NUBE 2025

Michael Gerardi, MD, FACEP, Incoming AAEP President. Priyanka Amin, MD and Jennifer Peltzer-Jones, PsyD, RN

It is important to recognize the difference between schizophrenia and bipolar disorders both in diagnostic evaluation and treatment.  There are occasionally organic causes of manic episodes and it is important to recognize these causes as soon as possible.  Bipolar disorders have intermittent symptoms and treated more like a seizure disorder and with seizure medications.  These patients can be very creative and very high functioning, and similarly have very high rates of suicide.

This presentation will look at the causes of manic episodes, the recommended evaluation, the clinical considerations, the current treatment options, the prognosis, the importance of continuity of care of these patients, and what to communicate to the family to expect.

Learning Objectives:

Consider the causes that might mimic manic episodes and their management.

Recognize that manic episodes are similar to seizures both in evaluation and treatment.

Understand the high suicide risk of patients with bipolar disorder.

Acetaminophen overdose is a potentially fatal clinical syndrome, warranting prompt and accurate assessment and clinical care. Acetaminophen toxicity can occur from acute ingestion, or chronic use over time. Though this talk focuses on acute hepatic consequences of overdose, inadvertent exposure over time often has a worse prognosis due to later recognition and treatment. The acute toxidrome has 4 stages, whereby stage 2 is what appears to be a resolving syndrome. However, if unrecognized, this may progress to severe hepatotoxicity and death. An Acetaminophen level 4 hours after the overdose that is greater than 150 mcg/mL warrants urgent initiation of the antidote N-Acetylcysteine and inpatient hospitalization.

Acetaminophen pharmacology is critical to treatment. Toxicity occurs when the body's innate metabolic pathways are saturated, causing build-up of a toxic metabolite which binds to hepatocytes, leading to liver injury and fatality. N-Acetylcysteine treatment enhances the clearance of the toxic metabolite, and should be promptly started. There are specific protocols for oral and for IV management. Astute and correct treatment has high success rates, though serious complications may result. In cases where Acute Liver Failure occurs, there is a high mortality rate, and 1/3 of patients will require a liver transplant. Fortunately, if N-Acetylcysteine is given within 8-10 hours after the overdose, serious hepatotoxicity is uncommon and death is extremely rare, regardless of the initial serum concentration.

Learning Objectives:

An appreciation of the emergent nature of Acetaminophen overdose.

Using the serum Acetaminophen level to decide when to treat.

Proper use of the antidote N-Acetylcysteine.

In 2018 , the FDA has granted psilocybin a “ breakthrough therapy designation “ status for treatment- resistant depression. One year later , another “ breakthrough therapy designation” was granted to Psilocybin for treatment of MDD. This designation reflects the drug potential to treat resistant psychiatric disorder. Recent studies reveals that psilocybin assisted therapy offer a wide range of possible therapeutic benefits ( for example in alcohol use disorder , tobacco use disorder and end-of-life anxiety and depression). In this presentation, I will explain what is psilocybin-assisted therapy and what disorders it  help with based on recent studies.

Learning Objectives:

Obtain knowledge on history of psychedelic therapy from the past to the present time.

Discuss psilocybin pharmacology and phases of psilocybin therapy.

Discuss therapeutic benefits of psilocybin based on recent studies.

Daniel Kahneman’s Nobel prize winning research, on behavioral economics, established how humans often make snap decision that often defy logic. Physicians are no different. Emergency physicians are, in fact, more likely to use “fast thinking” compared to other physicians. This is in part due to needing to make quick decisions based off a triage model on a large volume of patients. However, this can create a bias in how we diagnosis and treat patients.

Bias can occur through implicit bias or subconscious perceptions. These often include unconscious feelings about something one cannot control like race, gender, and weight. Microaggressions are often subconscious buy can also be conscious and often reflect biases in the form of words and gestures. Emergency psychiatry has its own form of microaggressions by using words like “boarder,” “borderline,” and “frequent flyer.” Although these terms might help the physician segment medicine’s harsh realities, it paints the patient in a negative light, leading to poorer quality of care. This presentation will look at things like implicit bias and microaggressions that can occur during an interview by utilizing research from both the diversity, equity, and inclusion (DEI) and psychiatry fields.

However bias is not always subconscious. Chart checking is an invaluable tool that can inform decision making based on past events. When one relies to much on past history rather than current presentation, this can lead to bad outcomes for our patients. Unfortunately, one may never know when a potential negative event occurs in the emergency department since it will occur out of sight and hence a confirmation bias occurs.

The psychiatric interview is a unique skill that goes beyond the traditional subjective, objective, assessment, plan (SOAP) note. During training we teach students, residents, and fellows the art of the psychiatric interview but often do not reassess our own interviewing skills. However, since the interview is highly subjective itself, it leads to more bias compared to other components of medicine. How does one retrain oneself to the level of naivety of first year medical students, while still retaining the knowledge of a season attending?

This presentation will begin by providing a brief overview of the history of bias in medicine with more of a focus on psychiatry and basic DEI principles. Next the speakers will share real life examples of when medicine have failed in emergency psychiatry due to an overreliance on chart checking. The speakers will also discuss their own personal mental health journeys where bias has come into play in their treatment. Finally, it will conclude with how one can look at the art of interviewing and try to remove bias as much as possible by providing real world clinical skills.

Learning Objectives:

Define implicit bias and microaggression.

Understand how mircoagressions and other forms of bias are used in everyday settings including mental health.

Utilize interviewing skills to help eliminate common points of bias during clinical interviews.

The goal of this presentation is to propose a framework for conceptualizing adolescent social media use behavior that relies on a functions-based approach. We will describe an algorithm for eliciting a social media use history that focuses on evaluating function-specific behaviors and interactions and assess for related risk and resilience factors.

Background: 
Social media (SM) use among adolescents soared over the past decade, raising questions and concerns about its impact on youth mental health. While research points to a correlation between this rise and negative mental health outcomes, there is a paucity of literature discussing approaches to screen for SM use and assess for associated risk and resilience factors. The problem with available screening assessments is that they rely on specific knowledge of the applications. The issue with this is that SM applications cycle rapidly, making it difficult to keep up. Previous practices focused on “screen time” as a measure for SM use. However, recently, some researchers have advocated for a more nuanced, multi-dimensional approach that highlights “how” and “why” adolescents use SM. In this poster, we propose a framework for identifying “use types” that satisfies this nuanced model, focusing primarily on the function of SM use, and evaluating risk and resilience factors associated with each use type.

Methods: 
A literature survey was conducted to identify variables of SM use such as type of engagement and type of online interactions, paying particular attention to risk and resilience factors associated with each category of use. We describe a function-based algorithm that attempts to provide direct clinical guidance on how to conduct the SM use segment of the psychiatric interview without requiring extensive knowledge of the applications used by adolescents. To do that, we focused our framework on 5 main SM functions: social networking, image sharing, video sharing, direct messaging, and streaming.

Results: 
When examining the literature, we identified two major parameters describing adolescents' engagement with SM. First, is the type of use, categorized into consumption and contribution. Second, is the type of interactions, divided into public and private. Recognizing these parameters, we created an algorithm that focuses on eliciting SM use history by asking three major questions: “What function are they using? How are they using SM? And Who are adolescents engaging with on SM?”. By combining type of use with type of interactions, we were able to identify four general use types: private consumption, private contribution, public consumption, and public contribution. We then identified risk and resilience factors associated with each use type found in the literature.

Conclusions: SM use has become a fixture in the life of adolescents. Due to the significant role it plays and the implications of its use during this phase of development, it is imperative that child psychiatrists are able to accurately evaluate use and assess for risk and resilience factors associated with it. Using our framework, clinicians can assess the adolescent’s SM use and understand both their risk and resilience factors without relying on prior application knowledge.

Learning Objectives:

Learn how social media consumption and contribution behavior can be elicited and formulated during a psychiatric interview.

Learn how public vs private interactions impact adolescent mental health and how to ask about these interactions in a psychiatric interview.

Develop an assessment of the adolescent’s social media use type and explore possible protective and risk factors.

Has this happened to you? You are on busy shift and have just admitted an 88-year-old patient to the hospital because the family says that caring for patient at home “has become too much.”  As you walk into the next room, you see that your new patient is also in her 80’s and has dementia.  The patient looks amazing, but the daughter who cares for her looks exhausted and depressed.  How long will it be before this caregiver is also overwhelmed?  You realize that the best thing you could do to help the patient is to help the caregiver.  But what can you do?

In this dynamic, case-based lecture, we will explore the issues related to Caregiver Stress and Burnout among those who care for older adults. We will offer practical tips aimed at healthcare providers who encounter the impacts of caregiver stress in the clinical setting but who may not feel equipped to help. As faculty from Geriatrics and Emergency Medicine, we will share insights drawn from the literature as well as from experiences in our ACEP Level 1 Accredited Geriatric Emergency Department.

Learning Objectives:

By the end of this lecture, the audience will understand:

• What caregiver stress and burnout are and how they impact both sides of the patient-caregiver dyad.
• How to identify caregiver stress and burnout, including how to use clinical screening tools to find cases that might go unrecognized.
• How to make effective recommendations and interventions to help caregivers who are experiencing stress and burnout as they try to meet the increasing needs of loved ones at home.

Richard deShazo (2018) writes about  "…the unfortunate role and responsibility of organized American medicine in past and present health disparities in our country." A long history of slavery, racism and mass incarceration in the US continue to rear their pernicious heads in how we provide health care to minoritized and marginalized communities in particular.  Racial and ethnic bias have a habit of showing up stronger and often unconsciously in situations of stress, ambiguity, and time pressure.  As such, health and mental healthcare practitioners who work under these conditions in urgent and emergency care settings are susceptible to misperceptions that can lead to unequal treatment and medical error.  In fact, the National Standards for Culturally and Linguistically Appropriate Services (CLAS STANDARDS) were developed in 2001 and revised in 2013 by the Office of Minority Health specifically to provide guidance for health care administrators and practitioners to rectify these inequalities.  This is the imperative of health justice and equity in medicine and behavioral health.

This interactive and participatory session will draw from humanities and poetry to highlight the pernicious nature of bias and to illuminate the psychological, interpersonal and organizational challenges at hand. The session aims to help participants understand the perils of stereotyping in clinical settings, and will provide tangible tools and strategies for enhancing awareness. understanding, and communication skill development towards greater health equity, and practitioner and patient satisfaction with care. Moreover we will explore the power and importance of assertive and empowering communication approaches towards equity in patient advocacy. The presentation will focus on both practitioner awareness and skill development, as well as taking an organizational and healthcare team perspective on transforming how care is delivered toward the elimination of health inequities and the enhancement of health justice.

Learning Objectives:

By the conclusion of this presentation, participants will deepen their understanding of the role of bias and stereotyping in health inequities.

By the conclusion of this presentation, participants will deepen their self-reflection on biased communication with patients and family members in acute behavioral and emergency settings.

By the conclusion of this presentation, participants will grow their capacity for assertive communication in helping colleagues and team members remain accountable to the CLAS Standards of culturally and linguistically appropriate services in clinical settings.

This presentation walks participants through an understanding of the biggest contributors to their areas of stress in a healthcare workplace environment in the context of critical incident and disaster response and recovery, and what can be done to effectively and reasonably reduce symptoms and increase active coping. We will cover examples of cognitive, behavioral, and emotional challenges while discussing practical and accessible strategies for recognizing and managing through burnout, compassion fatigue and moral injury experiences in healthcare. Participants will also come away with a better understanding of the most effective and efficient ways to helpfully engage patients and colleagues who may be experiencing crisis, or who are just in need of support while also developing insight into their own resilience and coping tactics and styles.  

Learning Objectives:

Recognize common experiences and behavioral indicators of burnout, compassion fatigue and moral injury.

Develop and understanding of elements needed for an effective coping plan.

Assess personal, active coping strategies and effective crisis deescalation strategies.

Our work is rewarding, yet stressful and not without risk.  Despite our best efforts at providing optimal care and managing risk, adverse events, although infrequent, can have profound impacts on individuals who care for patients, on institutions, patients and families.  Unanticipated deaths or injuries and other adverse events occurring within our facilities or following discharge from emergency departments, or who are cared for by mental health clinicians can represent personal and professional crises for practitioners. Existing literature on adverse outcomes in health care tends to focus on medical errors such as missed diagnoses or procedural errors.  Physicians caring for such patients can be considered “second victims” due to the emotional impacts following such events and some health systems have peer support programs in place to assist such providers.   There is less data on adverse outcomes in behavioral health not involving medical errors, such as patient suicides shortly or immediately after discharge, overdose deaths or harms inflicted on others by a patient; and on the impacts on clinicians who care for such patients.  

Emergency behavioral health providers are faced with the task of conducting risk assessments and determining level of care such as hospitalization vs. discharge. As such they may be subject to perceived accountability of patient behaviors following discharge from emergency departments. At the same time, community resources and options for containing risk, including inpatient bed availability may be limited, necessitating outpatient disposition. Suicide deaths involving patients currently in treatment or shortly after discharge can be particularly emotionally impactful on clinicians due to the nature of the therapeutic relationship as well as institutional responses which may view all suicide deaths as “adverse events”. Indeed, many institutions have “zero suicide” initiatives with the admirable, but unachievable goal of eliminating suicide deaths among behavioral health patients. If an organizational assumption is that all suicide deaths are preventable, caregivers who learn of the death of a patient by suicide may experience feelings of failure, fear of reprisal or even post-traumatic symptoms.

Hospital Adverse Event or Sentinel Event review committees are often tasked with the important work of conducting root cause analyses, morbidity and mortality reviews, institutional risk management or minimizing liability. Such committees may or may not have a goal of providing support to members of the care team. Within behavioral health, given the importance of supporting clinicians who have cared for patients involved in adverse events, while lessons learned for system improvement, specific behavioral health Adverse Event Committees can be uniquely suited to accomplish both tasks simultaneously. Providing immediate emotional support and reassurance to providers, allowing sufficient time between psychological first aid efforts and detailed case reviews; and prioritizing suggestions for systems improvements over individual responsibility are important functions of such committees.

This presentation will provide an overview of the topic of adverse events in behavioral health, and impacts on clinicians. We will then provide case examples to illustrate how a behavioral health Adverse Event Committee can help support providers and identify areas of potential system improvements.

Learning Objectives:

To provide an overview of behavioral health adverse events and impacts on clinicians.

To learn how to better support clinicians following behavioral health adverse events such as patient suicides.

To highlight the unique roles of a behavioral health Adverse Event Review Committee.

The imposter phenomenon (IP) is a negative state of self-doubt experienced by various professions, genders, and races, with a prevalence rate reported from 9-82%. If you were to do a quick internet search, there are numerous TED Talks, social media sites, and business professional literature dedicated to exploring and explaining IP. In emergency psychiatry, IP can surface in a variety of forms: as a contributor to/direct source of distress in patients, burnout in trainees, or stunted professional growth with experienced staff. IP has been psychiatrically linked with depression and anxiety, and those who experience it may struggle with personal relationships and/or marital distress. In the workplace, leaders and administrators need to recognize and address IP as it is linked to turnover, procrastination, and inability for managers and supervisors to appropriately delegate. In academic settings, IP causes more subjective distress in non-white groups than stress that comes from racial discrimination. Despite these many negative outcomes, IP does not easily fit into a diagnostic category, and so it is not always discussed or taught in an academic setting (outside of perhaps a lecture in medical school). However, because of the risk that IP can pose to anyone, at any point in one's career, and because of its prominence in popular culture, it is imperative that we are able to identify and address IP in our patients, our peers, our colleagues, and ourselves. This talk will provide an academic overview of this concept, risks for developing it, signs to identify it, ways to combat it, and how to psychiatrically treat it in therapy. Based off of a 2020 ACGME small group discussion outline, an experiential component ("think-pair-share") will be utilized to engage the audience in active learning. Popular media clips will be incorporated to capture the audience's attention, and when possible, the audience will be encouraged to share their own experiences in dealing with IP or caring for patients who are suffering from IP. Supervisors will also be given information on how to address IP with trainees using the ACGME recommendations.

Learning Objectives:

At the end of the presentation, the audience will be able to define imposter phenomena, prevalence, and negative outcomes from it.

At the end of the presentation, the audience will be able to list 2 risk factors for experiencing imposter phenomena.

At the end of the presentation, the audience will be able to list 3 interventions to combat imposter phenomena.

When errors are made in the practice of medicine the results can be devastating. Unfortunately, errors are all too common. It is estimated that hundreds of thousands of patients die each year as a result of medical error, and medical error might be the third leading cause of death in the US, behind only heart disease and cancer.  Commonly cited risks for making errors are high workload, time pressure, multitasking, and multiple handoffs- all things that are extremely common in emergency psychiatry. Caring for patients with mental illness in crisis can certainly leave one prone to mistakes. Behavioral health patients in emergency departments have a longer length of stay, often causing their care to run over several shift, increasing the risk of handoff errors.  When mistakes are made in the care of patient in emergency psychiatry the results could not only cause immediate harm to the patients, or to the community, but can also have a long-lasting effect eroding the trust in a medical system that could provide them with help.  We will review the type of errors that are common in the field of emergency psychiatry through several case reviews, and spend the final half of the presentation discussing the recovery process.  We will review the literature and common practice around the responses to errors. We will look at the individual responses, with patients, with staff and with families, as well as systemic approaches to responding to errors. We will discuss some error prevention techniques that can easily be implemented in emergency departments.

Learning Objectives:

Attendees will be able to identify common causes for errors in the medical setting.

Attendees will learn skills for navigating responses to medical errors.

Attendees will learn techniques for error prevention in the emergency psychiatry setting.

Priyanka Amin, MD, Jennifer Peltzer-Jones, PsyD, RN, NUBE Program Chairs