CLINICAL HANDBOOK OF SCHIZOPHRENIA

34. Emergency, Inpatient, and Residential Treatment 341performed on patients who have acute exacerbations of illness; this also includes an investigationof drug or alcohol intake, which frequently contributes to psychotic worsening.It is important to be aware that exacerbations of symptoms caused by drug and alcoholabuse, which lead to psychiatric destabilization, can sometimes be managed by simplywaiting for the drug effects to dissipate.Many patients can be rapidly stabilized in the emergency room setting, then dischargedto their original environment. In some cases, stabilization can be accomplished ina few hours. However, many emergency facilities have special policies and proceduresthat allow for longer stays, frequently up to 24 hours, after which the patient may have tobe admitted or considered for admission. Some facilities have designated areas for thepurpose of longer stays that are often quieter and geographically distant from the morecentral medical- and trauma-oriented areas.Psychopharmacological Management in Emergency RoomsPatients frequently require psychopharmacological intervention, which can promotemore rapid stabilization given the use of appropriate agents. In many cases, the cause forexacerbation of schizophrenic illness is related to reduced medication intake, which perhapsmay be due to adherence problems, stolen medications, or the patient’s inability toreceive or obtain medications. Sometimes, when it is difficult to ascertain whether the patienthas been adherent to a medication regimen, obtaining blood levels of medicationscan be useful. If a patient is on a medication that requires periodic monitoring of serumlevel, such as lithium or valproate, checking the level can then serve two purposes—as anindicator of both therapeutic level and adherence.Even when the cause of symptom exacerbation is medical or psychosocial in nature,psychopharmacological intervention may be helpful in reducing symptoms and agitation.In general, antipsychotic medications are most commonly used to reduce symptomsacutely and stabilize the patient. The choice of medication is dependent on the specific issuesof the patient. Often, patients who have had adherence problems may be placed onceagain on their initial treatment regimen, although an attempt should be made to addressthe cause of the nonadherence. Otherwise, high-potency antipsychotics are often used (eitherfirst- or second-generation drugs), according to either the clinical needs of the patientor any formulary restrictions of the facility.Confidentiality and Release of InformationPatient confidentiality is an extremely important issue that should always be maintained,particularly in an emergency room environment, which can become pressured and chaotic.The American Medical Association, the American Psychiatric Association, and theAmerican Association of Psychiatry and the Law all have ethical guidelines. As a generalrule, information exchanged between the patient and the clinician is confidential. However,exceptions include situations in which the patient is a danger to self or others, expressesthe intent to commit a crime, is a suspected victim of child abuse, is involved incivil commitment proceedings or court-ordered examination, or has certain medicalemergencies. Facility rules and regulations may not exist for every possible situation, inwhich case, clinicians must use their best judgment. However, clinical decisions should bebased not on concern for avoiding litigation, but on what is best at the time for the safetyof the patient and of others, and treatment of the patient.Although complex, the Tarasoff principle (Tarasoff v. Regents of the University ofCalifornia, 1976), which is not standard for all states, provides a commonly used legal