Educational Articles

Medically Screening Psychiatric Patients in the Emergency Department

 

            It has been reported from 1991-2002 that 6% of all ED visits were for behavioral disorders. Now, that number exceeds 8-11%. With the increase in visits and decrease in the number of facilities, the emergency department is often bogged down with psychiatric evaluations and psychiatric boarding holds. This crisis is across the nation and across the many medical disciplines. There is no relief in sight. With this crisis, the emergency department has become the default refuge or the safety net of the mentally ill. It has fallen to the emergency physician to screen and evaluate patients with psychosis or altered mental status and arrange for acute treatment options or to have the patient treated in a long-term facility.

             ACEP has several articles and clinical opinions on this subject. Two of the more helpful papers are “Care of the Psychiatric Patient in the Emergency Department” and “Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department.” Patients come to the ED by various methods from walk-ins, ambulance, an Order of Protective Custody or under arrest for a crime or complaint. ACEP clinical policy generally states it is our responsibility to determine if the patient is gravely disabled, a threat to self, or a threat to others. Secondly, we are to determine if it is due to a medical reason or a primary psychiatric reason. Our psychiatric colleges request or expect that we “medically clear” the patient before consult or transfer to a mental health facility. This should be considered a focused medical assessment to rule out medical causes. Both requests are perfectly reasonable and within our scope of practice,

           

 We will first look at a few definitions, so we are all on the same page.

 

·      Psychosis: The condition of the mind where there is a loss or disconnect with reality. It has been estimated that 13-23% people will experience symptoms during their life time and 1-4% will meet criteria for a psychiatric disorder. We see them in the ED at some point during their lifetimes.

 

·      Gravely disabled: Inability to take care of one’s self.

 

·      Homicidal or Suicidal: An attempt or threat on the life of another or self.

 

·      Delusions: Strongly held false beliefs (bizarre or non-bizarre).

 

·      Hallucinations: Wakeful sensory experiences of content that is not actually present.

 

·      Agitation: Increased acute state of anxiety, heightened emotional arousal and motor activity.

 

            As emergency physicians, we need to rule out a medical cause for psychosis. We first divide the differential diagnosis into two different groups, psychosis due to primary psychiatric disorder and psychosis due to medical disorder. While not pathognomonic, certain clinical presentations can give us clues.

 

·      Primary psychiatric disorder:

o   Family history often present

o   Onset in teen to mid thirties

o   Slow insidious onset

o   Auditory hallucination

o   Variable presentations

 

·      Primary medical condition:

o   Family history maybe present

o   Onset 40’s or later

o   Fast onset

o   Non-auditory hallucinations

o   Presents as a or during a medical complaint

 

Here are lists of primary psychiatric disorders and medical conditions to consider.

 

·      Primary psychiatric disorders (defined by the DSM):

o   Schizophrenia

o   Schizophreniform

o   Schizoaffective

o   Delusional disorder

o   Brief psychotic disorder

o   Schizotypal disorder

o   Major depressive disorder

o   Bipolar disorder

o   Substance-induced psychoses

 

·      Medical conditions:

o   Delirium

o   Endocrine disorders

o   Hepatic or renal disorders

o   Infectious diseases

o   Inflammatory or demyelinating disorders (SLE, MS, etc.)

o   Metabolic disorders

o   Neurodegenerative (Alzheimer’s, Parkinson’s, etc.)

o   Neurological

o   Vitamin Deficiency

 

Now that we know the differential diagnosis, we need to narrow down the list with our usual tools: the history and physical, laboratory testing, and if indicated, imaging. In this case, interviewing the patient will provide you with clues to guide you further. Your interview should focus on establishing a timeline of the symptoms, any prior diagnoses, treatment, and a complete past and current medical history, family history and substance abuse history. Many times, the patient is extremely non-helpful and corroborative sources of information are needed such as family or nursing home to substantiate the information received from the patient. The mental status exam should be done paying attention to the patient’s appearance, behavior, mood and affect, unusual thought processes, or evidence of perceptional disturbances.

Common medical work up will include the following labs: CBC, CMP (or BMP with Hepatic Panel), TSH, UA, UPT (if appropriate), UDS, blood alcohol level, and vitamin B12 (cobalamin). Often times other labs are requested or are part of your facility’s protocols, and you might need to get an HIV test, salicylate level, acetaminophen level, or other drug levels. Imaging may include a CT with contrast (or MRI) for suspected trauma, toxoplasmosis, neoplasm or infection. Other testing may include an EEG, EKG, lumbar puncture (with testing for syphilis) or hormone levels. If substances, medicines and medical etiologies have been ruled out as the cause of the psychosis, a primary psychiatric disorder should be considered.

Initial management of the psychosis patient needs to answer three major questions 1.) Are they at risk of harming themselves? 2.) Are they at risk of harming others? 3.) Are they unable to take care of themselves?

Placing the patient in a reduced stimulation environment/situation is a good adjunct to decreasing the patient’s agitation. When dealing with an agitated patient always speak calmly and refrain from arguing or trying to convince the patient that their delusional ideas are not real.

A rapid acting first-generation antipsychotic and/or rapid acting benzodiazepine are often necessary to sedate severely agitated or potentially violent patients.  Ativan and Haldol are typical first line agents used in agitated patients. Often times, Geodon or Zyprexa are used as single, less sedating agents and are often preferred by psychiatrist. Remember many psychiatric drugs have the potential to cause prolongation of the QTc interval, so a baseline EKG should be performed in elderly or patients with a cardiac history. Restraints either chemical or physical should be used with care and only in extreme situations of violent or extremely agitated patients that are a danger to themselves or others. Proper documentation and following of hospital policies and procedures is paramount in these cases.

Psychiatric evaluation or consult for these patients is often needed once a medical reason has been ruled out. Unless the facility has psychiatric services, many of these patients will require transfer to a mental health hospital for further evaluation by a psychiatrist often times on a physician’s emergency commitment or PEC. Increasingly, many hospitals are starting to have telemedicine services for psychiatric consults and evaluations. These services often benefit the patients with milder and chronic diseases who may not meet inpatient criteria. It may also benefit the patient who has had more of an impulsive gesture rather than a true overdose in a suicide attempt.

As noted earlier, inpatient support for the chronically mentally ill has decreased, and thus shifted the burden on the community and the local ED for many of these patients. In 2006, ACEP gave the following recommendations regarding evaluation of the psychiatric patient in the ED. Diagnostic evaluations should be dictated by the H&P and not routine labs for all patients. Urine drug screens do not affect ED management in alert, awake and cooperative patients and only need to be performed as requested by accepting facilities. A specific ETOH numerical value does not automatically diminish or invalidate the evaluation the patient’s cognitive abilities and should not a basis of when to start evaluation. Consider observation to see if signs and symptoms resolve with resolution of intoxication. For agitated patients, mono therapy with a benzodiazepine or antipsychotic is okay, and neither one has an advantage over the other. A combination may be better, if rapid or long acting sedation is needed or desired. Oral medications are the preferred route if the patient is cooperative and alert.

To summarize, the psychotic patient evaluation in the emergency department should strive to differentiate whether it is a primary psychiatric disorder or a medical condition. Treatment should be directed by the cause of the condition. In Louisiana, it may be necessary to fill out a physician’s emergency certificate form or PEC, if the patient is unwilling or unable, gravely disabled, or a danger to self or others in order to hold or transfer the patient for further psychiatric evaluation. There are state statues with regards to PECs that can be found at: www.legis.la.gov/legis/Law.aspx?d=85245, look specifically at RS28.53. The emergency physician is often the gate keeper for mental health in the area, use keys wisely.