Dr. Way and Colleagues Reply

To the Editor: We are pleased that Drs. Roy-Byrne and Russo found our report on psychiatric emergency room decisions to be of interest and applaud their efforts to develop a scale that can be used as a screening tool in such settings.

Their preliminary results concerning scale reliability and accuracy are encouraging. We hope that similarly strong results are obtained when use of the scale is extended to a wider variety of clinical settings with diverse populations of patients and raters. We have found that videotaped interviews can be an effective method for assessing interrater reliability across settings.

We are concerned, however, about the confusion regarding what the goals of a psychiatric emergency service and the associated standard of care should be. Is the emergency assessment driven by therapeutic, legal, or economic considerations? Can any limited or triage screening consistently serve all of these purposes? For example, can a defensible suicide risk assessment be accomplished without a reliable diagnostic assessment? Is it a good, thorough assessment, leading to prompt treatment, or is it a decision based on legal considerations or medical necessity? We think that there may need to be a categorization of psychiatric emergency service capabilities, as previously proposed by the American Medical Association (1), that takes these different goals into account.

Drs. Roy-Byrne and Russo’s last comment points to the difficulty in the context of psychiatric emergency assessments of developing support tools for decision making that are simultaneously reliable, accurate, and practical. Longer scales are almost always more reliable than shorter ones, but they are also less likely to be used carefully—or used at all. Given the importance of the decisions that are made in psychiatric emergency settings, however, all trade-offs between time and quality of information need to be weighed carefully.