For improved outcomes, connect first-episode schizophrenia patients to comprehensive care quickly

Rapid follow-up is key to preventing subsequent ED visits in patients with mental health concerns

Mental health experts believe that as with many acute medical conditions such as stroke and heart attack, early diagnosis and treatment can make a critical difference for patients with schizophrenia, potentially limiting the severity and progression of the disease. This is important to ED administrators and clinicians because the first opportunity to intervene in many of these cases often occurs in an emergency setting, although getting to a correct diagnosis may be difficult.

"A lot of these patients are extraordinarily anxious and they may be acting kind of odd," explains Cheryl McCullumsmith, MD, PhD, division director, Hospital Psychiatry, at the University of Alabama at Birmingham Medical Center (UABMC). "We also see patients who have more of what appear to be depressive symptoms. They may not be getting out of bed or going to school, and their parents are becoming increasingly concerned."

These types of symptoms can be due to substance abuse, intoxication, or other medical conditions, all of which need to be ruled out if this is a patient's first medical encounter, adds McCullumsmith. "It is very important to distinguish between psychosis and schizophrenia. Psychosis is a symptom like fever. Everyone with a fever doesn't have pneumonia, and everyone with psychosis doesn't have schizophrenia," she explains. "We have seen youngsters taking diet pills or taking steroids for weight-lifting. They come in and they are psychotic, but that doesn't mean they are schizophrenic."

Consider patient and family needs

However, for new cases of suspected schizophrenia, which is often first observed in teenagers, UABMC now has an added resource available to the ED. The First Episode Schizophrenia Clinic, which opened in May of this year, is set up to initiate aggressive, comprehensive treatment shortly after diagnosis. The goal is to lessen the complications associated with schizophrenia for both patients and family, explains Adrienne Lahti, MD, the clinic's director.

"There is data showing that the quicker you can make an intervention with medication, the better the outcome," says Lahti. However, she stresses that effective treatment also depends on how well the family understands the illness.

When there is a first episode of schizophrenia, the patient is not the only one in crisis, the family is in crisis as well, adds Lahti. "You can imagine having a 17-year-old boy who was doing pretty well, and you thought he was going to go to college, and then his grades are falling and he is staying in his room," she explains. "So it is critical to work with the family and let them know there are things they need to do, and the first thing is to be an advocate for their son."

For example, family members are critical to making sure that a patient takes his medication and shows up for medical appointments. "We encourage patients to stay in school and to stay functional," says Lahti. "There are studies showing that the more you can keep people functional the better the outcomes."

The First Episode Schizophrenia Clinic will see patients who have been referred from the ED as outpatients, and it will also work with hospital physicians to transition admitted patients to the clinic once they have been discharged.

Educate staff

The First Episode Schizophrenia Clinic at UABMC is the only such clinic in Alabama, and it is one of only a handful of similar care settings in the country. However, even without this resource, there are steps that EDs can take to improve the care they provide to patients who present with the signs or symptoms of schizophrenia.

Staff education is very important, explains McCullumsmith, noting that she conducts several grand rounds every year with emergency medicine staff. "Also, because we have psychiatry present here, we do a lot of one-on-one [with clinicians] when we are seeing patients. We talk to them about [psychiatric] cases," she says. "If you don't have psychiatry available in your ED, that is more difficult to do."

McCullumsmith advises clinicians to utilize a psychiatric rating scale, such as the Brief Psychiatric Rating Scale (BPRS), for example, when they have a patient who they suspect may be schizophrenic. "It gets into some symptoms of psychosis. It may not pick up on everything for a first episode, so it is not ideal," she says, noting that the instrument is primarily used by mental health care providers. "However, it will provide information about how to ask the questions, and this can be difficult."

When referring a patient with psychiatric issues to an outside provider, make sure that you provide a comprehensive assessment of what is going on with the patient, stresses McCullumsmith. "If you just give patients a referral and tell them to go to the local community mental health center, they are not going to go there and say that they are psychotic," she says. "They may not even know why they have been referred."

Instead, the outside provider should receive a copy of your notes so that he or she knows what workups you have done and what your concerns about the patient are, explains McCullumsmith. Otherwise, it is difficult for the provider to begin treatment.

Arrange for rapid follow-up

Patients who present to the ED with psychiatric problems need to have follow-up appointments soon after their visit or they are likely to be back in the ED in short order, explains McCullumsmith. "We had trouble getting rapid follow-up, not just for first-break [schizophrenia] patients, but for all patients with mental illness, so we established our own transitional clinic," she says. "We find that if we can actually see people within three days of their ED visit, they don't come back to the ED nearly as often. It takes twice as long for them to come back for a psychiatric reason."

Typically, patients are seen in the transitional clinic a few times before they are transitioned to their eventual mental health care provider. "We are working on showing that it is actually more cost-effective than ED visits," says McCullumsmith.

Not every ED is going to be able to establish a transitional clinic for patients with mental health problems, but McCullumsmith says administrators and clinicians can work toward establishing a means to rapid follow-up by building relationships with outside mental health providers. She is also a strong proponent of having social workers on staff who can work closely with patients who have mental health needs.

"We have a social worker who we have given the task of being our intensive case manager. She works with patients who are in distress and coming in frequently, and can't seem to make that next step of establishing regular care," explains McCullumsmith. "She digs in and finds out more about their history, makes follow-up calls, reminds them about upcoming appointments, and contacts family members to help get them to the appointments."

In some cases, the hospital will provide taxi fares or bus tokens to patients who have no other way to get to their appointments, and staff will also help to get patients established on medication for free. "We do a lot of things from the ED to really help get patients started in a program and to help keep them going," adds McCullumsmith.

Sources

  • Cheryl McCullumsmith, MD, PhD, Division Director, Hospital Psychiatry, University of Alabama at Birmingham Medical Center. E-mail: cmccs@uab.edu.
  • Adrienne Lahti, MD, Director, First Episode Schizophrenia Clinic, University of Alabama at Birmingham. E-mail: alahti@uab.edu.