Principles of Emergency Psychopharmacology

Darin D. Signorelli,

Ikechi Nnawuchi,

Scott Zeller

The guiding principles by which emergency psychiatrists perform their craft are best described by the American Psychological Association’s Task Force on Psychiatric Emergency Services. The task force defines an emergency “as a set of circumstances in which 1) the behavior or condition of an individual is perceived by someone, often not the identified individual, as having the potential to rapidly eventuate in a catastrophic outcome and 2) the resources available to understand and deal with the situation are not available at the time and place of the occurrence. Thus emergencies frequently involve a mismatch of needs and resources for which the emergency service must compensate” (1).

This is the world of the emergency psychiatrist, in which Gerson and Bassuck describe the goals as “rapid evaluation, containment and referral” (2). To function well in this arena, the emergency psychiatrist must draw on all of the skills he or she has learned to make rapid and accurate risk assessments. The stakes are much higher in the emergency department (ED) because patients are usually in acute crisis, putting them at much greater threat of severe adverse consequences.

Working in such an environment makes the mind-set of an emergency psychiatrist very different from that of other types of mental health professionals. Nowhere is this more evident than in the emergency clinician’s approach to prescribing medications. This chapter explores the general mind-set of emergency psychopharmacology.

SPECIFIC AIMS

When a person comes to the ED in crisis, the role of the emergency psychiatrist is to intervene quickly and to contain a psychiatric emergency. The main focus is safety, and staff must be proactive to ensure the well-being of the patients and those who may come into contact with them. Decreasing symptomatology and agitation are primary interventions toward this goal.

Historically, severely agitated patients would routinely be restrained and given intramuscular (IM) medications against their will. However, there has been a paradigm shift in the treatment of such patients in the last several years (3). Now, techniques such as verbal de-escalation, distraction with food or drink, and offering medications by mouth are the standard of care even with the most difficult of patients.

Past practice with medications frequently was to heavily sedate, or “snow,” the patient. However, the complications of oversedation are numerous, including interfering with the patient’s ability to participate in treatment through actions such as answering questions, hydrating themselves, or undergoing medical examinations and procedures. Oversedation hinders not only the psychiatric interview but also the medical evaluation, which thus might mask medical comorbidities (4).

This philosophy was echoed in a 2005 survey of 50 panel experts in emergency psychiatry who concluded that the preferred goal of emergency intervention was calming the patient without sedation, or inducing mild sedation to the point of drowsiness. The panel did not endorse sleep or heavy sedation as an appropriate goal of intervention. Other important factors in selecting a medication included the desire for an immediate, acute effect on behavioral symptoms; the patient’s history of response to the medication; patient preference of medication; limited risk of side effects; and ease of administration (e.g., no need for lab tests and simple dosing requirements) (5).

It is tempting for many clinicians to oversedate patients because they are obviously easier to manage in this state, and a sleeping person does not cause much disruption or violence. Yet the advantages of having a calm, awake, and conversant patient outweigh those of having a patient who is unresponsive for several hours, which can delay the medical clearance and evaluation of the patient for an appropriate disposition. The pressures of overcrowded emergency facilities, with space and resources at a premium, no longer allow for unnecessarily obtunded patients to be occupying beds.

TIMELINESS OF MEDICATION ADMINISTRATION IN EMERGENCIES

The psychiatric patient in an emergency may pose a grave danger to self and others; therefore, when appropriate, medication should be given promptly to ensure the safety of all concerned. Behavioral emergencies are often traumatic for the patient, and any course of action or inaction may have serious adverse effects (6). Once it is recognized that a condition requires a pharmacologic intervention, the decision to administer medication must be made quickly and without hesitation. This occurs after a brief assessment has been done and information about allergies, past adverse effects, and any medical contraindications has been elicited.

Whenever possible the patient should be involved in the choice regarding the specific medication to be administered. If the patient refuses, or the condition is such that he or she is unable to make that decision cogently, the emergency psychiatrist must act decisively. In virtually all municipalities, in those cases of mental illness in which an individual is emergently a danger to self or others, medication may be administered against the patient’s will. The reasons for the involuntary administration of medication must be documented clearly in the medical record to justify these actions.

Agitation, aggressive behavior, severe anxiety, acute psychosis, or extreme mood lability are common reasons to medicate patients in a psychiatric emergency. When patients are cooperative, the oral route is the most favorable. Even when the patient is aggressive, threatening, combative, or too disorganized to make a choice, medications should still be offered by mouth, and in some instances can still be delivered via this route. This can at times be achieved by instructing patients that emergency medication is required and that they have a choice in the matter: They can either accept medications orally, or a shot will be given against their will if they refuse. Often this may be enough to make patients agree to oral medications, even in a highly agitated state, because they do not wish to receive injections.

However, many times patients will refuse oral medications, and medication must be administered involuntarily in the IM form. Even if it is given involuntarily, however, every effort must be made to explain to the patient what medication is being administered, and why. This should also be well documented in the chart to justify why medication was given against the patient’s will.

MEDICATION CHOICES IN THE EMERGENCY DEPARTMENT SETTING

When choosing medications in emergency situations, a number of factors should be considered. Among these are route of administration, rate of onset of action, side effect profile, and drug interactions.

Route of Administration

There is a clear need for the use of both oral and parenteral medications in the emergency setting. This can give patients a choice and allows them some control in their own treatment. During what may be perceived as a very scary situation for a person in crisis, the opportunity to make this choice can help reduce the patient’s anxiety and help foster trust and cooperation with the treating physician.

Oral formulations such as rapidly dissolving discs or liquid elixirs can be especially helpful in acute care. Both reduce the cheeking of medications, can be mixed into pleasant-tasting juice or other liquids, and can possibly be substituted for an involuntary IM injection on occasion. With the patient’s consent, these may be given even to those in restraints in a safe manner—by placing the discs on a tongue depressor or via a syringe (sans needle) for the elixir—and delivered into the patient’s mouth. With this method, even if the patient bites down when the medication is administered, he or she bites the depressor or syringe, not the finger of the nurse or physician.

Intramuscular administration of medication is common in emergency situations because it allows for a rapid delivery of the medication and can be done without the patient’s cooperation if the need arises. This route, along with the rapidly dissolving disc and elixir formulations, is more often used in the emergency setting versus the nonacute outpatient setting.

Rate of Onset of Action

ORAL MEDICATIONS

When giving an oral medication in the ED, the most common choices for those in crisis are formulations that deliver the medication and treatment response as quickly as possible. Medications such as extended-release formulations are usually not a reasonable first choice in emergencies because they do not have as rapid an onset of symptom relief as the regular formulation of the drug. Similarly, medications that take several days or weeks to take full effect, such as anti-depressants, are usually not given in emergency situations, although they may be started in the acute care venue when planning for longer-term care or inpatient admission.

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