Emergency Psychiatry: Contemporary Practices in Managing Acutely Violent Patients in 20 Psychiatric Emergency Rooms

Although no comprehensive national directory of psychiatric emergency rooms exists to our knowledge, one source of information on a large number of such facilities is the American Association for Emergency Psychiatry, a national organization with approximately 170 members. Participants in our study were the medical directors of 20 psychiatric emergency rooms located throughout the United States. These individuals were selected from the membership list of the American Association for Emergency Psychiatry using a stratified random sampling procedure.

First, the membership was divided into four geographic areas of the country—Northeast, North Central, South, and West. Using a table of random numbers, five psychiatric emergency rooms from each region were selected and the medical director was contacted (N=20). The medical directors were asked whether their emergency room was a receiving unit for acutely violent patients and whether they themselves directly participated in the evaluation and treatment of such patients. If either of these criteria were absent, a second emergency room medical director from the region was contacted. All of the individuals who met the inclusion criteria were invited to participate, and all of them agreed to do so after the purpose of the study was explained.

A structured interview was conducted by telephone with each medical director during March 1998. The interview covered a description of the psychiatric emergency service and a variety of aspects of the medical director's practices in the management of acutely violent patients—that is, patients who were agitated or who were deemed to be at immediate risk for becoming combative. (A copy of the interview manual is available from the authors.)

To our knowledge, this study is the first to survey clinicians about their actual practices in the management of acutely violent patients in contemporary psychiatric emergency rooms. The sample size of 20 is small, which may limit the generalizability of the results. Nevertheless, the representativeness of the sample, its national scope, and the consistent findings suggest the value of further investigation with larger samples.

The results suggest that the strategies most frequently advocated in recent review articles for the assessment and management of violent patients are not generally applied by those responsible for the emergency management of acutely violent patients. When violent and agitated patients are brought to psychiatric emergency rooms, clinicians appear to place highest priority on prevention of patient and staff injuries by rapidly reducing violent behavior. Unless the patients are already well known to staff, clinicians most commonly manage acutely violent patients through restraints and intramuscular medications, typically a combination of neuroleptics and benzodiazepines, irrespective of diagnosis. Subsequently, potential causes of the violent behavior can be evaluated. Emergency room medical directors generally express the opinion that this medication regimen is effective for calming acutely violent patients and also permits referral to other levels of care within a 24-hour period.

One could argue that these practices involve risks of excessive coercion, overmedicating patients, and exacerbating underlying medical conditions. On the other hand, the clinical experience of practitioners suggests that these strategies rapidly ameliorate acute violence and thereby reduce the risk of injury.

The authors thank Judy N. Lam, Ph.D., for her assistance.

Dr. Binder is professor and Dr. McNiel is adjunct professor of psychology in the department of psychiatry at the University of California, San Francisco. Address correspondence to Dr. Binder at Langley Porter Psychiatric Institute, 401 Parnassus Avenue, San Francisco, California 94143-0984 (e-mail, [email protected]). Douglas H. Hughes, M.D., is editor of this column. Parts of this paper were presented at the annual meeting of the American Psychiatric Association held May 30–June 4, 1998, in Toronto.