CHAPTER 87 Emergency Psychiatry

Jennifer M. Park, MD, Lawrence Park, MA, MD, Laura M. Prager, MD

OVERVIEW

Over the past 20 years, emergency psychiatry has developed into an independent subspecialty practice within consultation-liaison psychiatry. Although formal board certification requirements are lacking, all accredited United States psychiatric residency-training programs follow minimum training guidelines for emergency psychiatry.¹ The emergence of emergency psychiatry as a specialized practice parallels the dramatic increase in patient volume in urgent and emergency care settings over the past decade. In 2001, there were over 2 million visits to United States emergency departments (EDs) for mental health–related chief complaints, accounting for more than 6% of all ED visits, and representing an increase in the percentage of all visits by 28% over the previous decade.² Among emergency mental health visits, substance-related disorders (30%), mood disorders (23%), anxiety disorders (21%), psychosis (10%), and suicide attempts (7%) are the most common.²

Psychiatric emergencies encompass a range of clinical presentations and diagnoses. Typically, such patients seek treatment in a state of crisis, unable to be contained by local support systems. Crises may be understood and addressed from a variety of perspectives, including medical, psychological, interpersonal, and social. Symptoms often consist of an overwhelming mental state that leads to increased dangerousness for that person or for others. Patients may have suicidal or homicidal (violent) ideation, overwhelming depression or anxiety, psychosis, mania, or acute cognitive or behavioral changes. A recent trend has also seen emergency services used for nonemergent conditions.² Increasing numbers of patients seek treatment at EDs for urgent conditions, routine conditions, or outpatient referrals because of lack of coverage for routine outpatient care, lack of community health care resources, or an inability to access health care.

The scope of emergency psychiatry includes core skills for psychiatric practice. In addition to the evaluation and treatment of severe psychiatric conditions, practitioners of emergency psychiatry are called on to evaluate and to manage suicidal behavior, homicidal (or violent) behavior, agitation, delirium, and substance intoxication or withdrawal states. Because clinical practice lies at the interface of medicine and psychiatry, having knowledge concerning the assessment and treatment of medical conditions that include psychiatric symptomatology is critical. Recently, emergency psychiatrists have also played important roles in an organized response to disasters.

The aim of this chapter is to provide a foundation for the clinical aspects of psychiatric emergency care. First, the general psychiatric emergency evaluation will be reviewed, with particular focus on common initial symptoms. Then, special topics and the emergency treatment of children will be examined.

DEMOGRAPHICS

As of 1991, the United States had about 3,000 dedicated psychiatric emergency services (PESs).³ Among the patients treated at these specialized services, approximately 29% are diagnosed with psychosis, 25% with substance abuse, 23% with major depression, 13% with bipolar disorder, and 22% with personality disorders⁴; co-morbidity is common. Suicidal ideation is present among approximately one-third to one-half of the patients.³

Though some patients may self-refer to a PES while in crisis, patients may be also be referred by family, friends, general practitioners, medical specialists, mental health treaters in the community, employees of local and state agencies, and staff of airports. Since the occurrence of several school shootings by students, schools in the United States have become a major source of emergency referrals for violence and for suicide assessments.⁵ Police officers and representatives of the legal system are also a source of referrals, as the PES serves as a conduit between the psychiatric system and the legal system.⁶ The role of the PES is to help the police identify those patients with psychiatric illness and to re-route them to appropriate care, while those without acute psychiatric illness are returned to the legal system.

TYPES OF DELIVERY MODELS

Two general models are used to deliver emergency psychiatric services. In one model, the PES exists as an independent service, co-located with a general emergency medical service or located separately in a stand-alone facility. In the other model, the PES may function as a consultation service that provides consultation to primary emergency medical services. The model of services offered is determined by the volume of patients and the financial resources available.⁷

The primary benefit of providing emergency psychiatric services in an area that is separated from the chaos of a busy ED is safety; it provides a more secure environment (e.g., with limited access to sharp or dangerous objects, quiet surroundings to decrease stimulation, individual rooms for private interviews, and the ability to observe and rapidly initiate psychiatric treatment). The unit may also have security staff who are trained to understand mental health issues and who can help to maintain a safe environment. Many units also have specialized rooms for restraint and seclusion.⁷

Most states have enacted legislation that allows for holding individuals against their will if they are unable to care for themselves or if they present a danger to themselves or to others. In the PES, if there is reason to believe that a person presents a substantial risk of physical harm to himself or herself, or to other persons, or presents a very substantial risk of physical impairment or injury (due to inability to care for oneself), the person may be held or sequestered in the PES facility for further evaluation.

Another benefit of a dedicated psychiatric unit is the opportunity to staff the unit with specialized personnel who are trained in emergency psychiatric care.^3,⁷ An interdisciplinary staff of psychiatric residents and attending physicians, nurses, social workers, and case managers can enhance the care of patients with acute illness, for example, by coordinating medical care with colleagues in the ED. Psychiatric nurses also play an important role in triage of mentally ill patients within the psychiatric unit and the ED. Their ability to manage the milieu in an emergency unit, provide individual support to patients, dispense psychiatric medications, and recognize situations that require immediate nursing and physician intervention is invaluable.

Some PESs also have access to “crisis beds” or facilities that are able to provide 24- to 72-hour observation. The ability to observe a patient whose mental state may change significantly after the initiation of antipsychotics or with a period of sobriety may decrease the need for inpatient hospitalization.^3,^7,⁸

A PES may also have a mobile crisis team, whose role is to evaluate patients in the community, to diffuse a crisis before a patient is treated at the ED, and to decrease rates of hospitalization. As early as 1980, mobile initial response teams were described as a component of California community mental health centers, and as an alternative to ED care.⁹ One report from 1990 demonstrated similar hospitalization rates among hospital-based and mobile team emergency interventions,¹⁰ whereas more recent reports have demonstrated decreased hospitalization rates associated with use of mobile teams.¹¹^–¹³

THE PSYCHIATRIC INTERVIEW

The psychiatric emergency evaluation is a concise, focused evaluation with a goal of diagnostic assessment, management of acute symptoms, and disposition to the appropriate level of care. Just as a visit to an ED for a medical complaint involves an initial triage (a brief evaluation of the severity of the problem), many emergency psychiatry models also depend on an initial assessment of the dangerousness of the psychiatric complaint in the context of co-morbid medical conditions. This initial, brief determination of acuity should screen for active medical issues that cause a change in mental status, substance intoxication or withdrawal, suicidal or homicidal ideation, and other types of psychiatric symptomatology.

The cornerstone of the initial psychiatric evaluation is a careful history that focuses on the temporal development of symptoms that have led to the emergency visit, on associated signs and symptoms, and on possible precipitants and causes. In addition, a past history of medical illnesses, psychiatric illnesses, medication usage, allergies, adverse reactions to medications, patterns of substance use, a family history of psychiatric illness, and a psychosocial history serve as important aspects of the initial evaluation. Table 87-1 describes the components of the evaluation and Table 87-2 describes the special features of a substance abuse evaluation.

Table 87-1 The Emergency Psychiatric Interview and Evaluation

• Chief complaint

• History of present illness, with a focus on symptoms and the context for these symptoms; include a safety evaluation, with assessment of suicidal and homicidal ideation, plan or intent, and any associated risk factors

• Past medical history, with a focus on current problems

• Past psychiatric history, particularly symptoms or events similar to the current presentation; include diagnoses, previous hospitalizations, and suicide attempts

• Allergies and adverse reactions to medications

• Current medications, including an assessment of compliance

• Social history, particularly how it contributes to the context for the emergency visit

• Substance use and abuse history

• Family history, including symptoms or diagnoses similar to the patient’s presentation

• Mental status examination

• Review of medical symptoms, particularly any medical symptoms that may account for the patient’s presentation

• Vital signs

• Physical examination, if indicated

• Laboratory studies and other tests, if indicated

• Assessment, including a summary statement, a statement about the patient’s level of safety, and a rationale for disposition recommendations

• Axes I through V according to DSM-IV criteria

• Plan and disposition

• Document any significant interventions (such as medication administration) and the outcome

Table 87-2 The Substance Abuse Interview

It is important to be aware of all potential information that may be included in an emergency psychiatric evaluation, and then choose to elaborate on areas that are most relevant to the patient at hand. The interview should be a fact-gathering mission, and the elements of the history should both tell a story about the current symptoms and provide support for the disposition that the psychiatrist chooses. For example, though the developmental history may not be an important part of the evaluation for an otherwise healthy-appearing adult patient with depression, it may be very important in the assessment of a young patient with obvious cognitive deficits.

The emergency evaluation always includes an assessment of the patient’s living situation and social supports, as well as a brief understanding of how he or she spends the day (e.g., at work, at school, or in a day program). This assessment defines the patient’s baseline level of function. In addition, a review of the patient’s health insurance is necessary, because this often dictates the types of treatment programs that are available as disposition options.

Often, presentations to the PES are complicated and confusing, and patients may be unable, or unwilling, to provide an accurate history. For this reason, an important feature of the evaluation is the collection of history from multiple sources (including family, friends, treaters, police, or emergency personnel who transported the patient). When several informants can be interviewed, data can be corroborated from the various sources, which can help the psychiatrist to make informed disposition decisions.

THE MEDICAL EVALUATION

For any patient treated at an ED with an altered mental status (be it a change in cognition, emotional state, or behavior), it is crucial to rule out an underlying medical condition that causes or contributes to the problem. A change in mental state may indicate a primary psychiatric condition, delirium (an acute and reversible condition secondary to a medical illness), or dementia (a chronic condition associated with long-term, irreversible brain pathology). Therefore, it is important to consider medical etiologies for any condition that appears psychiatric in nature. A missed medical diagnosis in lieu of an assumed psychiatric diagnosis could result in dire consequences for the patient.

A medical workup should be considered for any new onset of psychiatric symptomatology or any significant change or exacerbation of symptoms. This initial medical workup is often referred to as “medical clearance.” The term medical clearance generally refers to a medical evaluation aimed at ruling out underlying medical conditions that cause or contribute to a psychiatric presentation. While much attention has been paid to defining a standard for medical clearance, there is no clear consensus regarding the required elements of the medical evaluation.^14,¹⁵

One retrospective study of 212 consecutive patients who underwent a psychiatric evaluation at an ED demonstrated that among patients with a known psychiatric history and no medical complaints (38%), screening laboratories and radiographic results yielded no additional information; those patients could have been referred for further psychiatric evaluation with the history, the physical examination, and stable vital signs alone. Among the patients deemed to require further medical evaluation (62%), all had either reported medical complaints or their medical histories suggested that further evaluation would be necessary before psychiatric referral.¹⁶ Another study of the medical evaluation of ED patients with new-onset psychiatric symptoms (e.g., patients with intoxication with alcohol or drugs, overdoses, and previously diagnosed abnormal behavior were excluded) demonstrated that two-thirds had an organic cause for their psychiatric symptoms.¹⁷ These studies suggest that careful screening is important among patients with new-onset symptoms, but additional medical tests may be of little benefit among patients with known psychiatric disorders and without physical complaints or active medical issues.

The medical evaluation should involve a thorough medical history, a general review of systems, and the assessment of vital signs, followed by a physical examination or laboratory tests (or both) as indicated. One should be vigilant of characteristics (such as homelessness or intravenous [IV] drug abuse), which may put a patient at risk for additional medical conditions. The medical tests to consider are listed in Table 87-3.

Table 87-3 Tests to Consider in the Medical Evaluation of Patients with Psychiatric Symptoms

• Complete blood count (CBC; to monitor for infection, blood loss)

• Electrolytes, blood urea nitrogen (BUN), creatinine (metabolic changes, hyponatremia or hypernatremia, abnormal kidney function, dehydration)

• Glucose (hypoglycemia or hyperglycemia)

• Liver function tests and ammonia (liver dysfunction due to hepatitis or alcohol abuse)

• Pregnancy test

• Serum toxicology screen (ingestion, intoxication, poisoning)

• Medication levels (ingestion of medications such as lithium and tricyclic antidepressants)

• Urine toxicology screen (to identify or confirm substance abuse)

• Calcium, magnesium, and phosphorus (hypoparathyroidism or hyperparathyroidism, eating disorders, poor nutrition)

• Folate, thiamine (alcohol dependence, poor nutrition, depression)

• Vitamin B₁₂ (megaloblastic anemia, dementia)

• Thyroid-stimulating hormone; this result may not be available immediately, but may be available during an extended observation period (hypothyroidism or hyperthyroidism)

The following tests and imaging studies may also be considered in the medical workup:

• Lumbar puncture (infection, hemorrhage)

• Electroencephalogram (seizure, changes due to ingestion of medications, dementia)

• Computed tomography (CT) (acute hemorrhage or trauma)

• Magnetic resonance imaging (MRI) (higher resolution than CT for potential brain masses or lesions, posterior fossa pathology, or when radiation exposure is contraindicated)

Adapted from Alpay M, Park L: Laboratory tests and diagnostic procedures. In Stern TA, Herman JB, editors: Psychiatry update and board preparation, New York, 2000, McGraw-Hill.

THE SAFETY EVALUATION

The safety evaluation assesses the likelihood that an individual will attempt to harm himself or herself or someone else; it is a mandatory component of every emergency evaluation. With regard to self-harm, the intent may be to harm or to kill oneself (i.e., commit suicide). Suicide is the eighth leading cause of death in the United States, and over 90% of patients who commit suicide have at least one psychiatric diagnosis.¹⁸ Patients aged 15 to 24 years and those over age 60 are in the highest-risk groups for suicide.

The psychiatrist must ask about thoughts, plans, and intent of suicide and homicide. These questions should be followed up with more specific questions about access to the means for harm. If a patient has a plan or the intent to commit suicide, the lethality of the plan, as well as the patient’s perception of the risk, must be assessed. A medically low-risk plan may still coincide with a strong intent to die if the patient believes that the lethality of the attempt is high. Similarly, the possibility that the patient could have been rescued if he or she had followed through on the plan should be evaluated; an impulsive ingestion of pills in front of a family member after an argument conveys less risk than a similar attempt in a remote location. If a patient has attempted suicide previously, details of that attempt may facilitate an understanding of the current risk. In addition, the clinician should assess other risk factors for suicide.

The assessment of violence is similar to the assessment of suicide risk. Every patient should be asked about thoughts to harm others, as well as the patient’s potential plans and intent. Observation of the patient’s mental status, behavior, and impulsivity during the interview provides important information. Since previous behavior is the best predictor of future behavior, if there is any suspicion of impending violence, it is important to establish previous violent thoughts and behaviors, triggers leading to those events, and their relationship to substance abuse. Questions about legal issues related to violence are also appropriate. In addition, the target of violence should be assessed. Violence may lack a specific target, or may be directed toward a specific individual. If there is a likelihood of directed violence toward an identified person or persons, there will be a duty to warn the identified target.

The safety evaluation should include contact with others who know the patient. Although civil commitment laws differ from state to state, most states have provisions for the containment of a patient who is deemed at risk for harm to self or others; however, in many cases, a patient with suicidal or homicidal ideation will choose voluntary hospitalization. In cases in which the patient has acknowledged suicidal or homicidal ideation, but it has resolved during the course of the emergency visit, care must be taken to create a clear plan for steps that the patient should take if the feelings return. Most often, these involve contact with family members and treaters and a return to a psychiatric evaluation center or ED.

PSYCHIATRIC SYMPTOMS AND PRESENTATIONS

Diagnosis using DSM-IV criteria ¹⁹ can be difficult in the PES since patients are seen at a cross section in time, often in the worst crisis of their lives. Although patients will not necessarily fit the criteria exactly, a search for the most common disorders (e.g., mood disorders, psychosis, anxiety disorders, substance abuse, and a change in mental status caused by a medical etiology [delirium]) will facilitate assessment. The following pages will outline some of the most common psychiatric presentations and patient characteristics in the ED.