Journal Article Annotations
2020, 2nd Quarter

Emergency Psychiatry

Annotations by Scott Simpson, MD, MPH

Cannabinoid Hyperemesis Syndrome in Two French Emergency Departments: A Prospective Cohort.
University Students Presenting for Psychiatric Emergency Services: Socio-demographic and Clinical Factors Related to Service Utilization and Suicide Risk.

PUBLICATION #1 — Emergency Psychiatry

Cannabinoid Hyperemesis Syndrome in Two French Emergency Departments: A Prospective Cohort.

Julie Weiss, Romain Torrents, Baptiste Verhamme, Antoine Roch, Pierre Lazerges, Maeva Jego, Pierre Michelet, Nicolas Simon

Abstract: Fundam Clin Pharmacol 2020 Jun 21.doi: 10.1111/fcp.12580. Online ahead of print.

Chronic cannabis use can be associated with uncontrollable vomiting and abdominal pain. Diagnostic criteria for cannabinoid hyperemesis syndrome (CHS) were defined in 2012 by Simonetto et al. The objectives of this study were to describe the prevalence of CHS, the patients’ epidemiological characteristics and to show the difficulties encountered in caring for these patients in emergency departments, the extent of health care and an unsuitable follow-up in general practices. A prospective cohort of patients with CHS was recruited among a target population of patients leaving the adult emergency services of the Marseille hospitals Nord and La Timone between October 2017 and July 2018, with abdominal pain syndrome of unidentified etiology. Inclusion criteria for the CHS cohort were chronic cannabis use associated with nausea and vomiting. There were 48 patients included in the CHS cohort who took cannabis daily, in a target population of 2848 patients (i.e. 1.6%). A hot shower was the most effective symptomatic treatment in 54.2% of cases. Patients suffering from CHS spent significantly more hours in emergency departments (11 versus 6.5), and, on average, visits were more frequent (4.9 versus 3). 20.3% of them were hospitalised to continue pain medication. Once out of hospital, follow-up was limited, and weaning off cannabis, the only etiological treatment, was difficult to set up. Informing patients about CHS is essential and a hot shower could be systematically proposed, thus limiting an unnecessary extent of health care. CHS is genuine, medical staff should be made aware of it in occupational training, and it should be seriously considered in health policies.

PMID: 32564375

Annotation

The finding
The investigators prospectively identified emergency department (ED) patients with gastrointestinal (GI) symptoms of unknown etiology and screened them for cannabinoid hyperemesis syndrome (CHS) based on previously published diagnostic criteria. CHS comprised 1.6% of all unknown GI somatic complaints. CHS had longer median lengths of ED stay compared to other GI patients (12h v 6h, p=.04), more often left the ED against medical advice (8% v 4%, p=.03), and often required medication treatment in the ED—10% received opioids.

Strengths and weaknesses
Despite cannabis being illegal in the area of the study, the investigators identified a large cohort of patients with CHS and, for the first time, describe the adverse impacts of CHS on the course of emergency care. Applications of the CHS diagnosis was rigorous. The authors reported seeking to ascertain more data from patients after discharge, but these results are not reported; most likely, they could not retain a sufficient number of patients in the study. There was a large percentage of patients who did not complete the study questionnaire, and the study certainly underestimates the prevalence of CHS in the ED population.

Relevance
This study is the first to report a large cohort of CHS patients in the emergency setting. The condition is associated with significant rates of adverse events, including leaving against medical advice and longer ED stays. This report also reminds of of the high prevalence of medically unexplained symptoms in the ED. While 1.6% of unexplained GI symptoms in the ED were found to likely be CHS, the other 98-odd percent remained…unexplained.

Type of study
(http://ebm.bmj.com/content/early/2016/06/23/ebmed-2016-110401) prospective cohort study

PUBLICATION #2 — Emergency Psychiatry

University Students Presenting for Psychiatric Emergency Services: Socio-demographic and Clinical Factors Related to Service Utilization and Suicide Risk.

Victor Hong, Danielle R Busby, Stefaney O’Chel, Cheryl A King

Abstract: J Am Coll Health . 2020 Jun 12;1-10. doi: 10.1080/07448481.2020.1764004. Online ahead of print.

Objective
Given increases in mental health utilization among college and university students, this study examines clinical and socio-demographic characteristics in students presenting to psychiatric emergency services.

Participants
University students (N = 725; Mage = 22 years, SD = 4.0; 67% White) visiting psychiatric emergency services at a large academic health system between July 1, 2012 and June 30, 2016.

Methods
A retrospective review of students’ electronic medical records, which included responses to the Columbia-Suicide Severity Rating Scale, was conducted.

Results
Levels of suicide risk varied by students’ self-identified race. Nonwhite students were more likely to endorse a suicide attempt in the past week and less likely to be taking psychiatric medications than White students. International students were more likely to report a lifetime history of multiple attempts.

Conclusions
Disparities related to college student psychiatric emergencies warrant specific attention to specific racial/ethnic groups and international students to reduce and manage mental health crises.

Keywords
College mental health; emergency department; international students; mental health disparities; suicide.

Annotation

The finding
The investigators describe a series of 724 university students who presented to the psychiatric emergency service (PES) in a college town over 4 years. There were an increasing number of visits over time. Black students were two times more likely to present than students of other backgrounds relative to the composition of the college’s study body. Female students were more likely to endorse depression, while male students more often reported bipolar disorder. Male students more often presented via police. International students were more likely to report a lifetime history of suicide attempts. A high proportion of students were hospitalized (35%), about half of those involuntarily.

Strength and weaknesses
The chart abstraction methods were rigorous and well-described—multiple reviews coded each chart, and inter-rater reliability was strong. The inclusion of all presentations limits bias in interpreting results. The most significant limitations are that this study included only one PES in a single town and that authors did not review patients with lower acuity presentations seen outside the PES in the medical emergency department. Thus, these students likely represent the most serious mental health presentations that were too acute for outpatient walk-in clinics or general ED care.

Relevance
University students represent a growing number of emergency psychiatric visits, and there are unique risk factors for psychiatric crisis and access to care and social support among this population. Significant variations in presentations existed between male and female student, and international students may pose unique concerns. Emergency psychiatrists should be cognizant of care options for these students in their communities and pro-actively engage student mental health services.

Type of study
(http://ebm.bmj.com/content/early/2016/06/23/ebmed-2016-110401) case series