In the last decade emergency departments have seen a dramatic rise in the presentations for mental health related issues. In 2007 3.2% of presentations to emergency departments were mental health related, this is over 190 000 presentations. The emergency department is well suited for people with mental illness to attended, related to its 24hour 7days a week accessibility, it provides alternative to diminished psychiatric beds available, lack of community services and supports.
Its estimated 75% of mental health care is provided in the primary care sector, with limited access to specialist support. Emergency departments have tried to address this with implementation of 24-hour access to psychiatric liaison nurses, a duty psychiatric registrar and have a psychiatric consultant attached in some emergency departments. Even with these implementations, emergency departments still lack access to psychiatric beds and often have these patients boarded up in EDs for periods from 24-72 hours in extremes.
Emergency department clinicians need to have an a sound knowledge base regarding mental illness, to provide effective care to these patients, until definitive care can be provide by mental health clinicians and services. Patients in the emergency department will often require medical clearance for psychiatric assessment; the following gives a review of this process, and a brief insight into mental health disorders and their management.
What is the role of the ED in managing mental illness?
- Stabilization of the aroused or frightened patient
- Management of behavioural disturbance in the ED
- Exclusion of medical causes for the psychiatric presentation.
- Assessing the presence of co-morbid medical illness
- Determining the need for voluntary or involuntary admission
- Arranging referral to community services
- Liaison with family and other carers
The mental health patient – brief assessment schedule:
- Circumstances of referral
- Presenting problem
- Social circumstances
- Previous treatment
- Current mental health service
- Current medication
- Alcohol and other drug use
- Mental state examination
- Medical assessment and investigations
- Provisional diagnosis
- Risk assessment
- Treatment and disposition plan
Medically clearing the psychiatric patient:
Patients presenting to emergency departments with psychiatric complaints often have medical disorders and complaints that are contributing or causing their psychiatric complaint. Missed medical diagnosis in patient’s diagnosed with psychiatric disorder range in the literature from between 8-48%, with the highest missed diagnosis rate amongst first presentations.
The performing of the medical clearance of patients is a common task for emergency physician before admission to a psychiatric facility. The medical clearance sets out to determine if an organic cause is responsible for the patients presenting complaint.
Factors contributing to missed medical diagnosis include:
- Inadequate history
- Failure to seek alternative information from relatives, carers, and old medical records
- Poor attention to physical examination, and vital signs
- Absence of a reasonable mental state exam
To medically clear a psychiatric patient for admission you need to rule out:
- Toxidrome or intoxication, substance abuse makes it increasing difficult to perform an adequate assessment
- Underlying organic illness
- Perform a satisfactory history and physical examination
Investigations should be guided by history and physical examination.
- Vital Signs: Pulse, Respiratory rate, Blood pressure, Temperature, Pulse oximetry, BSL
- FBP, Urea, Electrolytes, Creatinine, TFT
- Paracetamol Level
- Urine drug screen
- +/- Head CT/MRI
- +/- Lumbar Puncture
Medical causes of psychotic episodes:
- Hypo- or hyper-thyroidism
- Huntington’s disease
- Wilson’s disease
- B12 deficiency
- Cerebral neoplasm
- Viral encephalitis
Medical conditions associated with depressive syndrome:
- Pernicious anaemia
- Pancreatic cancer
- Lung cancer
- Alzheimer’s dementia
- Vascular dementia
- Parkinson’s disease
- Huntington disease
- Central nervous system tumour
- Multiple sclerosis
Drugs of abuse associated with psychosis:
- Amphetamine and methamphetamine
“Remember the only real doctor and nurse an admitted psychiatric patient is going to see is in the emergency department”
Mental State Examination:
- Appearance and Behaviour
- Appearance; grooming, posture, clothing, build
- Behaviour- eye contact, cooperativeness, motor activity, abnormality of movement and expressive gestures
- Articulation disturbances
- Rate, Volume
- Quantity of information e.g. pressured, loud, slurred, mumbled
- Mood and Affect
- Mood e.g. depressed, euphoric, suspicious
- Affect e.g. restricted, flattened, inappropriate
- Range and Intensity
- Appropriateness and congruity
- Form of Thought
- Amount of thought and rate of production e.g. flight of ideas, derailment
- Continuity of ideas
- Disturbance in language and meaning
- Content of Thought
- Suicidal/ homicidal thoughts
- Overvalued ideas, obsessions and phobias
- Other perceptual disturbances e.g. derealisation, depersonalisation, & illusions
- Sensorium and Cognition
- Level of consciousness
- Memory: immediate, recent, remote
- Orientation: time, place, person
- Capacity to understand own symptoms/illness, knowledge of medication, amenable to treatment, likelihood of compliance with treatment and impaired judgement
Characteristic of Psychiatric Diagnosis
Borderline Personality Disorder:
- Rigid fixed perception of the world
- Commonly occurs in individuals with traumatic childhoods
- Extreme fear of abandonment
- Chaotic relationships, emotional dysregulation, and intense reactions to situations
- Dramatic, manipulative, and attention seeking behaviours
- Power struggles used to reduce anxiety, control environment
- Self-harm behaviours (e.g. cutting) used to manage intense feelings
- Can be chronically suicidal
- Also known as manic depressive illness
- Characterised by extreme mood swings and behaviours
- Caused by a disruption in brain chemistry
- Affect during mania can be either euphoric or irritable
- Mania characterised by grandiose or delusional thinking, rapid and pressured speech, and impulsive risky behaviours
- Characterised by delusions, disorganisation in thinking, and hallucinations
- Psychosis (unrelated to schizophrenia) can be short term, drug-induced, caused by medical issues or related to other mental illnesses, e.g. bipolar disorder or major depression
- Schizophrenia onset is typically during adolescents or young adulthood
- Schizophrenia is caused by a disruption in brain chemistry
- Patients with schizophrenia can be very frighten and anxious, not typically violent or aggressive
- New onset psychosis needs medical workup
- Can be acute major depressive episode or chronic (dysthymia)
- Typically cooperative while in ED, especially if no other psychiatric issues are involved e.g. personality disorder, substance abuse
- Major depressive disorder can be a progressive illness, which will worsen if left untreated
- Multiple issues, e.g. medical problems, relationship difficulties, financial troubles, and aging can be stressors
- Physical symptoms can include fatigue, nausea, and headaches
- Some patients will present wanting connection to services vs. hospitalisation, or treatment for medical issue related to depression
- Anxiety is more difficult emotion to handle than anger or depression
- “Cascade” of symptoms can be overwhelming to patients
- Patients may have difficulty making decisions and be uncooperative or irrational
- During panic attacks, patients are unable to process what is being said to them
- Anxiety is a strong component of many other psychiatric disorders
- Physical symptoms include nausea, chest pain, shortness of breath, dizziness, headaches
Why do patients self-harm and overdose?
Need to look at this question from several perspectives, e.g. individual’s intentions at the time of act, social precipitants, and mental health reasons.
- Significant proportion intend to die at time of the attempt
- Most want to escape from an intolerable situation or state of mind
- A sizable number of patients can offer no clear explanation other than “loosing control”
- A small minority of patients wanted to punish someone or make someone feel guilty.
- Evidence supports an excess of life events especially in the month before the self-harm attempt. Events experienced in younger people are often related to relationship difficulties, and in older people health or bereavement related.
- Mental health disorders risk factors for self-harm attempts are frequently seen among the depressed, alcohol or substance misuse, and personality disorders.
Treatment Strategies (non-pharmacological)
Borderline Personality Disorders:
- Avoid power struggles
- Give choices as often as possible; clear, reasonable and enforceable limits
- Do not react emotionally to behaviours
- No punitive treatments, threats, ultimatums, or excessive restrictions
- Be aware of non verbal communication, especially tone of voice
- Spend time (if possible) talking with patients to find out what they need and want from ED visits and try to accommodate them if you can
- Low stimulus, keep directions/statements short and simple
- Do not argue with patient
- Medicate for agitation
- Get a reliable sitter to observe patient
- Assume patient will be unpredictable and plan for it
- Approach slowly, using nonthreatening body language
- Do not feed into delusions, but do not directly contradict them either
- Ask about voices, what they are saying and how the patient feels about them
- Assess cognitive functioning to determine level of disorganization
- Low stimulus, medicate for agitation, consider medical aetiology is symptoms are new
- Ask what the patient needs from ED visit, explain options
- Be kind and reassuring, explain what is happening
- Offer food, warmth, comfort, may need to ask more than once
- Ask about stressors, supports, allow family/friends to visit if patient wants them
- Explore suicidal ideation, e.g. vague thoughts vs. specific plan with means
- Recognise, treat physical symptoms as real
- Assess patient’s understanding of what is happening
- Offer reassurance
- Specifically ask what would be most helpful to them; and what has worked in the past
- Humour, distraction may be helpful with mild to moderate anxiety.
Stay Tuned for further post on mental health in the ED.
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