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Most psychiatrists enter into a variety of professional relationships with other clinicians in which they prescribe medications or make recommendations about pharmacotherapy. This paper describes a set of guidelines for prescribing psychiatrists involved in consultation, collaboration, and supervision with other clinicians. The guidelines were developed by psychiatrists for the Harvard Risk Management Foundation. The terms consultation, collaboration, and supervision are defined, and the psychiatrist's roles and responsibilities in each type of arrangement are described. The guidelines limit consultation and collaboration to relationships with professionals who are licensed or credentialed. Based on the definitions, the paper describes a structure for working with other clinicians, which begins with a thorough assessment of the context and circumstances of the clinical situation. The guidelines strongly encourage structured communication among clinicians and with the patient and significant others, as well as clarification by clinicians of their respective responsibilities for treatment and follow-up.

In this position paper drafted by the committee on psychopathology of the Group for the Advancement of Psychiatry, the authors discuss merits and disadvantages of three different approaches to equitable coverage of mental illness: coverage for selected psychiatric diagnoses, coverage based on severity of impairment, and coverage of services. They believe that coverage of selected disorders has political appeal but is discriminatory and arbitrary; it is also impractical because clinicians may overdiagnose conditions covered by insurance and underdiagnose excluded conditions. Coverage based on severity of impairment, or disability, has similar limitations. The authors believe services should be the principal basis for coverage, as under general medical insurance. The approach is nondiscriminatory, and costs can be controlled through such means as managed care, changes in the payment system, or benefit design.

A review of trends in emergency psychiatry since 1981 indicates that the scope and complexity of the field have greatly increased. Clinicians have found it useful to identify patient groups with special assessment and treatment needs, including adolescents, the elderly, victims of rape and of domestic violence, and repeat visitors to the emergency service. The spread of AIDS requires greater medical attentiveness by psychiatric emergency clinicians, and two recreational substances of abuse, cocaine and inhalants, have become increasingly popular. The use of psychotropic drugs in the emergency room has received more attention, and new trends in rapid tranquilization are apparent. Also reviewed are current medicolegal controversies related to emergency room practice, findings on prediction and control of violence, and the use of the psychiatric emergency service as a training site.

The authors describe how an emergency psychiatry service in an inner-city general hospital has been able to expand its functions and strengthen its ties to community mental health agencies. A major factor in helping the emergency unit build closer relationships with community agencies is its contract with the state to perform evaluations of all admissions to the state hospital psychiatric unit serving the catchment area. The emergency unit performs triage and provides backup for the agencies, coordinates the management of multi-agency cases, and holds weekly educational conferences for agency staff. Using case examples, the authors illustrate how unit and agency staff collaborate to ensure continuity of patient care.

Repeat visitors to psychiatric emergency services constitute 7 to 18 percent of the total patients and account for up to a third of the visits. This frequently difficult-to-treat group has been described in six controlled and two uncontrolled studies. In a critical review of findings and methodology, the authors interpret and compare the available data about repeaters. Their major conclusions are that repeaters are more likely to lack social supports, to be currently in psychiatric treatment, and to have a chronic illness. Research approaches to further elucidate these patients' characteristics are suggested.