High-quality evidence is lacking for the impact on healthcare utilisation of short-stay alternatives to psychiatric inpatient services for people experiencing acute and/or complex mental health crises (known in England as psychiatric decision units [PDUs]). We assessed the extent to which changes in psychiatric hospital and emergency department (ED) activity were explained by implementation of PDUs in England using a quasi-experimental approach.

We conducted an interrupted time series (ITS) analysis of weekly aggregated data pre- and post-PDU implementation in one rural and two urban sites using segmented regression, adjusting for temporal and seasonal trends. Primary outcomes were changes in the number of voluntary inpatient admissions to (acute) adult psychiatric wards and number of ED adult mental health-related attendances in the 24 months post-PDU implementation compared to that in the 24 months pre-PDU implementation.

The two PDUs (one urban and one rural) with longer (average) stays and high staff-to-patient ratios observed post-PDU decreases in the pattern of weekly voluntary psychiatric admissions relative to pre-PDU trend (Rural: −0.45%/week, 95% confidence interval [CI] = −0.78%, −0.12%; Urban: −0.49%/week, 95% CI = −0.73%, −0.25%); PDU implementation in each was associated with an estimated 35–38% reduction in total voluntary admissions in the post-PDU period. The (urban) PDU with the highest throughput, lowest staff-to-patient ratio and shortest average stay observed a 20% (−20.4%, CI = −29.7%, −10.0%) level reduction in mental health-related ED attendances post-PDU, although there was little impact on long-term trend. Pooled analyses across sites indicated a significant reduction in the number of voluntary admissions following PDU implementation (−16.6%, 95% CI = −23.9%, −8.5%) but no significant (long-term) trend change (−0.20%/week, 95% CI = −0.74%, 0.34%) and no short- (−2.8%, 95% CI = −19.3%, 17.0%) or long-term (0.08%/week, 95% CI = −0.13, 0.28%) effects on mental health-related ED attendances. Findings were largely unchanged in secondary (ITS) analyses that considered the introduction of other service initiatives in the study period.

The introduction of PDUs was associated with an immediate reduction of voluntary psychiatric inpatient admissions. The extent to which PDUs change long-term trends of voluntary psychiatric admissions or impact on psychiatric presentations at ED may be linked to their configuration. PDUs with a large capacity, short length of stay and low staff-to-patient ratio can positively impact ED mental health presentations, while PDUs with longer length of stay and higher staff-to-patient ratios have potential to reduce voluntary psychiatric admissions over an extended period. Taken as a whole, our analyses suggest that when establishing a PDU, consideration of the primary crisis-care need that underlies the creation of the unit is key.

Severe mental disorders experience premature mortality mostly from physical causes. When a patient with a history of bipolar disorder is admitted to the emergency room (ER) for psychiatric symptoms, these are routinely interpreted as a psychiatric disturbance. However, a careful history should be performed to correctly interpret key clinical information to rule out somatic etiology and establish adequate diagnosis.

To describe a patient whose presenting symptoms were misdiagnosed as psychiatric relapse, rather than serious somatic comorbidity debut.

A 70-year-old man, with a history of type I bipolar disorder and multiple cardiovascular conditions, was admitted to the ER for self-referred nervousness, depressed mood, insomnia, and suicidal thoughts. Symptoms had greatly worsened the previous week to his consultation with paroxysmal episodes of severe anxiety, feelings of strangeness, and sensations of unpleasant odors.

During observation, the patient was found lying down with loss of consciousness, urinary incontinence, and amnesia of the event. Generalized tonic-clonic seizures were observed by neurologists while mental status examination was being performed. After symptoms were oriented as having a neurological etiology, the patient suffered cardiac arrest and defibrillation was required. After admittance to the intensive care unit and inpatient cardiology care, the patient was discharged from the hospital with the diagnosis of ventricular fibrillation due to drug-induced QT prolongation. There was no evidence of mixed depression or seizures once the cardiac dysfunction was identified and treated.

The psychiatric symptoms were the clinical manifestation of a generalized seizure-like activities that were attributed to transient cerebral hypoperfusion secondary to ventricular fibrillation.

No significant relationships.

Psychiatric emergencies in Major Depressive Disorder (MDD) are characterised by multiple types of symptoms including risk of self-harm and suicidal ideation. S-ketamine intranasally (Spravato) has recently been shown to help alleviate symptoms during depressive emergencies. In this case-series, we detail the clinical effects and usability of S-ketamine applied intranasally in a psychiatric emergency setting.

To describe the effects of S-Ketamine on depressive crises associated with suicidality and self-harm in a psychiatric emergency setting.

Patients with MDD in a psychiatric emergency were provided with intranasal S-Ketamine according to clinical indication in routine clinical care in a University inpatient setting. Clinical characteristics were assessed in a standardised manner and symptom measures were applied pre-and posttreatment. Experience with 10 patients is systematically described in this case-series.

Patients had a primary diagnosis of MDD accompanied by a variety of secondary psychiatric comorbidity. Among these 10 patients, the majority were female (70 %) and the mean age was 49.5 yrs (range 26-66). All cases were considered treatment resistant and suffered severe acute suicidal ideation. Across all cases, pre-treatment MADRS was 37 on average (range 20-47) indicating a severe form of MDD. High severity was confirmed in elevated BDI scores (pre-treatment 39). Post-treatment, MADRS scores were reduced to 18 on average, alongside BDI scores (mean 24). S-ketamine administration was well-tolerated and side effects such as dissociation were of short-lived duration.

S-Ketamine intranasally can be safely and effectively administered in an acute psychiatric setting to treat psychiatric emergencies.

BTB received honoraria for consultancy and presentations from AstraZeneca, Bristol-Myers Squibb, Lundbeck, Pfizer, Servier, Wyeth, LivaNova, Janssen, Novartis, Otsuka, Angelini.

Violence is considered both a societal issue and a public health issue. Due to the high economic, societal, and individual cost associated with exposure to violence, clinical risk assessment-tools are now being implemented in the public health care system as well as outside of it. To ensure early identification and prevention, various professional groups perform structured risk assessments in Norway, including police, doctors, and psychologists.

There is a need to examine competence and organizational factors, which may affect the ability to make accurate assessments in different levels of the health service, as well as in the police who often are involved in early identification and action-taking concerning violent individuals. Based on variation in risk assessment competencies, and characteristics of different work environments, our project aims to investigate whether some factors seem to be more important than others in clinical assessments when comparing different professional groups with or without a professional background in health care.

In our study, we will be able to tell if there is a significant difference in how different professional groups emphasize different risk factors, and in which way individual factors such as formal competencies, years of experience, and personal and professional attitudes to violence affect the risk violence assessments performed.

We hypothesize that retrospective, clinical, and dynamic risk-factors are interpreted differently by different professional groups, and therefore entail significant variations in assessments, and the health care provided.

In this planned study, we will examine variations in the practice of violence risk assessment in Norway.

No significant relationships.

Little is known about the need for mechanical restraint during non-voluntary transfers from patient’s homes to the psychiatric emergency department in patients diagnosed with Paranoid Schizophrenia. Although there is no evidence of its efficacy, one of the main tools used for the reduction of mechanical restraints is verbal de-escalation training.

The aim is to describe which symptoms predispose to mechanical restrain in patients with Paranoid Schizophrenia transferred in a non-voluntary manner from home to the psychiatric emergency department, and the effect on reducing mechanical restraints after receiving verbal de-escalation training.

All patients with Paranoid Schizophrenia who, after being visited by a home psychiatry team, have required non-voluntary transfer from their homes to the psychiatric emergency department were selected (N = 442).

Young age, being male, having a poor adherence to treatment, higher scores for de following variables; Excitement, Grandiosity, Suspiciousness, Hostility, Abstract thinking, Motor tension, Uncooperativeness, Poor attention, Lack of insight and Poor impulse control as well as lower scores in motor retardation on the PANSS, are related to a higher frequency of mechanical restrain (P<0,005). Before the verbal de-escalation training, 43.9% of the transferred patients required mechanical restraint, after the training, the need for restraints was reduced to 25.5% (P<0.001).

Training in verbal de-escalation has allowed an important reduction in mechanical restraints in patients with schizophrenia who have required non-voluntary transfers from home to the psychiatric emergency department.

No significant relationships.

Mental health disorders are considered a priority in health policies around the world. It is estimated that more than 900 million people worldwide have a mental disorder, in which stress-related disorders account for a high number of emergency department visits. The scientific literature has pointed out the importance of considering how gender and sex differences influence the clinical outcomes of people with mental illness, playing an important role in the clinical management of these patients.

The aim of this report is to investigate the presence of gender differences in the care of psychiatric patients attending the emergency department (ED), taking into account the clinical characteristics, reasons for consultation and practices.

The study considered all episodes of patients who visited the ED during 2017 and who were assessed by the psychiatric department. Statistical analyses were performed using IBM SPSS Statistic software.

During the 12 months period, a total of 3180 episodes were evaluated by the psychiatric department in the ED. Of them, 1723 were female (54,2%) and 1457 male. Regarding clinical data, there were found statistically significant differences with respect to the pharmacological prescription in the ED, specifically in the prescription of benzodiazepines, psychiatric diagnoses after discharge and the indication of hospital admission between women and men.

This study emphasizes the importance of considering the existence of gender differences in both the clinical presentation as well as in the care of psychiatric patients attending the ED. The analysis of these variables would help to improve the health care of psychiatric patients.

After World Health Organization declared that COVID-19 disease became a pandemic; like most, people in Turkey were affected by the emotionally challenging atmosphere. Previous outbreaks negatively effected mental health, increased suicide attempts and completed suicides.

Our study aimed to investigate psychiatry consultations from emergency service in a university hospital, to determine differencies in pandemia.

We conducted a monocenter retrospective study by examining the patients who applied to emergency servise and consulted to psychiatry department in three periods: between 11 March- 11 July, in 2018, 2019, and 2020. Patient’s sociodemographic and clinical variables were assessed.

There were no difference in distributions of applicants’ following variables between periods; age, sex, marital status, experiencing a first attack or an exacerbation, or outcome treatment. Among applicants with suicide attempts, there were no difference between periods in terms of the presence of recurrent suicide attempt (χ² = 0.297 p = 0.862). While emergency admissions with behavioral disorders increased, admissions with depressive symptoms decreased. Admissions with suicide attempts were statistically significantly higher in 2020 (Table 1). Recommendation of psychiatric inpatient treatment did not change between periods, while refusal of hospitalization recommendation decreased (Table 2).

In our sample, emergency psychiatry admissions with behaviour disorders and suicide attempts increased in pandemic period.

No significant relationships.

Catatonia, a complex psychomotor syndrome and psychiatric emergency, is encountered across various psychiatric disorders. Most findings have been derived in the context of schizohrenia, warranting more comprehensive understanding in affective disorders.

To evaluate the longitudinal course of affective disorders presenting with catatonia and factors influencing the same.

Medical records of 439 patients presenting with catatonia to the psychiatry emergency from 2014 to 2017 were reviewed till June 2020. 135 patients with a final diagnosis of affective disorder (67 bipolar and 68 unipolar) were identified. Poisson regression and survival analysis were used for longitudinal data.

77.6% of bipolar patients were initially diagnosed under psychotic spectrum disorders compared to 3% in unipolar. Bipolar patients had a significantly younger age of first catatonic episode, earlier illness onset, and longer duration of illness. Survival analysis showed no significant difference between groups in time to recurrence of mood episode, readmission or catatonia relapse, with both groups demonstrating a greater likelihood of catatonia relapse in first 20 months. Poisson regression showed that bipolar patients had fewer catatonic relapses longitudinally over 2.5-6.5 years (RR: 0.64, CI: 0.43-0.96), but warranted more electroconvulsive therapy sessions for catatonic relapses (RR: 2.33, CI: 1.49-3.50), with fewer episodes resolving with lorazepam (RR: 0.62, CI: 0.40-0.95) compared to unipolar patients over same time period.

Bipolar disorders appear to have an earlier onset but fewer episodes of catatonia over illness course. Poorer lorazepam response and higher number of ECT sessions for catatonia resolution longitudinally suggest a differential treatment response of catatonia in bipolar disorder.

No significant relationships.

The implementation of Intensive Home Treatment (IHT) aims to decrease the pressure on acute inpatient services that could lead to prevent hospitalization and reduce the number of hospitalization days and, ultimately, reduce cost in the mental health services. Although there are studies assessing the effectiveness of IHT, there is a shortage of research studying the cost-effectiveness.

The aim of this study is to present an cost-utility analysis of IHT compared to care as usual (CAU)

Patients between 18 and 65 years of age whose mental health professionals considered hospitalization were included. These patients were pre-randomized in either IHT or CAU and followed up for 12-months. For this study, the base case analysis was performed from the societal and healthcare perspective. For the cost-utility analyses the Euroqol 5D was used to calculate quality adjusted life years (QALYs) as a generic measure of health gains.

Data of 198 patients were used. From a sociatal perspective, the cost-utility analysis resulted in an incremental cost-effectiveness ratios (ICERs) of €58 730, and a 37% likelihood that IHT leads to higher QALYs at lower costs. The probability of IHT being cost-effective was >50% if there was no willingness to pay more for extra QALY than in the current situation under CAU.

Professionals working in crisis care are able to offer IHT with the same effect as other crisis care interventions at lower costs. IHT seem to be cost-effective compared with CAU over 52 weeks follow-up for patients who experience psychiatric crises.

No significant relationships.

Social determinants of health have the potential to influence mental health and addictions-related emergency department (ED) visits and the likelihood of admission to hospital. We aimed to determine how social determinants of health, individually and in combination, relate to the likelihood of hospital admission at the time of postpartum psychiatric ED visits.

Among 10 702 postpartum individuals (female based on health card) presenting to the ED for a psychiatric reason in Ontario, Canada (2008–2017), we evaluated the relation between six social determinants of health (age, neighbourhood quintile [Q, Q1 = lowest, Q5 = highest], rurality, immigrant category, Chinese or South Asian ethnicity and neighbourhood ethnic diversity) and the likelihood of hospital admission from the ED. Poisson regression models generated relative risks (RR, 95% CI) of admission for each social determinant, crude and adjusted for clinical severity (diagnosis and acuity) and other potential confounders. Generalised estimating equations were used to explore additive interaction to understand whether the likelihood of admission depended on intersections of social determinants of health.

In total, 16.0% (n = 1715) were admitted to hospital from the ED. Being young (age 19 or less v. 40 or more: RR 0.60, 95% CI 0.45–0.82), rural-dwelling (v. urban-dwelling: RR 0.75, 95% CI 0.62–0.91) and low-income (Q1 v. Q5: RR 0.81, 95% CI 0.66–0.98) were each associated with a lower likelihood of admission. Being an immigrant (non-refugee immigrant v. Canadian-born/long-term resident: RR 1.29, 95% CI 1.06–1.56), of Chinese ethnicity (v. non-Chinese/South Asian ethnicity: RR 1.88, 95% CI 1.42–2.49); and living in the most v. least ethnically diverse neighbourhoods (RR 1.24, 95% CI 1.01–1.53) were associated with a higher likelihood of admission. Only Chinese ethnicity remained significant in the fully-adjusted model (aRR 1.49, 95% CI 1.24–1.80). Additive interactions were non-significant.

For the most part, whether a postpartum ED visit resulted in admission from the ED depended primarily on the clinical severity of presentation, not on individual or intersecting social determinants of health. Being of Chinese ethnicity did increase the likelihood of admission independent of clinical severity and other measured factors; the reasons for this warrant further exploration.

The characteristics of patients who have repeated compulsory psychiatric admissions are largely unknown.

To investigate the frequency and risk factors for repeated emergency compulsory psychiatric admission (ECPA); and to identify targets for interventions to reduce repeated ECPA.

Data were collected from a database of electronic patient files (EPFs) held by three psychiatric emergency services (PES) in the Netherlands. Analyses were based on the data for adult patients (aged 18–75 years) with a first PES contact in 2010–2015. Using descriptive statistics and regression analysis, we studied the associations between baseline patient factors and repeated ECPA and time to readmission, within a 2-year follow-up period.

We included 6059 patients: 15.6% had two or more ECPAs. In total, 66% of second ECPAs had occurred within 6 months of the first. About 30% of all ECPAs were repeated ECPAs. Two baseline factors were associated with a higher frequency of a second ECPA: history of receiving any mental healthcare treatment, whether in-patient or out-patient or both, and a lower level of self-care. Three were associated with a lower frequency: ethnicity (other than Dutch), older age and suicidality. Lower Global Assessment of Functioning (GAF) scores and housing problems were associated with a shorter time to compulsory readmission and persistent psychiatric problems with a longer time to compulsory readmission.

We found that 15.6% of patients had two or more ECPAs. Two-thirds of the second ECPAs had occurred within 6 months of the first. Like earlier studies, the risk factors we identified suggest that interventions to reduce the risk of repeated compulsory psychiatric admission should seek to improve self-care, general daily functioning and homelessness.

People who present to hospital following self-harm are at high risk of suicide. Despite this, there are considerable variations in the management of this group across hospitals and the factors influencing such variations are not well understood.

The aim of this study was to identify the specific hospital and individual factors associated with care pathways following hospital-presenting self-harm.

Data on presentations to hospitals by those aged 18 years and over were obtained from the National Self-Harm Registry Ireland for 2017 and 2018. Factors associated with four common outcomes following self-harm (self-discharge, medical and psychiatric admission and psychosocial assessment before discharge) were examined using multilevel Poisson regression models.

Care pathways following self-harm varied across hospitals and were influenced by both hospital and individual factors. Individual factors were primarily associated with self-discharge (including male gender, younger age and alcohol involvement), medical admission (older age, drug overdose as a sole method and ambulance presentations) and psychiatric admission (male gender, methods associated with greater lethality and older age). The hospital admission rate for self-harm was the only factor associated with all outcomes examined. The availability of psychiatric in-patient facilities and specialist mental health staff contributed to variation in psychiatric admissions and psychosocial assessments prior to discharge. Hospital factors explained the majority of observed variation in the provision of psychosocial assessments.

Characteristics of the presenting hospital and hospital admission rates influence the recommended care pathways following self-harm. Provision of onsite mental health facilities and specialist mental health staff has a strong impact on psychiatric care of these patients.

Substance use and psychiatric illness, particularly psychotic disorders, contribute to violence in emergency healthcare settings. However, there is limited research regarding the relationship between specific substances, psychotic symptoms and violent behaviour in such settings. We investigated the interaction between recent cannabinoid and stimulant use, and acute psychotic symptoms, in relation to violent behaviour in a British emergency healthcare setting.

We used electronic medical records from detentions of 1089 individuals under Section 136 of the UK Mental Health Act (1983 amended 2007), an emergency police power used to detain people for 24–36 h for psychiatric assessment. The relationship between recent cannabinoids and/or stimulant use, psychotic symptoms, and violent behaviour, was estimated using logistic regression.

There was evidence of recent alcohol or drug use in 64.5% of detentions. Violent incidents occurred in 12.6% of detentions. Psychotic symptoms increased the odds of violence by 4.0 [95% confidence intervals (CI) 2.2–7.4; p < 0.0001]. Cannabinoid use combined with psychotic symptoms increased the odds of violence further [odds ratios (OR) 7.1, 95% CI 3.7–13.6; p < 0.0001]. Recent use of cannabinoids with stimulants but without psychotic symptoms was also associated with increased odds of violence (OR 3.3, 95% CI 1.4–7.9; p < 0.0001).

In the emergency setting, patients who have recently used cannabinoids and exhibit psychotic symptoms are at higher risk of violent behaviour. Those who have used both stimulants and cannabinoids without psychotic symptoms may also be at increased risk. De-escalation protocols in emergency healthcare settings should account explicitly for substance use.

Ethnicity may influence treatment decisions and treatment quality in mental disorders. There have been suggestions of institutional racism in mental health services.

In this study we aimed to compare treatment quality between two groups: Greeks and immigrants and prove whether in our clinic, ethnicity is a significantly restricting factor of treatment quality. This study was conducted with all in-patients of Second Psychiatric Clinic University of Athens at Attikon Hospital between April and December 2008.

A total of 101 in-patients aged 16-56 years old, were studed. There were 73 Greeks and 18 immigrants. The diagnoses were schizofrenia:36(49,31%) for Greeks and 10(55,55%) for immigrants, and mood disorders:37(50,68%) for Greeks and 8(44,44%) for immigrants. We considered that treatment quality is composed of factors such as: days of hospitalization, number of psychiatric medicines used before-during and after hospitalization, doses of: conventional and atypical antipsychotics, SSRI'S, SNRI'S, and mood stabilizers used before-during and after hospitalization.

In this study ethnicity was not significantly associated with rates of polypharmacy during and after admition. There was a reduction of medication prescribed after admission in both groups. Immigrants had longer inpatient stays than Greek patients. We saw similar rates of antipsychotics used in both groups, but Greeks were more likely to take mood stabilizers and SSRI'S-SNRI'S. There were also higher rates of atypical antipsychotics than antipsychotics used in both groups.

To describe an innovative model of emergency intervention with patients enduring severe stalking.

Catamnestic investigation of the institutional, psychopathological, clinical, legal and therapeutic aspects of severe stalking syndromes among 20 patients referred to emergency room with severe stalking syndromes.

A well structured model of multimodal psychiatric intervention is described and its results.

Comment: Severe stalking is a common issue in emergency psychiatry. These patients should be better detected and may benefit from the adequate psychiatric treatment. Further studies should investigate this innovative intervention in randomized clinical trials.