87: Emergency Psychiatry

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CHAPTER 87 Emergency Psychiatry

Jennifer M. Park, MD, Lawrence Park, MA, MD, Laura M. Prager, MD

KEY POINTS

• The safety assessment is crucial in emergency evaluations.

• The assessment and management of acute agitation are particularly important.

• It is critical to diagnose acute medical problems during psychiatric emergencies.

• Signs of intoxication and withdrawal that may herald psychiatric emergencies should be identified and treated.

• Psychiatric care plays an important role in responses to disasters.

OVERVIEW

Over the past 20 years, emergency psychiatry has developed into an independent subspecialty practice within consultation-liaison psychiatry. Although formal board certification requirements are lacking, all accredited United States psychiatric residency-training programs follow minimum training guidelines for emergency psychiatry.¹ The emergence of emergency psychiatry as a specialized practice parallels the dramatic increase in patient volume in urgent and emergency care settings over the past decade. In 2001, there were over 2 million visits to United States emergency departments (EDs) for mental health–related chief complaints, accounting for more than 6% of all ED visits, and representing an increase in the percentage of all visits by 28% over the previous decade.² Among emergency mental health visits, substance-related disorders (30%), mood disorders (23%), anxiety disorders (21%), psychosis (10%), and suicide attempts (7%) are the most common.²

Psychiatric emergencies encompass a range of clinical presentations and diagnoses. Typically, such patients seek treatment in a state of crisis, unable to be contained by local support systems. Crises may be understood and addressed from a variety of perspectives, including medical, psychological, interpersonal, and social. Symptoms often consist of an overwhelming mental state that leads to increased dangerousness for that person or for others. Patients may have suicidal or homicidal (violent) ideation, overwhelming depression or anxiety, psychosis, mania, or acute cognitive or behavioral changes. A recent trend has also seen emergency services used for nonemergent conditions.² Increasing numbers of patients seek treatment at EDs for urgent conditions, routine conditions, or outpatient referrals because of lack of coverage for routine outpatient care, lack of community health care resources, or an inability to access health care.

The scope of emergency psychiatry includes core skills for psychiatric practice. In addition to the evaluation and treatment of severe psychiatric conditions, practitioners of emergency psychiatry are called on to evaluate and to manage suicidal behavior, homicidal (or violent) behavior, agitation, delirium, and substance intoxication or withdrawal states. Because clinical practice lies at the interface of medicine and psychiatry, having knowledge concerning the assessment and treatment of medical conditions that include psychiatric symptomatology is critical. Recently, emergency psychiatrists have also played important roles in an organized response to disasters.

The aim of this chapter is to provide a foundation for the clinical aspects of psychiatric emergency care. First, the general psychiatric emergency evaluation will be reviewed, with particular focus on common initial symptoms. Then, special topics and the emergency treatment of children will be examined.

DEMOGRAPHICS

As of 1991, the United States had about 3,000 dedicated psychiatric emergency services (PESs).³ Among the patients treated at these specialized services, approximately 29% are diagnosed with psychosis, 25% with substance abuse, 23% with major depression, 13% with bipolar disorder, and 22% with personality disorders⁴; co-morbidity is common. Suicidal ideation is present among approximately one-third to one-half of the patients.³

Though some patients may self-refer to a PES while in crisis, patients may be also be referred by family, friends, general practitioners, medical specialists, mental health treaters in the community, employees of local and state agencies, and staff of airports. Since the occurrence of several school shootings by students, schools in the United States have become a major source of emergency referrals for violence and for suicide assessments.⁵ Police officers and representatives of the legal system are also a source of referrals, as the PES serves as a conduit between the psychiatric system and the legal system.⁶ The role of the PES is to help the police identify those patients with psychiatric illness and to re-route them to appropriate care, while those without acute psychiatric illness are returned to the legal system.

TYPES OF DELIVERY MODELS

Two general models are used to deliver emergency psychiatric services. In one model, the PES exists as an independent service, co-located with a general emergency medical service or located separately in a stand-alone facility. In the other model, the PES may function as a consultation service that provides consultation to primary emergency medical services. The model of services offered is determined by the volume of patients and the financial resources available.⁷

The primary benefit of providing emergency psychiatric services in an area that is separated from the chaos of a busy ED is safety; it provides a more secure environment (e.g., with limited access to sharp or dangerous objects, quiet surroundings to decrease stimulation, individual rooms for private interviews, and the ability to observe and rapidly initiate psychiatric treatment). The unit may also have security staff who are trained to understand mental health issues and who can help to maintain a safe environment. Many units also have specialized rooms for restraint and seclusion.⁷

Most states have enacted legislation that allows for holding individuals against their will if they are unable to care for themselves or if they present a danger to themselves or to others. In the PES, if there is reason to believe that a person presents a substantial risk of physical harm to himself or herself, or to other persons, or presents a very substantial risk of physical impairment or injury (due to inability to care for oneself), the person may be held or sequestered in the PES facility for further evaluation.

Another benefit of a dedicated psychiatric unit is the opportunity to staff the unit with specialized personnel who are trained in emergency psychiatric care.^3,⁷ An interdisciplinary staff of psychiatric residents and attending physicians, nurses, social workers, and case managers can enhance the care of patients with acute illness, for example, by coordinating medical care with colleagues in the ED. Psychiatric nurses also play an important role in triage of mentally ill patients within the psychiatric unit and the ED. Their ability to manage the milieu in an emergency unit, provide individual support to patients, dispense psychiatric medications, and recognize situations that require immediate nursing and physician intervention is invaluable.

Some PESs also have access to “crisis beds” or facilities that are able to provide 24- to 72-hour observation. The ability to observe a patient whose mental state may change significantly after the initiation of antipsychotics or with a period of sobriety may decrease the need for inpatient hospitalization.^3,^7,⁸

A PES may also have a mobile crisis team, whose role is to evaluate patients in the community, to diffuse a crisis before a patient is treated at the ED, and to decrease rates of hospitalization. As early as 1980, mobile initial response teams were described as a component of California community mental health centers, and as an alternative to ED care.⁹ One report from 1990 demonstrated similar hospitalization rates among hospital-based and mobile team emergency interventions,¹⁰ whereas more recent reports have demonstrated decreased hospitalization rates associated with use of mobile teams.¹¹^–¹³

THE PSYCHIATRIC INTERVIEW

The psychiatric emergency evaluation is a concise, focused evaluation with a goal of diagnostic assessment, management of acute symptoms, and disposition to the appropriate level of care. Just as a visit to an ED for a medical complaint involves an initial triage (a brief evaluation of the severity of the problem), many emergency psychiatry models also depend on an initial assessment of the dangerousness of the psychiatric complaint in the context of co-morbid medical conditions. This initial, brief determination of acuity should screen for active medical issues that cause a change in mental status, substance intoxication or withdrawal, suicidal or homicidal ideation, and other types of psychiatric symptomatology.

The cornerstone of the initial psychiatric evaluation is a careful history that focuses on the temporal development of symptoms that have led to the emergency visit, on associated signs and symptoms, and on possible precipitants and causes. In addition, a past history of medical illnesses, psychiatric illnesses, medication usage, allergies, adverse reactions to medications, patterns of substance use, a family history of psychiatric illness, and a psychosocial history serve as important aspects of the initial evaluation. Table 87-1 describes the components of the evaluation and Table 87-2 describes the special features of a substance abuse evaluation.

Table 87-1 The Emergency Psychiatric Interview and Evaluation

• Chief complaint

• History of present illness, with a focus on symptoms and the context for these symptoms; include a safety evaluation, with assessment of suicidal and homicidal ideation, plan or intent, and any associated risk factors

• Past medical history, with a focus on current problems

• Past psychiatric history, particularly symptoms or events similar to the current presentation; include diagnoses, previous hospitalizations, and suicide attempts

• Allergies and adverse reactions to medications

• Current medications, including an assessment of compliance

• Social history, particularly how it contributes to the context for the emergency visit

• Substance use and abuse history

• Family history, including symptoms or diagnoses similar to the patient’s presentation

• Mental status examination

• Review of medical symptoms, particularly any medical symptoms that may account for the patient’s presentation

• Vital signs

• Physical examination, if indicated

• Laboratory studies and other tests, if indicated

• Assessment, including a summary statement, a statement about the patient’s level of safety, and a rationale for disposition recommendations

• Axes I through V according to DSM-IV criteria

• Plan and disposition

• Document any significant interventions (such as medication administration) and the outcome

Table 87-2 The Substance Abuse Interview

It is important to be aware of all potential information that may be included in an emergency psychiatric evaluation, and then choose to elaborate on areas that are most relevant to the patient at hand. The interview should be a fact-gathering mission, and the elements of the history should both tell a story about the current symptoms and provide support for the disposition that the psychiatrist chooses. For example, though the developmental history may not be an important part of the evaluation for an otherwise healthy-appearing adult patient with depression, it may be very important in the assessment of a young patient with obvious cognitive deficits.

The emergency evaluation always includes an assessment of the patient’s living situation and social supports, as well as a brief understanding of how he or she spends the day (e.g., at work, at school, or in a day program). This assessment defines the patient’s baseline level of function. In addition, a review of the patient’s health insurance is necessary, because this often dictates the types of treatment programs that are available as disposition options.

Often, presentations to the PES are complicated and confusing, and patients may be unable, or unwilling, to provide an accurate history. For this reason, an important feature of the evaluation is the collection of history from multiple sources (including family, friends, treaters, police, or emergency personnel who transported the patient). When several informants can be interviewed, data can be corroborated from the various sources, which can help the psychiatrist to make informed disposition decisions.

THE MEDICAL EVALUATION

For any patient treated at an ED with an altered mental status (be it a change in cognition, emotional state, or behavior), it is crucial to rule out an underlying medical condition that causes or contributes to the problem. A change in mental state may indicate a primary psychiatric condition, delirium (an acute and reversible condition secondary to a medical illness), or dementia (a chronic condition associated with long-term, irreversible brain pathology). Therefore, it is important to consider medical etiologies for any condition that appears psychiatric in nature. A missed medical diagnosis in lieu of an assumed psychiatric diagnosis could result in dire consequences for the patient.

A medical workup should be considered for any new onset of psychiatric symptomatology or any significant change or exacerbation of symptoms. This initial medical workup is often referred to as “medical clearance.” The term medical clearance generally refers to a medical evaluation aimed at ruling out underlying medical conditions that cause or contribute to a psychiatric presentation. While much attention has been paid to defining a standard for medical clearance, there is no clear consensus regarding the required elements of the medical evaluation.^14,¹⁵

One retrospective study of 212 consecutive patients who underwent a psychiatric evaluation at an ED demonstrated that among patients with a known psychiatric history and no medical complaints (38%), screening laboratories and radiographic results yielded no additional information; those patients could have been referred for further psychiatric evaluation with the history, the physical examination, and stable vital signs alone. Among the patients deemed to require further medical evaluation (62%), all had either reported medical complaints or their medical histories suggested that further evaluation would be necessary before psychiatric referral.¹⁶ Another study of the medical evaluation of ED patients with new-onset psychiatric symptoms (e.g., patients with intoxication with alcohol or drugs, overdoses, and previously diagnosed abnormal behavior were excluded) demonstrated that two-thirds had an organic cause for their psychiatric symptoms.¹⁷ These studies suggest that careful screening is important among patients with new-onset symptoms, but additional medical tests may be of little benefit among patients with known psychiatric disorders and without physical complaints or active medical issues.

The medical evaluation should involve a thorough medical history, a general review of systems, and the assessment of vital signs, followed by a physical examination or laboratory tests (or both) as indicated. One should be vigilant of characteristics (such as homelessness or intravenous [IV] drug abuse), which may put a patient at risk for additional medical conditions. The medical tests to consider are listed in Table 87-3.

Table 87-3 Tests to Consider in the Medical Evaluation of Patients with Psychiatric Symptoms

• Complete blood count (CBC; to monitor for infection, blood loss)

• Electrolytes, blood urea nitrogen (BUN), creatinine (metabolic changes, hyponatremia or hypernatremia, abnormal kidney function, dehydration)

• Glucose (hypoglycemia or hyperglycemia)

• Liver function tests and ammonia (liver dysfunction due to hepatitis or alcohol abuse)

• Pregnancy test

• Serum toxicology screen (ingestion, intoxication, poisoning)

• Medication levels (ingestion of medications such as lithium and tricyclic antidepressants)

• Urine toxicology screen (to identify or confirm substance abuse)

• Calcium, magnesium, and phosphorus (hypoparathyroidism or hyperparathyroidism, eating disorders, poor nutrition)

• Folate, thiamine (alcohol dependence, poor nutrition, depression)

• Vitamin B₁₂ (megaloblastic anemia, dementia)

• Thyroid-stimulating hormone; this result may not be available immediately, but may be available during an extended observation period (hypothyroidism or hyperthyroidism)

The following tests and imaging studies may also be considered in the medical workup:

• Lumbar puncture (infection, hemorrhage)

• Electroencephalogram (seizure, changes due to ingestion of medications, dementia)

• Computed tomography (CT) (acute hemorrhage or trauma)

• Magnetic resonance imaging (MRI) (higher resolution than CT for potential brain masses or lesions, posterior fossa pathology, or when radiation exposure is contraindicated)

Adapted from Alpay M, Park L: Laboratory tests and diagnostic procedures. In Stern TA, Herman JB, editors: Psychiatry update and board preparation, New York, 2000, McGraw-Hill.

THE SAFETY EVALUATION

The safety evaluation assesses the likelihood that an individual will attempt to harm himself or herself or someone else; it is a mandatory component of every emergency evaluation. With regard to self-harm, the intent may be to harm or to kill oneself (i.e., commit suicide). Suicide is the eighth leading cause of death in the United States, and over 90% of patients who commit suicide have at least one psychiatric diagnosis.¹⁸ Patients aged 15 to 24 years and those over age 60 are in the highest-risk groups for suicide.

The psychiatrist must ask about thoughts, plans, and intent of suicide and homicide. These questions should be followed up with more specific questions about access to the means for harm. If a patient has a plan or the intent to commit suicide, the lethality of the plan, as well as the patient’s perception of the risk, must be assessed. A medically low-risk plan may still coincide with a strong intent to die if the patient believes that the lethality of the attempt is high. Similarly, the possibility that the patient could have been rescued if he or she had followed through on the plan should be evaluated; an impulsive ingestion of pills in front of a family member after an argument conveys less risk than a similar attempt in a remote location. If a patient has attempted suicide previously, details of that attempt may facilitate an understanding of the current risk. In addition, the clinician should assess other risk factors for suicide.

The assessment of violence is similar to the assessment of suicide risk. Every patient should be asked about thoughts to harm others, as well as the patient’s potential plans and intent. Observation of the patient’s mental status, behavior, and impulsivity during the interview provides important information. Since previous behavior is the best predictor of future behavior, if there is any suspicion of impending violence, it is important to establish previous violent thoughts and behaviors, triggers leading to those events, and their relationship to substance abuse. Questions about legal issues related to violence are also appropriate. In addition, the target of violence should be assessed. Violence may lack a specific target, or may be directed toward a specific individual. If there is a likelihood of directed violence toward an identified person or persons, there will be a duty to warn the identified target.

The safety evaluation should include contact with others who know the patient. Although civil commitment laws differ from state to state, most states have provisions for the containment of a patient who is deemed at risk for harm to self or others; however, in many cases, a patient with suicidal or homicidal ideation will choose voluntary hospitalization. In cases in which the patient has acknowledged suicidal or homicidal ideation, but it has resolved during the course of the emergency visit, care must be taken to create a clear plan for steps that the patient should take if the feelings return. Most often, these involve contact with family members and treaters and a return to a psychiatric evaluation center or ED.

PSYCHIATRIC SYMPTOMS AND PRESENTATIONS

Diagnosis using DSM-IV criteria ¹⁹ can be difficult in the PES since patients are seen at a cross section in time, often in the worst crisis of their lives. Although patients will not necessarily fit the criteria exactly, a search for the most common disorders (e.g., mood disorders, psychosis, anxiety disorders, substance abuse, and a change in mental status caused by a medical etiology [delirium]) will facilitate assessment. The following pages will outline some of the most common psychiatric presentations and patient characteristics in the ED.

The Depressed Patient

Depression is a common reason for seeking treatment at a PES. The severity of the depression may vary from mild to extremely severe; it may occur with or without psychosis or suicidal thinking. Anhedonia and other neurovegetative symptoms of depression are common complaints. Anxiety or anger attacks are often co-morbid with depression, and a history of mania must be assessed in every depressed patient to screen for bipolar disorder. Other medical conditions, especially hypothyroidism, must be considered. The severity of symptoms and the ability to participate in work and other routines may contribute to a diagnosis; however, the assessment of safety is essential in treatment planning.

The Anxious Patient

Although symptoms of anxiety may reflect a primary anxiety disorder, anxiety often heralds other disorders. Patients with psychosis may first describe anxiety about people who might try to harm them; patients with depression may have anxiety about financial or relationship difficulties. If a patient is able to differentiate between worries that come and go and discrete panic attacks, the diagnosis may be clarified. Psychomotor agitation, fidgeting, and pacing co-occur with anxiety, but may also correlate with psychosis, alcohol withdrawal, or cocaine intoxication. Medical problems (such as hyperthyroidism and delirium) and medication side effects (such as akathisia) may also be confused with anxiety.

The Psychotic Patient

Patients with psychosis suffer from disorganized thinking or suffer from hallucinations, delusions, or other forms of disordered thought (such as ideas of reference, thought broadcasting, or thought insertion). Patients with psychosis vary greatly in the severity of their symptoms; they may be affected by paranoia that has affected their work or relationships, or suffer from loose associations, delusions, or aggressive behavior. Because some patients have lost touch with reality, and may be at risk for agitation or dangerousness, awareness for the safety of staff and other patients must be maintained. Among patients with new-onset psychosis, severe anxiety is common, and it may be difficult to differentiate from paranoia.

It is also important to rule out medical causes for symptoms, particularly among patients who lack a history of psychosis and whose age falls outside the usual range for psychosis (late teens to mid-twenties). Auditory hallucinations are more common with psychiatric disorders, whereas visual hallucinations are more common in medical disorders, delirium, and substance abuse. Seizure disorders, delirium, metabolic changes, infections, ingestion, and withdrawal from alcohol or benzodiazepines should be considered in the differential for new-onset psychosis. Among the elderly with new-onset hallucinations, delirium and dementia should be considered.

The Manic Patient

Manic patients stand out in the PES; they are often disruptive and provocative, with pressured speech, grandiosity, irritability, and flight of ideas. Such patients may be dressed or behave in an odd or seductive manner, and may have impulsively traveled long distances. In mania with psychosis, paranoid thoughts and delusions or hallucinations often arise, leading to a lack of insight into their condition. It is important to assess for medical causes of mania, as well as for acute intoxication with cocaine or phencyclidine (PCP). Steroids can also contribute to manic symptoms, as can antidepressant medications.

The Patient with Intoxication or Withdrawal

Patients with substance intoxication or withdrawal often come to the attention of emergency personnel because of acute medical symptoms (such as unconsciousness, difficulty breathing, or confusion). However, they may also come to the ED requesting referral for detoxification services or other substance abuse treatment. Substance abuse is frequently co-morbid with other psychiatric conditions. The following will outline the substances of abuse seen in the PES and key concepts in the assessment of substance abuse.

The Patient with a Change in Mental Status

When treating a patient who displays a significant change in mental state, it is the task of the emergency psychiatrist to identify the underlying etiology. Generally speaking, changes in mental state represent delirium, dementia, or psychiatric conditions. Because psychiatric conditions are often a diagnosis of exclusion in the acute presentation, delirium and dementia must be ruled out. The Folstein Mini Mental State Examination ²² can be useful to screen for cognitive changes. Dementia, a chronic and progressive condition characterized by memory and other cognitive impairments, is discussed elsewhere in this textbook (see Chapter 19).

Delirium, as defined by DSM-IV,¹⁹ is a fluctuating state of consciousness and cognition that is caused by a variety of medical conditions. Delirium, also known as acute confusional state or encephalopathy, typically has an acute onset (over hours to days), has a fluctuating course, and is reversible. Disturbance in consciousness, reduced awareness of the environment, attentional difficulties, disorientation, and an inability to think or speak coherently are common symptoms of delirium. Psychomotor agitation is also common, though psychomotor retardation is possible. Symptoms typically associated with psychiatric diagnoses (such as auditory and visual hallucinations, acute changes in mood, and psychotic or disorganized thoughts) may also be seen in delirious states. In general, it can be said that any medical condition can potentially cause any type of alteration in mental state. While certain underlying medical conditions are commonly associated with certain symptoms (e.g., anxiety or agitation with pheochromocytoma, mania with use of corticosteroids, and depression with interferon treatment), the underlying medical condition cannot be diagnosed by its presentation alone; all possible medical conditions must be considered.

Delirium may represent a serious or life-threatening condition. These conditions include Wernicke’s encephalopathy, hypoxia, hypoglycemia, hypertensive encephalopathy, intracerebral hemorrhage, meningitis/encephalitis, poisoning (exogenous or iatrogenic), and seizures. Their assessment and treatment are outlined in Table 87-4. Other, less urgent conditions (including subdural hematoma, septicemia, subacute bacterial endocarditis, hepatic or renal failure, thyrotoxicosis or myxedema, delirium tremens, anticholinergic psychosis, and complex partial status epilepticus) may require acute interventions.²³ Once acute causes of delirium have been ruled out, other potential causes of delirium should be considered (see Chapter 18 for a more detailed discussion of delirium). When a medical diagnosis has been made, the primary objective is to address the underlying etiology. Nonetheless, symptomatic treatment of confusion or agitation associated with delirium can be administered.

Table 87-4 Potentially Life-Threatening Causes of Delirium

Condition	Diagnostics	Treatment
Wernicke’s encephalopathy	Clinical triad: change in mental status, gait instability, ophthalmoplegia	Thiamine 100 mg IM (may see improvement over the course of hours)
Hypoxia	Oxygen saturation/ABGs	Treat etiology
Hypoglycemia	Blood glucose	PO/IV administration of glucose, dextrose, sucrose, or fructose
Hypertensive encephalopathy	Blood pressure	Antihypertensive medication
Hyperthermia/hypothermia	Temperature	Cooling or warming interventions
Infectious process (e.g., sepsis, bacteremia, subacute bacterial endocarditis)	Infectious workup	Treat infectious agent/site
Intracerebral hemorrhage	MRI/CT	Per hemorrhage type/location
Meningitis/encephalitis	LP, MRI	Antibiotic medication
Metabolic (e.g., chemical derangements, renal failure, hepatic failure, thyroid dysfunction)	Laboratory investigations	Per derangement
Poisoning/toxic reaction (e.g., environmental exposures, medications, alcohol, illicit substances)	Toxicology panel	Per toxin
Status epilepticus	EEG	Anticonvulsants or IV benzodiazepines (or both)

ABGs, Arterial blood gases; CT, computed tomography; EEG, electroencephalogram; IM, intramuscular; IV, intravenous; LP, lumbar puncture; MRI, magnetic resonance imaging; PO, oral (per os).

If medical causes of delirium have been ruled out, a primary psychiatric diagnosis should be considered. Often, a diagnosis of an Axis I primary mood or thought disorder can be made based on symptomatology. If the patient does not meet diagnostic criteria for an Axis I disorder, an Axis II personality disorder or personality traits should be considered. Agitation or threatening behavior may not be due to either an Axis I or II condition, but may be representative of problems with behavior, and thus may not be amenable to acute psychiatric treatment.

The Agitated Patient

In the emergency setting, evaluation and treatment may be complicated by agitation, defined as the physical manifestation of internal distress. Agitation may be a sign of psychiatric distress or be related to an underlying medical etiology. Early signs include pacing, tapping of the fingers and feet, sighing, moaning, breathing heavily, fidgeting, staring intensely, or appearing distracted by internal stimuli. Physical signs (such as elevations in blood pressure, pulse, or respiratory rate) may be noted. Pressured or loud speech, invasion of others’ personal space, clenching of the jaw, or tension of other muscles often indicate escalating agitation. Agitation can herald a psychiatric emergency; it jeopardizes the safety of the patient, as well as others in the treatment environment, and it impedes optimal evaluation and treatment.

Agitation is best managed by attempting to prevent or treat it as early as possible. The agitated patient should be enlisted in this task (i.e., to monitor his or her own internal state, to report increases in anxiety or distress, and to consider effective means for the reduction of distress in order to avert any behavioral dyscontrol). Modulation of the environment (by decreasing interpersonal interactions and auditory or visual stimulation) is an important initial step in management. A safe environment (free from the risk of harm) should be created to reduce agitation for some patients. Staff or family members should be available to communicate with the patient. Offers of food and drink may also be helpful.

Rapid movements, yelling, slamming doors, and throwing objects are important signals that the patient is out of control. Threats or attempts to harm oneself or others signal that more must be done to keep the patient and the staff safe. If there is a risk of harm to the patient or to others, a physically safe environment, without access to objects that could be used as weapons, using the least restrictive means possible, should be arranged. Pharmacological interventions to reduce agitation should also be considered. Further discussion of management of agitation, including medications and restraint and seclusion, is provided later in this chapter.

Drug or alcohol intoxication or withdrawal (including nicotine withdrawal), delirium, injury, pain, dementia, psychosis, mania, anxiety, and borderline and antisocial personality disorders are just a few of the diagnoses that lead to agitation in the PES.

MANAGEMENT OF ACUTE SYMPTOMS

The primary goal in the PES is to manage acute crises. The intervention chosen will depend on the patient’s needs, the severity of illness, and the time and resources available. For some patients, the intervention consists of the opportunity to speak to an understanding clinician, who can form an alliance, demonstrate empathy, and provide reassurance. Other patients require extensive laboratory tests or restraint for agitation. Between those extremes are various therapeutic interventions designed to decrease the acuity of the patient’s situation, to provide education about mental illness and treatment, and to help the patient and family members make informed decisions about treatment. The interventions provided in the PES can be broken down into four categories: the environmental intervention, the psychological intervention, the medication intervention, and use of restraint and seclusion (the option of last resort).

Environmental Intervention

Though resources and space may be limited, the environmental intervention is of critical importance for a patient in crisis. The environment will determine if the patient will sit, stand, or lie on a stretcher; if he or she will wear street clothes or a hospital gown; and if the clinician will be alone with the patient or be accompanied by family or other emergency staff. If possible, the interview should occur in a quiet, clean setting, where the patient and the clinician can both sit comfortably and not be overheard by strangers in the ED. This, of course, is dependent on the patient’s behavior; the presence of other staff or security in the ED is paramount for safety when working with a patient who appears agitated or impulsive. Attention to the patient’s basic needs (e.g., offering a blanket in a cold room, being sure that the patient has access to a restroom, and offering the patient something to drink or eat) will assist in forming an alliance.

Psychological Intervention

Forming an alliance during a brief interview in an emergency setting can be a challenge. PESs are often busy, with long waits for evaluation and treatment; clinicians who work there are often pulled in different directions. A sympathetic comment after a patient has experienced an extended wait can facilitate an alliance.

The psychiatrist should allow the patient a few minutes at the beginning of the interview to describe the situation. This helps the patient feel heard, allows a brief assessment of the patient’s mental status, and gives the psychiatrist time to formulate a plan to guide the course of the interview. Often, due to time constraints, the PES evaluation involves more closed-ended screening questions (to rule out major symptoms or diagnoses) than occurs in other psychiatric arenas. Empathic comments demonstrate concern and allow the clinician to interject with appropriate questions to guide the interview.

In the emergency service, the psychological intervention is often pragmatic. It may consist of formation of an empathic connection and education about psychiatric symptoms, treatments, or the mental health system. The clinician may help the patient gain insight into the problem at hand and brainstorm about alternative solutions. Some dependent patients will want help to make a decision about treatment, whereas the clinician may want to lead narcissistic patients to create solutions themselves. The psychiatrist may offer reassurance that a problem is not as overwhelming as it seems or that help is available. The patient’s and the family’s unstated wishes or concerns should be identified and managed.

Questions or techniques that allow the patient to regress are rarely helpful in the emergency service; instead, the patient should be encouraged to identify coping skills that have been helpful at other times. Though the patient should be allowed to describe difficult feelings and to release tension, there should be an expectation that the patient behave within the boundaries of what is safe and appropriate in that environment (e.g., it is not appropriate to punch walls to demonstrate anger). There will be times when a patient is too ill to participate within these boundaries, and accommodations can be made, but this usually indicates a need for referral to a higher level of care.

Another key to providing therapeutic care in the emergency setting is to understand potential countertransference reactions. Amidst the stress of overcrowded and chaotic EDs and PESs, staff at every level can become cynical and angry. Care must be taken to separate these frustrations from the health and welfare of patients. Acting on countertransference reactions can lead to unprofessional behavior and can compromise clinical care and safety. For many years at Massachusetts General Hospital, psychiatric residents have participated in a weekly supervision session that focuses on recognizing countertransference reactions and enhancing resilience after long nights in the PES.²⁴ Awareness of stress levels and scheduled breaks (to eat meals and to relax during long shifts) are necessary to the provision of good care on an emergency service.

Intervention with Medication

Never underestimate the power of medication in a psychiatric emergency. For some patients, particularly those who are psychotic or acutely agitated, this may be the primary intervention. Medication can decrease anxiety and paranoia, improve disorganization, and help a manic patient to sleep. Benzodiazepines decrease symptoms of alcohol withdrawal. Some patients who are initially overwhelmed are able to participate in the interview and psychological intervention only after medication has been administered. Medication should be considered early and often in the process of an evaluation. If the patient uses a medication at home on an as-needed basis for similar symptoms or has tried a medication before, the same medication can be offered to minimize potential side effects of new medications. If the patient has not tried medications, consideration of the symptoms, differential diagnosis, intended means of administration of the medication, and potential side effects will help narrow down the options.^25,²⁶

Potential medication regimens in the PES include benzodiazepines (particularly lorazepam [0.5 to 1 mg] orally [PO] or intramuscularly [IM]; a benzodiazepine should always be the first choice if alcohol withdrawal is suspected); an atypical neuroleptic (such as risperidone [0.5 to 1 mg] in oral tablet, liquid, or rapidly dissolving form or olanzapine [2.5 to 5 mg] in oral tablet or rapidly dissolving form); and high-potency neuroleptics (such as haloperidol) combined with a benzodiazepine and an anticholinergic agent (diphenhydramine or benztropine) for more severe agitation. A commonly used combination that can be administered PO or IM is haloperidol 5 mg and lorazepam 2 mg, plus diphenhydramine 25 to 50 mg (for prophylaxis of dystonia). Newer parenteral formulations of atypical neuroleptics for the management of acute agitation are also available; options include olanzapine 10 mg IM, ziprasidone 20 to 40 mg, and aripiprazole 10 to 15 mg. Table 87-5 lists a range of medications that are used for adult patients in the PES.

Table 87-5 Medications Frequently Used in the Psychiatric Emergency Service for Adult Patients

Medication	Starting Dose^*	Formulation Available
Benzodiazepines
clonazepam (Klonopin)	0.5 mg	PO
chlordiazepoxide (Librium)	25-50 mg	PO/IM/IV
diazepam (Valium)	5-10 mg	PO/IM/IV (oral solution available)
lorazepam (Ativan)	0.5-1 mg	PO/IM/IV (oral solution available)
oxazepam (Serax)	15-30 mg	PO
Typical Antipsychotics
chlorpromazine (Thorazine)	25-50 mg	PO/IM (oral solution available)
fluphenazine (Prolixin)	5-10 mg	PO/IM (oral solution available)
haloperidol (Haldol)	5-10 mg	PO/IM/IV (oral solution available)
perphenazine (Trilafon)	4-8 mg	PO (oral solution available)
Atypical Antipsychotics
olanzapine (Zyprexa)	5-10 mg	PO/IM^†
quetiapine (Seroquel)	25-50 mg	PO
risperidone (Risperdal)	1-2 mg	PO^† (oral solution available)
ziprasidone (Geodon)	20 mg (10-20 mg IM)	PO/IM
Other Agents
benztropine (Cogentin)	0.5-1 mg	PO/IM/IV
buspirone (BuSpar)	5-10 mg	PO
clonidine (Catapres)	0.1 mg	PO
diphenhydramine (Benadryl)	25-50 mg	PO/IM/IV (oral solution available)
gabapentin (Neurontin)	100-200 mg	PO
propranolol (Inderal)	20 mg	PO (oral solution available)
trazodone (Desyrel)	25-50 mg	PO

IM, Intramuscular; IV, intravenous; PO, oral (per os).

* Starting doses are for healthy adult patients. Consider lower doses in patients who are elderly or have a history of head injury or mental retardation.

† Also available in an orally disintegrating tablet.

Elderly patients, patients with mental retardation, and patients with a history of head injuries can be particularly sensitive to anticholinergic side effects or to paradoxical reactions of medications. Smaller initial doses of medica-tion should be used, with increases made slowly in these populations.

Restraint and Seclusion

In general, use of the least restrictive means of restraint is considered the standard of care in psychiatry. However, this must be balanced with the risk of imminent danger as determined by the assessment.

Restraint and seclusion are treatments of last resort when the patient is at imminent risk of harming himself or herself or someone else. Unfortunately, controlled studies com-paring the impact of methods of restraint and seclusion are lacking.²⁷ Recent efforts have focused most on methods for reducing the need for restraint and seclusion in psychiatric settings.

All staff involved in restraint and seclusion should be well trained in the techniques for the safe management of aggressive behavior. Generally, it is the physician who orders restraint or seclusion, but the entire team should be clear about the reason for the restraint and the procedures involved. Each member of the team should feel responsible for maintaining the safety of the patient and the other staff.

The patient in seclusion or restraint should also be monitored at all times. In most facilities, there is a limit to the time that the patient may remain in restraint; however, attempts should always be made to remove the restraints as soon as possible. Almost every patient who requires restraint or seclusion can benefit from medication to decrease the symptoms that have led to agitation.

Treatment after the Acute Crisis

The availability of outpatient treatment varies greatly by location and by available resources in the hospital or the community. Some PESs offer prescriptions for medications on discharge and even provide follow-up while patients are awaiting referral to outpatient facilities. Other programs only treat acute problems and do not prescribe, but may have access to urgent appointments or to an outpatient program with a short wait-list. Either way, after the management of the acute problem, treatment planning is part of every disposition.

The emergency psychiatrist must have a thorough knowledge of the local mental health resources. Inpatient units, crisis stabilization units, residential treatment services, partial hospitalization programs, detoxification units, and outpatient programs serve as alternative levels of care after the PES evaluation. Admission criteria vary and many programs depend on prior approval by insurance companies. The acuity of the patient’s symptoms, the insurance coverage, and the psychosocial support system must all be weighed to determine the appropriate level of care. Decisions made with the patient, the family, and with other treaters should be coordinated.

SPECIAL POPULATIONS

The Personality-Disordered Patient

Patients with borderline or antisocial personalities usually require a significant amount of time from PES staff to coordinate their care. Such patients may request services or favors that are outside of the normal routine of the unit. They may file complaints or even threaten to harm or kill themselves or others if the clinician is unwilling to provide the treatment that the patient prefers. Often these threats are statements of desperation, though each statement must be evaluated with the patient’s history and current situation in mind.

Problems often occur due to splits between staff members who disagree about how the patient should be managed. The most important aspect of the treatment of these patients is for the PES team to provide clear boundaries regarding the scope of care available, the role of individual staff members, and the goal of the emergency intervention. Outside contacts who know the patient may be able to provide insight for the purposes of the safety assessment.

The Grieving Patient

Management of acute grief (e.g., following a traumatic event or a death within the ED, the loss of a relationship, or the anniversary of a loss) is a common reason for referral to the PES. Grief is the normal response to loss. Grief can manifest in many ways, including feelings of shock, sadness, anxiety, anger, and guilt.²⁸ The most common symptoms are outlined in Table 87-6. A patient may exhibit any of these symptoms during the emergency evaluation. Brief periods of hearing the voice of a deceased spouse or feeling unable to participate in the routines of daily life are normal; they allow the patient time to come to terms with the loss. However, extended periods of depressed mood, anhedonia, and other neurovegetative symptoms may indicate an episode of major depression and require more immediate treatment.

Table 87-6 Symptoms of Grief

Adapted from Lindemann E: Symptomatology and management of acute grief, Am J Psychiatry 151(6 suppl):155-160, 1994.

The role of the psychiatrist in working with a grieving patient is to provide a supportive environment. Some patients will want to sit quietly, others will want to talk, and others will cry. If the situation is ongoing (e.g., a family member’s injury is being treated in the ED), only accurate informa-tion should be provided and giving false hope should be avoided. Patients should be helped to recognize how they have handled losses in the past, and similar coping skills should be supported.

Victims of Domestic Violence and Trauma

Domestic violence (i.e., an individual’s use of force to inflict emotional or physical injury on another person with whom the individual has a relationship) affects spouses, partners, children, grandparents, and siblings of all races and genders. Between 2 and 4 million women are abused each year in the United States, and domestic violence has become the leading cause of injury among women between 15 and 44 years of age.²⁹ Men can also be victims of domestic violence.

Patients in the PES should be asked whether they have been a victim of violence or trauma, whether this contributes to their symptoms, and if they are safe in their current living environment. Symptoms of posttraumatic stress disorder should be screened for and included in treatment planning. Patients need not be asked to describe exhaustive details about past traumas. Instead, the patient can be helped to understand that the process of working through trauma should occur with a therapist who can provide long-term support, and then provide an appropriate referral.

The Homeless Patient

It is estimated that approximately one-fifth of the patients who are treated at PESs are homeless,⁴ and this characteristic adds complexity to the psychiatric evaluation. When a patient has insomnia or the fear of being harmed by others, it may be difficult to determine whether the symptoms are due to a psychiatric disturbance or to the inherent risks of homelessness. Homeless patients are at greater risk for substance abuse, tuberculosis, skin conditions, and other serious chronic medical conditions (such as diabetes, acquired immunodeficiency syndrome [AIDS], and cancer); it is especially important to provide good medical screening during the assessment. The clinician must also account for the patient’s housing situation and access to meals and medical care in the course of disposition planning. A treatment plan adapted to these realities is much more likely to succeed.³⁰

Emergency Assessment of Children

Demographics

There are very few studies of emergency psychiatric presentations among children. It is estimated that there are about 434,000 annual pediatric visits for mental health conditions in the United States, which constitutes about 1.6% of ED visits in this age-group (under age 19). Adolescents between 13 and 17 years of age account for more than two-thirds of the visits, and suicide attempts account for 13% of the visits. The most common diagnoses include substance-related disorders (24%), anxiety disorders (16%), attention-deficit and disruptive disorders (11%), and psychosis (10%). Nineteen percent of ED mental health visits result in inpatient admission, compared to only 9% of non–mental health visits in the same age-group.³¹ A study that analyzed data about young people (ages 7 to 24 years) treated at EDs for deliberate self-harm reported an annual rate of 225 per 100,000.³² Among those patients, 56% were diagnosed with a mental disorder (including 15% with depression and 7% with substance use disorders), and 56% were referred for inpatient admission. Frequent precipitants for ED visits include family crises (e.g., death, divorce, financial stress, and domestic abuse), disturbed or truncated peer relationships, and recent change of school.³³^–³⁵

Basic Principles

Few child psychiatric emergencies are life-threatening; all result from the complex interaction of psychosocial, biological, and systems issues.

The primary goal is the safety of the child, and this principle must guide all subsequent plans for treatment or disposition. The clinician must always consider the possibility of abuse or neglect as the precipitant for the visit to the ED.

The evaluation itself is based on a developmental approach. The clinician must choose age-appropriate techniques with which to conduct the assessment.

The emergency psychiatric assessment of a child is often more complicated and time-consuming than the evaluation of an adult. The clinician must be familiar with resources for children and families within the community mental health system. Thorough evaluation often requires phone calls to outside providers (including pediatricians, school administrators, guidance counselors, and outpatient mental health professionals).

The Evaluation

The initial step in the assessment of a child in the PES is identification of the child’s legal guardian(s). In routine cases, the legal guardians are the biological parents who accompany the child to the hospital. In complex cases, the child’s legal guardian may be court-ordered to be only one parent, another relative, a foster parent, or a representative of the state agency responsible for the care and protection of children. Custody can be split into several parts, and one guardian can have legal (or decision-making) custody while another guardian retains physical custody. Sometimes a child remains in the home of the biological parent but a state agency assumes responsibility for decisions regarding medical care. The clinician should never assume that the adult who accompanies the child is the legal guardian or that a friend or neighbor can offer consent for the assessment. Except in very rare, extenuating circumstances, the legal guardian must come to the assessment center and participate in the evaluation, because that person will be a key factor in disposition.

The clinician who evaluates children in an ED should base the method of assessment on the age of the child, although the interview may also include many standard elements of the psychiatric history as listed in Table 87-1. The style and process of the interview and mental status examination depend on the age of the child.

Preschoolers (1 to 5 years), many of whom may be preverbal, are unable to provide a coherent narrative of the events leading up to the ED visit. The clinician must interview the parent or guardian to obtain the details of the history, but should also pay careful and close attention to the interaction between the child and the caregiver, as well as to the child’s hygiene. Mental status assessment should focus on the child’s behavior, level of agitation, mood, affect, and ability to take direction and accept reassurance from the caregiver. Common precipitants for ED visits in this age-group include impulsive or dangerous behaviors (such as running away from home or from a caregiver in a public place, fire-setting, or hitting a younger sibling).

Latency-age children (5 to 11 years) can often provide a clear description of the event that brought them to the ED but usually lack the ability to place the specific event within a larger context. It is often helpful for the clinician to interview the parent or caregiver before meeting with the child. Assessment of the mental status includes observations of the child’s interaction with the caregiver, attention to speech and language, and direct questions about mood, affect, and risk for self-injurious behavior. Children who are younger than 6 years old might retain their “magical thinking” and thus not yet be able to distinguish fantasy from reality.

Adolescents (12 to 18 years) should ideally be interviewed before the clinician speaks with caregivers or other concerned adults. This approach reinforces and supports the adolescent’s desire for autonomy and control. Mental status assessment involves assessment of mood, affect, thought process and content, cognition, insight, and judgment, as well as suicidal and homicidal ideation.

Finally, the evaluation must include an assessment of the social situation. Being familiar with the local communities and school systems around your hospital will help you to better understand the social context. An inner-city school with few resources is very different from a wealthy suburban school with counselors and school nurses who can identify new problems and monitor medications; knowing this will help you to make decisions about the treatment plan. It is also important to know the types of treatments that the child has accessed before. A child whose severe depression has failed to improve after several medication trials and participation in months of residential treatment programs is very different from one who seeks treatment for the first time with anxiety symptoms. The previous treatment history will inform your disposition decision.

Management

The agitated or aggressive child requires rapid diagnostic assessment and management. The differential diagnosis should focus first on organic (medical) causes of the behavior (including elevated lead levels [particularly for children under 5 years]), seizure disorders, metabolic abnormalities, medication (prescription or over-the-counter) ingestion or overdose, withdrawal from medication or recreational drugs, hypoxia, infection, and intoxication.

If an organic etiology is suspected, vital signs and laboratory studies should be obtained immediately. Laboratory studies might include a complete blood count (CBC), serum electrolytes (including blood glucose), serum and urine toxic screens,³⁶ and, in young women, a pregnancy test. It is usually helpful to control the environment and to decrease stimulation by placing the child in seclusion, sometimes with one family member who can be soothing and reassuring. With very young children, it can be helpful to offer food and drink.

Sometimes it is necessary to administer medication to control agitated or acutely intoxicated children, particularly if they are in danger of harming themselves or others. It is best to ask the parent or guardian which medications the child usually takes and administer either an additional dose of a standing medication or an existing as-needed (PRN) medication. Administration of an oral medication is always preferable to an intramuscular injection, but it is not always possible if the child is unable to respond to verbal direction or limit-setting.

The choice of medication and route of administration depend on the severity of the agitation and the age of the child. Medications to consider include diphenhydramine (1.25 mg/kg/dose PO or IM if the child has no history of paradoxical excitation); clonidine (at a dose of 0.05 to 0.1 mg PO); an atypical neuroleptic (such as risperidone [0.5 to 1 mg] in oral tablet, liquid, or rapidly dissolving form, or olanzapine [2.5 to 5 mg] in oral tablet or rapidly dissolving form or IM preparation); benzodiazepines (particularly lorazepam [0.5 to 1 mg] PO or IM can be helpful but can also cause paradoxical excitation and disinhibition); and for an older, acutely agitated adolescent, it is appropriate to use a high-potency neuroleptic (such as haloperidol) combined with a benzodiazepine and an anticholinergic agent (diphenhydramine or benztropine).

Physical restraints (e.g., locked leather restraints) are sometimes necessary and should be placed only by trained security personnel according to guidelines established by the state department of mental health. Family members should leave the room during any form of restraint.

LEGAL RESPONSIBILITIES OF THE EMERGENCY PSYCHIATRIST

The emergency psychiatrist is responsible for knowing the legal regulations and local standards of care related to capacity evaluations, confidentiality, release of information, commitment standards, and mandatory reporting for patients with psychiatric symptoms who are treated at the PES. Although specific standards may differ, the following features may assist with understanding these general responsibilities. In all cases, it is important to document carefully all steps involved in the decision-making process and to consult with a forensic psychiatrist or legal counsel trained in mental health law in difficult cases.

Capacity Evaluation

The capacity evaluation is often requested by other medical providers to determine whether a patient has the ability to make an informed decision about a particular medical procedure or decision. A patient is presumed to have capacity to make medical decisions until proven otherwise. The key components of this evaluation include the assessment of whether the patient can understand the relevant information, appreciate the consequences of the decision, and communicate a reasonable explanation for the choice. In many cases, the psychiatrist will find that the patient’s ability to make a clear and rational decision is dependent on an opportunity to learn more about the specific medical procedure. If the psychiatrist can coordinate further communication between the medical or surgical team and the patient, the need for the capacity evaluation may become obsolete.

Confidentiality and Release of Information

The care of psychiatric patients requires a strong commitment to confidentiality; in the emergency setting, all attempts are made to gain permission for any collateral contact regarding the patient’s condition. However, in the care of patients who present a risk of harm to themselves or others, it is sometimes necessary to contact treaters or family members without the patient’s consent. It is important to document clearly why the contact was made and to use the contact to gain information that will assist in the safety assessment. The clinician should limit the confidential information provided to the other party.

Another situation in which a breach in confidentiality may be justified is when a clinician learns that a patient is at imminent risk to harm another individual. The standards for the clinician’s duty to protect the potential victim are different in every state, but most are based on the original Tarasoff case in California in 1976.³⁷

Civil Commitment

Civil commitment refers to the state’s ability to hospitalize an individual involuntarily because of risk of harm due to mental illness.³⁷ The commitment regulations and processes vary by state. Most regulations incorporate risk of harm to self, risk of harm to others, and inability to care for self, all due to psychiatric pathology, as the basis for civil commitment. The safety evaluation described in this chapter provides the clinician with a basic outline of an assessment to determine risk and is an important component of the assessment that may lead to civil commitment.

Mandatory Reporting

Most states have regulations regarding mandatory reporting for suspected child abuse,³⁸ elder abuse,³⁹ and abuse of individuals with mental retardation. In most cases, mandatory reporters are obligated to report situations in which they suspect abuse, whether or not they have clear evidence; they are protected against claims of a breach of confidentiality under these conditions.³⁷ Mental health clinicians should be aware of whether they are considered mandatory reporters in their state and how to contact the appropriate agencies.