Chapter 48. Emergency Psychiatry

Emergency psychiatry encompasses the urgent evaluation and management of patients with active symptoms. The definition of emergency is determined by the ability of the patient or the patient's social environment to tolerate these symptoms. Although these emergency evaluations are most commonly performed in hospital settings, mobile crisis teams permit completion of emergency assessment in community settings.

The goals of emergency psychiatric care are similar to those of emergency medical–surgical care: (1) triage, (2) expeditious, pertinent assessment, (3) accurate differential diagnosis, (4) management of acute symptoms, and (5) appropriate discharge planning.

Triage

The triage function determines the degree of urgency of the patient's presentation and the initial pathway for evaluation of the patient. The triage clinician must first distinguish between situations that constitute a genuine emergency and those that, although perceived as such by the patient or others, can safely await later assessment.

Next, the triage clinician must correctly identify, among a variety of emergency situations, those that reflect a need for psychiatric evaluation as a first step. This is a critical decision as patients may have both medical and psychiatric complaints or exhibit behaviorial problems that may originate from a medical, neurological or substance induced disorder. A medical evaluation including a brief history of the presenting complaint and physical assessment including vital signs is a critical component of this triage function.

Lastly, the triage clinician must assure the safety of patients until they can be evaluated by a psychiatrist or other mental health professional. In emergency room (ER) settings where patients often present with severe injuries, it is possible to overlook the needs of a well-groomed patient arriving with no obvious disorder. However, this patient may have suicidal or homicidal ideation that can be as life threatening as any other medical emergency and requires immediate attention to ensure the safety of the patient and others.

While initial triage is most commonly undertaken by nursing personnel, the psychiatrist must assume an active role in the training and supervision of those clinicians and in the formulation of standards and clinical criteria applied during the triage “sorting” function. Triage is only as effective as the quality of the standards and the rigor with which they are applied.

Assessment

Assessment of psychiatric patients under emergency circumstances focuses on the need to quickly evaluate the pertinent aspect(s) of the patient's presentation, with special attention to potential life-threatening issues. Although the patient may have had an initial brief medical evaluation and triage to psychiatry, the clinician should continue to be alert to the possibility that the patient has a medical disorder or substance induced disorder underlying their presentation.

The clinician should assemble as much data as possible before addressing the patient directly. For example, if information suggests that the patient may be dangerous to themselves or to others, appropriate security arrangements should be made. For example, the patient may need to have a staff member be assigned to sit with them to assure safety or be searched for potential weapons.

During the initial moments of the direct encounter with the patient, the clinician should form an overall impression of the patient. This impression may include data from sources like the patient's level of consciousness, appearance, willingness to engage with the clinician, apparent mood, psychomotor retardation or agitation and initial conversation. This initial period of direct observation can be helpful in determining whether the patient has been triaged correctly or whether additional medical evaluation or security arrangements are required.

Despite the common pressure to proceed expeditiously, clinicians should attempt to be thorough in both their medical or psychiatric evaluations. Special attention should be focused on recent psychosocial stressors, which may have precipitated the patient's presentation in the ER. These stressors may include disruptions in housing and work or disruptions in important relationships, including romantic relationships, family relationships, and the patient's relationship with their current outpatient clinician. Events like an argument with a family member or friend, or the vacation of an outpatient clinician, can precipitate a patient's presentation for emergency treatment. Clinicians in emergency settings should include information from others in patient's life in their assessment; this collateral information may be quite pertinent to the overall evaluation of the patient.

The emergency assessment must include the presenting history and psychosocial stressors, past and current medical problems, current engagement in medical and psychiatric treatment, current medications and adherence to the medical regimen, history of past and current substance abuse, social history including the patient's living and financial arrangements and current status of significant relationships, physical examination (including neurological screening exam), mental status examination, and screening laboratory workup. This assessment will help determine what other appropriate laboratory, toxicology, or imaging studies should be ordered.

Diagnosis

The pressures of the emergency setting do not allow the detailed diagnostic assessment possible in other settings. However, the clinician should construct a differential diagnosis which can be utilized to guide further emergency evaluation. In constructing this differential diagnosis a high priority must be given to medical, neurological and substance induced etiologies of the presenting complaint. Table 48–1 lists four sequential questions that must be considered in making a differential diagnosis.

Initial Treatment

Treatment interventions, when appropriate as an emergency procedure, will usually follow the diagnostic assessment. However, sometimes the clinician must intervene before gathering all the diagnostic information. This is particularly true when the patient must be kept safe due to concern about being a danger to self or others. In most circumstances, emergency interventions will fall into one or more of four categories: Environmental management, medication, crisis intervention, and education.

Environmental Management

As noted above, clinicians must be attentive to providing a safe environment for patients. These interventions often occur before a full evaluation is completed. In addition to ensuring a safe environment, patients may benefit from having diminished stimulation in their environment. Availability of a “quiet room” is often helpful to reducing psychomotor agitation.

At times, modifying the home environment of a patient may avoid a hospitalization. Providing alternative short-term housing during a crisis, respite care for an elderly patient or emergency placement of a child can decrease the patient's symptoms.

Medication Interventions

Clinicians in ER settings should be careful about initiating pharmacological interventions for several reasons. First, initial diagnostic impressions may prove inaccurate. Second, the full laboratory assessment of the patient may not be complete. Third, treatment with medications may produce sedation which can mask other signs of medical illness. Lastly, the clinician in the ER will likely not be treating the patient in follow-up. Therefore, in general, pharmacological interventions should be limited to those needed to help manage the patient in the emergency setting.

Clinicians in the emergency setting utilize medications like benzodiazepines and antipsychotics in order to manage symptoms of psychomotor agitation. The use of benzodiazepines like lorazepam may be appropriate treatment for severe anxiety or for agitation associated with alcohol or sedative withdrawal. Treatment with an antipsychotic like haloperidol is sometimes useful for treating psychomotor agitation in patients with acute psychotic states. When a patient is acutely agitated or threatening these medications can be given intramuscularly to minimize time of onset.

Giving a patient medication to manage symptoms until the patient is seen in outpatient treatment requires careful consideration of several factors including the patient's compliance, issues of safety, and the amount of time before outpatient follow-up care will begin. The possibility that the patient is seeking benzodiazepines or pain medication because of an addiction should be considered before prescription of benzodiazepines or narcotics. In general, patients should not be given more than a few days supply of medication at any one time.

Crisis Intervention

Psychological strategies based on a biopsychosocial understanding of the situation can often de-escalate a crisis. Such techniques include ventilation, identification of alternatives, clarification of interpersonal roles, interpretation of meaning, or simply empathic listening. Meeting with the patient and their family or significant other can help resolve difficulties that may have led to the patient seeking care in an emergency setting.

Education

An important but often overlooked component of treatment in the ER is the opportunity for preventive education. The patient, family members, significant others, and even other caretakers will sometimes benefit greatly from education about the disorder. For example a patient with new onset panic disorder may be able to avoid returning to the ER if sufficiently educated about the nature of their disorder. Clarification of the situation in a way that can avoids unwarranted guilt or confusion will be helpful to all involved. The patient and others important to the patient may avoid a sense of alienation, shame, and hopelessness by better understanding the diagnosed illness, its prevalence, and its prognosis.

Discharge Planning

Discharge planning from a psychiatric emergency depends on the resources that are realistically available. In general, at least four issues must be considered: (1) initial level of care, (2) the patient's willingness to seek treatment, (3) timing of initial follow-up care, (4) interval provisions, and (5) communication with the patient and subsequent caretakers.

Initial Level of Care

As the most restrictive and expensive alternative, 24-hour inpatient care should be utilized only after careful consideration of several factors. Commonly accepted criteria for such care include mental illness associated with imminent danger to self or others, grave impairment of function to a degree that prohibits self-preservation in the most supportive environment available, and diagnostic uncertainty that could result in a lethal outcome.

Less restrictive alternatives include crisis housing with less intensive staff observation, partial or day hospitalization, and intensive or routine outpatient follow-up care. The objective is to provide the least restrictive level of care that meets the patient's clinical needs. The patient's ability to pay for different services is a factor which unfortunately can determine what follow-up care is able to be provided to the patient. In some settings, indigent patients may have access to more services than low-income patients without Title XIX entitlements.

The Patient's Willingness to Seek Treatment

A patient presenting for psychiatric treatment may not have been brought to the ER voluntarily. Frequently, the police or the family members bring an individual to the ER for treatment. If a determination is made that the patient requires inpatient level of care, and the patient is unwilling to be admitted, the clinician may need to initiate an involuntary hospitalization process. While the administrative processes vary in each state, licensed physicians are able to involuntarily admit patients who meet standards of suicidality, homocidality, or who are unable to care for themselves due to their mental illness.

In general, patients with psychiatric disorders have the same right to refuse treatment that patients with other medical conditions have. In most instances, if a patient in an ER does not meet legal requirements for involuntary hospitalization and is unwilling to seek outpatient care, the patient's decision must be respected. Patients who report not wanting outpatient treatment should be provided options for accessing care should they change their minds after discharge from the ER.

Timing of Initial Follow-Up Care

For patients interested in outpatient treatment, the discharge planning should include determination of the clinically permissible time interval before a less restrictive level of care is available. For example, a situation that requires urgent outpatient follow-up care should not be scheduled 2 or 3 weeks later.

Interval Provisions

If too much time will elapse before initial follow-up care can be scheduled, the patient and relevant others should be informed of what to do. In most cases, if a scheduled return to the ER is anticipated, the clinician who provided the initial emergency assessment is best prepared to handle return visits.

Communication with the Patient & Subsequent Caretakers

A breakdown in communication with clinicians providing outpatient care often frustrates the patient and can lead to nonadherence with the plan of care developed in the emergency setting. The precise discharge plan should be written out and given to the patient (and, when appropriate, to the family, significant others, and clinicians who will assume the patient's subsequent care). An opportunity to raise questions, seek clarification of details, and better understand the clinical rationale of the discharge plan should be a routine part of this process.

Equally important is, the timely communication with other professional caretakers who are to provide subsequent treatment. This communication should provide enough detail for other clinicians to begin active treatment with the patient. A smooth transition in care gives the patient a reassuring sense of continuity from emergency onset to final initiation of outpatient treatment.

Four special issues merit special consideration in the setting of emergent psychiatric evaluation: Suicide, homicide and other violence, disaster psychiatry, and the medico–legal aspects of psychiatric evaluation and treatment in the emergency setting.

Suicide

Suicide accounts for about 30,000 deaths each year in the United States. The number of attempted suicides is many times larger. Up to 80% of individuals who commit suicide have seen a physician or other health care personnel within two weeks before their deaths; most often this health care professional was not in the mental health care field. Therefore it is extremely important that all health care professionals be alert to the signals of distress and risk factors for suicide; this is especially true in emergency psychiatry where assessment of patients with suicidal ideation is a common occurrence.

Perhaps the single most important element in the assessment of suicidal risk is constant awareness of the possibility that it exists. The patient may make no direct reference to self-destruction unless asked; this question is of course an essential component of any emergency psychiatric evaluation. Assessment of risk factors known to predispose to suicide is one method to quantify the risk that the patient will attempt suicide (Table 48–2). However, many patients with serious mental illness, especially those with dual diagnosis (mental illness and a substance abuse disorder) will have many of the risk factors known to predispose to suicide. Clinical judgment and the patient's ability to work with the clinician to develop a treatment plan that mitigates certain stresses and risk factors will help determine whether the patient is able to safely leave the emergency evaluation setting or requires inpatient treatment. Clear documentation of the assessment, including risk factor assessment is critical in the evaluations of the suicidal patient.

Homocidal Ideation and Violence

The relationship between violence and mental illness is complex. Although intense media coverage of violence perpetrated by patients with mental disorders can lead one to think that this is a common occurrence, it is important to note that more patients with serious mental disorders are more often victims of violence than perpetrators of violence. However, patients with severe mental illness, perhaps especially those with psychotic paranoid component, can act on their delusions that someone is going to hurt them or that they are being told to kill another person. As with the assessment of suicidal ideation, many clinical and epidemiologic factors need to be considered in the assessment of homicidal ideation or violence risk (Table 48–3). The clinician who is called upon to make an emergency assessment must be aware of the legal ramifications (see Chapter 50), he or she is best advised to approach the task with the admonition that justice is served best by thorough, objective, accurate assessment and documentation.

Disaster Psychiatry

In the aftermath of terrorist attacks and natural disasters interest in the psychiatric aspects of response to these events has grown. It is reasonable to expect that in future disasters people, communities, and governments will look to psychiatrists for leadership. While this is a rapidly developing field, some valuable lessons have already been learned. Broadly, successful responses to these situations should be shaped by the type of disaster and the affected populations. These will, of course, vary from situation to situation but an analysis in these terms can help to plan for appropriate initial and enduring responses. Among the different types of disasters are ones without warning (terrorist attacks, earthquakes), ones with some warning, (hurricanes, floods), and those with potentially longer-term notice (infectious disease outbreaks). The impact of these events can be modified by such variables as intensity and duration of the event, number of people and particular sub-populations affected, degree to which those people are affected, and post-disaster response issues such as ongoing safety and available resources. Following a disaster, initial attention is frequently directed at “new” casualties or the population that is presumed to have suffered psychologically as a result of the disaster. And in fact, survivors of recent disasters have illustrated psychological morbidity associated with these events that have, at times, surprised responders. However, recent experience has also shown the need to address two other critical populations at these times. Responders have observed the pressing, and at times, overwhelming needs of those patients already receiving mental health treatment prior to the disaster. Some groups of patients, such as the severely mentally ill population, are particularly vulnerable to stress and can present in a decompensated state with records that can be inaccessible or destroyed. Lastly, the mental health needs of staff, both mental-health and nonmental-health providers, needs to be carefully monitored as they try to provide services to patients in dire need and under extremely trying circumstances.

Medico–legal Aspects of Psychiatric Care in Emergency Settings

Given the acuity of patient presentations and the frequent risk assessments being completed, attending to the medico–legal aspects of emergency psychiatry is of great importance. Clinicians working in emergency psychiatric settings must have access to legal advice and should have a low threshold to consult with legal counsel. Clear documentation of the patient's history, risk factors, and the clinician's decision-making process (including consultation with other clinicians and with legal counsel), and treatment plan is imperative.

Involuntary Patients

As suggested above, patients may be brought to the ER by the police or by the family because of suicidal ideation, homicidal ideation or due to other aberrant thoughts and behaviors. Once in the emergency setting they may decide they do not want to consent for evaluation or for treatment. In general, if there is suspicion that a patient may be at risk of hurting themselves or others, common law principles would allow holding the patient until a full evaluation can be completed.

As noted above, all states have methods providing for involuntary hospitalization of patients evaluated to be at significant risk of injury to themselves or others. Clinicians working in these settings should be know how to apply these laws and what right of appeal patients may have.

Confidentiality

Patients have the right to expect clinicians to respect the confidentiality of their communications. There are some circumstances in which common law and case law may support breaching patient confidentiality. One common circumstance involves a patient refusory to allow communication with an outpatient clinician. For example, the clinician may suspect a drug overdose and need to know the medications that the patient was taking. In this clear emergency setting, allowance would generally would be made under common law to proceed with contacting the outpatient clinician. In situations in which there is a less clearly life-threatening situation, the clinician may need to respect the patient's confidentiality and not contact the outpatient clinician.

Duty to Warn

If a clinician working in an ER believes that a patient poses a significant risk of injury to another person, and the patient leaves the ER before being admitted to the hospital inpatient unit, the ER clinician may be required to warn the individual thought to be at risk. This Duty to Warn stems from California case law, Tarasoff vs. Regents of the University of California (1976). This precedent has not been endorsed in all states.

Patients with a variety of clinical syndromes may present in a health care setting for emergency psychiatric treatment (Table 48–4). The following sections discuss the disorders most commonly requiring emergency treatment.

Geriatric Conditions

Assessment

Elderly patients presenting with a psychiatric emergency require careful medical assessment as coexisting medical disorders and medical treatments often precipitate psychiatric presentation. A thorough review of systems, a complete physical examination, and appropriate screening laboratory tests, including a urinalysis, are imperative in this age group. A medically oriented evaluative approach may be more effective than a traditional psychiatric one.

In addition to determining whether the patient may have any sensory deficits, the clinician should speak clearly and slowly to geriatric patients. When a cognitive disorder is suspected, the clinician should ask short and simple questions in a straightforward manner, should repeat them as necessary and should strongly consider a collateral source to ensure the accuracy of the history.

Common geriatric emergencies include delirium, dementia, depression, and psychosis. Delirium and dementia may coexist with each other and with depression and psychosis (Chapter 14).

Delirium

Because delirium is characterized by an acute change in mental status, presentation for emergency evaluation is not uncommon. Delirium is characterized by acute changes in concentration, which may be accompanied by other cognitive changes, perceptual changes like hallucinations or delusions and behavior changes like psychomotor retardation or agitation.

Delirium is a medical emergency that has a potentially fatal outcome; the possibility that the patient is delirious should be high on the differential list for all elderly patients presenting in the ER with an acute change in mental status or behavior. As soon as the clinician suspects delirium, a thorough medical evaluation should be initiated to determine the etiology. Urinary tract or other infections, onset or worsening of a medical or neurological condition, and adverse drug interactions, drug side effects (especially anticholinergic side effects) or drug intoxication secondary to an unintentional overdose related to cognitive impairment are all potential causes of delirium.

Dementia

Elderly patients with dementia are often brought to the psychiatric emergency setting with acute psychomotor agitation, including combativeness. If the psychomotor agitation is of new onset, delirium or pain must be suspected and the medical workup initiated. If no medical etiology is found, the possibility that the patient is in pain from constipation, urinary retention, fall or other source should be investigated. If no medical or pain source is identified, the patient may have had onset of a psychotic component to the dementia. If no psychotic component is present, the patient may have been upset by something or someone in the environment and have been unable to express their frustration except through agitation or combativeness. A careful review of the events precipitating the crisis may reveal the environmental issue needing to be changed.

Depression

Depressed elderly patients may minimize mood symptoms but exhibit marked diminishment in interest in activities. Suicidal risk is high in elderly white men living alone and so assessment of risk and construction of a treatment plan must be especially carefully considered for this population.

Psychosis

Presentation with new onset psychosis in the elderly necessitates review for coexisting delirium or dementia. However, recent reports have emphasized that up to 10% of patients with a lifetime history of schizophrenia may have late life onset of illness.

Treatment and Discharge Planning

Because of the high likelihood of a coexisting medical illness, elderly patient presenting in the psychiatry emergency setting are best treated in collaboration with a medical team.

For patients with cognitive disorders, the highly stimulating environment of most ERs are difficult to tolerate. If available, these patients benefit from provision of a quieter, less chaotic environment.

Demented patients who present with psychomotor agitation or combativeness due to a frustration with their environment may be calm upon removal from their environment and transfer to the emergency setting. Clinicians in the ER should work with caregivers to determine what the precipitant might have been and determine how to mitigate that precipitant in the future. When possible, it is preferable for elderly demented patients to be returned to their home environment as admission to hospital itself can predispose the demented patient to worsening of their cognitive status. Knowledge of community resources like respite programs, adult day care, and visiting nurse agencies with psychiatric or dementia care expertise can aid in returning the patient to the community.

If an elderly patient remains agitated and or combative in the emergency setting, clinicians should make efforts to determine whether the individual can be managed with close staff attention, diverting the patient's attention to other topics by talking about family or reading a magazine together. Because of the high incidence of side effects in the elderly, medication management in the emergency setting should be avoided if possible. If medication is necessary to control physical aggression a low dose of an antipsychotic (e.g., haloperidol 1 mg) is usually preferable to benzodiazepines. Low-potency antipsychotics (e.g., thioridazine or chlorpromazine) should be avoided due to anticholinergic side effects, which can worsen or precipitate delirium.

Alcohol Abuse

Assessment

Alcohol-related presentations are among the most common psychiatric emergencies. Presentations to emergency settings are most frequently associated with acute alcohol intoxication and withdrawal, including withdrawal delirium.

The clinical picture of intoxication generally depends on the patient's blood alcohol level (BAL) as determined by a breathalyzer test, but BAL cannot be used exclusively. In most jurisdictions, an individual with a BAL of 0.08–0.1 or greater is considered legally intoxicated. If a patient is intoxicated, the clinician must ascertain whether another chemical in addition to ethanol is related to the clinical presentation. A toxicology screen is essential. An intoxicated state is characterized by a combination of markedly maladaptive behavior or psychological changes and physical changes (e.g., slurred speech, ataxia, nystagmus, stupor, coma) that appear during or after alcohol ingestion.

Alcohol withdrawal delirium typically appears three days after cessation of or reduction in the context of heavy and extended alcohol use. It is characterized by a hyper adrenergic state, agitation, insomnia, gastrointestinal symptoms, hallucinations, hand tremors, and seizures.

Psychotic, mood, and anxiety disorders may be related to alcohol use. A thorough medical evaluation is warranted to exclude physical conditions that resemble intoxication or withdrawal.

Treatment and Discharge Planning

Patients with alcohol abuse often present with denial of their illness and should be interviewed in emergency settings in a manner consistent with the tenets of motivation enhancement. Clinicians should be knowledgeable about the availability of detoxification and treatment facilities in order to provide access to treatment if the patient is motivated. Patients presenting with alcohol abuse should have a physical examination including neurological exam to ensure the patient has not sustained injuries due to a fall or other accident while intoxicated.

A common and complex question is determining when a patient with alcohol intoxication or withdrawal is able to be safely discharged from the ER. After the BAL is below the legal limit for intoxication, the clinician must evaluate whether the patient continues to have significant mental or physical problems related to intoxication. If the patient is no longer acutely intoxicated, screening for other symptoms of psychiatric disorder like depression or psychosis and for the presence of suicidal or homicidal ideation should be completed. As substance abuse raises the risk of suicidal and violent behavior, a patient who exhibits these symptoms need to be evaluated and managed carefully, including consideration for inpatient treatment.

When possible it is preferable to discharge a patient with alcohol abuse or dependence accompanied by family or friends. Appropriate referral may include an outpatient detoxification or rehabilitation program, partial hospitalization, intensive or routine outpatient treatment, and Alcoholics Anonymous.

Assessment

Clinical history, specific physical examination findings, and a Toxicology screen may offer evidence of other drugs of abuse (Table 48–5).

Treatment and Discharge Planning

The management of intoxication or withdrawal depends on the specific type of drug (Chapter 15). Associated physical and psychiatric symptoms must be factored into the immediate treatment plan in a manner similar to that described with alcohol abuse.

Chemical restraints (e.g., lorazepam or haloperidol), seclusion, or physical restraints may be needed to manage violent behavior associated with drug intoxication. It is rarely indicated to start opiate detoxification in the ER setting as withdrawl from opiates is not life threatening, and starting these agents may reinforce the idea that the emergency setting can be utilized at times when opiates are not otherwise available. The principles of outpatient referral are the same as for alcohol.

Psychosis

Assessment

A psychotic state may occur either as a completely new event or as the exacerbation or reactivation of chronic psychotic disorder (see Chapters 16 and 17). The distinction is important because new-onset psychosis frequently warrants hospitalization, whereas the chronic condition often can be managed readily in cooperation with an outpatient team. Because of the high frequency of substance abuse disorders among patients with psychotic disorders, clinicians should strongly suspect substance use as contributing to new onset or exacerbations of psychosis. Assessment should also consider the patient's medical condition; adherence with prior treatment recommendations including psychiatric medications; the severity of impairment in activities of daily living; the patient's dangerousness to self and others; the presence of delusions, command auditory hallucinations, or thought disorder; and impairment of judgment about potentially dangerous situations.

Treatment and Discharge Planning

New onset acute psychotic conditions generally require hospitalization. Command hallucinations with suicidal or homicidal intent or impaired judgment and evidence of dangerous behavior may warrant involuntary hospitalization. Severe psychomotor agitation or threatening behavior may require physical restraint or psychopharmacologic intervention (e.g., haloperidol or lorazepam by mouth or intramuscularly depending on the clinical situation and cooperation of the patient).

Determination of the most appropriate and least restrictive level of care should include consideration of inpatient treatment, partial hospitalization, and outpatient care. When outpatient follow-up care will suffice, attention must be given to appropriate inclusion of the patient's outpatient clinicians, case managers, family members and other caretakers in developing the outpatient care plan. Initiation or adjustment of antipsychotic medication may be indicated after collaboration with the outpatient clinician and necessary laboratory studies are completed.

Depression

Assessment

A common presentation to the psychiatric ER is a depressed patient with melancholic features and suicidal ideation or behavior (see Chapter 18 and the discussion on suicide earlier in this chapter). In addition to identifying current stressors and probing for a history of depression, the clinician must pay close attention to comorbid conditions such as medical illness, psychosis, substance abuse, anxiety, and personality disorders.

Discharge Planning

As noted previously in this chapter, an inpatient treatment is frequently the most appropriate setting for patients with significant suicidal ideation or attempt. The availability of a vigorous, reliable support system may allow a less restrictive alternative to be considered. Referral for outpatient follow-up care of a depressed patient with suicidal ideation requires forethought about many factors such as safety, availability of supportive monitoring, time interval to next visit, access to help in the event of recurrent emergency, and advisability of medication use. In general, the patient should not be given antidepressant medication in an ER setting as the prescribing clinician will not be able to provide follow-up and there is increasing evidence that some antidepressants may precipitate suicidal ideation, especially in adolescent patients. Small doses of anxiolytics or hypnotics to treat anxiety and insomnia may be utilized to diminish symptoms until the patient is able to connect with outpatient treatment.

Mania

Assessment

The cardinal features of mania are elevation of mood or irritability and marked increases in goal directed behavior (see Chapter 18). Other frequently associated findings include grandiosity, pressured speech, flight of ideas, insomnia, increased psychomotor activity, social or economic indiscretion, and poor concentration. The manic patient generally does not initiate the search for help, but rather the people around him can no longer tolerate their behavior.

Assessment of the patient with bipolar disorder should include consideration of stimulant ingestion like cocaine, amphetamines, phencyclidine, and other medications like steroids. Cluster B personality disorder may also have mood instability which can be difficult at times to differentiate from bipolar disorder.

Discharge Planning

In the ER, a typical agitated patient with mania warrants immediate intervention. As in the case of acute psychosis, pharmacotherapy (e.g., lorazepam) with or without physical restraint may be required. Valproate or an atypical antipsychotic like olanzepine can be used as an alternative or adjunctively. The primary goal is to contain the patient's agitation as quickly as possible so that the patient may be transferred safely to an inpatient setting.

A clear-cut manic episode, especially if associated with psychotic symptoms, usually warrants inpatient care. A dual-diagnosis program should be considered when mania is associated with chemical abuse or dependence. Proper treatment of such comorbid conditions requires intervention other than the use of mood-stabilizing drugs.

Catatonia

Assessment

Catatonia is a rarely encountered clinical syndrome characterized by either excitement or withdrawal. The excited type is characterized by extreme purposeless motor activity, the withdrawn type is characterized by negativism, mutism, rigidity, posturing, waxy flexibility, and stupor. Catatonia is an emergency situation that requires immediate assessment to ensure medical problems like encephalitis or other causes of delirium are not present. Neuroleptic malignant syndrome (NMS) (described later in this chapter) merits consideration as a cause of catatonia.

Treatment and Discharge Planning

A thorough medical workup must be pursued in order to ensure significant medical problems are not involved in the presentation. Inpatient care is warranted because dehydration can be a major complication. Lorazepam can bring about quick improvement.

Acute Anxiety States

Assessment

Panic attack, acute stress disorder, adjustment disorder, posttraumatic stress disorder, conversion disorder, and dissociative states may lead patients to seek treatment in the ER (see Chapters 19, 20, and 21 for common presenting symptoms for these anxiety disorders).

Clinicians assessing patients presenting with anxiety disorders in emergency settings should be mindful of the events preceding the patient's presentation. For example, a patient with acute anxiety may not reveal to the triage staff that the precipitant for their anxiety was a traumatic event like an assault or a rape. Clinicians in psychiatry emergency settings should be aware of hospital protocols for counseling rape victims and managing evidence collection.

Treatment and Discharge Planning

Many patients with anxiety symptoms respond positively to supportive crisis oriented psychological interventions. Panic and other acute anxiety states respond favorably and quickly to a benzodiazepine such as lorazepam.

Most anxiety disorders can be managed on an outpatient basis with a balanced combination of pharmacotherapy and psychosocial interventions. A marked restriction of activities of daily living or other severe functional impairment may neccesitate inpatient care. Panic disorder patients, in the middle of a panic attack, may have suicidal ideation and have a higher than normal rate of attempting suicide. Reassurance that outpatient treatment can be efficacious and access to a benzodiazepam like lorazepam can usually help avoid inpatient hospitalization for these patients.

Personality Disorders

Assessment

Patients with Cluster B personality disorders frequently present in the ER after committing an impulsive act in the context of an interpersonal difficulty. The assessment of the patient with personality disorder can be made difficult by their mood lability, irritability, and use of defense mechanisms like displacement, projection and splitting.

Treatment and Discharge Planning

Identifying and managing one's own inner reactions to these patients and helping staff maintain therapeutic boundaries are key components to the treatment of patients with Cluster B personality disorders. A “here and now” approach, focused on resolution of the current stressor, is nowhere more important than in this clinical situation. The patient may frustrate clinicians utilizing this approach by refusing to provide permission to contact others important to resolving the presenting complaint. Evaluation of suicidal ideation is difficult in these patients as their mood instability and impulsivity means that a suicide attempt can be precipitated in response to an event that was difficult to predict. Comorbid substance abuse disorders are frequently present and worsen these patient's impulsivity, making the assessment of suicidality even more difficult.

It is extremely important to be in contact with the patient's treating clinicians and other caregivers in order to enlist them in helping to devise a treatment plan for the patient. Inpatient treatment can be regressive for these patients and so under most circumstances should be avoided. However, at times, inpatient care is unavoidable due to the patient's clinical presentation. Clinicians in emergency settings should have ongoing collaborative relationships with clinical programs like dialectical behavioral treatment programs or case management programs that care for patients with severe personality disorders; these collaborations can minimize the disruptions and staff splitting that can occur when these patients make frequent use of emergency settings.

Neuroleptic Malignant Syndrome

Assesment

NMS is a serious and potentially lethal symptom-complex. In NMS, three sets of symptoms appear very rapidly in response to antipsychotic (neuroleptic) treatment: (1) alteration in level of consciousness, (2) Autonomic symptoms like hyperthermia, tachycardia, labile hypertension, and tachypnea, and (3) neuromuscular symptoms like “lead pipe” muscle rigidity. Elevated creatinine phosphokinase level and leukocytosis are common laboratory findings. While the triad of altered mental status, muscle rigidity, elevated temperature, and hypertension should arouse the clinician's suspicion that NMS is present, the presence of even only one of these elements can be cause for concern. The syndrome can appear at any time, not only shortly after initiation of the antipsychotic.

Clinicians should evaluate the patient for other disorders, especially infections, which might be present.

Treatment

Antipsychotic medication must be stopped at once as NMS is frequently lethal. Supportive treatment like fluids, cooling blankets and medications to maintain blood pressure should be provided in a medical intensive care setting. The prescription of dantrolene or bromocriptine is indicated in situations where the patient is not responding to supportive interventions.

Conclusion

As in other fields of medical practice, patients present with urgent psychiatric symptoms that may be life threatening and require emergency evaluation. The first duty of a well-prepared clinician is to recognize which of those situations is more critical than others and then to identify correctly the pertinent problem(s) and to intervene appropriately. Central considerations include whether the patient presents an imminent danger to self or others and whether the patient has grave psychological or behavioral impairment that prevents the patient from living safely in the community.

Common interventions include safety precautions, astute observation, sensitive inquiry, consideration of unsuspected medical conditions, crisis oriented psychological treatment, judicious use of psychopharmacologic agents, and referral to the most appropriate and least restrictive level of follow-up care. Not to be overlooked is the admonition that psychiatric emergency care should always be provided in a respectful manner, no matter how disturbed or disruptive the patient may be.