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Preliminary Report on Consumer Experiences of Psychiatric ...

Preliminary Report on Consumer Experiences of Psychiatric ...

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availability of inpatient care. While Psychiatric Emergency Rooms are importantservices, they are often “crowded, underfunded, and facing increasing staff shortages anda dwindling availability of hospital beds” (Stefan, 2006). These factors contribute tounpleasant experiences for both service users and staff. Many service users view EDswith “bitterness and distrust”, and ED staff often feels they lack the time or the skills toprovide appropriate care to those in psychiatric crisis (Stefan, 2006).This shift in the locus of mental health care and the social context within whichmental health services are provided has led to some people frequently using psychiatricemergency room services. The frequent use of PES services has been studied primarilyfrom one perspective, which assumes frequent use of these services to be an inappropriateor inefficient use of mental health services. Patients who frequently use PES services arelabeled as “recidivists” and often described as treatment resisters, frequent flyers,revolving door patients, or "unmotivated or at least ambivalent" (Goldfinger, Hopkin, &Surber,1984, p.15). Frequent users have been estimated to constitute 7 to 18% of PERpatients (Bassuk & Gerson, 1980; Buaer & Balter, 1971; Slaby & Perry, 1981).Research efforts have focused on identifying the clinical and socio-demographiccharacteristics of these patients and determining how they differ from "non-frequent"users of services. In most studies, age has not proven to be a significant distinguishingvariable. Bassuk and Gerson (1980), however, found a statistically significantoverrepresentation of repeaters in the 31-to-50 age group. Women were not overrepresented among repeaters in three controlled studies (Bassuk & Gerson, 1980; Buaer& Balter, 1971; Slaby & Perry, 1981). Other variables that have failed to discriminatebetween repeaters and non-repeaters include, race, education and unemployment.Repeaters were more likely to lack social supports (Bassuk & Gerson, 1980; Miller,1968; Munves, Trimboli & North, 1983), to have a prior psychiatric hospitalization(Bassuk & Gerson, 1980; Buaer & Balter, 1971; Munves, et al., 1983), to be concurrentlyin psychiatric treatment, and to have a chronic psychiatric illness (Slaby & Perry, 1981).The data also suggests that repeaters are more often self-referred and more likely to behospitalized (Buaer & Balter, 1971). Assumptions are then often made that thesecharacteristics, i.e., social isolation, are causal in their frequent use of PER services.Many assumptions have been made by researchers studying frequent users of PER5

services including that frequent use of PER services is inappropriate, costly, and leads tonegative treatment outcomes. "One serious difficulty inherent in any discussion ofeffective treatment for the acute care recidivists is the remarkable paucity of ourknowledge about them." (Goldfinger, et al., 1984, p.20). The current socio-historicalcontext of mental illness necessitates a re-examination of these assumptions. The PERhas always served as an open door for mental health care. Emergency rooms can bedescribed as barometers for society. People who are pushed to the margins by pressuresoperating in society will be disproportionately represented among those seeking care atthe PER. The manifest function of the PER is to provide emergency psychiatric care forpeople in acute crisis, parallel to the general emergency rooms. However, PERs alsoserve a latent function of safety, food, shelter and social interaction (Malone, 1998).Appropriate use of PER services by patients struggling with chronic mentalillness has been inadequately defined. However, “recidivism” has been defined in manyways. There is little agreement about how many visits are needed for a patient to belabeled recidivist. Definitions tend to be determined by the length of the study, andcriteria include a minimum of two or more visits in the time period. Definitions ofrepeaters vary liberally from one visit per year (Bassuk & Gerson, 1980; Munves, et al.,1983; Slaby & Perry, 1981), to more than one visit in six months (Buaern & Balter, 1971;Miller, 1968; Ungerleider, 1960), to more than one visit per four months (Schwartz,Weiss, & Miner, 1972). This variability in the criteria used to define recidivism has ofcourse led to even greater disagreement as to the characteristics of recidivist patients. Themost frequent method used for studying “recidivist” patients however defined, has beenquantitative analyses. A variety of clinical and social variables are examined to determinewhich characteristics differentiate 'recidivist' and 'non-recidivist' patients. Finally,researchers often assume that these differentiating characteristics are causally linked tothe patient's presentation at the emergency services). For instance, if patients described as“recidivists” are less likely than other patients to have social support, researchersconclude that this is an important factor in the reason for their visit.The current literature on psychiatric emergency service utilization provides uswith inadequate knowledge to design psychiatric emergency interventions and care thatmeet the standards outlined in the President’s New Freedom Commission ong>Reportong>. A6

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