Over half the people (young and middle aged adults) who appeared for care at the psychiatric

unit of a municipal hospital from one Health District in New York presented crisis situations requiring immediate response. The authors conclude that a clinical psychiatric service in a metropolitan area must be prepared to deal with a large number of emergencies.

THE EPIDEMIOLOGY OF PSYCHIATRIC EMERGENCIES IN AN URBAN HEALTH DISTRICT

Mayer Fisch, M.D.; Ernest M. Gruenberg, M.D., Dr.P.H., F.A.P.H.A.; and Cynthia Bandfield, M.S.

THlls paper reports an exercise in community diagnosis. Epidemiological data are frequently demanded by those engaged in planning community health services, and they are entitled to the best available information regarding the incidence and prevalence of conditions requiring service. In the mental health specialties, such planning has depended very heavily on mental hospital admission rates; to these data have recently been added information about clinic utilization patterns. When these data are combined with prevalence surveys, such as that recently reported by Srole and Langner2 in the midtown area of New York, a rather confusing picture emerges. Admission rates which are, in all conscience, high enough, are contrasted with enormously higher prevalence rates of significant psychiatric disorder. A cooperative venture by the School of Public Health and the Department of Psychiatry at Columbia University has led to a number of studies which seek to provide more information of practical value to those who are organizing services in our immediate health district. Each year some 700 residents of this district are admitted to all state, private and voluntary psychiatric hospitals
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within New York State. Of these, approximately 300 are admitted directly to these institutions, while the other 400 go via the psychiatric unit of the municipal general hospital which serves the district, as well as a much larger part of the city. This hospital is not located within the district. However, an additional 500 patients per year from the district pass through the municipal general hospital psychiatric unit without being referred to State Hospitals. This group of patients does not appear in statistics available from any administrative source at this time. Even when we have hospital statistics, they tend to give us information only about age, sex, color, and diagnosis. But as in other fields of medicine, diagnosis leaves the thoughtful student of community health problems uncertain as to the level of severity and the nature of the service problems that the particular patients present. Thus, from one point of view, knowing the number of diabetics in a population is the most important measure of the prevalence of diabetes. However, for community diagnosis, and to provide information for community health services, the number of cases of diabetic coma is at least as important. We wondered whether it was possible
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to get some idea of the number and nature of emergency situations which were being presented by psychiatric patients. There are many presenting syndromes representing acute states of abnormal mental functioning, as illustrated in psychiatric textbooks and in the American Public Health Association's "Guide to Control Methods of Mental Disorders."1 It is believed that each of these syndromes is capable of being manifested by patients in different diagnostic groups. Likewise, most of the diagnoses in psychiatry may be manifested by almost any one of the acute emergency

syndromes. We decided to explore the frequency of the different acute syndromes presenting emergency situations and the relationship of these emergency situations to diagnosis. We assumed that a very large proportion of these emergencies would appear at the municipal hospital psychiatric unit. As noted, most psychiatric hospitalizations from the district occur at this point, and it is the only facility to which there are channels of virtually automatic referral and admission in case of need. The health district is on the periphery of Manhattan Island and is almost purely residential in character. It consists virtually exclusively of apartment houses and the commercial establishments which serve the local population. In 1960, this population comprised 269,000 persons. It contains representative segments of most of the ethnic groups that constitute New York City, and its economic range is from lower class to upper middle, with only few representatives of either extreme of the social scale. The population is about one-quarter Negro, a proportion which is gradually increasing.

Age, Sex, Race Groupings Table 1 presents the over-all admissions statistics from our health district
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to the municipal hospital psychiatric unit, for the year ending June 30, 1962. (There were 923 patients from the district who went to this hospital; as noted earlier, about 300 other patients went directly to other more remote psychiatric facilities.) This table is divided into age, sex, and race groupings, with the admission rate per 1,000 inhabitants of the district in each corresponding bracket. Population figures are derived from the 1960 census. This table shows a rise in rates with age through age 30, succeeded by a marked decline in the 40's and 50's, with a rise in rates again after age 65. Analysis by five-year age groups revealed a pattern no different from that shown here by the ten-year groupings. It will be noted that there is no outstanding sex difference in admission rates, but that the rates of nonwhites or Negroes of both sexes are quite consistently more than twice those of whites. This differential is found in nearly all mental hospital admission rates. A similar contrast has been shown between the economically privileged and deprived segments of white populations. The total minimal incidence of psychiatric hospitalization per year, 3.4 per 1,000, is notably high. By contrast, admission rates to New York State psychiatric hospitals for the last available year are as follows: For New York State as a whole, 1.6 per 1,000; for New York City, 1.8; for Manhattan, 2.8; and for this health district, 1.7. This admission rate of 3.4 per 1.000 to the psychiatric unit of the municipal hospital appears to depict a different situation from that experienced by the more remote State Hospital. The subgroup of greatest risk consists of males in the 2534-year-old age bracket where the rate is 6.9 per 1,000, 5.4 for whites, and 12.2 for Negroes. In order to qualitatively describe this flow of admissions and to focus on psyS73

Table 1-Admissions to Psychiatric Unit Rates per 1,000 Population by Sex, Race, and Age
Age in Years
Total

Male 0.4 5.0 6.9 5.4 3.4 2.6 2.4 5.9

3.6

Female
0.2 4.6 5.8 4.7 2.9 1.9 3.8 5.1
3.3

Total
0.2 2.9 4.3 3.2 2.1 1.9 3.2 4.4
2.4

White M
0.2 3.2 5.1 3.1 2.2 2.4 2.2 5.2 2.5

F
0.3 2.7 3.5 3.3 2.0

Total
0.7 11.0 11.6 8.5 6.1 3.3 3.0 12.9

Nonwhite M
1.2 11.5 12.2 10.2 6.6 3.1 3.0 10.9

F 0.2 10.5 11.1 7.3 5.6 3.5 3.0 14.1 6.2

Less than 15 15-24 25-34 3544 45-54 55-64 65-74 75 and over

0.3 4.8 6.3 5.0 3.1 2.2 3.2 5.4

3.4

1.5 3.9 3.9

2.3

Total

6.6

6.9

Age in Years
Less than 15 15-24 25-34 35-44 45-54 55-64 65-74 75 and over

Number of Admissions by Sex, Race, and Age White F M Total Male Female Total
16 146 223 185 133 88 78 54
923
10 71 114 87 63 48 26 23 442 6 75 109 98 70
40 52 31 8 69 108 80 65 61 67 39 3 36 62 34 30 36 21 18

Total
8 77 115

Nonwhite M
7

F 1 42 63 52 35 15 6 10
224

5 33 46 46 35 25 46 21
257

35
52

105
68 27 11 15

53 33 12 5
5

Total

481

497

240

426

202

chiatric emergencies arising in the community, we chose to concentrate on patients in the 15-44-year-old age group. Patients in this age bracket constituted over half of the total admissions (554 out of 923), and their admissions are most apt to arise in a crisis situation. All patients in this age group who were admitted from the health district were therefore given a direct psychiatric examination as soon after admission as possible, usually within one or two days, either by one of the authors or by one of two other psychiatrists who are members of this research team. This examination was completely apart from the usual procedures of the hospital. It was not done to arrive at a specific diagnosis or treatment recommendation, but
574

to describe the general nature of the problem and the principal reason for admission to the hospital. However, two groups of patients within this age group were systematically not examined:
1. Those patients returning from convalescent care, but who were still on the rolls of a State Hospital. Such patients may pass through this municipal psychiatric unit if return to full inpatient status is required; however, they are already in a treatment channel and will usually he returned within a day or two to the State Hospital from which they had been released. 2. Prisoners or patients under court remand. These patients are generally sent in for psychiatric "clearance," as it were, pending some legal action. They were not examined because of their uniquie administrative status.

Admissions in these two categories

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have been included in our count and rates of total admissions, but were not examined by a member of our group and are not included in the tabulations which follow. There were 394 admissions of patients between the ages of 15 and 44, who were not prisoners nor on the rolls of another hospital. These 394 admissions were accounted for by 175 males and 219 females; 185 whites and 208 Negroes. Nearly all of these patients were examined by us. In those few instances where examination was missed for one reason or another, the hospital chart yielded sufficient information for inclusion in this report. A review of the diagnosis of these cases, as made by the regular hospital staff after their normal series of examinations, revealed that there were only three clinical categories which accounted for a substantial number of admissions in this age group. These were, in order of frequency, schizophrenia, 177; conditions associated with alcohol, 107; and psychoneurotic depressive reaction, 64. All other diagnostic categories accounted for only 46 admissions. Concerning the diagnoses associated with alcohol, it is the policy of the hospital not to admit patients for simple alcoholic intoxication; some other complication or feared complication must be present to warrant admission. The majority of the cases in the grouping of "alcohol" received a final diagnosis of acute brain syndrome due to alcohol, while far fewer received the diagnosis of alcoholism. There were only eight diagnoses of simple alcoholic intoxication. Diagnoses associated with alcohol were. as expected, more frequent in males., but were also far from rare in females, the numbers being 69 and 38. respectively. Illness attributed to alcohol was more frequent in Negroes, but the sex ratio was about the same in both races. Psychoneurotic depressive reaction was diagnosed more than twice as often in females as in males, and more
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often in whites than in Negroes. Schizophrenia accounted for substantially more female than male admissions, but veterans hospitals may be treating many of the men who would otherwise come to this hospital with this condition. Table 2 shows these admissions divided by sex and race but tabulated by the principal reason for admission to the hospital. This table and the one following are presented only in terms of absolute numbers. However, an approximation of population rates of any particular category in these tables can be derived by cross reference with Table 1. Many cases presented several of the phenomena listed in this table. In such instances, we selected the single most outstanding reason, or the sine qua non, for the person being in the hospital at this time. We have been speaking of emergencies, but efforts to adequately define this concept, so that each admission could be reliably and independently judged as to whether or not it represented an emergency, led to increasing ambiguity. We have therefore chosen to divide the reasons for hospitalization into two categories-those which inherently represent an emergency situation, and those which do not. A review of the type of situations included in the former category will probably best define the nature of the emergencies of which we are speaking. It will be noted that these constitute well over half the admissions. However, a great many of the cases in the lower part of the table also constituted emergencies, in that the need for hospitalization was equally pressing. This classification is obviously not intended as a new, competing scheme of psychiatric nosology. It does, however, add a vivid and relevant dimension for describing the frequency of phenomena which bring people to psychiatric attention. It is purely descriptive, and in some ways is reminiscent of the classifications used by psychiatrists of more than a century ago, before the
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Table 2-Principal Reason for Hospitalization by Sex and Race Patients 15-44 Years of Age*
Total

White M

Nonwhite T F M

Emergency Situations Suicide attempt, gesture, or major threat Assaultive or violent behavior Bizarre, obviously "crazy" behavior Unmanageable household behavior Acute confusion Delirium tremens

94 35 45 17 11 34 236

24 17 22 8 5 27 103

70 18 23 9 6 7
133

58 17 21 11 5 4
116

15 11 10 6 3 4
49

43 6 11 5 2 0
67

36 18 24 6 6 30
120

9 6 12 2 2 23
54

27 12 12 4 4 7 66

Total
Other Problems Delusional ideation Hallucinations Simple withdrawal Subjective emotional complaints Subjective somatic complaints Other and unknown
Total Total Admissions
*

31 25 9 38 15 40
158 394

11 11 4 16 7 23 72

20 14 5 22
8

17
86

18 7 2 16 7 20

6 4 2 7 5 14 38
87

12 3 0 9 2 6 32

13 18 7 22 8 20
88

5 7 2 9 2 9
34

8 11 5 13 6 11

70
186

54
120

175

219

99

208

88

Not including prisoners and patients of other hospitals returning from convalescent status.

clinical entities of our current nomenclature were recognized. Delirium tremens is of a somewhat different descriptive level than the other categories to which the reasons for admission have been reduced. It was retained in the grouping because of its relatively idiosyncratic constellation of symptoms, and its high incidence. The most outstanding finding portrayed in this table is the high frequency of suicidal behavior among women; suicidal attempts, gestures, or major threats accounted for approximately onethird of the admissions of women in this group. It is interesting to note that assaultive or violent behavior was about equally frequent in both sexes. However, review of the individual cases did reveal a sex difference in this category. Aggres576

sive behavior in men was usually more focused, consisting of an attack on someone; in women, overt violence was usually more diffuse, consisting of breaking furniture or throwing things about. Table 3 presents a cross tabulation of hospital diagnosis and reason for admission among these same cases. The notable finding depicted in this table is its diffuseness, with some cases in nearly each cell. This indicates the wide variety of causes which may lead to the hospitalization of patients in any of these diagnostic categories and, conversely, that most presenting problems may reflect a variety of clinical conditions. There are, however, certain clusterings within the cells. The largest number of cases admitted for suicidal behavior received the diagnosis of psychoneurotic depressive reaction. In most of these
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cases the diagnosis was made only because of the one act which led to hospitalization. Most denied any continuing suicidal intent or significant depression after they were at the hospital and were soon discharged. Many of the acts were probably attention getting devices or indirect forms of aggression. This table combines both sexes. When the data were analyzed separately for men and women, there was one sex difference that appeared to be significant. Suicidal behavior, while rarer in men, was more apt to be associated with major schizophrenic phenomena in men than in women. Any other sex differences in the relationship between diagnostic category and reason for hospitalization could be attributed to the higher frequency of disorders associated with alcohol in men. Assaultive or violent

behavior and hallucinations were both associated most often with alcohol in men, whereas in women they usually denoted schizophrenia. It is noteworthy that simple withdrawal, when severe enough to warrant hospitalization, is usually associated with schizophrenia. Subjective somatic complaints as a presenting problem may be associated with a variety of conditions, not infrequently schizophrenia. Of course, in all of the instances where a patient was hospitalized for subjective somatic complaints, a physician somewhere had already decided that these symptoms were due to psychiatric disorder, or the patient would not have appeared at this particular hospital. This psychiatric unit of the municipal general hospital can offer little active treatment. Because of the constant

Table 3-Principal Reason for Hospitalization by Diagnosis Patients 15-44 Years of Age*
Diagnosis
Total

Alcohol
13 10 5 3 4 28 63

Schizo- Neurotic phrenia Depression

22 21 35 11 2 4 95

Other 16 3 1 3 4 2 29

Emergency Situations Suicide attempt, gesture, or major threat Assaultive or violent behavior Bizarre, obviously "crazy" behavior Unmanageable household behavior Acute confusion Delirium tremens

94 35 45 17 11 34 236

43 1 4 0 1 0 49

Total
Other Problems Delusional ideation Hallucinations Simple withdrawal Subjective emotional complaints Subjective somatic complaints Other and unknown Total
Total Admissions
*

31 25 9 38 15 40
158 394

4 12 0 9 2 17
44 107

27 10 8 14 8 15 82
177

0 1 0
9 2 3

0
2 1 6 3

5
17

15
64

46

Not including prisoners and patients of other hospitals returning from convalescent status.

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577

Table 4-Disposition of Patients 15-44 Years of Age*-Per cent Discharged to the Community Without Further Hospitalization
By Diagnosis Alcohol Schizophrenia Neurotic depression Other All Admissions
By Principal Reason for Hospitalization Emergency Situations Suicide attempt, gesture, or major threat Assaultive or violent behavior Bizarre, obviously "crazy" behavior

Unmanageable household behavior Acute confusion Delirium tremens

Total Other Problems Delusional ideation Hallucinations Simple withdrawal Subjective emotional complaints Subjective somatic complaints Other and unknown
Total
* Not including prisoners and patients of other pitals returning from convalescent status.

hos-

stream of new admissions, it must make some disposition of most of its patients within less than two weeks. They are then either discharged back into the community, in nearly all cases then receiving no further treatment, or they are sent on to a State Hospital. Table 4 presents the percentage of these patients, arranged both by diagnostic group and by the nature of the reason for hospitalization, who were discharged back into the community. It will be noted that except for the schizophrenics, nearly all are soon discharged. Schizophrenia is not a homogeneous diagnostic category, and the term has come to be used with ever increasing
578

latitude. Many of the patients who received this diagnosis did not manifest the clinical characteristics attributed to schizophrenia by the European psychiatrists of the turn of the century who first described the syndrome. However, among the 30 per cent of the schizophrenics who were discharged into the community there were several who had experienced episodes of florid psychosis, but with rapid disappearance of symptoms, so that no protracted hospitalization was deemed necessary. Examination of the relationship between disposition and reason for hospitalization indicates that a higher proportion of the emergencies than of the other cases are soon discharged into the community. We do not know their subsequent fate. These emergency admissions, by and large, probably occur in people less profoundly ill than those presenting the other problems. They often represent acute, impulsive reactions against an environment which the individual at that point perceives as intolerable. These crises were in many instances probably preventable. We are left to speculate as to the effect of this crisis and hospitalization upon each patient. We suspect that hospitalization is not usually perceived by these patients as beneficial and rarely channels them into a therapeutic situation. A broader availability of community services, particularly facilities which might be equipped to handle these problems on an outpatient basis and to follow through on their treatment, might reduce the incidence of such crises.

Conclusions Over-all admission rates to mental hospitals from this urban health district are extremely high as compared to most published data about defined populations. We believe that this is attributable to several factors. First, the area is one of high density apartment residences;
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second, the usually published data do not include admissions to readily accessible acute psychiatric services without certification procedures; and third, the high level of acceptability or utilization of psychiatric hospitalization by the New York City population. The degree to which such services are occupied with the treatment of acute crises associated with alcohol in men and with the management of suicidal behavior in women is particularly striking. We have confirmed that the syndromes of acute psychiatric emergencies are widely distributed in different diagnostic groups and that the different diagnostic groups are represented in almost every acute emergency syndrome. Despite a high level of mental health education during the past few decades, over half of the patients in early and middle adult life who appear for inhospital psy-

chiatric care at a municipal facility still present severe syndromes of a crisis nature, which require immediate, and sometimes drastic, response by service agencies. Any clinical service to be offered to such a metropolitan district must be prepared to deal with a large volume of severe psychiatric emergencies.
ACKNOWLEDGMENTs-The authors would like to express their appreciation to the Bellevue Psychiatric Hospital, represented by: Arthur Zitrin, M.D., director; and with particular acknowledgment to Lawrence A. Cove, M.D., and Richard A. Markoff, M.D., who performed most of the examinations on which this report is based.

REFERENCES
1. Program Area Committee on Mental Health, APHA. Mental Disorders: A Guide to Control Methods. New York, N. Y.: The Association, 1962. 2. Srole. L.; Langner, T. S.; Michael, S. T.; Opler, M. K.; and Rennie, T. A. C. Mental Health in the Metropolis. New York, N. Y.: McGraw-Hill, 1962.

Dr. Fisch is research associate, Dr. Gruenberg is professor of psychiatry, and Mrs. Bandfield is biostatistician, Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, N. Y. This paper was presented before a Joint Session of the Epidemiology and Mental Health Sections of the American Public Health Association at the Ninetieth Annual Meeting in Miami Beach, Fla., October 16,1962. This investigation was supported by Public Health Service Research Grant 5-RII MH 478-3 and a grant from the Foundations' Fund for Research in Psychiatry.

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