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The AAEP listserve Discussion Forum has been lively recently with several good questions and debates. For those of you who have not signed up, please contact our office at [email protected] to become part of this invaluable resource, or visit our revamped website at emergencypsychiatry.org. Inside this issue Dear AAEP Members, (Continued on page 2) The Medical Clearance Protocols Group Update ............................. 6 Announcements .......................... 2
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Inside this issue
Announcements .......................... 2
The Care of Psychiatric Patients in Emergency Settings ..................... 3
Consult Corner ............................ 4
The Medical Clearance Protocols Group Update ............................. 6
Behavioral Emergencies Seminars Update ........................................ 7
Save the Date .............................. 8
American Association For
Emergency Psychiatry
Newsletter Winter Issue 2011
Letter from the President
Dear AAEP Members,
Whether you are looking to get involved in cutting-edge research, have access to
professional networking, get great educational opportunities, or just have fun with your
industry peers, AAEP is clicking on all cylinders right now.
Project BETA, the AAEP-members-only research initiative on Best practices in Evaluation
and Treatment of Agitation, is in full swing, with over thirty members divided into five
workgroups. We are presently in discussions with psychiatric journals to devote an entire
issue or supplement to the project, with six articles in production. We will also be
debuting the findings at the American Psychiatric Association’s Institute for Psychiatric
Services meeting this October in San Francisco.
Meanwhile, the AAEP Task Force Consensus Statement on Medical Clearance is nearing
completion. This is an outstanding collaborative piece that should help set nationwide
standards for medical evaluation of psychiatric patients. See page six for details on their
progress.
Plans are underway for our educational and social get-together in Honolulu in May.
While final details have not been set, make sure you keep Sunday evening open. All I can
tell you now is that it will likely involve a first-hand look at how Emergency Psychiatry is
done in a tropical setting – and it will include a visit to a place they serve drinks with fruit
and toothpick umbrellas in oversized glasses.
AAEP will also be presenting what promises to be another well-attended course during
the APA proceedings in Hawaii. Entitled “Emergency Psychiatry Course: Theory to
Practice,” it will be held Sunday, May 15, 2011, from 11:30 am-3:30 pm in the Hilton
Hotel. AAEP members Jon Berlin, MD, Rachel Glick, MD, Seth Powsner, MD and Scott
Zeller, MD will be the faculty.
The AAEP listserve Discussion Forum has been lively recently with several good questions
and debates. For those of you who have not signed up, please contact our office at
[email protected] to become part of this invaluable resource, or visit our
revamped website at emergencypsychiatry.org.
There are plenty of other exciting projects in the works. Our 2011 Web Conference Series
is ready to kick off soon with a top-flight assortment of speakers and topics. Preparations
are underway for an Emergency Psychiatry Certification Course to be held in Las Vegas in
(Continued on page 2)
Scott L. Zeller, MD
President 2010-2012
December of this year. And our AAEP Journal, Emergency Psychiatry, will be making its
triumphant return in the near future.
Remember that most of what was just described is available to AAEP members only. Don’t
miss out – if you haven’t yet, please renew your membership; you can easily do so online at
our website. And there is always room for more, so please let your colleagues know about
us and encourage them to join us.
We hope to see you in May in Hawaii, till then we wish you all the best for a happy and
healthy 2011. Thanks for being a member of the AAEP, the Voice of Emergency Psychiatry.
Hope to see you soon,
Scott Zeller, MD President
AAEP Member Announcement -- Project BETA makes news headlines! Special Report: Project BETA Stresses Verbal De-escalation for Agitated ED Patients.
Letter from the President (continued)
2
AAEP Member Announcements
What’s going on with your
Emergency Psychiatry facility, with
you and your staff? We’d like to
know and share it with other AAEP
members in our informal
newsletter. Has your program
moved to a new building? Did you
or one of your attendings publish
an article related to Emergency
Psychiatry? Have you, your staff, or
your program recently been
honored? Is there a new
educational or training process you
are using that you believe could
help your peers? We welcome you
to share any news relevant to
Emergency Psychiatry with your
fellow members. Please send your
announcements to us either by
email or see the attached
Announcement Form and send
your news to:
AAEP Member Announcements
Janet Richmond, MSW of Waban, MA writes:
I’d like to share the following article with the AAEP Membership.
Psychiatric Patients Often Warehoused in Emergency Departments for a Week or More
Medscape Medical News, 2011-01-24
Scott Zeller, MD of Orinda, CA was featured on the cover of:
Psychiatry Weekly, 2011-01-17
http://www.psychweekly.com/aspx/article/articledetail.aspx?articleid=1229
Project BETA makes news headlines!
Special Report: Project BETA Stresses Verbal De-escalation for Agitated ED Patients
http://journals.lww.com/em-news/Fulltext/2011/02000/
Special_Report__Project_BETA_Stresses_Verbal.2.aspx
Emergency Medicine News, February 2011 - Volume XXXIII - Issue 2 - pp 19-20
Send your announcements to
Members-only Listserv
AAEP has recently created a listserv
discussion group that is available via
invitation to members in good
standing only. This will be a great
opportunity to discuss pressing
issues, diagnostic dilemmas and
treatment approaches in Emergency
Psychiatry, and obtain consultation
from your fellow experts on difficult
cases. Please accept the invitation
and join us today!
There is nothing to fear, it will be
very easy to unsubscribe if you
choose to do so at a later time.
If you have misplaced or did not
received your invitation email, please
contact Jacquilyn Davis at:
The Care of Psychiatric Patients in Emergency Settings: AAEP Visits CT
Drs. Scott Zeller and Seth Powsner (President and President-Elect of the AAEP) traveled to
Wallingford CT, to participate in two sessions for members of the Connecticut Hospital
Association (CHA) on Thursday, January 12, 2011.
The sessions, which ran in the morning and afternoon, discussed “the prevalence of psychi-
atric emergencies, the varied models of delivering urgent psychiatric interventions, and the
major goals of emergency psychiatric care.”
Between sessions, staff of the AAEP promoted the organization to the registrants, by set-
ting up a small table of literature about the AAEP. It surprised some to learn that there is a
place for emergency psychiatry professionals. One registrant was so surprised to see an
emergency psychiatry organization she smiled and exclaimed, “You exist!”
This event was an excellent example of collaboration through the medical community to
share knowledge about emergency mental health and how all professionals can learn and
grow together for the benefit of the patient.
All members of the AAEP who plan to present on the topic of emergency psychiatry are
encouraged to contact the AAEP Offices for a promotional packet. This packet will include
information on the AAEP, applications for membership, materials on upcoming meetings,
and much more. We encourage you to take advantage of this opportunity to spread the
word about the AAEP and get your colleagues involved in this organization. For more infor-
mation, contact Jacquilyn Davis at [email protected] or call 888-945-5430.
3
Members who plan to present on topics in Emergency Psychiatry are encouraged to
contact the AAEP Office for an AAEP Promotional Packet to help spread the word about
the American Association of Emergency Psychiatry, its upcoming meetings, publications
and much more. This information is free to active members of the AAEP. See the article
below for details.
Upcoming Events
American Psychiatric Association
164th Annual Meeting
May 14-18, 2011
Honolulu, HI
Emergency Psychiatry Course:
Theory to Practice
Sunday, May 15, 2011
11:30 a.m. - 3:30 p.m.
Hilton Hotel, Honolulu, HI
AAEP Social Event
TBA
Institute on Psychiatric Services
October 27-30, 2011
San Francisco, CA
Introducing the AAEP Promotional Packet
Q: Where should I sit when I’m waiting to take the stand to defend a mental health hold? I work in a psychiatric emergency service [PES] and don’t have to go to court often—I release a lot of holds at the door—but when I do, I see myself as advocating for the patient. Before the hearing, the corporation counsel asks me a few questions. I know I’d be welcome near his table. Yet I feel funny being cast in the role of the patient’s adversary; I’m there as his advocate, to help him get treatment. My prefer-ence would be to sit near the patient and the public defender representing him, but I don’t think they feel the same way. How should I position myself?
A: The answer is embedded in your question.
Some people don’t believe it’s even possible to begin treatment on an involuntary basis. The idea that a person may have a right to it when he’s unsafe and lost his ability to reason is an anathema to them. They may never see you as an advocate.
By your question, I can tell you’ve actually worked with patients. You know that, apart from its safety net function, a PES exists primarily to begin the treatment of patients who are resisting engagement in treatment. They don’t think they’re sick. Or they don’t think that you can help. So a primary objective becomes helping them overcome their resistance to the therapeutic alliance. You counter their distrust or skepticism with repeated reassur-ances, inquiries into the nature of their problem, active listening and concrete attempts to be useful. Many involuntary patients will end up signing in voluntarily.
Patients who get sick and know they need help can have their problem handled over the phone, in their doctor’s office, or at the hospital voluntarily. They’re open to suggestions. They bypass PES.
Some visitors to PES can be engaged, treated and released. Some didn’t really need to be held in the first place. Some may have risk factors that made someone in the community nervous, but they’re willing to get help, and their problem is best managed on an outpa-tient basis. The public defender never sees how often your commitment to patients lead you to uphold a person’s right to refuse treatment.
On the other hand, you realize some mental health holds are necessary. Patients may be experiencing a dangerous flare-up of their illness. They may be very fearful or suspicious of treatment, and engagement during a relatively brief stay in the emergency department can be difficult, leaving you little choice. Unfortunately, as the admitting doctor, you are not often the one who continues to work with the individual in the inpatient unit. You don’t have the opportunity to build on your initial efforts to engage him. You can’t win him over. So, if you do see him in court, he has probably continued to resist engagement on the unit, and you are still looked upon as the bad guy who locked him up.
But, as you indicate, you are still his advocate. You were concerned for his health and safety, and you hospitalized him because you have a moral obligation to override his objec-tions to it when he’s in danger and not thinking clearly. You have a medico-legal responsi-bility. You make some tough calls. You say to him, “This isn’t easy for me to say, and it might not be easy for you to hear, but as your doctor right now I have to be honest with you. You’re experiencing a psychiatric emergency, and I have to insist.”
The public defender doesn’t see it that way, or at least act like he sees it that way. HE is the patient’s advocate. He is for the patient. He is there to protect the patient from you. YOU are the enemy. Treatment is something you perform on someone, not something you do together. You are acting as an agent of society that believes it has the right to control people and keep itself safe. You don’t represent the patient’s welfare at all. You’re a con-trol freak. You are willing to give him strong medicine despite its dangerous side effects. You are paternalistic at best. Or else you agree that the patient doesn’t have to be com-
Consult Corner: Position in Court By: Jon Berlin, MD
4
Interested in writing for the Newsletter?
All members of AAEP are invited to
submit articles for publication the
Newsletter. We welcome articles
relevant to the field of Emergency
Psychiatry from all perspectives:
from psychiatrists working in a PES
to social workers, nurses, students,
or physicians in the field.
Newsletters are sent to the
Membership electronically on a
quarterly basis.
For deadlines and additional
information on how you can
contribute to the Newsletter,
please contact Jacquilyn Davis at
888-945-5430 or email
5
mitted, but you don’t have the guts to say so yourself. You’re too averse to risk. Commit-ting someone against his will is not a tough call. Releasing someone with risk factors is a tough call. You want the court to do it. If there’s a bad outcome, let the judge take the blame. Or perhaps, you haven’t kept up with your post-modern philosophy and you’re a just pawn of our oppressive social order. You exist to diagnose and marginalize people who are different, so that society doesn’t have to face the peculiarities and insanity in it-self.
These are some possibilities. It’s also possible your local public defender is privately root-ing for you. You may be the one he calls when a relative needs professional help. None-theless, there’s a fundamental problem you’re running into, and that is the difference be-tween legal decision-making and clinical decision-making. In court, two attorneys argue opposing sides of an issue. It’s a debate. They can clash sharply in open court over the right to refuse treatment versus the right to receive treatment, then go out and have cof-fee together afterwards. The process for arriving at justice is adversarial and dialectical. The relative merits of each argument are ultimately for the judge to decide.
By contrast in everyday clinical practice, it is the clinical practitioner who weighs the evi-dence and the merits of each argument on each side. You drop some mental health holds at the door, and you uphold others. You don’t spend your day doing just one or the other. You consider the benefits of involuntary hospitalization (rapid assessment, greater safety, more intensive treatment) versus the drawbacks (potential damage to engagement, in-creased stigma, removal from family and work). You tolerate ambiguity and make judg-ments.
The public defender, as well as your district attorney or corporation counsel, may not get this about you. Their job is to personify the deliberation externally—they are actors in a drama—and they see witnesses as being for one side or the other, too. The legal process is set up this way. An individual needs an advocate. Weighing opposing rights implies torn loyalties. For our part, we are so accustomed to the process of internal decision-making that we may not realize how foreign it is to attorneys on both sides.
You may be against what the patient says he wants for himself at a given time, but you are never against the patient. When the public defender is cross-examining you, he’ll ask ques-tions that force you to articulate the evidence and the reasoning in favor of releasing a commitment. He will make some good points. Keep an open mind. This is an opportunity to demonstrate your clinical decision-making and conceivably even deepen it. When de-fending commitments, feel free to acknowledge they're imperfect and should be time-limited. But, unfortunately, as tools for safety and engagement, they are sometimes neces-sary.
I don’t think we can sit near either attorney. We have more in common with the judge. My preference is to sit somewhere in back, and in the middle.
Consult Corner (continued)
“You exist to diagnose and marginalize people who are different, so that society doesn’t have to face the peculiarities and insanity in itself.”
“Committing someone against his
will is not a tough call. Releasing
someone with risk factors is a
tough call. You want the court to
do it. “
Late in 2009, several members of AAEP expressed an interest in establishing a consensus statement on medical clearance of psychiatric patients in an emergency department set-ting. This interest was further fueled by an article in the Psychiatric News (“Psychiatrists, Emergency Physicians May Part Ways on Value of Tests,” December 4, 2009), which stated, “to test or not to test…remains an open question among ED doctors and psychiatrists.”
Out of this interest, a Task Force was created to investigate the feasibility of such a consen-sus, and to provide one if possible. The members of the task force are Michael Allen, M.D., Michael P. Wilson, M.D., Ph.D., Anthony Ng, M.D., Leslie Zun, M.D., M.B.A., Jennifer M. Peltzer-Jones, R.N., Psy.D., and Eric L. Anderson, M.D.
With such a monumental (and admittedly controversial) topic such as medical clearance, the task force felt it appropriate the divide the consensus statement into two parts. Part 1 is comprised of an overview of the problem and reason for the task force effort, a review of the literature with respect to the prevalence of medical issues in psychiatric patients, a review of the literature on medical screening, presentation of current evidence-based and other guidelines for medical clearance of psychiatric patients, and barriers to medical screening of psychiatric patients in the emergency department.
Part 2 presents controversies over medical clearance, medical clearance as currently prac-ticed in select states, the AAEP consensus statement on the medical evaluation of psychiat-ric patients with 8 listed recommendations, and a future direction for research.
The Task Force set as its goal finalization of the 2-part document for submission in January 2011. However, two new and exciting developments are now being integrated into this effort. The first is the establishment of the Best practices in Evaluation and Treatment of Agitation (BETA) group. While the BETA group is not specifically focusing on medical clear-ance per se, it is hoped the efforts of the Medical Clearance Task Force can be cross-referenced with the BETA group’s efforts.
The second development is a renewed interest in this same topic by our colleagues in the American College of Emergency Physicians (ACEP). The ACEP published a evidenced based statement in 2006, and at least two AAEP members were involved with that effort. The Task Force has reached out to members in the ACEP in an effort to make this current ven-ture a joint rather than AAEP-only effort. In addition, plans are underway to see if the American Academy of Emergency Medicine (AAEM) wishes to join, making the venture a three-organization endorsement.
The Medical Clearance Protocols Group Update By: Eric Anderson, M.D.
6
To view the article, Psychiatrists,
Emergency Physicians May Part
Ways on Value of Tests mentioned
in this article, go to: http://
pn.psychiatryonline.org/
content/44/23/33.2.full
The American Association for Emergency Psychiatry would like to invite all members and colleagues in the field of Emergency Psychiatry to submit a manuscript or book review for publication in the AAEP Journal, Emergency Psychiatry.
This Journal is intended to be a forum for the exchange of multidisciplinary ideas. Manuscripts are welcomed that deal with the interfaces of emergency psychiatry. This includes psychiatric evaluation of indi-viduals in the emergency room setting,
education and training in the field and re-search into causes, and treatment of be-havioral problems. Manuscripts are evalu-ated for style, clarity, consistency, and suitability.
Submit manuscripts or queries electroni-cally to: Jacquilyn Davis, Administrative Assistant, at: [email protected]. Include the address, telephone number, and email address for the corresponding author on all manuscripts.
Calling All Authors!
7
Evaluating and treating the psychiatric patient in the emergency setting is a challenge for emergency medicine and psychiatric care providers. To meet this challenge, the Depart-ment of Emergency Medicine at Mount Sinai Hospital and Chicago Medical School put on two valuable conferences focusing on behavioral emergencies. The conferences were en-dorsed by many prestigious organizations including the Illinois Nurses Association, Illinois College of Emergency Physicians, and American Academy of Emergency Medicine. These endorsements also included the American Association for Emergency Psychiatry and Insti-tute for Behavioral Healthcare Improvement.
The Second Annual Regional Update on Behavioral Emergencies was held in Chicago on October 26th. There was an impressive group of speakers from the Chicago area and the keynote speaker came from Milwaukee. Some of topics presented included pediatric psy-chiatric issues, redesigning the emergency department to improve psychiatric services, telepsychiatry and EMTALA issues. The conference was attended by 160 participants.
The National Update in Behavioral Emergencies was held in Las Vegas December 2nd and 3rd. The conference had speakers from US and Canada discusses subjects vital to emer-gency psychiatry. These topics included treatment in the ED, PTSD, behaviors associated with head trauma, acute psychological care for victims of terrorist and disasters and facti-tious, malingering and somatoform disorders. There were 100 attendees including physi-cians, nurses, social workers, physician assistants and psychologists at this conference.
The success of these conferences demonstrates the need to learn and discuss issues sur-rounding the patient presenting with a behavioral emergency. We plan to host similar conferences this year with the addition of skills labs and possible certification. These plans will be finalized and the announcement of the upcoming conferences will be made shortly.
Behavioral Emergencies Seminars Update By: Leslie Zun, M.D.
The Behavioral Emergencies
Seminars were held October 26,
2010 and December 2-3, 2010.
Plans for the next Seminar are in
the works and will be publicized
shortly.
AAEP Board Roster
President
Scott Zeller, MD
President-Elect
Seth Powsner, MD
Immediate Past President
Anthony Ng, MD
Board of Directors:
Leslie Zun, MD, MBA
Jagoda Pasic, MD, PhD
Daryl Knox, MD
Rachel Glick, MD
Social Work Liaison:
Janet Richmond, MSW
Past President - 2006-2008:
Avrim Fishkind, MD
Past President - 2004-2006:
Jon Berlin, MD
AAEP Executive Office Staff:
Executive Director
Jacquelyn Coleman, CAE
Administrative Assistant
Jacquilyn Davis
American Association for Emergency Psychiatry One Regency Drive
P.O. Box 30 Bloomfield, CT 06002 Phone: 888-945-5430
Fax: 860-286-0787 Email: [email protected]
Website: www.EmergencyPsychiatry.org
Emergency Psychiatry: Theory and Practice Seminar
The American Association for Emergency Psychiatry (AAEP) will be pre-
senting a Seminar entitled Emergency Psychiatry: Theory and Practice
at the APA’s 164th Annual Meeting in Honolulu, HI, May 15, 2011. The
Seminar will take place at the Hilton Hotel from 11:30 a.m. - 3:30 p.m.
Speakers include Dr. Scott Zeller, President of the AAEP, Drs. Rachel
Glick and Jon Berlin, Members on the AAEP Board of Directors, and Dr.
Seth Powsner, President Elect of the AAEP. To register for this event,
please visit the APA’s website at www.psych.org/annualmeeting.
The AAEP will also be hosting a Social Event that evening and we invite
all members of the AAEP to attend.
We hope to see you in Honolulu!
SAVE THE DATE May 15, 2011
