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

USPSTF 2018, APA 2018

• – 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.

Sources

• – JAMA. 2018;320(18):1899-1909.

• – Am J Psychiatr. 2018;175(1):86-90.

Comments

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

2. Use disorder-focused psychosocial intervention for patients with alcohol dependence.

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

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

   2. Consider gabapentin or topiramate if patient has not responded to above (https://psychiatryonline.org/doi/pdf/10.1176/appi.books.9781615371969)

ANXIETY

Population

• – Adults.

Recommendations

NICE 2018

• – Recommends cognitive behavioral therapy for generalized anxiety disorder (GAD).

• – Consider sertraline first 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

• – nice.org.uk/guidance/cg113

ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD)

Population

• – Children age 4–18 ...