Rothschild AJ. Acute grief and disaster victims. In: Hyman SE ed. Manual of psychiatric emergencies, 2nd edition. Boston: Little Brown, 1988:42-47. ISBN 0316387207, 9780316387200.

OBJECTIVE: Psychiatric symptoms play a crucial role in psychology and psychiatry. However, little is known about how dimensions of symptoms--other than symptom level--relate to psychiatric outcomes. Until recently, methods for measuring dynamic aspects of symptoms have not been available to clinicians or researchers. The authors sought to test whether systematic patterns of change in psychiatric symptoms can be recovered across weekly assessments of individuals at high risk for violence. A secondary objective was to explore whether dynamic features of symptoms (specifically, oscillation speed and dysregulation) are concurrently associated with violence, an important indicator of functional impairment for these individuals. METHOD: Participants (N=132) were drawn from a sample of patients evaluated at the emergency room of an urban psychiatric hospital. Patients actuarially classified as being at high risk for violence were eligible for participation in the study. Participants and collateral informants were interviewed weekly for 26 weeks following an acute psychiatric evaluation. Psychiatric symptoms were assessed using the Brief Symptom Inventory. Measures of symptom fluctuation and regulation were derived using dynamical systems models. Involvement in violence was assessed using self, informant, and official reports. RESULTS: Individuals' symptom dynamics were recovered by a linear oscillator model that described how quickly symptoms oscillated and whether symptoms were amplifying or moving back toward equilibrium across time. Patterns of rapid symptom fluctuation and symptom amplification were concurrently associated with violence. CONCLUSIONS: Psychiatric researchers and clinicians have long been interested in adopting more dynamic approaches to understanding symptom change. This study is the first to demonstrate that systematic fluctuations in symptom patterns may be captured by dynamic models. Moreover, the concurrent association between symptom dynamics and violence suggests avenues for future research to test how features of symptom fluctuation could affect behavior.

Previous research on the prediction of violence in mentally ill individuals has focused primarily on determinations about the appropriateness of institutional confinement. The assessment and management of violent, mentally ill individuals in the community, however, requires clinicians to take a more detailed look at the factors that might precipitate or inhibit violence in the community. This paper examines a model of conditional prediction, in which clinicians provide assessments of the factors that they expect to be associated with violence in particular patients. These types of predictions were elicited from clinicians for a sample of 712 patients seen in an urban psychiatric emergency room. These patients were then followed in the community for 6 months, using both interviews and official records. Results showed that clinicians were generally accurate about the seriousness and location of the violence, but overestimated the role of medication compliance and drug use in the violent incidents.

OBJECTIVE: The objective was to describe continuity of care approaches for psychiatric emergencies in the emergency department. METHODS: A national survey of all 138 academic emergency departments in the United States was conducted. RESULTS: Most emergency physicians (81%) had no systematic method for identifying psychiatric emergency patients with high recidivism. In order to promote outpatient care, sites commonly reported using intensive interventions, including scheduling outpatient appointments prior to discharge (72%) and in-house case management (64%). CONCLUSION: While systematic identification of repeat psychiatric emergency patients was uncommon, emergency departments reported using a variety of fairly intensive strategies to promote continuity of care with outpatient mental health services.

OBJECTIVE: The study examined factors associated with admission to public and private hospitals from a mental health care emergency screening system operating under a longstanding mandate to maximize use of private inpatient treatment. METHODS: For 206 patients evaluated at the mental health emergency screening site over a two-and-a-half-month period, data were collected on demographic and clinical characteristics, admission history, services received during the emergency encounter, system variables such as time the patient spent at the emergency screening site, number of admission sites asked to accept the patient, and all reasons cited by providers for refusing to admit the patient. Logistic regression was used to develop a model of factors most likely and least likely to be associated with private hospitalization. RESULTS: Overall, 60 percent of the sample was refused admission by one or more providers, and 55 percent, who were not accepted by and private hospital, became public patients. Private hospital admission was associated with patient or family involvement in referral and disposition, private or Medicaid insurance, a presenting problem of depression or suicidality, and longer time spent at the emergency screening site. Public admission was associated with no insurance, a past history of major public hospitalization, current or past history of assaultiveness, a presenting problem of aggression, and lack of any discharge site. CONCLUSIONS: Private providers are reluctant to admit patients who have characteristics associated with public hospitalization. In the restructuring of health care, a more fully privatized system will likely be called on to absorb such patients. Their care, treatment, and impact on the system should be carefully monitored and evaluated.

Discusses legal and ethical issues of psychiatric emergency care.

Data from child and adolescent emergency mental health screening episodes prior and subsequent to privatized Medicaid managed care in Massachusetts are used to investigate the relationship between payer source and disposition and to compare the match between clinical need and disposition level of care. Having Medicaid as the payer in the post-Medicaid managed care period decreased the odds of hospitalization by nearly 60%. None of the clinical need variables that contributed to hospitalization for Medicaid episodes in the pre-Medicaid managed care period were significant in the post-Medicaid managed care period. Multiple forces shaping professional standards, decision making, and quality of care are described. Public sector agencies must lay the groundwork for comprehensive evaluation prior to the implementation of privatized Medicaid managed care initiatives.