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AAEP Position Statements

The following are established Position Statements put forth by the American Association for Emergency Psychiatry.

AAEP Response to Police Engagement of Homeless/Displaced People in New York

RELEASE DATE: December 20, 2022

The tools of emergency psychiatry are powerful and mission and scope are reaching.  We are, nonetheless, unable to fix a profoundly broken social safety net system and neither emergency nor inpatient hospital beds can replace desperately needed coordinated systems of care in our community. The American Association for Emergency Psychiatry stands for compassionate and evidenced-based care for people with behavioral emergencies. This policy is neither.  

Human rights matter deeply in emergency psychiatry and involuntarily committing people in this manner that does not meet healthcare criteria is a disservice to those we care for, and a misuse of vital resources used to help so many others with psychiatric emergencies.   

We care for our patients deeply and respecting their legal rights is paramount.  

American Association of Emergency Psychiatry Statement on Armed Responses within Emergency Departments

RELEASE DATE: April 22, 2021

Last week, a patient died in the context of an armed response by security and law enforcement within a medical emergency department (Mt. Carmel St. Ann’s Hospital, Columbus, Ohio).

The emergency department is a critical intersection of health care and law enforcement.  Security is essential for patients and staff.  No staff should worry about a shooting in their workplace; no patient should worry about being shot by police.   

Hospital and public safety administrators, as well as law enforcement and emergency medical teams, need to collaborate to ensure safety.   The Emergency Department is the area of the hospital most likely to be faced with situations involving firearms, and it is incumbent upon health systems and the professionals it employs to prepare, plan, and process for such unfortunate occasions. The decision to have armed security within an Emergency Department is not one without controversy and complications for either direction.  It is paramount for the hospital involved to prepare staff with significant investment to hiring appropriate staff, training them in all best practices (including non-armed interventions), and preparing policies and procedures.

The use of law enforcement should not preclude the initial intervention of medical professionals looking to clinically address agitation (as an emergency medical condition) and related target symptoms.  By tending to these tenets, there is a greater likelihood of not only being prepared for such events but also minimizing overall risk. 
 

Respectfully,

Tony Thrasher, D.O., DFAPA (AAEP President)
Jack Rozel, M.D., MSL (AAEP Past President)
Junji Takeshita, M.D. (AAEP President Elect)

 AAEP: Racism and Violence Cannot Be Tolerated

(June 2020)

Every day in our work in emergency psychiatry and medicine, we see people impacted by – and, sometimes with their crises entirely defined by – social determinants of health. That phrase – social determinants of health – encompasses many things, but inarguably it includes structural and systematic bias and racism. What has played out over recent days honoring the memories and grieving the loss of George Floyd, Breonna Taylor, Ahmaud Arbery, and so many more – and decrying the way they were killed – has challenged us to put in words how we are feeling. 

The research on structural bias and racism in healthcare is extensive. The impact is measurable, sustainable, and concerning. And as much as it pains us to say this, we know that the field of psychiatry and the mental health system itself play roles in this as well, both historically and at present. Dr. Martin Luther King observed, “Of all the forms of inequality, injustice in healthcare is the most shocking and inhuman.” 

But we take heart in being a part of AAEP because we know that our mission uniquely positions us to help people, including those most impacted by racial and social injustice. Our mission calls us to provide compassionate and evidence-based care; those values fully align with helping our patients, our teams, our communities, and our systems fight racism and its impact on health. We can condemn unjust and needless killings. We can champion the just and equitable care of those entrusted to us. 

We can look continuously at ourselves and strive to improve. We can speak loudly and without qualm that racism is wrong.  

Sincerely,

Jack Rozel, President
Tony Thrasher, President-Elect
Les Zun, Immediate Past President

Joint Statement: Care of Patients with Behavioral Health Emergencies and Suspected or Confirmed COVID-19

(April 2020) | Download as PDF
 
Joint statement by the American Association for Emergency Psychiatry, American College of Emergency Physicians, American Psychiatric Association, Coalition on Psychiatric Emergencies, Crisis Residential Association, and the Emergency Nurses Association. 
 
As with environmental disasters and other crisis events, pandemics may exceed people’s usual coping skills and capacity which, in turn, may lead to problems with anxiety, depression, increased use of substances, as well as exacerbation of underlying psychiatric disorders. Factors including, but not limited to, social and physical isolation, uncertainty, fear, evolving facts, changes in how individuals access outpatient care and public health recommendations contribute to this stress. This impacts people with and without pre-existing psychiatric illnesses and can contribute to a number of challenges for our already taxed emergency and crisis healthcare system. The most severely ill people with psychiatric illness have high rates of baseline medical comorbidity, reduced access to primary care medical resources, and may lack resources to participate in telehealth services. As a result, this group may have an elevated vulnerability to COVID and have limitations in accessing services other than emergency and crisis settings(1). For care of the behavioral health patient with suspected or confirmed COVID-19: 

  1. Encourage preparedness by supporting education and training on the treatment of psychiatric disorders and best-practices for the care of the behavioral health patient.

  2. Staff must have access to appropriate, adequate personal protective equipment (PPE).

  3. Encourage the use of existing, available behavioral health crisis services to mitigate unnecessary visits to the emergency department for psychiatric emergencies or for diverting people from psychiatric hospitals whenever possible.

  4. Support medical screening via telehealth/telephonic and clinical pre-admission screenings and assessments by qualified, licensed professionals. Additionally, we advocate for expanded use of telehealth, including prescribing of controlled substances for opioid use disorder via telemedicine, for patient and provider safety in line with infectious disease recommendations (i.e. social distancing). Encourage novel use of telehealth in high-risk environments for diversion and mitigation of unnecessary ED visits.

  5. Recognize that patients who present with psychiatric complaints may also have co-occurring medical disorders that should have a proper medical evaluation. Use pre-existing, evidence-based recommendations and screening algorithms in order to perform appropriate and directed medical evaluations. Encourage providers to identify alternate methods and modalities to make those assessments in the current COVID environment.

  6. Understand that people will present in acute psychiatric crisis who are at risk of, have symptoms consistent with or have tested positive for COVID-19, who will not meet medical admission criteria but will meet criteria for further psychiatric care. Mental health and substance use care, based on the needs of the individual, must remain available.

  7. Discourage the use of restraints while keeping people in the least restrictive setting possible that corresponds to their condition or presenting symptoms.

  8. Ensure that medical personnel is evaluating for signs of domestic violence in children, partners and spouses, the elderly, those with intellectual and developmental disabilities, and other vulnerable populations, as the implementation of social distancing and home-based self-quarantine could increase those risks.

  9. Encourage staff to formulate aftercare services that are based on existing resources and partnerships in the community.

  10. Provide individuals at risk of suicide with local and national resources of people to talk to if they are feeling suicidal (local crisis call center number, National Suicide Prevention Lifeline, Trans LifeLine, The Trevor Project, and Crisis Text Line).

  11. Encourage the creation and use of Psychiatric Advanced Directives by patients, wherever local jurisdictions permit, that will help provide treatment guidance for providers by patients before their symptoms worsen to the point of impairment in psychiatric medical decision making.

  12. Encourage and promote self-care amongst those providing care to our patients and their families. Acknowledge that healthcare workers will be committed to assisting all shortages/vacancies during these times of crisis and that it is just as important to maintain one’s individual health and wellness for the overall stability of the patients and the care delivery system. In addition to using one’s own internal coping skills and resources, staff should be made aware of all other local, state, and regional options for care.

  13. Ensure that there is adequate funding, governmental, non-governmental and private, to support all activities noted above and ensure that all insurance agencies, public and private, provide appropriate and reasonable reimbursement for the care and treatment of patients with behavioral emergencies.

 1 Osborn, David P J. 2001. “The Poor Physical Health of People with Mental Illness.” Western Journal of Medicine 175 (5): 329–32.

AAEP Position Statement: Evaluation of Persons of Concern in Relation to Violence, Mass Shootings and Mental Illness

(April 2018)

In the wake of any highly publicized mass shootings attention seems inevitably drawn to the issue of mental illness.  Public narratives on this issue are often incorrect, misleading and stigmatizing. Evidence clearly indicates that at least 90% of violence is not driven by mental illness and that the vast majority of people living with mental illness are not violent.  Mass shootings are a rare subtype of violence; studies of mass shootings use inconsistent and at times nonspecific definitions of mental illness as well as of what constitutes a mass shooting itself.  Likely, as few as 15-25% of perpetrators of such attacks have a prior psychiatric diagnosis, which itself says nothing as to a causal relationship.

Inarguably, there is an intersection between violence and mental illness: there is a small subset of people with mental illness who, often at the peak intensity of their illness and in the presence of numerous other risk factors, are violent. There is also evidence that some people who plan or engage in mass shootings are driven towards such acts at least in part by their psychiatric illness. Psychiatric emergency services routinely evaluate people with or without psychiatric illnesses who are at potential risk of violence.  In the wake of any highly publicized threat or attack of this nature, threats and referrals for evaluations of threats go up often impacting referrals to psychiatric and emergency services.

The American Association for Emergency Psychiatry exists to champion the advancement of evidence based, compassionate care for behavioral emergencies through research, education and interdisciplinary collaboration. As such, it is our position, based upon available evidence and best practices that:

  • All threats of violence must be taken seriously and receive a psychiatric evaluation within the capacity of the facility

  • Optimal use of emergency and general psychiatric services will not eliminate community violence or mass shootings because of the limited role psychiatric illness plays in such events; however, when such cases do arise and are clinically identified, every reasonable clinical intervention should be considered

  • Recognizing that violence is often multifactorial, consultation and collaboration amongst professionals (including healthcare and law enforcement) should be used to support
    multidisciplinary assessment and intervention including accessible psychiatric treatment

  • Emergency Department and PES decision making should reflect clinically appropriate, ethical and legal practices

  • Care of violent and threatening patients is challenging and PES and ED programs should provide staff wellness resources to support optimal team performance

  • The science of violence and firearm injury prevention is an actively developing science.  Clinicians should consider violence an essential element of continuing education and the AAEP will prioritize relevant education and training for the membership

  • Understanding concerns about media-related contagion, communications by healthcare providers or hospital spokespersons relating to such events should adhere when possible to best practices (www.reportingonmassshootings.org) including avoiding glamorizing the assailant or attack, using behavioral health experts to explain the science, and explaining that violence and mass shootings are complex with multiple causes.

AAEP Position Statement: Suicide Screening

(September 2017)

The American Association for Emergency Psychiatry promotes timely, compassionate, and effective mental health services for persons with mental illnesses, regardless of their ability to pay, in all crisis and emergency care settings. Based on our mission, AAEP supports universal suicide screening of patients in the emergency setting and appropriate funding for screening and indicated services.