Use of restraints and pharmacotherapy in academic psychiatric emergency services

Psychiatric emergency services (PES) are an increasingly important component of mental health services. To assess the type and scope of services delivered in the PES setting, the American Association for Emergency Psychiatry sponsored an Expert Consensus Panel Survey of these services in 1999. The questionnaire was mailed to medical directors of PES facilities with 91% (n = 51) responding. More than 90% of the respondents were teaching sites. Restraints were reportedly used in a mean of 8.5% of presentations for a mean of 3.3 h per episode. Restraint utilization correlated with the percentage of psychotic patients treated, but not with a wide variety of other patient and service variables. Involuntary medications were used in 16% of cases, though in oral form in 29% of those cases. A large majority (94%) endorsed mild sedation permitting further assessment as the appropriate endpoint and rejected sleep or heavy sedation as an endpoint (82%). Benzodiazepines received the strongest endorsements and 82% indicated it would be appropriate to administer a benzodiazepine alone for agitation first and initiate antipsychotic treatment subsequently if appropriate. When there is no history of prior antipsychotic exposure, 60% favored a benzodiazepine alone. However, given a history of previous antipsychotic treatment, only 8% endorsed this strategy. Most respondents (78%) preferred to use oral medication for treating behavioral emergencies, whenever possible but 70.3% reported regular use of an IM combination of a benzodiazepine and high-potency typical neuroleptic when necessary. In addition to managing emergencies, 82% of services initiated standing medications for patients being admitted to hospital settings and 70% initiated regular medication treatments for patients being released to the community. Of patients started on oral antipsychotics, 42% received an atypical antipsychotic. Reflecting medication characteristics of particular importance in emergency settings, most respondents (92%) cited selective serotonin reuptake inhibitors as the preferred type of antidepressant, and divalproex or related compounds (90%) for treatment of bipolar disorder in the PES.