Elsevier

General Hospital Psychiatry

Volume 27, Issue 3, May–June 2005, Pages 189-193
General Hospital Psychiatry

Emergency Psychiatry in the General Hospital
The emergency room is the interface between community and health care institution. Whether through outreach or in-hospital service, the psychiatrist in the general hospital must have specialized skill and knowledge to attend the increased numbers of mentally ill, substance abusers, homeless individuals, and those with greater acuity and comorbidity than previously known. This Special Section will address those overlapping aspects of psychiatric, medicine, neurology, psychopharmacology, and psychology of essential interest to the psychiatrist who provides emergency consultation and treatment to the general hospital population.
Stability of the diagnosis of first-episode psychosis made in an emergency setting

https://doi.org/10.1016/j.genhosppsych.2005.02.002Get rights and content

Abstract

Objective

This study aimed at evaluating the stability of the first psychotic episode diagnosis in the emergency context.

Methods

Fifty-nine patients were selected during a 15-month period and were followed for an average of 19.35 ± 6.12 months. The admission and discharge emergency diagnosis were compared with the longitudinal diagnosis, obtained by the application of Structured Clinical Interview for DSM-IV Axis I Disorders — clinical version at the end of the follow-up. Severity rating scales (Brief Psychiatric Rating Scale, Young Mania Rating Scale and Hamilton Rating Scale for Depression) were applied in the emergency assessment.

Results

Agreement between admission emergency diagnosis and longitudinal diagnosis was unsatisfactory (k=0.25), whereas that between emergency discharge and longitudinal diagnosis was satisfactory (k=0.57). Brief psychotic disorder diagnosis presented higher sensitivity rates but low specificity, comprising several false positives. Bipolar disorder had the highest rates of specificity.

Conclusion

Brief psychotic disorder may not be a useful concept in the emergency assessment. A short period of observation can improve emergency psychiatric diagnosis.

Introduction

The accuracy of psychiatric diagnosis has been increasingly considered during the last two decades. Indeed, the improvement of diagnostic classification and the development of structured interviews and rating instruments have greatly contributed to the enhancement of psychiatric diagnosis reliability and validity [1].

Several factors could interfere with the reliability of psychiatric diagnosis, including the diagnostic system selected, the evaluator's experience, patient's clinical characteristics and the situation or condition where the diagnostic interview is conducted [2].

The psychiatric diagnosis elaborated in an emergency service presents a series of shortcomings inherent in that setting. In general, time is limited, frequently without additional information from relatives, and in most of the cases, there is a need for immediate intervention [3], [4]. The examiner's observation can also be jeopardized because of the intrinsic aspects of the situation itself, such as demand pressures and need of agility in the forwardness of the cases. Furthermore, the severity of symptoms, which justify looking for an emergency service, could interfere in the quality of information given.

The role of emergency psychiatric services within a network of mental health services has been modified and amplified by changes in mental health policies, which encourage the use of alternative treatment setting in preference to exclusive psychiatric hospitalization [5]. Often emergency services receive patients in their first episode of mental disorder providing an entry point into the health system. The significance of a precise diagnosis is highlighted in a first episode of a mental disorder since all decisions about prognosis and therapeutic approach will be based on the initial diagnostic impression. Moreover, in clinical settings, there is a tendency to keep the first diagnosis made at time of the patient's initial admission into the mental health system, even with subsequent assessments by different clinicians [6].

Although the systematic use of operational diagnostic criteria could be an alternative to enhance the reliability of the psychiatric diagnosis made during an emergency assessment [7], good agreement between evaluators is not enough to assure the stability and the predictive validity of diagnosis in first-episode psychoses. For instance, three fourths of the patients that had received an initial diagnosis of schizophreniform disorder, according to DSM-IV [8], had their diagnosis modified after 6 months [9] and around one third of patients with the initial diagnosis of schizophreniform disorder received a follow-up diagnosis of affective disorder [10].

The aim of this study was to verify the accuracy of psychiatric diagnosis made in an emergency setting. For this purpose, we adopted two strategies. Firstly, we studied the stability of the diagnosis throughout the validity of the emergency diagnoses compared with longitudinal diagnosis made using the Structured Clinical Interview for DSM-IV (SCID) [11]. Secondly, we compared the profile of symptoms presented at the emergency assessment with the longitudinal diagnosis.

Section snippets

Patient population

The sample was composed of all patients admitted in the emergency psychiatric unit of the Clinical Hospital of Ribeirão Preto Medical School, São Paulo University, Brazil, during a period of 15 months in a first episode of a psychotic disorder. First-episode psychosis was defined by the presence of at least one of four symptom groups (delusion, hallucination, disorganized thoughts and disorganized or catatonic behavior) for up to 6 months. Patients with mental disorders due to general medical

Results

The average admission length of time in the emergency room was 2.16±1.82 days and the average follow-up length of time was 19.35±6.12 months.

Discussion

The initial diagnosis made in an emergency psychiatric context has shown poor agreement with the psychiatric diagnosis made through a gold standard pattern, that is, based on a longitudinal follow-up, taking into account all sources of information and applying structured interviews [19], confirming previous results concerning the difficulties of establishing reliable diagnosis in an emergency setting [3], [4]. However, the overall agreement of the discharge emergency diagnosis as compared to

Acknowledgments

The authors are very grateful to Professor Frederico G. Graeff for his comments and suggestions in the revision of the manuscript.

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    This work was done at the Department of Neurology, Psychiatry and Medical Psychology, Clinical Hospital of the School of Ribeirão Preto, São Paulo University, Brazil.

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