors [13] found female patients (51.5%) to be more ER were, in descending manner, refill, natural exacerbation prevalent than male patients (48.5%) at ER of general of illness, familial conflict, and social problems. Most of the hospital. These differences might be explained by the patients were alert and there were no reported comatosed nature of sample, the difference in the predominant patients at ward. Most of the patients were single, had low diagnoses, and the study design. education level, and were unemployed. Most of the admitted patients were alert (81%), followed We found the most prevalent psychiatric diagnoses in a by drowsy (15.5%), and then stuporous (3.5%), and there descending manner: schizophrenia (30.4%), mood dis- were no comatosed patients reported. It is in harmony orders (28.8%), substance-related disorders (21.4%), with the study by Khashaba et al. [13] who reported that anxiety disorders (9.6%), developmental disorders, and 65.5% of their patients were alert followed by drowsy, the lowest somatoform disorders (0.14%). In all, 3.3% had stupor, and coma (26.5, 6.5, and 1.5%, respectively), and no formal psychiatric disorder. In partial agreement with in accordance with the study by Henneman et al. [28]. No us were the findings of Oyewumi and colleagues [19–21] comatosed patients were reported at psychiatric ward who found that substance and alcohol abuse disorders because of the policy of thorough medical and neurolo- were the most common prevalent causes (29, 70, and gical examination and the prohibition of keeping coma- 32.8%, respectively) of psychiatric emergencies. In our tosed psychiatric patients at ward. previous study [13] it was found that somatoform Moreover, hospitalized male patients were found to have disorder (24.5%) is the most prevalent diagnoses, less familial support from their families and were more followed by mood disorders (18.5%), then schizophrenia severe with little cooperativeness from their families than (11%), anxiety (9.5%), and finally substance-related female patients. This sex differences might explain the disorders (8%). These controversies with our previous high rate of attending ER and hospitalization in male study might be attributed to many factors including the patients than in female patients. nature of our sample in a mental hospital as the previous one was conducted in a general medical hospital. The high rate of schizophrenia, mood-related disorders, and substance-related disorders implies that psychiatric In our study, the main causes of attending ER were self- ER team should be aware about its management. referral and refill of medicine (31%), natural exacerbation of mental illness (26%), familial conflict (16%), and social Our study might have some limitations in full description problem (15%). However, Adityanjee et al. [22] found that of diagnoses of admitted patients, lack of data about self-referrals account for 77% of the sample and patients duration of stay at hospital, and follow-up. However, it brought by the police for 21% of the sample. Others [23] might be recommended to overcome these limitations in reported family quarrels as the first cause followed by a second-phase study.

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