Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + ADULT PSYCHIATRIC PATIENTS IN THE EMERGENCY DEPARTMENT Download Section PDF Listen +++ +++ Populations ++ –Adult patients presenting to ED with psychiatric symptoms. –Adults with abnormal liver chemistries. +++ Recommendations ++ –No role for routine laboratory testing. Medical history, examination, and previous psychiatric diagnoses should guide testing. –No role for routine neuroimaging studies in the absence of focal neurological deficits. –Risk assessment tools should not be used in isolation to identify low-risk adults who are safe for ED discharge if they present with suicidal ideations. ++ Source ++ –Nazarian DJ, Broder JS, Thiessen ME, Wilson MP, Zun LS, Brown MD; American College of Emergency Physicians. Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med. 2017;69(4):480-498. + ALCOHOL USE DISORDERS Download Section PDF Listen +++ +++ Population ++ –Adults. +++ Recommendations ++ CDC 2018, USPSTF 2013, ASAM 1997 ++ –For patients identified with an Alcohol Use Disorder, provide a brief intervention and schedule follow-up via SBIRT (Screening Brief Intervention, and Referral to Treatment) model. –Refer all patients with life-threatening withdrawal such as seizure or delirium tremens to a hospital for admission. –Refer more stable outpatients to a behavioral therapy such as the IOP (Intensive Outpatient Program), an RTC (residential treatment center), or a Sober Living facility. –Recommend prophylactic thiamine for all harmful alcohol use or alcohol dependence. –Refer suitable patients with decompensated cirrhosis for consideration of liver transplantation once they have been sober from alcohol for ≥3 mo. –Recommend pancreatic enzyme supplementation for chronic alcoholic pancreatitis with steatorrhea and malnutrition. +++ Comments ++ Assess all patients for a coexisting psychiatric disorder (dual diagnosis). Addiction-focused psychosocial intervention is helpful for patients with alcohol dependence. Consider adjunctive pharmacotherapy under close supervision for alcohol dependence: Naltrexone and Acamprosate have the best evidence for their use (COMBINE Trial https://www.ncbi.nlm.nih.gov/pubmed/16670409). + ANXIETY Download Section PDF Listen +++ +++ Population ++ –Adults. +++ Recommendations ++ NICE 2011 ++ –Recommends cognitive behavioral therapy for generalized anxiety disorder (GAD). –Recommends sertraline if drug treatment is needed. –If sertraline is ineffective, recommend a different selective serotonin reuptake inhibitor (SSRI) or selective noradrenergic reuptake inhibitor (SNRI). –Avoid long-term benzodiazepine use or antipsychotic therapy for GAD. ++ Source ++ –http://www.nice.org.uk/nicemedia/live/13314/52599/52599.pdf + ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD) Download Section PDF Listen +++ +++ Population ++ –Children age 4–18 y. +++ Recommendations ++ AAP 2011 ++ –Initiate an evaluation for ADHD in any child who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity. –Consider children with ADHD as children with special health care needs. –For children age 4–5 y, parent- or teacher-administered behavior therapy is the treatment of choice. –Methylphenidate is reserved for severe refractory cases. –For children age 6–18 y, first-line treatment is with FDA-approved medications for ADHD ± behavior therapy. ++ Source ++ –http://pediatrics.aappublications.org/content/early/2011/10/14/peds.2011-2654.full.pdf +++ Population ++ –Children, young adults, and adults. +++ Recommendations ++ NICE 2018 ++ –Health care and education professionals require training to better address the needs of people with ADHD. –Recommends against universal screening for ADHD in nursery, primary, and secondary schools. –A diagnosis of ADHD should only be made by a specialist psychiatrist, pediatrician, or other appropriately qualified health care professional with training and expertise in the diagnosis of ADHD. –Health care professionals should stress the value of a balanced diet, good nutrition, and regular exercise for children, young people, and adults with ADHD. –Drug treatment is not recommended for preschool children with ADHD. –Drug treatment is not indicated as the first-line treatment for all school-age children and young people with ADHD. It should be reserved for those with severe symptoms and impairment or for those with moderate levels of impairment who have refused nondrug interventions. –Where drug treatment is considered appropriate, methylphenidate, atomoxetine, and dexamfetamine are recommended, within their licensed indications, as options for the management of ADHD in children and adolescents. –For adults with ADHD, drug treatment should be the first-line treatment. Following a decision to start drug treatment in adults with ADHD, lisdexamfetamine or methylphenidate should normally be tried first. Atomoxetine or dexamfetamine should be considered in adults unresponsive or intolerant to an adequate trial of methylphenidate. –For all patients, obtain a second opinion or refer to a tertiary service if ADHD symptoms are not controlled on one more stimulants and one nonstimulant. –Do not offer any of the following medications for ADHD without advice from a tertiary ADHD service: Guanfacine for adults. Clonidine for children with ADHD and sleep disturbances, rages, or tics. Atypical antipsychotics in addition to stimulants for people with ADHD or coexisting pervasive aggression, rages, or irritability. ++ Source ++ –https://www.nice.org.uk/guidance/ng87/chapter/Recommendations#medication +++ Comments ++ Essential to assess any child with ADHD for concomitant emotional, behavioral, developmental, or physical conditions (eg, mood disorders, tic disorders, seizures, sleep disorders, learning disabilities, or disruptive behavioral disorders). For children 6–18 y, evidence is best to support stimulant medications and less strong to support atomoxetine, ER guanfacine, and ER clonidine for ADHD. + AUTISM SPECTRUM DISORDERS Download Section PDF Listen +++ +++ Population ++ –Children and young adults. +++ Recommendations ++ NICE 2011, updated 2017 ++ –Consider autism for regression in language or social skills in children <3 y. –Clinical signs of possible autism have to be seen in the context of a child’s overall development, and cultural variation may pertain. –An autism evaluation by a specialist is indicated for any of the following signs of possible autism: Language delay. Regression in speech. Echolalia. Unusual vocalizations or intonations. Reduced social smiling. Rejection of cuddles by family. Reduced response to name being called. Intolerance of others entering into their personal space. Reduced social interest in people or social play. Reduced eye contact. Reduced imagination. Repetitive movements like body rocking. Desire for unchanged routines. Immature social and emotional development. ++ Source ++ –https://www.nice.org.uk/guidance/cg128 ++ American College of Medical Genetics and Genomics 2013 ++ –Every child with an ASD should have a medical home. –A genetic consultation should be offered to all patients with an ASD and their families. –Three-generation family history with pedigree analysis. –Initial evaluation to identify known syndromes or associated conditions. Examination with special attention to dysmorphic features. If specific syndromic diagnosis is suspected, proceed with targeted testing. If appropriate clinical indicators present, perform metabolic and/or mitochondrial testing (alternatively, consider a referral to a metabolic specialist). Chromosomal microarray: oligonucleotide array-comparative genomic hybridization or single-nucleotide polymorphism array. Deoxyribonucleic acid (DNA) testing for fragile X (to be performed routinely for male patients only). –Methyl-CPG-binding protein 2 (MECP2) sequencing to be performed for all females with autism spectrum disorders (ASDs). –MECP2 duplication testing in males, if phenotype is suggestive. –Phosphatase and tensin homolog (PTEN) testing only if the head circumference is >2.5 standard deviation (SD) above the mean. ++ Source ++ –https://www.nature.com/articles/gim201332 + DEPRESSION Download Section PDF Listen +++ +++ Population ++ –Children and adolescents. +++ Recommendations ++ USPSTF 2016 ++ –Adequate evidence showed that SSRIs, psychotherapy, and combined therapy will decrease symptoms of major depressive disorder in adolescents age 12–18 y. –Insufficient evidence to support screening and treatment of depression in children age 7–11 y. ++ Source ++ –USPSTF. Depression in Children and Adolescents: Screening. 2016. +++ Comment ++ Good evidence showed that SSRIs may increase absolute risk of suicidality in adolescents by 1%–2%. Therefore, SSRIs should be used only if close clinical monitoring is possible. + EATING DISORDERS Download Section PDF Listen +++ +++ Population ++ –Adults and children with eating disorders. +++ Recommendations ++ APA, accessed 2018 ++ –Psychiatric management begins with the establishment of a therapeutic alliance. –Recommend a multidisciplinary approach with a psychiatrist, dietician, social worker, and physician. –Components of the initial evaluation include: A thorough history and physical examination. Assessment of the social history. An evaluation of the height and weight history. Any family history of eating disorders or mental health disorders. Assess attitude of eating, exercising, and appearance. Assess for suicidality. Assess for substance abuse. Recommend nutritional rehab for seriously underweight patients. Recommend nasogastric tube feeding over parenteral nutrition for patients not meeting caloric requirements with oral feeds alone. Psychosocial rehab for patients with both anorexia nervosa and bulimia nervosa. Prozac is preferred agent to prevent relapse during maintenance phase of bulimia nervosa. Labs CBC. Chemistry panel. TSH. Additional testing Bone mineral densitometry if amenorrhea for more than 6 mo. Dental evaluation for history of purging. ++ Source ++ –http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/eatingdisorders.pdf + PREGNANCY, SUBSTANCE ABUSE Download Section PDF Listen +++ +++ Population ++ –Pregnant or postpartum patients using alcohol or illicit drugs. +++ Recommendations ++ WHO 2014 ++ –Health care providers should ask all pregnant women about their use of alcohol and other illicit drugs at prenatal visits. –Health care providers should offer a brief intervention and individualized care to all pregnant women using alcohol or drugs. –Health care providers should refer pregnant women with alcohol or cocaine or methamphetamine abuse to a detoxification center. Women with opioid addiction should continue a structured opioid maintenance program with either methadone or buprenorphine. Women with a benzodiazepine addiction should gradually wean the dose. –Mothers with a substance abuse history should be encouraged to breast-feed unless the risks outweigh the benefits. –Carefully monitor and treat infants of substance abusing mothers. ++ Sources ++ –ASAM. https://www.asam.org/advocacy/find-a-policy-statement/view-policy-statement/public-policy-statements/2017/01/19/substance-use-misuse-and-use-disorders-during-and-following-pregnancy-with-an-emphasis-on-opioids –http://www.who.int/substance_abuse/activities/pregnancy_substance_use/en/ + TOBACCO ABUSE, SMOKING CESSATION Download Section PDF Listen +++ +++ Population ++ –Adults, including pregnant women who smoke tobacco. +++ Recommendations ++ USPSTF 2015, AAFP 2015 ++ –Current evidence is insufficient to recommend electronic nicotine delivery systems for tobacco cessation in adults, including pregnant women. –Current evidence is insufficient to assess the benefits and harms of pharmacotherapy interventions for tobacco cessation in pregnant women. ++ Sources ++ –USPSTF. Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions. 2015. –ACOG. https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Smoking-Cessation-During-Pregnancy ++ Table Graphic Jump Location | Download (.pdf) | Print TOBACCO CESSATION TREATMENT ALGORITHM Five A’s Ask about tobacco use. Advise to quit through clear, personalized messages. Assess willingness to quit. Assist to quit,a including referral to Quit Lines (eg, 1-800-NO-BUTTS). Arrange follow-up and support. aPhysicians can assist patients to quit by devising a quit plan, providing problem-solving counseling, providing intratreatment social support, helping patients obtain social support from their environment/friends, and recommending pharmacotherapy for appropriate patients. Use caution in recommending pharmacotherapy in patients with medical contraindications, those smoking <10 cigarettes per day, pregnant/breast-feeding women, and adolescent smokers. As of March 2005, Medicare covers costs for smoking cessation counseling for those who (1) have a smoking-related illness; (2) have an illness complicated by smoking; or (3) take a medication that is made less effective by smoking. (http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=130).Source: Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: Quick Reference Guide for Clinicians. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service; 2008 (http://www.ahrq.gov/legacy/clinic/tobacco/tobaqrg.pdf). ++ Table Graphic Jump Location | Download (.pdf) | Print MOTIVATING TOBACCO USERS TO QUIT Five R’s Relevance: personal Risks: acute, long term, environmental Rewards: have patient identify (eg, save money, better food taste) Road blocks: help problem-solve Repetition: at every office visit ++ Table Graphic Jump Location | Download (.pdf) | Print TOBACCO CESSATION TREATMENT OPTIONSa Pharmacotherapy Precautions/Contraindications Side Effects Dosage Duration Availability First-Line Pharmacotherapies (approved for use for smoking cessation by the FDA) Bupropion SR History of seizure History of eating disorder Insomnia Dry mouth 150 mg every morning for 3 d, then 150 mg bid (Begin treatment 1–2 wk prequit) 7–12 wk maintenance up to 6 mo Zyban (prescription only) Nicotine gum — Mouth soreness Dyspepsia 1–24 cigarettes/d: 2-mg gum (up to 24 pieces/d) 25+ cigarettes/d: 4-mg gum (up to 24 pieces/d) Up to 12 wk Nicorette, Nicorette Mint (OTC only) Nicotine inhaler — Local irritation of mouth and throat 6–16 cartridges/d Up to 6 mo Nicotrol Inhaler (prescription only) Nicotine nasal spray — Nasal irritation 8–40 doses/d 3–6 mo Nicotrol NS (prescription only) Nicotine patch — Local skin reaction Insomnia 21 mg/24 h 14 mg/24 h 7 mg/24 h 15 mg/16 h 4 wk Then 2 wk Then 2 wk 8 wk NicoDerm CQ (OTC only), generic patches (prescription and OTC) Nicotrol (OTC only) Varenicline Renal impairment Nausea Abnormal dreams 0.5 mg qd for 3 d, then 0.5 mg bid for 4 d, then 1.0 mg PO bid 12 wk or 24 wk Chantix (prescription only) Second-Line Pharmacotherapies (not approved for use for smoking cessation by the FDA) Clonidine Rebound hypertension Dry mouth Drowsiness Dizziness Sedation 0.15–0.75 mg/d 3–10 wk Oral clonidine—generic, Catapres (prescription only), transdermal Catapres (prescription only) Nortriptyline Risk of arrhythmias Sedation Dry mouth 75–100 mg/d 12 wk Nortriptyline HCL–generic (prescription only) bid, twice daily; FDA, Food and Drug Administration; OTC, over-the-counter; PO, by mouth; qd, every day.aThe information contained within this table is not comprehensive. Please see package inserts for additional information.Source: U.S. Public Health Service.