Solving ethical problems in medical settings during psychological assessment: a decisional model.

The unique culture of medical settings impacts the style, pace, and quality of psychological consultation provided in that setting. Matters of life and death and other health emergencies, relationships with the courts, and contact with severely impaired patients are typical events. Medical psychologists (MPs) share many, but not all, of the ethical values that guide provision of services by other medical professionals under such circumstances. This generates the need to develop an interdependent but independent ethical orientation on the part of MPs in all professional activities, including psychological assessment. In this article, background information is presented on values that frequently drive medical treatment that may conflict with the MPs' ethical standards. A model appropriate for use in situations requiring complex decisional processes is reviewed, and vignettes are presented as examples of bioethical problem solving under this systematic decisional framework.

Association of alcohol use and other high-risk behaviors among trauma patients.

BACKGROUND: Risk behaviors and psychological problems may limit recovery after trauma, may be related to injury recidivism, and may limit the effectiveness of alcohol interventions in trauma patients. The aim of the current study was to evaluate the prevalence of behaviors associated with injury and their relationship with alcohol use in adult trauma patients. METHODS: A prospective cohort of 301 adult patients admitted to a single Level I trauma center were interviewed regarding risk behaviors and alcohol use. RESULTS: There was evidence of acute and/or chronic alcohol use in 48.2% of cases. Over three fourths of patients (77%) engaged in one or more high-risk driving practices, 40% engaged in one or more violence-related behaviors, and 19% reported suicidal ideation in the last year. These risk behaviors were more common in patients who evidenced acute and/or chronic alcohol use. CONCLUSION: Behaviors that place an individual at greater risk for traumatic injury are common among seriously injured adult patients admitted to an urban Level I trauma center and frequently coexist with alcohol use. Their importance to injury, injury recidivism, and recovery after trauma requires further investigation.

Toward a redefinition of psychiatric emergency.

OBJECTIVE: To compare three methods for rating legitimate use of psychiatric emergency services (PES) in order to develop criteria that can differentiate appropriate from inappropriate PES service requests. METHOD: Ratings of PES visits by treating physicians and ratings of the same visits made during review of medical records. STUDY DESIGN: Two previously used methods of identifying justified PES service use were compared with the treating physician's rating of the same: (1) hospitalization as visit outcome and (2) retrospective chart ratings of visit characteristics using traditional medico-surgical criteria for "emergent" illness episodes. DATA EXTRACTION METHODS: Data were extracted through use of a physician questionnaire, and medical and administrative record review. PRINCIPAL FINDINGS: Agreement between the methods ranged from 47.1 percent to 74.1 percent. A total of 21.7 percent of visits were rated as true health "emergencies" by the traditional definition, while 70.4 percent of visits were rated as "necessary" by treating physicians, and 21.0 percent resulted in hospitalization. Acuteness of behavioral dyscontrol and imminent dangerousness at the time of the visit were common characteristics of appropriate use by most combinations of the three methods of rating visits. CONCLUSIONS: The rating systems employed in similar recent studies produce widely varying percentages of visits so classified. However, it does appear likely that a minimum of 25-30 percent of visits are nonemergent and could be triaged to other, less costly treatment providers. Proposed criteria by which to identify "legitimate" psychiatric emergency room treatment requests includes only patient presentations with (a) acute behavioral dyscontrol or (b) imminent dangerousness to self or others.

The nature of help-seeking during psychiatric emergency service visits by a patient and an accompanying adult.

Utilization rates for urban psychiatric emergency services remain high, and the decision to seek care in this setting is poorly understood. Three hundred individuals accompanying patients to a psychiatric emergency service were interviewed about their help seeking and choice of treatment setting. Twenty-three of the interviewees (7.7 percent) were caregivers accompanying patients with severe and persistent mental illness. They were significantly more likely than other interviewees to know the difference between psychiatric emergency services and services offered by other outpatient providers. More than half reported that the patient they accompanied was intermittently noncompliant, which required visiting either a walk-in service during a moment when the patient was cooperative or a facility equipped to provide involuntary treatment.

A comparison of psychotic and nonpsychotic substance users in the psychiatric emergency room.

Current illicit drug and alcohol users were identified by laboratory evaluation of urine samples from nonpsychotic patients without a primary clinical diagnosis of a substance use disorder seen in a psychiatric emergency room. Urine screens revealed that 32 of 93 nonpsychotic patients (34 percent) had used a substance just before visiting the emergency room. Compared with nonusers, users were more often Caucasian females with adjustment disorders who admitted their previous substance use. The prevalence of concurrent use among nonpsychotic patients was higher than among psychotic patients. Nonpsychotic and psychotic users differed in gender, marital status, level of suicidality, self-report of use, the clinician's suspicion of use, use of seclusion during the visit, admitting status, level of care, and disposition.

Substance use among patients with a psychotic disorder in a psychiatric emergency room.

OBJECTIVE: This study used laboratory tests to identify current drug and alcohol users among psychotic patients seeking treatment in an urban psychiatric emergency room. Rates of clinician-suspected use and self-reported use were compared, as were treatment and disposition of users and nonusers. METHODS: Logistic regression modeling was used to identify factors that differentiated current substance users from nonusers in a sample of 112 psychotic patients. RESULTS: Laboratory analyses revealed that 24 of the 112 psychotic patients (21 percent) had used alcohol or an illegal substance before visiting the emergency room. Younger age, male gender, African-American ethnicity, clinician-suspected substance use, and presentation in the emergency room between 7 p.m. and 7 a.m. were associated with a higher likelihood of positive results on the urine test. Only five of the patients who had positive results (21 percent) self-reported substance use. Clinicians suspected that 59 patients (53 percent) were under the influence; however, only 17 of those suspected (29 percent) had positive laboratory results. Patients with positive laboratory results required more intense care in the psychiatric emergency room and were more often hospitalized. CONCLUSIONS: Some demographic and clinical factors were associated with concurrent substance use among psychotic patients in the emergency room. Clinicians' suspicions of use in this sample of psychotic patients lacked specificity due to the fact that potential use was suspected in a large number of cases for which laboratory results were negative. In contrast, self-reported use was uncommon among patients with positive results. Because neither clinician judgment nor patient self-report meaningfully predicts current substance use, routine urine drug screens may be appropriate.