Author: Dr. Corey Goldstein
Intro
We had a great lecture from Dr. Goldstein on psychiatric emergencies and he was also nice enough to write the below blog post for it as well! Very helpful talk as he can approach it from multiple perspectives as he has worked as a psychiatric attending and is about to finish his residency in emergency medicine. Hope you enjoy.
Psychiatric Emergencies
There is significant variance in training programs with regard to psychiatric emergencies. Many programs also have crisis workers, psychiatry residents, and/or attending physicians who often evaluate and/or consult on patients who present to the Emergency Department (ED) with a behavioral health complaint. Although this can be helpful to the ED flow and provides an expert opinion, it results in less hands-on experience to the Emergency Medicine (EM) resident. This can translate into a less than optimal training experience to many EM residents who will go on to see the vast majority of psychiatric patients without additional consultation. Regardless of supports in place, it is imperative that the EM resident knows how to do a proper evaluation of a psychiatric patient, to determine the need for acute treatment, and to establish an appropriate disposition.
The role of the Emergency Physician (EP) in mental health care has never been more important. Inpatient psychiatric beds have been dwindling over the past three decades, despite the fact that the number of patients presenting to the ED with behavioral health complaints has increased by more than double. Psychiatric patients often have more medical problems than those without a psychiatric diagnosis, with higher morbidity and mortality as well. Moreover, psychiatric patients often spend more time in the ED as compared to those with a primary medical or surgical complaint, which is noteworthy, given the additional time that may be necessary to secure proper inpatient acceptance.
The EP must not see the psychiatric patient as merely presenting with a behavioral health complaint, but rather as a whole with the possibility of underlying illness being a potential cause of their reported symptoms. There are several medical illnesses that can present as behavioral in origin – and even when the primary issue is psychiatric, it is critical not to miss comorbid medical issues. Inpatient psychiatric units are often not equipped to deal with unresolved medical problems, and this can delay a patient’s transfer to the appropriate unit for further psychiatric stabilization. Lastly, patients experiencing psychosis may not be able to effectively communicate medical symptoms or may not see their relevance.
We are often asked to give “medical clearance,” but there is no accepted universal definition for this term. What is requested by a psychiatry service may not be appropriate or necessary on the part of the EP, and therefore, there ought to be a collaboration between our two services to increase comfort level. Rather than use the term medical clearance in documentation, it is reasonable to state that the patient does not have an acute medical condition that requires urgent treatment that would preclude going to an inpatient psychiatric facility.
The term psychiatric hold has slight variation from state to state but generally means that the patient is required to be admitted for further stabilization and treatment. The criteria for a medical hold include a danger to oneself, a danger to others, or the inability to care for him/herself, i.e. gravely disabled. The latter term can be misunderstood and can translate into patients being discharged or admitted inappropriately. Therefore, it is important to understand state law and to consider each of these criteria when considering involuntary inpatient evaluation. Of utmost importance is collateral history, which can change disposition. If you have a crisis worker available to you, he or she can be instrumental in helping to obtain collateral history and should, therefore, be viewed as a vital member of the evaluation team. However, always bear in mind that the ED provider is ultimately responsible for treatment and disposition. Understanding how to evaluate a patient properly is critical.
Agitation is a common issue among patients with psychiatric complaints. While verbal de-escalation is always the best first strategy, feeling comfortable with medical treatment approaches is necessary, particularly given the prevalence of these issues. While a patient may benefit from benzodiazepine or anti-psychotic monotherapy, there is evidence to suggest that those with more significant agitation, may have faster and better control of agitation with a combination of the two. There are several options available and one must consider potential adverse effects, such as respiratory depression with benzodiazepines and extra-pyramidal effects as well as QT prolongation with anti-psychotics. While Haloperidol has been a mainstay of antipsychotic treatment in the ED, newer agents such as Olanzapine and Ziprasidone can be considered in the appropriate patient.
Of course, helping to prevent agitation is critical and, in order to do so, one must consider the nature of the psychiatric patient’s experience in the ED. As above, they can often stay for prolonged periods of time, may not have access to entertainment options such as a television or their mobile phone, and designated rooms are typically relatively empty in order to ensure safety. Frequently checking-in, providing access to food and water, allowing appropriate visitors, and being mindful of anything else that can help to improve the patient’s overall experience can be quite helpful – and the right thing to do.
There are varying levels of comfort when prescribing medications to those psychiatric patients who will be discharged. Securing access to a treating psychiatrist or therapist, to programming, and to additional social/support services can be a challenge. Nevertheless, psychiatric patients should be viewed similarly to other patients in that they can often benefit from some form of ongoing treatment – and of course, follow up. Giving a patient a small supply of medications should be considered if appropriate, with primary care follow up at the least. Whether it is an outpatient psychiatric provider or a primary care provider, one should consider communicating the recommended treatment plan.
Our next psychiatric emergency blog entry will address mood and anxiety disorders, and additional topics. Thank you for taking the time to read this blog post! Please feel free to provide any feedback and to express interest in additional topics!
Helpful Links:
RebelEM – Proper Chemical Restraints
EMDocs – Properly Restraining Patients
ACEPNow – Medical vs. Psychiatric Disorder
References
Nazarian DJ, Broder JS, Thiessen ME, Wilson MP, Zun LS, Brown MD. Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med. 2017 Apr 1;69(4):480-98.
Amin M, Wang J. Routine laboratory testing to evaluate for medical illness in psychiatric patients in the emergency department is largely unrevealing. West J Emerg Med. 2009;10(2):97-100.
Donofrio JJ, Santillanes G, McCammack BD, et al. Clinical utility of screening laboratory tests in pediatric psychiatric patients presenting to the emergency department for medical clearance. Ann Emerg Med. 2014;63(6):666-675.e3.
Mason J, Herbert M, Swadron S. Feb 2019. EM:RAP, “C3 Psychiatric Emergencies – Part 1,” available at https://www.emrap.org/episode/c3psychiatric/c3psychiatric
Sartorious N. Comorbidity of mental and physical diseases: a main challenge for medicine of the 21st century. Shanghai Archives of Psychiatry. 2013 Apr; 25(2):68-69
Druss B, Walker ER. Mental Disorders and Medical Comorbidity. The Synthesis Project: New Insights from Research Results. 2011 Feb
Hedman L, Petrila J, Fisher W, Swanson J, Dingman D, Burris S. State Laws on Emergency Holds for Mental Health Stabilization. Psychiatry Online. 2016 Feb