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American Association For Emergency Psychiatry Newsletter Spring Issue 2011

Letter from the President Dear Members, At the AAEP we are as busy as ever. We have many upcoming events, projects and lectures. We hope you will be joining us! For everyone who attended the APA in Hawaii this month, we hope you were able to join us for the Sunday evening tour of how Emergency Psychiatry is done in paradise when we visited Queen’s Medical Center. Right afterwards, we had a great social event/members meeting at RumFire – on our own balcony patio overlooking the ocean. This was a wonderful chance for AAEP colleagues to meet, sample hearty appetizers, and drink tropical cocktails under the setting sun. The AAEP will continue to host events like these and we are already planning one during the IPS meeting in October. Project BETA, our guidelines project for Best Practices in the Evaluation and Treatment of Agitation, is running full steam ahead, with first drafts already completed by all five workgroups. There is still time to get involved if you would like to serve as an in-house peer reviewer for any of the drafts. We will be presenting the guidelines at the IPS in San Francisco this autumn, and are in discussion with several journals about publication of the entire project. Email the AAEP office if this interests you. Another project we have recently begun is a Center of Excellence award for emergency psychiatry/crisis intervention programs. We are in the process of creating initial criteria for evaluation of sites but can certainly use more of you experts in amassing these. Again, please contact the AAEP office if you’d like to be a part of this charter program. Our 2011 web conferences series is now ready and the lineup of speakers and topics is terrific. This is a great educational opportunity that can be attended in the comfort of your home or office. Six presentations are on tap for this year; please see the enclosed for all the details. You may register today by sending in the enclosed registration form.

Scott L. Zeller, MD President 2010-2012

Inside this issue Announcements .......................... 2 AAEP at the APA in Honolulu, HI May 2011 ................................ 3 Calling all Authors! ...................... 4 Red Cross - Volunteers Needed .. 5 Topics in Emergency Psychiatry Web Conference Series 2011 .............. 6 Behavioral Emergencies Conference and Pre-Conference .................... 10 Consult Corner ............................ 12 Project BETA Update ................... 15

And it is not too early to think about attending the National Conference on (Continued on page 2)

Save the Date .............................. 16

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 invite 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:

Letter from the President (continued) Behavioral Emergencies December 1 and 2 in Las Vegas. This should be a fantastic opportunity to update your emergency psychiatry knowledge base with two days of CME. Emergency medicine docs, psychiatrists, and crisis professionals will be lecturing and attending. Information is enclosed. And finally, please remember to pay your dues if you haven’t already. This can be done online with a few simple clicks. There are so many things available to active members only – access to our listserve discussions, receiving our journal Emergency Psychiatry, being able to participate in our projects, and discounts on our web conferences. In addition, it is the best way to stay involved with your peers – through the Voice of Emergency Psychiatry, the AAEP.

Scott Zeller, MD President

“What’s going on with your Emergency Psychiatry facility, with you and your staff?”

AAEP Member Announcements Glenn Currier, MD, MPH of Pittsford, NY writes: I’d like to share the following article with the AAEP Membership. The American Association of Suicidology and the Suicide Prevention Resource Center have collaborated to produce this document which may be downloaded from the websites of either organization at or at

Anthony Ng, MD, of Bangor, ME writes: I’d like to share the following with the AAEP Membership.

Send your announcements to


“… with regards to the recent tornado onslaught in the Midwestern portion of the US, including Joplin, MO. APA has reached out to the local district branches affected by these storms and alerted them to the Disaster Psychiatry web site, DisasterPsychiatry.aspx. In addition, a letter of condolence was sent to the district branch that handles Joplin, MO. That letter lists additional resources that may be helpful. On the ground, Dr. Arshad Husain, Central Missouri District Branch Disaster Chairperson, has offered his assistance to the affected area, the Western Missouri District Branch. Lastly, the American Red Cross is looking for volunteers to travel to the region.

Members of the AAEP joined staff of Queen’s Hospital in Honolulu, HI for a site visit of their Psychiatric Services in their Emergency Department.

AAEP at the APA in Honolulu, HI May 2011 The American Association for Emergency Psychiatry (AAEP) traveled to Honolulu, HI in May of this year to attend the American Psychiatric Association’s (APA) 164th Annual Meeting. We had many highlights during this time including a seminar on emergency psychiatry, a workshop on the global perspective of emergency psychiatry, a site visit to Queen’s Hospital and a reception on the edge of Waikiki Beach. If you were in attendance, then you can attest to the success of this meeting. On Saturday, May 14, Rachel Glick, Julien de Carvalho, Andres Rousseaux, Yutaka Sawa, and Mitsuru Suzuki conducted a workshop entitled, “Emergency Psychiatry: A Global Perspective.” Psychiatrists from Europe, North America, South America and Asia outlined the current state of psychiatric emergency care in their home country, and described the psychiatric emergency service in which they work. Each included their approach to dealing with agitated patients, and shared their thoughts about involuntary treatment, how and when this should occur, including the legal framework for such treatment in their countries. After the presentations, there was time for discussion among participants. On Sunday, May 15, Jon Berlin, Rachel Glick, Seth Powsner, and Scott Zeller presented a seminar entitled “Emergency Psychiatry: Theory and Practice.” This comprehensive session is a revision of the Course presented at last year’s Annual Meeting. Beginning with a historical overview, the seminar included in-depth talks on the emergency psychiatric evaluation, management of agitation, risk assessment, medical evaluation of the psychiatric emergency patient, and disposition/legal issues. The session also included case discussions and time for questions and discussion.

The AAEP joined the APA in beautiful Honolulu, HI May 14-18, 2011.

On Sunday, May 15, the AAEP held its Annual Social Event & Business Meeting. Starting at 5 (Continued on page 4)


AAEP at the APA (continued) pm, members of the AAEP gathered at Queen’s Medical Center for a site visit of the psychiatric services of the emergency department. Staff at Queen’s Medical Center showed the members through the ED and we convened in a forum setting to discuss how psychiatric emergency services are similar or different in various locations. It was interesting to hear the advances in technology used at EDs and typical mental health emergencies found across the country. Following the site visit, members traveled to RumFire, a popular beachside bar located in the Sheraton Waikiki Hotel for a casual reception. The Upper Ewa Patio, overlooking Waikiki Beach, was reserved for the members. Appetizers were provided and members purchased drinks as they mingled and continued their discussion sparked during earlier events. During the reception, a short Business Meeting was conducted, during which the winner of this year’s Resident Award, Dr. Erick Cheung, was honored. The AAEP will continue to host Social events during the IPS and APA meetings and we hope to grow our attendance each year. Please join us in San Francisco in the fall during the IPS meeting. We are planning a site visit to a local PES and a casual reception to follow. Information on this and other events during the IPS will be announced this summer.

AAEP President, Scott Zeller (left) presenting Dr. Erick Cheung (right), this year’s Resident Award Recipient, with a plaque during the Annual Business Meeting and Reception. Congratulations, Dr. Cheung!

Calling All Authors! 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 individuals in the emergency room setting,


education and training in the field and research into causes, and treatment of behavioral problems. Manuscripts are evaluated for style, clarity, consistency, and suitability. Submit manuscripts or queries electronically to: Jacquilyn Davis, Administrative Assistant, at: Include the address, telephone number, and email address for the corresponding author on all manuscripts.

AAEP Promotional Packet

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.

Red Cross - Volunteers Needed Marguerite I. Bird, Director, Disaster Response Network, American Psychological Association sent the following information to DRN Coordinators across the country and we’d like to share this with our members. The American Red Cross national headquarters continues to seek disaster mental health volunteers who are available to deploy to relief operations through the Disaster Services Human Resources System for a two week assignment (10 day minimum). Chapters in disaster-affected areas are working with local volunteers to provide assistance (hopefully those of you who are in disaster- affected states and able to volunteer have already been communicating with your chapter). We’ve learned that volunteers who were heading to on-going operations were re-routed to Missouri following yesterday’s deadly tornado in Joplin. At present, there are additional DMH positions in Missouri, a need for volunteers to staff second and third waves in Alabama and Mississippi, and a potential need, if flooding continues, to establish relief operations in Louisiana by week’s end. The situation is ever-changing and we will try to keep you updated as we learn more.

“The American Red Cross national headquarters continues to seek disaster mental health volunteers who are available to deploy to relief operations through the Disaster Services Human Resources System”

Please note that Red Cross headquarters DMH activity has let chapters know (Red Cross Operations Update 3) that they may limit training requirements for DMH to: 1) Disaster Services: An Overview, and 2) Foundations of Disaster Mental Health (including required paperwork – background check, DSHR application, health status record, code of conduct). While it is preferable that volunteers also have Psychological First Aid (PFA), not having this training should not unduly delay a DMH volunteers from being assigned to relief operations. PFA is being offered on several disaster relief operations and volunteers are likely to be able to take the training while on assignment.

Marguerite I. Bird Director, Disaster Response Network Practice Directorate American Psychological Association 750 First Street NE, Washington, DC 20002-4242 Tel: (202) 336-5902 | Fax: (202) 336-5797


American Association for Emergency Psychiatry

Topics in Emergency Psychiatry Web Conference Series Mental health professionals working in emergency settings face pressure to quickly, efficiently and appropriately assess, treat, and triage patients. This series will provide the opportunity for distance learning on the most critical psychiatric emergency topics.

Risk Management and the Patient with Suicidal Behaviors in the Emergency Department: Supporting Patient Safety and Reducing Professional Liability Risk Evidence Based Evaluation of the Psychiatric Patient Informed Consent and Measuring Competence in Emergency Department Settings Guidelines for Assault and Violence Prevention and Management on Inpatient Psychiatric Units From Crisis to Prevention: Assessing Suicide, Improving Precision and Reducing Burden in the Emergency Room EMTALA Requirements for Psychiatric Emergencies: What a Hospital Needs to Know Each presentation will be one hour in length and can be viewed live from the comfort of your home or office computer. Participants are given time at the end of each presentation for a question and answer session. We encourage all participants to take advantage of this opportunity to discuss the topic material with the speaker and fellow registrants. Participants may register under a single or group rate. Group rates are perfect for classroom settings and we recommend using a speaker phone and projection screen. All conference rates allow the use of one telephone line and one Internet connection. If you require the use of additional lines, be sure to send payment for each line you plan to utilize. Software Requirements: All participants should dial into the conference call from a landline for the best sound quality. PC users – Microsoft Windows 2000 or later, using: Firefox version 3.6 or Internet Explorer version 7 or earlier, with JavaScript or ActiveX enabled. Mac users – Apple Macintosh (OS X 10.3.9 or later), using: Safari 1.3 or later. Special Thanks to our Sponsor: Professional Risk Management Services, Inc. is a proud sponsor of the AAEP’s 2011 Topics in Emergency Psychiatry Web Conference Series. We are grateful for their continued support and invite you to view their website at

Topics in Emergency Psychiatry June 15, 2011 1:00 p.m. – 2:00 p.m. Eastern Risk Management and the Patient with Suicidal Behaviors in the Emergency Department: Supporting Patient Safety and Reducing Professional Liability Risk Suicide remains the most prevalent professional liability risk for the emergency department psychiatrist. Charles D. Cash, Senior Risk Manager of Professional Risk Management Services, Inc. will kick off this year’s series with an informative presentation that will review patient safety and strategies to reducing professional liability risk in the emergency department. July 22, 2011 Evidence Based Evaluation of the Psychiatric Patient

1:00 p.m. – 2:00 p.m. Eastern

Leslie Zun, MD, Professor and Chair of the Department of Emergency Medicine at Chicago Medical School, and member of the AAEP Board of Directors, will present his highly acclaimed presentation on medical clearance. This presentation will provide participants with an overview of the medical clearance process including a review of “need to test” and medical clearance protocols. August 4, 2011 1:00 p.m. – 2:00 p.m. Eastern Informed Consent and Measuring Competence in Emergency Department Settings There is much uncertainty about the scope and limits of rights of informed consent and determinations of competence in emergency department settings, especially in emergencies involving people with psychiatric or developmental disabilities, or individuals who are intoxicated. National certification and licensing standards require the patient to be involved in his or her own treatment but do not address situations where the patient's capacity is questionable. Legal standards for informed consent and determinations of competence vary from state to state, as do court determinations in case law raising the issue. Susan Stefan, JD, Visiting Professor at the University of Miami School of Law is named as “one of the country's most highly regarded experts in mental disability law” by the National Association for Rights Protection and Advocacy (NARPA). Her presentation will discuss basic principles, set out the range of different approaches in different states, and examine practical suggestions to navigate complex situations. September 13, 2011 1:00 p.m. – 2:00 p.m. Eastern Guidelines for Assault and Violence Prevention and Management on Inpatient Psychiatric Units This presentation will review a set of guidelines developed by a workgroup of clinical representatives from the NYC municipal hospital system. It is tailored to offer safe approaches for the prevention and management of violence on inpatient psychiatric services based on best practices utilized throughout the city as well as an extensive literature review. Two members of this workgroup have graciously agreed to present and discuss these guidelines: Maryann Popiel, MD, Assistant Professor of the Department of Psychiatry and Behavioral Sciences at Jacobi Medical Center, and Gary S. Belkin, MD, PhD, MPH, Senior Director for Psychiatric Services at NYC Health and Hospitals Corporation Office of Behavioral Health and Associate Professor and Director of the Program in Global Mental Health.

October 5, 2011 2:00 p.m. – 3:00 p.m. Eastern From Crisis to Prevention: Assessing Suicide, Improving Precision and Reducing Burden in the Emergency Room Suicide prevention efforts in emergency settings depend upon appropriate identification and screening, but the field of emergency psychiatry has been challenged by a lack of standardized approaches to assessing suicidal ideation and behavior. This presentation, presented by Kelly Posner, PhD, Principal Investigator of Columbia/FDA Classification Project for Drug Safety Analyses and Director of the Center for Suicide Risk Assessment at Columbia University, discusses the Columbia-Suicide Severity Rating Scale (C-SSRS), frequently recommended by the FDA and other international health agencies for the assessment of suicidal ideation and behavior, and used across a wide range of settings, including inpatient and outpatient medical and psychiatric departments, hospitals, surveillance efforts, and emergency rooms. The instrument includes operationalized thresholds for triggering referrals in a low burden way and with associated reduction in unnecessary burden. Prospective, systematic measurement of suicidal ideation and behavior help to optimize safety and management, improve identification, reduce false positives and reduce burden. November 15, 2011 12:00 p.m. – 1:00 p.m. Eastern EMTALA Requirements for Psychiatric Emergencies: What a Hospital Needs to Know The final presentation in this series promises to be an informative discussion, reviewing the obligations of physicians and hospitals under the Emergency Medical Treatment and Active Labor Act (EMTALA). Participants will understand the definition of an emergency medical condition, stabilized, and transfer as specified in the regulation. Emphasis will be placed on the relevance of EMTALA obligations for psychiatric emergencies, appropriate transfers, mandatory reporting and recipient hospital responsibilities. Derek Robinson, MD, Chief Medical Officer of Centers for Medicare and Medicad Services and CDR Frances R. Jensen, MD, Medical Officer of the United States Public Health Service, EMTALA Technical Lead, will make this joint presentation.

Be sure to register in advance for all 6 conferences to receive the full discounted price. Active members of AAEP receive an additional discount for all conferences, so be sure to pay your membership dues prior to registering. Please share this information with your colleagues and invite them to attend as well.

Topics in Emergency Psychiatry - Registration Form 

June 15, 2011 – 1:00 p.m. Risk Management and the Patient with Suicidal Behaviors in the Emergency Department: Supporting Patient Safety and Reducing Professional Liability Risk Charles D. Cash

July 22, 2011 – 1:00 p.m. Evidence Based Evaluation of the Psychiatric Patient Leslie Zun, MD

August 4, 2011 – 1:00 p.m. Informed Consent and Measuring Competence in Emergency Department Settings Susan Stefan, JD

September 13, 2011 – 1:00 p.m. Guidelines for Assault and Violence Prevention and Management on Inpatient Psychiatric Units Maryann Popiel, MD and Gary S. Belkin, MD, PhD, MPH

October 5, 2011 – 2:00 p.m. From Crisis to Prevention: Assessing Suicide, Improving Precision and Reducing Burden in the Emergency Room Kelly Posner, PhD

November 15, 2011 12:00 p.m. EMTALA Requirements for Psychiatric Emergencies: What a Hospital Needs to Know Derek Robinson, MD, MBA, FACEP and CDR Frances R. Jensen, MD

Single Conference Fee Member Rate: Non-member Rate: Group Rate – Through a Member: Group Rate – Non-member:

$50.00 $70.00 $85.00 $110.00

Series Fee (All 6 Conferences) Member Rate: $270.00 Non-member Rate: $380.00 Group Rate – Member: $460.00 Group Rate – Non-member: $600.00

Requires telephone line for audio and web access. See software requirements for details. One phone/internet connection per registration fee. Password and 800 phone number will be sent with confirmation. Total Number of Phone Lines (Price per line): _______

Payment Included $ ______________________

Name:_______________________________________________________________________________________ Phone Number: ___________________________________ Email:______________________________________ Facility:______________________________________________________________________________________ Address: _____________________________________________________________________________________ City:______________________________________ State:__________ Province: __________________________ Postal / Zip Code:_______________________ Country:_______________________________________________ Payment:  Check -- Make check payable to “AAEP.” Must be drawn from a U.S. Bank in U.S. dollars.  VISA  MC Account #____________________________________________________________________ Expiration Date: ________________ Authorized Signature: ___________________________________________ American Association for Emergency Psychiatry One Regency Drive, P.O. Box 30, Bloomfield, CT 06002 Phone: 888-945-5430; Fax: 860-286-0787; Email:

Pre Conference November 30, 2011 1:00 p.m. - 5:00 p.m.

Go to for additional information on each Conference

Consult Corner: Requests for Psychotropic Medication in the Emergency Department (ED) By: Jon Berlin, MD Q: I’m an emergency medicine physician. My role with psychiatric cases is handling three things: medical clearance, acute agitation/danger to others, and suicidality. My seeing so much psychiatric ambulatory care is a function of a fragmented mental health system in my community. I know that and I’ve made my peace with it—I’m the safety net. But I’m busy. I hear some psychiatrists bemoan the fifteen-minute med check in managed care, but in my world 15 minutes is a long time. I can sometimes do the ED equivalent of a med check in 5 minutes. Do psychiatrists want more time with patients than necessary or am I missing something? I am open to any tips you have on how I can be more effective.

Please direct comments or questions to Dr. John Berlin directly at:

A: EDs often try to create an ambulatory care track, but it’s a mistake to let up on the role you describe for yourself. Let me present a case vignette illustrating why attention to risk should always be a guiding principle and how the failure to do so could have quite serious consequences. This vignette is of a new patient, not a known patient, so it’s a little different than your med check, but it falls under the heading of a routine request for psychotropic medication. By the way, wondering about how to be more effective with psych cases puts you on the cutting edge. The disarray of the mental health system is national in scope (1), and visits to the ED for mental health-related complaints are on the rise. I might also point out an interesting parallel between your gradual acceptance of responsibility for the mental health population and the gradual process a mental health sufferer goes through accepting that he or she has a problem. In a way, the circumspect approach each of you takes to the doctor-patient relationship is a complementary struggle giving you something in common, which can be a useful starting point. THE CASE OF MS. V: Triage nurse interview A 45 year-old woman presents herself to a freestanding Psychiatric Emergency Service (PES) on a Monday morning with a request to be started on medicine for auditory hallucinations. The triage nurse obtains the following information: Ms. V* has come in voluntarily, but her family had pressured her all weekend to get help. She is unaccompanied, however, and could not be more specific about their concerns. For her own part, she is tired of hearing voices, having heard them for twenty years or more. She has to be at work by late morning and hopes her request can be handled quickly and without too much trouble. She has no history of previous psychiatric treatment, but is ready to try it now. Though her problem is not an emergency, her lack of insurance has forced her to seek care in an emergency setting. She is in good health and on no medication. Vital signs are stable. Urine drug screen, intoximeter, and pregnancy test are negative. She never had a drug problem. She lives alone and is not currently in a relationship. She went to prison in her twenties for stabbing her boyfriend at the time with a knife, and she had a domestic violence charge a few years ago. She had an uncle once diagnosed with schizophrenia. He had gone to prison for murder, where he eventually committed suicide. Ms. V believably assures the nurse she has never been suicidal. She does admit she is a recovering alcoholic and says she achieved sobriety without professional help, but the hallucinations are proving more intractable. She hears several different voices criticizing her and talking amongst one another. None of them command her to hurt herself or others. They are less noticeable when she is working or interacting with people.


Consult Corner (continued) They are more noticeable when she’s inactive and they are especially bad right after lying down for the night. Ms. V has no thoughts of hurting herself or others. She is not depressed or agitated. She’s neat and clean. She is fully cooperative and relates her history in a matter-of-fact, respectful manner. She’s alert and oriented and exhibits no cognitive deficits. The triage nurse has done a nice job. She assigns Ms. V to the ambulatory care track. Psychiatrist evaluation (10 minutes) Cases of new onset mental illness warrant a thorough medical evaluation. Since Ms. V reported a 20-year history of illness, the psychiatrist in the freestanding PES decided to arrange for the workup to be done as soon as possible after his initial intervention. Had Ms. V presented to an ED instead of a PES, it would have been very appropriate to complete a history and physical, labs, and head imaging. (Ultimately, Ms. V did have these things, and they proved to be non-contributory). The psychiatrist introduced himself to Ms. V and took in her countenance, appearance, and ability to interact with him. She was just as the triage nurse had described: calm, well cared for, and pleasant. He expected her mental status exam to be positive for hallucinations but otherwise unremarkable. He summarized in a few seconds what he had learned from the nurse and commended Ms. V for seeing help. He then said he wanted to understand better why she was presenting for treatment at this particular time. She had heard the voices for years. Why now? (He knew her family might have this and other useful information, but contacting them before talking to her, even with her permission, would be going behind her back. Premature elicitation of collateral history devalues the patient’s ability to speak for herself, which in turn undermines the delicate process of engaging a cautious individual in the doctor-patient relationship). Ms. V understood his question but couldn’t say. He asked her what it was really like to live with voices day in, day out. His goal was to discover the underlying state of mind—the uncomfortable mix of thoughts and feelings—that prompted Ms. V to seek help. What were the contours of this extraordinary decision point or crisis mental state? She replied that the voices were irritating, adding that she was not sure the voices were hallucinations at all. Her family considered them to be all in her head, but she thought the voices might be something real that people in her building were doing to her. Asked to elaborate, Ms. V said that people were spying on her in her apartment with invisible cameras. They might be creating the voices too. He asked how she knew this, and she said it was because the cameras were so perfectly hidden that she had been unable to find any of them. She also had her suspicions as to exactly which people were after her. He asked what it was like for her to live this way, and she said she couldn’t take it any more. He then asked if she was thinking of doing something about it. She said she wanted to confront these people, but she was afraid that they might get angry and attack her. The previous Friday, she had gone to a relative she knew to be a drug dealer to ask if she could borrow one of his guns. She had no intentions of harming anyone, but when she approached the individuals that were harassing her, as she intended to do, she wanted to be able to defend herself. The psychiatrist paused to consider what he had learned thus far. He decided his focused emergency evaluation could be concluded: he had formulated some diagnostic impressions and an opinion about her risk. He wondered why Ms. V had never been diagnosed or treated before. There was more to the story. But he knew enough. Her history of felony


Consult Corner (continued) Members-only Listserv AAEP has recently created a listserv discussion group that is available via invitation to members in good standing only. This is 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

assault, her loss of reality testing, her plan to confront her persecutors and her attempt to secure a handgun constituted imminent dangerousness. She needed medication and she needed inpatient care. Psychiatric management (10 minutes) At this point, the psychiatrist told Ms. V he thought she was right to request medicine, and he presented her with some different options. She clarified her need to be able work later in the day and asked for a prescription to go. He recommended a trial dose of risperidone while still in PES, and she agreed. He returned about 20 minutes later. She was alert and more relaxed. There were no unpleasant side effects, but her psychosis was unchanged. He reiterated how glad he was that she had come in for help, but went on to say that said her condition was more serious than she seemed to know. In particular, he shared his grave concern that she was at risk for shooting someone she believed to be persecuting her who might actually not be doing anything to her at all. She was in danger of an action that would send her back to prison, and he wanted to help her prevent that. She needed to begin her treatment on an inpatient basis. She offered to attend outpatient treatment conscientiously and asked to leave the PES. He said he was sorry, but she would have to stay. Ms V was unhappy but did not escalate. The psychiatrist excused himself to initiate a mental health hold and to request that his PES disposition manager arrange psychiatric hospitalization.

received your invitation email, please contact Jacquilyn Davis at:

“The issue of risk of harm to self or others must be considered in every case.” Discussion This case illustrates a number of points: The issue of risk of harm to self or others must be considered in every case. It’s part of the EMTALAmandated Medical Screening Exam for emergency medical conditions. A probing assessment of risk can often be done in a reasonable amount of time by ED standards if one goes about it in a focused way. Ms. V is an unusual case, but not an esoteric “zebra” requiring knowledge of rare conditions. Patients often need preparation before being asked direct questions about suicidal and homicidal ideation. The interviewer’s goal should be to establish rapport and gently search out the precipitating crisis state of mind that led to the visit. (2, 3) In emergency work, the crisis state of mind is often occult. It led to a dangerous behavior driving the referral to the emergency setting. In this case, the crisis state of mind led to Ms. V asking a relative for a gun. This alarmed the family and prompted them persuade her to seek professional help. (During her subsequent hospitalization, the family did provide the additional information that Ms. V had already been accosting her neighbors angrily with a knife in her hand). A dangerous behavior is often considered the chief complaint. However, the real chief complaint is a state of mind that caused the individual to resort to the dangerous behavior. In this case, neither came to the surface spontaneously. With psychotic individuals, a good avenue to determining risk is to inquire into how it feels to live with the symptoms. Some patients indicate they’ve learned to put up with them. Some patients live in despair and become at risk for suicide. A small percentage of paranoid patients take steps to protect themselves that put others at significant risk.


If a patient needs antipsychotic medication and is either requesting or open to taking one, it is not a bad idea to prescribe it very early on, often after just a minute or two of evaluation. This is a window

Consult Corner (continued) of opportunity not to be missed. It stabilizes a person for a more vigorous interview, and it mitigates a bad reaction to a disposition decision that a patient may not agree with. Conversely, it is also very hard to persuade a patient to accept medication who is angry about an adverse disposition. In retrospect, it would have been useful to give Ms. V medicine soon after the first time he commended her for seeking help.

*Details of this case have been changed to disguise the identity of the individual. References: President’s New Freedom Commission on Mental Health, 2003. Shea, SC. The Practical Art of Suicide Assessment. John Wiley & Sons, Inc. Hoboken, NJ, 2002. Berlin JS, Gudeman J, “Interviewing for Acuity and the Acute Precipitant”, in Glick, et al. Emergency Psychiatry: Principles & Practice. Lippincott Williams & Wilkins, 2008.

Jon Berlin is Associate Clinical Professor, Departments of Psychiatry and Emergency Medicine, Medical College of Wisconsin and Medical Director of the Crisis Service of the Milwaukee County Behavioral Health Division. Please direct comments or questions to

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: psychiatrists working in a PES, 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

Project BETA Update By: Garland H. Holloman, Jr., MD Project BETA is on the move. Each of the five workgroups – Psychiatric Evaluation, Medical Evaluation, De-escalation, Pharmacological Management and Restraint and Seclusion – has uploaded their respective draft to the Project BETA website for review by the others. Working through a Yahoo Group has been quite a challenge. Some of our members discovered that their institutions limited access to Yahoo, and the format just didn’t work for all. Nevertheless, with superb leadership from our workgroup leaders, our members rallied. They have had email exchanges, conference calls and online meetings to get the job done. They have done a magnificent job and it has been quite exciting watching the documents come together. Our AAEP Board recently met in Hawaii, and reviewed and discussed the current drafts. The Board is currently providing feedback to the Project BETA workgroup members, who then will begin to fine-tune their documents in preparation for the formal presentation of their work at the IPS meeting in October. The challenge of Project BETA has been to develop guidelines for best practices in the evaluation and treatment of agitation in the emergency setting. Our members are experts in the field, and the guidelines developed will represent the consensus of the members. Project BETA is a group effort, and it is not too late to have your voice heard if you have an interest in becoming involved. Just contact Jacquilyn Davis, get registered, access the documents and share your thoughts by posting them to the Yahoo Project BETA list server.


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

SAVE THE DATE October 27-30, 2011 IPS Conference - San Francisco, CA The AAEP will be unveiling Project BETA: Best Practices in Evaluation and Treatment of Agitation at the 63rd Institute on Psychiatric Services this coming October. This session will be held in the San Francisco Marriott Marquis Hotel located at 55 Fourth Street, San Francisco, CA on Sunday, October 30, 2011, from 8:30-11:30 a.m. As the AAEP has maxed out meeting rooms in previous years, this year’s venue fits up to 160 people. Our goal is to have another packed house, so please plan to attend for what should be an exciting seminar and discussion. A social event is currently being planned for this location and details will be sent via email once available.

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: Website:

AAEP Newsletter - Spring 2011  

American Association for Emergency Psychiatry's Newsletter - Spring, 2011 Issue