The Prescription of Psychotropic Medications for Patients Discharged From a Psychiatric Emergency Service

Carrie L. Ernst, M.D.; Suzanne A. Bird, M.D.; Joseph F. Goldberg, M.D.; and S. Nassir Ghaemi, M.D.

Objective: Considerable debate exists about the value and wisdom of initiating "definitive" pharmacotherapies, particularly antidepressants, in the psychiatric emergency setting. We evaluated the nature and prevalence of medication prescriptions for patients discharged from an urban psychiatric emergency service and the extent to which pharmacotherapy initiation was predictive of follow-through with aftercare.

Method: Records were reviewed for 675 consecutive individuals evaluated and discharged from a community-based psychiatric emergency service over a 3-month period (January 2003-March 2003). Information was obtained regarding diagnoses, past and current treatments, and demographic and clinical features, as well as outcomes for the subgroup of patients who received aftercare appointments within the institutional system.

Results: Fifty-five percent of psychiatric emergency service visits resulted in discharge, with psychotropic drug prescriptions given to about 30% of this group. Prescriptions most often included antidepressants (64%), benzodiazepines (25%), nonbenzodiazepine sedatives (20%), antipsychotics (18%), and mood stabilizers (10%). After controlling for potential confounders, the decision to prescribe was significantly associated with a clinical diagnosis of major depressive disorder or bipolar disorder and the preexisting use of psychotropic medications. Nonprescribing occurred most often in discharged patients who had suicidal ideation, substance abuse or dependence, and an existing outpatient psychiatrist. Follow-up emergency service and new outpatient appointments were more often given to patients discharged with a prescription, but follow-through with aftercare was not more likely in this group.

Conclusions: Psychiatrists in an emergency service prescribe antidepressants or other major psychotropics for about one third of discharged patients, rarely in the presence of suicidality or substance abuse or dependence, and with little evidence that initiating such medications in the emergency setting promotes more successful bridging to outpatient treatment.

(J Clin Psychiatry 2006;67:720-726)

Received Sept. 5, 2005; accepted Oct. 19, 2005. From the Department of Psychiatry, Massachusetts General Hospital, Boston (Dr. Ernst), Harvard Medical School, Boston (Drs. Ernst and Bird), and the Department of Psychiatry, Cambridge Health Alliance, Cambridge (Dr. Bird), Mass.; the Silver Hill Hospital, Affective Disorders Program, New Canaan, Conn. (Dr. Goldberg); the Department of Psychiatry Research, The Zucker Hillside Hospital, North Shore-Long Island Jewish Health System, Glen Oaks, N.Y. (Dr. Goldberg); and the Bipolar Disorder Research Program, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, and the Rollins School of Public Health, Emory University (Dr. Ghaemi), Atlanta, Ga.

Presented at the 157th annual meeting of the American Psychiatric Association, May 1-6, 2004, New York, N.Y.

Dr. Goldberg is a consultant to Eli Lilly and GlaxoSmithKline, and has received honoraria from and serves on the speakers or advisory boards for Abbott, AstraZeneca, Bristol-Myers Squibb, Eli Lilly, and GlaxoSmithKline. Dr. Ghaemi has received grant/research support from Janssen, AstraZeneca, Novartis, Abbott, and Elan; has received honoraria from Janssen, Abbott, GlaxoSmithKline, Forest, Eli Lilly, and AstraZeneca; and serves on the advisory boards for Janssen, GlaxoSmithKline, and AstraZeneca. Drs. Ernst and Bird report no financial affiliations or other relationships relevant to the subject of this article.

Corresponding author and reprints: Joseph F. Goldberg, M.D., Silver Hill Hospital, 208 Valley Rd., New Canaan, CT 06840 (e-mail: JFGoldberg@yahoo.com).