a. Olive View—UCLA Medical Center, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA 90024, USA
While patient entry into a psychiatric emergency service (PES) can be an important first step toward improved mental health, PESs have become increasingly more complex. Over the years, on top of providing triage and disposition, PES has become the place where psychiatric treatment may be rendered for patient safety. In times of economic recession, however, PESs may also have become de facto psychiatric wards [1].
Allen and Currier [2] have surveyed 51 psychiatric emergency services to assess the type and scope of services delivered. They found that psychiatrists initiating treatment with medications have become the norm, not the exception, in the PES. In comparison to the consultation model (in which psychiatrists are consultants to the emergency department), the PES model is found to be more timely, effective and safe [3]. As PES may act as a barometer of the overall mental health system, Boudreaux et al. [4] have developed and applied ten quality indicators to eight PESs across the nation. The study reinforced that even in the busy psychiatric emergency settings, benchmarking can ultimately improve quality of care.
Two years ago, in this Journal, an editorial [5] highlighted the importance of providing quality care in the PES. Optimal and appropriate care may be achieved only when safety, effectiveness, efficiency, timeliness, equity and patient-centeredness are actively promoted. The editorial explicitly called for future research to examine the relationship between quality of care and racial disparity. In this issue, Unick and colleagues [6] provide a timely report on whether ethnicity plays a role in clinical, demographic and service system characteristics in the PES and subsequent inpatient admission.
The authors reported on patients admitted to the only 24-h PES operating in San Francisco County in a 3-month period in 2005. Inpatient admissions from the PES were associated with delusions and deteriorated psychosocial functioning. Multiple previous PES visits in the past 2 years, as well as being admitted to PES on a Sunday, were associated with lower probability of inpatient admissions. These associations highlighted that despite inpatient admission should be strictly based on clinical necessity, other factors contribute to the algorithm of evaluation and disposition in the PES. Further studies should investigate the impact of clinical, demographic and service system characteristics on PESs nationwide.
Unick et al [6] noted that, in San Francisco County, African Americans were over-utilizing and Asians were under-utilizing the PES than adults in the population at large. The authors found that both Asians and blacks had higher levels of functional impairment on PES admission in comparison to other ethnicity groups. Not only that, Asian patients also had a higher probability of being admitted to the inpatient unit when compared to White patients. Clearly, ethnicity plays a role in PES utilization and inpatient admission.
What are the clinical implications of the growing emphasis on cultural emergency psychiatry? Asian Americans are one of the fastest growing groups in the US, particularly in the Los Angeles, New York, and San Francisco areas. Despite being labeled as a group of “model minorities,” multiple studies [7], [8] and [9] have shown that Asian Americans suffer from equal or higher rates of depression and suicides, but underutilize any type of mental health services, in comparison to the mainstream population. In the current study [6], the data confirm that few Asian Americans seek psychiatric emergency treatments. Not only that, many of them were sicker than others on PES admissions. Future studies should investigate whether limited access to care and cultural barriers contribute to the under-utilization of PES among different ethnicity groups.
While heterogeneity in mental health risk factors exist among different Asian subgroups, i.e., Chinese, Filipino, Korean, Vietnamese, etc., they are often aggregated in mental health services data collection. There are indeed numerous differences among different Asian ethnic sub-groups. For example, Southeast Asians are more likely to be refugees and immigrants from the Vietnam War. Thus, they may be under higher risk of loss, depression and post-traumatic stress disorders. Despite that PESs are exceedingly busy, clinicians should strike for providing culturally appropriate emergency psychiatric care. Furthermore, equity can only be achieved when cultural barriers are removed. Future studies should examine mental health disparities by ethnic subgroups among Asian Americans in the PES.
This study had a number of limitations. The main limitation of this study was its retrospective nature and the fact that it included only patients from a single PES. Second, the findings may not be applicable to other settings. However, this study represents a commendable effort to capture how clinical, demographic and service system characteristics are influencing decision making in the PES. This study also fills an important gap by providing a current snapshot of how cultural barriers may interfere with quality PES care.
The current health care costs have become increasingly unsustainable. Acute psychiatric hospitalization is the most expensive and restrictive level of care available in the mental health system. On top of providing culturally sensitive services, PES should strike for equity, efficiency and quality by removing cultural barriers and improving access to care. Providing cost-effective, timely, patient-centered health care in the PES would be a vital first step to ensure appropriate use of our scarce healthcare resources. To thrive in an era of healthcare reform, we must take up the unparalleled opportunities for system reform in all levels of psychiatric service to provide quality of care.
References
[1] T.T. Lo and B.K. Woo, The impact of unemployment on utilization of psychiatric emergency services. Gen Hosp Psychiatry, 33 3 (2011), pp. e7–e8.
[2] M.H. Allen and G.W. Currier, Use of restraints and pharmacotherapy in academic psychiatric emergency services. Gen Hosp Psychiatry, 26 1 (2004), pp. 42–49.
[3] B.K. Woo, V.T. Chan and N. Ghobrial, et al. Comparison of two models for delivery of services in psychiatric emergencies. Gen Hosp Psychiatry, 29 6 (2007), pp. 489–491.
[4] E.D. Boudreaux, M.H. Allen and C. Claassen, et al. The Psychiatric Emergency Research Collaboration-01: methods and results. Gen Hosp Psychiatry, 31 6 (2009), pp. 515–522.
[5] B.K. Woo and D.L. Sultzer, A key step for quality care in psychiatric emergency settings. Gen Hosp Psychiatry, 31 6 (2009), pp. 503–504.
[6] G.J. Unick, E. Kessell, E.K. Woodard, M. Leary, J.W. Dilley and M. Shumway, Factors affecting psychiatric inpatient hospitalization from a psychiatric emergency service. Gen Hosp Psychiatry, 33 (2011), pp. 618–625.
[7] S. Sue and J.Y. Chu, The mental health of ethnic minority groups: challenges posed by the supplement to the surgeon general's report on mental health. Cult Med Psychiatry, 27 4 (2003), pp. 447–465.
[8] B.K. Woo and T.T. Lo, How often do Chinese Americans stay on treatment after transitioning from outpatient mental health to primary care setting?. Gen Hosp Psychiatry, 33 1 (2011), pp. e5–e6.
[9] D.T. Takeuchi, R.C. Chung and K.M. Lin, et al. Lifetime and twelve-month prevalence rates of major depressive episodes and dysthymia among Chinese Americans in Los Angeles. Am J Psychiatry, 155 10 (1998), pp. 1407–1414.
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