Chapter 25: Behavioral Health Disorders

ADULT PSYCHIATRIC PATIENTS IN THE EMERGENCY DEPARTMENT

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

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

1. Assess all patients for a coexisting psychiatric disorder (dual diagnosis).

2. Addiction-focused psychosocial intervention is helpful for patients with alcohol dependence.

3. Consider adjunctive pharmacotherapy under close supervision for alcohol dependence:

   1. Naltrexone and Acamprosate have the best evidence for their use (COMBINE Trial https://www.ncbi.nlm.nih.gov/pubmed/16670409).

ANXIETY

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)

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 ...