20: Psychiatric Emergencies

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Section 20 Psychiatric Emergencies

Edited by George Jelinek

20.1 Mental state assessment

Epidemiology

Recent estimates place mental health disorders as one of the three leading causes of total burden of disease and injury in Australia, alongside cancer and cardiovascular disease.4,5,6 In middle age, it is the leading cause of non-fatal disease burden in the Australian population. There is no doubt that mental health disorders have a high prevalence, are disabling and are high cost in both human and socioeconomic terms.4,5

In terms of disability, it has been estimated that having moderate to severe depression is the equivalent of having congestive cardiac failure,6 chronic severe asthma or chronic hepatitis B.5 Severe post traumatic stress syndrome was comparable to the disability from paraplegia and severe schizophrenia was comparable to quadriplegia, in terms of disability.5 Over the last 10 years emergency department (ED) presentations have risen 8% in the USA, whereas mental health presentations for the same time period have risen 38%, contributing significantly to ED overcrowding.7 This trend has been mirrored in Australia.

Contributing to this may be:

The Australian Institute of Health and Welfare report into Mental Health Services in 2007 estimated that there were over 190 000 occasions of service to Australian EDs where the primary problem was thought to be due to a mental health disorder. This was estimated to be approximately 3.2% of total presentations to public hospital EDs.4 This correlates well with other studies and US figures, which estimate 2–6 % of emergency medicine presentations are primarily due to mental health disorders.1,7,8,9

Two-thirds of these people are between the ages of 15 and 44 years (compared to 42% for the general population presenting to a suburban ED. 29% have anxiety and neurotic disorders, 21% mental and behavioural disorders due to psychoactive substance abuse, 19% mood disorders and 17% schizophrenia or delusional disorders.7

This, of course, is a gross underestimate of the prevalence of mental health disease in the ED as many patients remain undiagnosed, and many have active medical conditions and a mental health diagnosis may be secondary.8

It is estimated that 17.7% of adult Australians admitted to hospital report a mental health issue in the previous 12 months. An estimated 0.4–0.7% of the adult population suffer from a psychotic episode in any one year.5 Mental health issues are highly prevalent and relevant.

Introduction to the mental state examination

The mainstreaming of mental health patients into general EDs has brought problems and anxieties for staff. Staff often feel a lack of confidence because they are dealing with a population of patients unfamiliar to them. They also feel inadequate due to poor assessment skills.9,10

Mental health patients are often seen as ‘low yield’, unrewarding and there is often a negative attitude expressed toward them.9,10 A high proportion have drug and alcohol intoxication. This confounds the evaluation and treatment, lengthens the stay of these patients within the ED and delays their disposition. Mental health patients are sometimes perceived as ‘frequent flyers’ – victims of chronic disease that can never be cured – and can be seen as burdensome and unrewarding.

These negative attitudes have resulted in mental health patients being assigned lower triage categories and longer waits to be seen by staff than mainstream patients. They have a higher chance of leaving before assessment has begun or is complete and the overall increase in length of assessment time has the potential to increase violence in the ED.9,10

With this in mind, there has been much work over the last 10 years on the assessment of mental health patients in a general ED.

Triage

The Mental Health Triage Scale (Table 20.1.2) has been developed and modified to be included into the Australian Triage Scale (ATS).3,9,11 It is very broad and asks the triage nurse to make four assessments: risk of suicide/self harm, risk of aggression/harm to others, risk of absconding and whether the patient is intoxicated. From this, the triage nurse determines the ATS and urgency of initial treatment. It is also helpful to determine if the patient is known to a mental health service.

Table 20.1.2 The Mental Health Triage Scale

ATS 2 Patient is violent, aggressive or suicidal, or is a danger to self or others
Requires police escort/restraint
ATS 3 Very distressed or acutely psychotic
Likely to become aggressive
May be a danger to self or others
ATS 4 Long-standing or semi-urgent mental health problem and/or has supporting agency/escort present
ATS 5 Patient has a long-standing non-acute mental health disorder but has no support agency
Many require referral to an appropriate community resource

Many centres have developed a triage risk assessment proforma. For ease of use, many of these have included ‘tick box’ areas. A compilation of multiple assessment tools used throughout Australia is shown in Tables 20.1.3, 20.1.4 and 20.1.5.1,2,3,5,11,12

Table 20.1.3 Brief screening suicide risk template

Mental state image Active disease
imageDepression
imagePsychosis
imageHopelessness/despair/guilt/shame
imageAnger/agitation
imageImpulsivity
Suicide attempts/thoughts imageContinual/specific thoughts
imageFormulated plan
imageIntent
imagePast history of attempt with high lethality
imageMeans
imageSuicide note
imageRisk of being found
imageOrganizing personal affairs
Substance abuse imageCurrent misuse
Supports imageLack of or hostile relationships
Loss imageRecent major loss (even perceived): significant relationship, job, housing, financial difficulties, independence
imageRecent/new diagnosis of major illness or chronic illness
Patients then stratified into high, medium or low risk

Table 20.1.4 Aggression risk tool

imageAlert on chart
imagePrevious history of violence/threatening behaviour: verbal or physical
imageAggressive behaviour/thoughts
imageHomicidal ideation
imageUse of weapons previously
imageAccess to weapons
imageIntoxicated
imageMiddle aged male
Patient then stratified into high, medium or low risk

Table 20.1.5 Risk of absconding

Mode of arrival
imagePolice
imageHandcuffed
imageFamily/carer coercion
imageVoluntary
imagePast history of absconding behaviour
imageAlert on chart
imageVerbalising intent to leave
imageLack of insight into illness
imagePoor/non-compliance with medication
Patients then stratified into high, medium or low risk

It is recommended that any patient who scores ‘high risk’ in any one area or ‘medium risk’ in two areas is treated as a ‘high risk’ patient. Ensuing management of ‘high risk’ patients depends on: local protocols, levels and presence of security, police intervention, restraint and sedation guidelines and guidelines for the urgent assessment by ED and/or by mental health services.

The formal psychiatric interview

Introduction

The environment in which the mental state assessment is conducted is important. Behaviourally disturbed people are unable to tolerate noise and have short concentration spans. The interview room should be quiet, private, make the patient feel safe and the interviewer should avoid all interruptions. These prerequisites are increasingly difficult to attain in current access-blocked environments.

The interviewer should sit at the same level as the patient and impart empathy. The voice should be quiet and calming. The interviewer should use non-judgemental language and open-ended questions.3,13 It is important that the interviewer also feels safe and secure. If any risk is felt, the interviewer should have security or police present in the room or just outside. Depending on state legislation and hospital policy, the interviewer may request to have the patient searched. The interviewer should also note the nearest duress alarm and/or choose to wear a personal alarm. The interviewer should sit within easy access of an exit and should never be boxed into a corner. If an interviewer begins to feel uncomfortable, there is always the option of leaving and returning to complete the assessment at a later stage. All threats, attempts and gestures suggestive of violence should be treated seriously.

Alcohol Drug use Tobacco use

The process of obtaining a mental health assessment is different to that of a general medical assessment. In a general medical history, a series of questions is asked and the response is written. In a mental health assessment, responses are also interpreted. The interviewer is asked to form an opinion as to how thoughts are processed, based on observations. The interviewer is asked to interpret the patient’s thought patterns by what and how the patient tells the interviewer.

Appearance, attitude and behaviour

This determines the patient’s ability to self care. Table 20.1.8 lists features that may require particular attention. Attitude is important as it may indicate whether a patient is compliant with management and treatment. Abnormal posturing or repetitive behaviours should be noted. These may indicate increasing thought disturbance. With increasing aggression and agitation, there may be motor restlessness, pacing and hand wringing. Tension may escalate rapidly, and steps should be taken early to diffuse the situation.

Table 20.1.8 Appearance, attitude and behaviour

General:

Cleanliness:

Eye contact:

Facial expression:

Reaction to interviewer:

Motor:

Speech:

The interviewer should note the rate, volume and rhythmicity of speech. This can range from completely mute, through monosyllabic answers, to rapid, loud speech indicative of pressure of speech. The tone, inflection content and structure of speech should also be noted. The interviewer should determine if the speech is fluent, if the thoughts behind it are logical and whether it flows appropriately for the situation.

Thought disorder

This is speech that does not reach its goal, is not fluent and is interrupted often with many pauses and/or changes in direction. A list with explanations is given in Table 20.1.9.

Table 20.1.9 Thought disorders

Circumstantiality Delays in reaching goals by long-winded explanations, but eventually gets there
Distractible speech Changes topic according to what is happening around the patient
Loosening of associations Logical thought progression does not occur and ideas shift from one subject to another with little or no association between them
Flight of ideas Fragmented, rapid thoughts that the patient cannot express fully as they are occurring at such a rapid rate
Tangentiality Responses that superficially appear appropriate, but which are completely irrelevant or oblique
Clanging Speech where words are chosen because they rhyme and do not make sense
Neologisms Creation of new words with no meaning except to the patient
Thought blocking Interruption to thought process where thoughts are absent for a few seconds and are unable to be retrieved

Conclusion

Although time-consuming and seemingly unrewarding, a good mental health assessment is vital for the appropriate management and disposition of what is an increasingly large group of patients in the ED. If able to formulate an opinion on the risk assessments regarding suicide, violence and flight risk and the aims of the MSE, the emergency medical officer will be able to present to mental health services a comprehensive picture of the patient.

Only then will the mental health professional be able to administer mental health first aid,5 the principles of which are:

References

1 Crowe M, Carlyle D. Deconstructing risk assessment and management in mental health nursing. Journal of Advanced Nursing. 2003;43(1):19-27.

2 Risk McSherryB. Assessment by Mental Health Professionals and the Prevention of Future Violent Behaviour. Australian Government. Australian Institute of Criminology, 2004. July

3 NSW Department of Health. Framework for suicide risk assessment and management. Emergency Department, 2004. http://www.health.nsw.gov.au. Online. Available

4 The Australian Institute of Health and Welfare. Mental health services in Australia 2004–5. (Mental Health Series No 9). Canberra: Australian Institute of Health and Welfare, 2007.

5 Kitchener B, Jorm A. Mental health first aid manual. Melbourne: Orygen Research Centre, 2002.

6 Clinical Practice Guidelines Team for Depression, Royal Australian and New Zealand College of Psychiatrists. Australian and New Zealand clinical practices. Practice guidelines for the treatment of depression. Australian and New Zealand Journal of Psychiatry. 2004;38:389-407.

7 Larkin GL, Classen CA, et al. Trends in US Emergency Departments. Visits for mental health conditions, 1992–2001. Psychiatric Services June. 2005;56(6):671-677.

8 ACEP Clinical Policies Subcommittee. Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Annals of Emergency Medicine. 2006;47(1):79-99.

9 Smart D, Pollard C, Walpole B. Mental health triage in emergency medicine. Australian and New Zealand Journal of Psychiatry. 1999;33:57-66.

10 Happell B, Summers M, Pinikahana J. Measuring the effectiveness of the national Mental Health Triage Scale in an emergency department. International Journal of Mental Health Nursing. 2003;12:288-292.

11 Department of Health and Ageing. Emergency triage education kit. Australian Government. 2007:37-48.

12 Department of Human Services, Victorian Emergency Department. Mental health triage tool. Online. http://www.health.vic.gov.au/emergency/mhtriagetool.pdf. Available

13 Meyers J, Stein S. The psychiatric interview in the emergency department. Emergency Medicine Clinics of North America. 2000:173-183.

20.2 Distinguishing medical from psychiatric causes of mental disorder presentations

Introduction

Emergency physicians are facing a significantly increased volume and complexity of mental disorder presentations. Increased numbers relate to increased community care for chronic mental illness, the ageing population and frequent substance abuse. Intoxicated patients, with and without mental disorder, are increasingly being presented to emergency departments (EDs) for assessment due to concerns about patient or community safety. These patients frequently display impulsive, suicidal or violent behaviour and are often difficult to manage. A thorough understanding of the assessment and appropriate disposition of mental disorder presentations is essential for all emergency physicians.

The concept of differentiating an organic from a psychiatric basis for a mental disorder is becoming increasingly blurred as research shows the biological and genetic basis of many traditional psychiatric illnesses. The accepted terminology for classification of mental disorder is also rapidly changing. One accepted Western standard is the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV).1 To emphasize the biological basis of many traditional psychiatric illnesses, DSM-IV no longer uses the term ‘organic mental disorder’. Despite this change, current clinical management and disposition still revolve around the traditional distinction of organic (medical) from psychiatric problems.

In practice emergency physicians need a simple classification defining the principal diagnosis of the presenting mental disorder consistent with current DSM-IV terminology. This should assist diagnostic, management and disposition accuracy. Table 20.2.1 is such a suggested classification. A more simplistic grouping into psychiatric, medical, substance-related or anti-social behaviour may even suffice. Correct assignment by the emergency physician to the appropriate classification, and hence appropriate disposition, reduces medical costs and morbidity.2

Table 20.2.1 A simple classification of principal diagnosis of mental disorder for emergency physicians

DSM-IV terminology Broad traditional clinical grouping Likely principal management and disposition
Axis 1
Clinical disorder due to a general medical disorder Organic Medical
Delirium, dementia and amnestic and other cognitive disorders Organic Medical
Substance-related disorder – intoxication or withdrawal disorder Organic Medical
Substance-related disorder – substance induced persistent disorder Organic Psychiatric
Clinical disorder (not identified to above or axis II principal diagnosis) Psychiatric Psychiatric

General approach

Patients with abnormal behaviour labelled as psychiatric after routine medical and psychiatric assessment frequently have a final diagnosis of a medical cause or precipitant for the mental disorder. The incidence of missed medical diagnosis ranges between 8 and 46%.24 A prospective study of ED patients in the USA showed a medical diagnosis in 63% of patients with first psychiatric presentations.5 Deciding whether a particular presentation of mental disorder is medical or psychiatric is often difficult, as there are very few absolutes that distinguish medical from psychiatric illness. Careful collection and weighing of appropriate information commonly leads to an accurate differential diagnosis.

Some diagnoses and dispositions can be determined quickly after a medical and psychiatric history, with the addition of a mental state and full physical examination. This may sometimes take place without expensive diagnostic procedures.6 Other presentations are difficult and require extensive and intensive evaluation, repeat evaluation, observation in hospital and significant investigations before the diagnosis is clear.

Many initial assessments in EDs are difficult and inaccurate owing to the presence of intoxicating substances or difficult patient factors. The latter may include poor communication ability, poor cooperation with examination, antisocial behaviour, intentional obscuring of information or denial of problems. Intoxicated patients may have other complex and distracting issues, such as threats of violence or self-harm, possible head injury, possible unknown substance overdose, and poor cooperation with necessary history, examination and investigations. A non-judgemental approach with prudent intervention based on known or likely risks, close monitoring in a safe environment, and repeated reassessment of physical and mental state over time are necessary to obtain an accurate diagnosis and optimal outcome.

Studies on medical clearance by ED staff, primary-care physicians and psychiatrists have repeatedly shown a poor ability to discover medical conditions. This failure is commonly due to one or more of the following factors: inadequate history, failure to seek alternative information from relatives, carers and old records, poor attention to physical examination, including vital signs, absence of a reasonable mental state examination, uncritical acceptance of medical clearance by receiving psychiatric staff and failure to re-evaluate over time.7 A recent study noted that medical conditions were most easily identified in the ED by the triage nurse or medical officer asking whether any medical conditions existed in addition to the patient’s psychiatric complaints.8

Conversely, studies have shown that many patients admitted with a medical diagnosis frequently have a physical presentation of a classic psychiatric disorder. In addition, patients who frequently present to EDs with physical problems commonly have abnormal illness behaviour. Inability to recognize this leads to inappropriate diagnosis and management, with subsequent treatment failure.

Psychiatric patients also have a higher incidence of physical illness than the general population. The comorbid illness may not have been diagnosed previously in this socially disadvantaged population.

Evaluation requires a thorough approach and a commitment of time and effort. Special skills are required for medical clearance and psychiatric interview. A coordinated and focused medical and psychiatric assessment has the highest yield of correct diagnoses.2 Proformas may improve compliance and documentation of important details.

Triage

Triage is vital, as many patients presenting with apparent psychiatric problems have medical conditions. The patient previously labelled psychiatric must be carefully triaged to avoid any new medical problems being overlooked. Psychiatric patients have been found to express their physical illnesses in different ways from those without mental illness. They may be suffering from severe or life-threatening illness, but fail to communicate this to their medical carers. Correct identification at the point of entry by nursing staff facilitates correct management and reduces morbidity and mortality.9 Many patients with psychiatric illness are also a significant risk to themselves or others, and require urgent intervention. Questions regarding safety should always be raised10 (Table 20.2.2).

Table 20.2.2 Triage safety questions10

Is the patient a danger to him or herself?
Is the patient at risk of leaving before assessment?
Is the patient a danger to others?
Is the area safe?

Nursing staff should use a triage checklist to identify likely organic presentations (Table 20.2.3). These are indications for urgent medical assessment. If these are absent and a psychiatric diagnosis is likely, then an appropriate urgency rating by Australasian Triage Scale for psychiatric presentations should be applied. This triage categorization for psychiatric presentations has been developed and verified, and allows reasonable waiting time standards for urgency to be applied (Table 20.2.4).11

Table 20.2.3 High-yield indicators of organic illness

Table 20.2.4 Guidelines for Australasian Triage Scale coding for psychiatric presentations11

Emergency: Category 2
Patient is violent, aggressive or suicidal, or is a danger to self or others, or requires police escort.
Urgent: Category 3
Very distressed or acutely psychotic, likely to become aggressive, may be a danger to self or others.
Experiencing a situation crisis.
Semiurgent: Category 4
Long-standing or semi-urgent mental health disorder and/or has a supporting agency/escort present (e.g. community psychiatric nurse*)
Non-urgent: Category 5
Long-standing or non-acute mental disorder or problem, but the patient has no supportive agency or escort. Many require a referral to an appropriate community resource.

* It is considered advantageous to ‘up triage’ mental health patients with carers present because carers’ assistance facilitates more rapid assessment.

Triage should consider patient privacy issues if the history obtained is to be accurate. Collateral information from the carers with the patient should always be diligently obtained, carefully considered and documented. Integration of all this information should allow the patient to be placed in an appropriate and safe environment where continuing visual and nursing observations can occur while further assessment is awaited. An emerging trend is to use nursing triage to immediately refer likely psychiatric presentations to mental health clinicians without formal ‘medical clearance’. This method appears effective and efficient for both patient and clinicians. Most triage referral systems have built-in medical safety nets and have been operating now for some years without obvious increase in adverse outcomes. They are yet to be validated by scientific studies.

History

A careful traditional medical history is the most common identifier of medical illness as a cause of a mental disorder presentation. Substance-related disorders are also most easily identified on history. A careful drug history, including prescribed, recreational and over-the-counter medications, should always be included. A slow onset and a previous psychiatric history are more commonly associated with psychiatric illness. Conversely, rapid onset, no premorbid decline and no past psychiatric history favour a medical cause. Poor recall of recent events may indicate delirium.

Family history is often a key indicator of psychiatric or medical cause. For example, a depressed 30-year-old man with a family history of Huntington’s disease or porphyria is more likely to have a physical cause. Conversely, an 18-year-old man with a hypomanic presentation and a strong family history of bipolar disorder more likely has a psychiatric cause. Suicidal and homicidal risk should be assessed routinely to ensure safety. Escalating immediate risk can often be recognized by combining patient perceived lethality and inquiry about any transition from thoughts, to actual plans and finally to actions. For patients with previous psychiatric illness the system review is a useful screen for organic illness.

HIV is an increasingly important area as HIV-related illness becomes the new great mimic of modern psychiatry and medicine. Practices likely to have put the patient at risk should be explored. These may have been in the distant past. Known positive HIV status always warrants assessment for an organic cause of any new behavioural disturbance. Clinically, these problems often initially present with symptoms of mild anxiety or depression. Many treatable medical causes are only evident after significant investigations.12

Delirium, a highly specific but not absolute indicator of medical or substance-induced disorders, should always be sought. By definition this requires a history of recent onset and of fluctuation over the course of the day. Classically there will be subtle changes in level of consciousness or the sleep–wake cycle. Patients may not be able to attend sufficiently to give this history if delirious. The psychiatric history, including life profile, may give evidence of the presence or absence of premorbid decline. An abrupt onset of abnormal behaviour with no premorbid decline is more suggestive of an organic cause.

Examination

Lack of attention to important details of the examination is a frequently identified cause of missed medical illness. Areas that commonly yield positive findings, but which are frequently omitted, are the neurological examination, a search for general or specific appearances of endocrine disease, the toxidromes, examination for signs of malignancy, drugs or alcohol abuse, and vital sign examination.

Mental state examination

This is an account of objective findings of mental state signs made at the time of interview. It is the psychiatric equivalent of the medical examination, and specifically details the current status.13 Observations made by other staff in the department, such as hallucinations, may be very significant and can be included with the source identified. Careful consideration of the mental status frequently clearly distinguishes medical from psychiatric illness, and guides further investigation and management. For example, the presence of delirium or other significant cognitive defects make an organic illness almost certain. Delirium can be very subtle. Sometimes, owing to the fluctuating nature, the patient may appear normal on a single interview. Other less obvious features, such as lability of mood, variability of motor activity or lapses in patient concentration making the interview more difficult, can be the only clues and can be easily overlooked. The importance of formulation using collateral history and repeated mental state examination is stressed. Documentation is important so that mental status changes with time during assessment can be appreciated.

Examination tools

Cognitive defects may be rapidly and reliably identified in the ED during mental status examination by the use of Folstein’s Mini Mental State Examination (MMSE)14 (Table 20.2.5). A score of less than 20 suggests an organic aetiology. A fall of two or more points on serial MMSE is highly suggestive of delirium.15 Elderly patients with delirium or cognitive defects are frequently not recognized by emergency physicians.16 These patients are at high risk of morbidity and mortality.17 Simple assessment methods such as the confusion assessment method (CAM) are rapid, reliable methods of identifying delirium in older patients, suitable for ED use.18 Use of such simple methods should be encouraged to reduce inappropriate disposition. The tests above are suitable screening tools for EDs but are not intended to replace formal neuropsychological assessment. Proformas of medical history, mental state examination and physical examination may improve thoroughness of assessment and documentation.

Table 20.2.5 Mini-mental state examination14,15

Date of assessment Cognition Points
Orientation
1. What is the date? 1
What is the day? 1
What is the month? 1
What is the year? 1
What is the season? 1
2. What is the name of this building? 1
What floor of the building are we on? 1
What city are we in? 1
What state are we in? 1
What country are we in? 1
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3. I am going to name three objects. After I have said them I want you to repeat them. Remember what they are because I am going to ask you to name them in a few minutes.
APPLE TABLE PENNY
  APPLE 1
  TABLE 1
  PENNY 1
Code first attempt and then repeat the answers until the patient learns all three.
Attention and calculation
4. Can you subtract 7 from 100, and then subtract 7 from the answer you get and keep subtracting until I tell you to stop? 93 1
86 1
79 1
72 1
65 1
OR
5. I am going to spell a word forwards and I want you to spell it backwards. The word is ‘WORLD’.
Now you spell it backwards. Repeat if necessary.
  D 1
  L 1
  R 1
  O 1
  W 1
Recall
6. Now what are the three objects I asked you to remember?
  APPLE 1
  TABLE 1
  PENNY 1
Language
7. Show wristwatch
What is it called?
Interviewer: Show pencil
What is it called? 2
8. I’d like you to repeat a phrase after me.
‘NO IFS ANDS OR BUTS’ 1
9. Read the words on the bottom of this table and do what it says. 1