Journal Article Annotations
2016, 3rd Quarter
Annotations by Scott A. Simpson MD MPH
Also of interest:
Patients with borderline personality disorder (BPD) often present in crisis to emergency departments (ED), where the environment is ill-suited to addressing those patients’ needs: staff are transient, shift work necessitates frequent hand offs, and training for managing BPD is lacking. This review describes a practical approach to the treatment of BPD in emergency settings. The author proposes core principles (psychoeducation for the patient, a focus on interpersonal stressors, and an “active, authentic” approach) as a foundation for common clinical challenges, including self-harm, prescribing for BPD, and the involvement of family. Staff attitudes and countertransference may result in iatrogenic harm of the patient, for example, unnecessary inpatient hospitalizations, inadequate safety assessments, and hostile staff behaviour. The review finishes with a well-written case vignette that considers the merits and pitfalls of multiple clinical choices throughout the evaluation – an entertaining format that is also thought-provoking.
The finding: More than 1% of women will present to an emergency department (ED) for a mental health complaint in the postpartum period. The investigators studied all women (n=8728) in a Canadian province who had an emergency psychiatric visit in the year after giving birth. The ED was the first episode of postpartum psychiatric care for 60% of women; compared to women who had an outpatient visit as their first mental health visit, first presenters were less likely to have a prior psychiatric diagnosis (51% versus 74% of patients) or outpatient psychiatric care prior to delivery (11% versus 29%). Reasons for presentation were roughly similar in both groups, but inpatient psychiatric hospitalization was not common (14% versus 20%). The median time to first visit was 5 months, and only about 25% of ED visits occur prior to 2 months postpartum. The authors found that patients receiving their first episode of care in the ED were more likely to be economically marginalized and postulate that barriers to accessing outpatient care precipitate unnecessary ED visits.
Strength and weaknesses: The authors provide a rich description of an understudied patient population. The authors estimate they capture over 98% of births. The authors are most interested in the effect of economic marginalization on patients’ utilization; however, it is unclear which barriers complicate access to care for patients in a system where outpatient mental health is freely available. The authors posit that these barriers include access to psychological treatments and “limited acceptability of drug treatments for depression and anxiety.” However, the study’s methodology cannot prove this, and it remains unclear why most women in the study used the ED for care.
Relevance: Most postpartum women in need of mental health care will first seek treatment through an emergency department. Emergency psychiatrists must be familiar with psychiatric management in the postpartum period.