The Nature of Help-Seeking During Psychiatric Emergency Service Visits by a Patient and an Accompanying Adult

Interviewees were 300 persons accompanying patients to the psychiatric emergency service of an urban public teaching hospital that has an average of 10,000 visits a year and treats patients for up to 23 hours. Additional characteristics of the study site and population have been described elsewhere (5). Interviewees were a sample presenting between 11 am and 11 pm Monday through Saturday in the summer of 1995. All spoke English, were 17 years of age or older, accompanied a patient over 17 years of age, and provided informed consent. They were classified as primary care providers or as noncaregiver companions by self-report. The study was approved by the hospital's institutional review board.

The semistructured interview used for this study included the Dysfunctional Behavior Rating Instrument (6) and the Instrumental Activities of Daily Living Rating Scale (7). Information was also obtained about the type of help sought, such as hospitalization and medications, the reasons for accompanying the patient, and the reasons for selection of the psychiatric emergency service as treatment provider.

It was hypothesized that persons accompanying patients with more extensive treatment histories would have different help-seeking patterns than less experienced help seekers. Therefore, patients with severe and persistent mental illness were identified using 1988 criteria from the National Institute of Mental Health: a diagnosis of psychotic disorder or severe character disorder, illness duration of two years or more, and functional disability. Functional disability criteria included current moderate behavioral dysfunction, which was measured as a score of 30 or higher on the Dysfunctional Behavior Rating Instrument; mild impairment in activities of daily living, which was measured as a score of 19 or higher on the Instrumental Activities of Daily Living Rating Scale or current homelessness; and moderate impairment in performance at work, which was measured as current joblessness.

For some analyses, self-identified caregivers of persons with severe and persistent mental illness were compared with all other interviewees, which included noncaregiver companions of persons with severe mental illness and caregivers and companions of persons without severe mental illness.

Demographic information— age, race, and sex— and clinical information, such as voluntary or involuntary admission status and DSM-IV diagnosis, was obtained from medical records. Symptom onset was defined as recent when it was within 72 hours of coming to the emergency service. The degree of observable behavioral problems in the psychiatric emergency service— continuous, intermittent, or absent— was rated in keeping with Murdach's emergency illness episode criteria (8).

Level of care is a local billing code designating the intensity of treatment in the psychiatric emergency service. In this analyses, level I represents intense care, in which medical interventions such as laboratory testing or medications were used or when seclusion lasted more than eight hours; level II represents minor care, in which such measures were absent or lasted less than eight hours. Disposition was categorized as hospitalized or not.

To determine whether the results from the patient-companion dyads included in the study were generalizable, chi square analysis and t tests were used to compare these visits with those of other dyads not included in the study. Interview results were then tallied, and responses from caregivers accompanying patients with severe and persistent mental illness were compared with responses of other interviewees to identify ways in which previous help-seeking experience influenced utilization patterns.

Results from analyses of the interviews appear to support different patterns of use of the psychiatric emergency service according to features of the help-seeking dyad. Overrepresentation of some groups in the interview pool does not appear to have obscured these differences. Half of the interviewees who were not caregivers of persons with severe mental illness were unable to differentiate unique features of treatment in the emergency setting. Despite the close relationship between most interviewees and the patient they accompanied, some interviewees may not have been involved enough to accurately reflect the patient's care-seeking efforts. However, other patients' visits to the emergency service appear to be the result of fairly uninformed service use.

Given the differences between the psychiatric emergency service and other providers, indiscriminate use of the emergency service may have an adverse impact on the success of the help-seeking effort (9). A triage and referral function built into the emergency service intake process with seamless transitions to other community-based systems (10) might go a long way toward promoting more effective service use.

Data from this study further imply that families providing care to intermittently noncompliant individuals with severe and persistent mental illness have specific service needs. Clinicians report that burnout among caregiving families is frequently associated with significantly reduced quality of life for patients with severe mental illness. It is in the best interests of patients, care providers, and treatment systems, therefore, to find ways to address these service needs directly, and the psychiatric emergency service may be able to play a pivotal role in augmenting such efforts.

This research was partly supported by Mental Health Connections, a partnership between Dallas County Mental Health-Mental Retardation and the department of psychiatry of the University of Texas Southwestern Medical Center. Funding was from the Texas state legislature and the Dallas County Hospital District. The research was also partly supported by grants MH-41115 and MH-53799 from the National Institute of Mental Health. The authors thank Martin Lumpkin, Ph.D., and Tom Carmody, Ph.D., for technical support and Kenneth Z. Altshuler, M.D., and Maurice Korman, Ph.D., for administrative support.

The authors are affiliated with the University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas 75235-9070 (e-mail, [email protected]). Dr. Claassen and Dr. McIntire are assistant professors, Dr. Hughes is professor, and Dr. Roose and Dr. Basco are clinical assistant professors in the division of clinical psychology. Dr. Gilfillan is assistant professor in the department of psychiatry.