Emergency Psychiatry

Introduction

Over the past 20 years, emergency psychiatry has developed into an independent subspecialty practice within psychiatry. Although formal board certification requirements are lacking, all accredited US psychiatric residency-training programs follow minimum training guidelines for emergency psychiatry. The emergence of emergency psychiatry as a specialized practice parallels the recent dramatic increase in patient volume in emergency care settings. In 2001, there were over 2 million visits to US 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. By 2007, 8% of all ED visits were related to mental health complaints.

Psychiatric emergencies encompass a range of clinical presentations and diagnoses. Typically, 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 puts the patient or others at risk. Patients may have suicidal or homicidal ideation, overwhelming depression or anxiety, psychosis, mania, or acute cognitive or behavioral changes; these presentations may occur in the context of active substance use. Emergency services are also used for non-emergent conditions. Increasing numbers of patients seek treatment at EDs for non-urgent conditions, in order to secure outpatient referrals due to a general scarcity of community-based outpatient resources, or an inability to navigate the complex mental healthcare system. This volume increase, coupled with the dearth of available outpatient services, the limited number of inpatient psychiatric beds, and the demands of insurance companies for prior authorization for care, has led to longer lengths of stay for many psychiatric patients in the ED, especially for, among others, those who demonstrate acute safety issues (suicidal or homicidal ideation), are hostile and aggressive, have significant but not necessarily active co-morbid medical issues, or are uninsured.

The scope of emergency psychiatry includes core skills for psychiatric practice, as well as more specialized skill sets. In addition to the evaluation and treatment of acute psychiatric conditions, practitioners of emergency psychiatry must evaluate and 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, emergency psychiatrists must also be skilled in the assessment and treatment of medical conditions that involve psychiatric symptoms.

This chapter provides a foundation for the clinical aspects of psychiatric emergency care. First, we review the psychiatric emergency evaluation, and then address special topics including common emergency psychiatric presentations, management of acute substance intoxication and withdrawal, management of agitation, the emergency treatment of children who present with acute psychiatric crises, and legal issues in emergency psychiatry.

Demographics

As of 1991, the United States had approximately 3000 dedicated psychiatric emergency services (PESs). By 2007, roughly 86% of general hospitals provided some type of emergency psychiatric care, with 45% having either a psychiatric emergency service or an in-house consultation service and 41% contracting with an outside source for emergency psychiatric care. Approximately 29% of the patients treated are diagnosed with psychosis, 25% with substance abuse, 23% with major depression, 13% with bipolar disorder, and 22% with personality disorders; co-morbidity is common. Approximately one-third to one-half of patients voice suicidal ideation.

Though patients may self-refer to a PES, many are referred by family, friends, primary care providers, medical specialists, community mental health providers, and employees of local, state, and public agencies. Multiple high-profile school shootings have prompted schools in the United States to refer students to PESs for emergency risk assessments. Police officers and representatives of the legal system can also be a source of referrals, as there is often overlap between the mentally ill and/or active substance users and the legal system. Patients with acute psychiatric illnesses, e.g., delirium or paranoia that manifests as hostility or aggression, are sometimes taken into custody for their own safety or for the safety of others. Such patients require emergency psychiatric assessment to determine if their behavior is primarily due to an acute psychiatric illness and if they require mental health services.

Types of Delivery Models

Delivery of emergency psychiatric services within a general hospital typically falls into one of two models. In the first, the PES exists as an independent service, either co-located with a general emergency department or located separately in a stand-alone facility nearby. In the second model, the PES functions as a consultation service that provides recommendations to primary emergency medical services. Some institutions utilize hybrid models; the type of service offered within a specific hospital is usually determined by the volume of patients and available financial and staff resources.

Delivery of emergency psychiatric care through an independent service offers several benefits. The first is safety: a PES that is separated from the chaos of a busy ED offers a secure environment, in which providers can assess patients within a less-stimulating environment while also limiting access to dangerous objects. Such a unit allows the staff to observe the patients, formulate an initial diagnosis, and initiate psychiatric treatment rapidly. The unit may also have security staff who are trained to understand mental health issues, and can help maintain a safe environment for patients and staff. Many units also have specialized rooms for restraint and seclusion. In addition, an independent PES is more likely to have individual rooms for private interviews, thus protecting patients' privacy and allowing them to maintain their dignity.

Another benefit of a dedicated psychiatric unit is the opportunity to staff the unit with specialized personnel with training in emergency psychiatric care. An interdisciplinary staff of psychiatrists, nurses, social workers, and case managers can enhance the care of psychiatric patients, by coordinating medical evaluations with ED colleagues, initiating psychopharmacologic treatment, focusing on therapeutic patient interactions, and using their specialized knowledge of psychiatric services to facilitate appropriate disposition. Psychiatric staff also manage the milieu in an emergency unit, provide individual support to patients, and recognize when situations require immediate intervention.

Some PESs also have access to “crisis beds” 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.

The Psychiatric Interview

The psychiatric emergency evaluation is a concise, focused evaluation with the goals of diagnostic assessment, management of acute symptoms, and disposition to the appropriate level of care. Just as a medical ED visit 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, as well as the overall medical stability of the patient. This initial determination of acuity should screen for active medical issues, including those that may cause a change in mental status or psychiatric symptomatology.

Many patients are willing to participate in a psychiatric evaluation, but some are not. Most states have legislation that allows for holding individuals against their will if there is evidence of inability to care for self, or dangerousness to self or others due to mental illness. In the PES, if patients meet these criteria, they may be held involuntarily for further evaluation.

The cornerstone of the initial psychiatric evaluation is a careful history that focuses on the temporal relationship between the acute symptoms that led to the emergency visit, associated signs and symptoms, and possible precipitants. In addition, important aspects of the evaluation also include information regarding significant medical history, psychiatric diagnoses and treatments, current and past medications, allergies and adverse reactions to medications, patterns of substance use, family history, and psychosocial history. Specific history of prior suicide attempts or violent behavior should always be included in an emergency assessment. Table 45-1 describes components of the evaluation, and Table 45-2 describes the special features of a substance use evaluation.

It is important to consider all of the information that could be included in an evaluation and then to focus 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 ultimate disposition. 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 is 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 s/he spends the day (e.g., at work, at school, or in a therapeutic program). This assessment defines the patient's baseline level of function. In addition, in many countries, including the United States, a review of the patient's health insurance is necessary because it often dictates the types of treatment programs that are available for disposition.

Often, PES presentations are complicated, and patients may be unable, or unwilling, to provide an accurate history. Therefore, it is important to collect information from multiple sources including, but not limited to, outside medical records, family, friends, treaters, police, emergency personnel, pharmacies, or statewide prescription monitoring programs. Ideally, patients will give consent for collateral sources to be contacted. If a patient declines to give this permission, the importance of the type of information sought must be balanced against a violation of the patient’s wishes and a potential violation of confidentiality. In addition, clinicians should be mindful about only gathering, and not releasing, information, particularly without patient consent. When data can be obtained and corroborated from various sources, psychiatrists are able to make better informed risk assessments and disposition decisions.

The Medical Evaluation

The purpose of the medical evaluation, often called “medical clearance,” is to determine that there is no identifiable medical cause contributing to the patient's psychiatric presentation that requires acute medical intervention, and that the patient is medically stable enough to receive care in their intended disposition setting. Consideration of medical etiologies and co-morbidities is important because many psychiatric hospitals have limited resources to manage medical conditions. The ED medical evaluation may be the most comprehensive that the patient receives, particularly because many psychiatric patients do not have regular contact with primary care physicians. A missed medical diagnosis because of an assumed psychiatric diagnosis could result in dire consequences. Yet, there is no standard process for medical clearance in the ED, and the need for routine laboratory and other diagnostic testing remains controversial.

Non-geriatric patients with presentations consistent with their prior psychiatric histories, without significant medical conditions or active physical complaints, may be sufficiently evaluated by history, review of systems, physical examination, and vital signs, without additional laboratory testing. Elderly patients or those with known medical problems, new-onset psychiatric symptoms, or a change in previous psychiatric symptoms, will benefit from additional medical testing, including labs or even diagnostic imaging. Practitioners should be vigilant of factors (e.g., homelessness or substance use) which may put patients at risk for additional medical conditions. The medical tests to consider are listed in Table 45-3 .

One retrospective study 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 psychiatric evaluation with the history, 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. Another study demonstrated that two-thirds of ED patients with new-onset psychiatric symptoms had an organic cause. 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 Safety Evaluation

The safety evaluation is a mandatory component of every emergency evaluation and it assesses the imminent likelihood that an individual will attempt to harm oneself or someone else. Suicide is the eighth leading cause of death in the United States, and more than 90% of patients who commit suicide have at least one psychiatric diagnosis. Patients 15 to 24 years of age and those over 60 are at the highest risk for suicide. The safety evaluation is a key factor in determining the overall plan for disposition.

The psychiatrist must ask about thoughts, plans, and intent of suicide and homicide. These questions should be followed by more specific questions about access to lethal means, particularly firearms. If a patient has a plan or intent to commit suicide, the potential 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 is high. Similarly, the possibility that the patient could have been rescued if s/he had attempted the plan should be evaluated; an impulsive ingestion of pills in front of a family member 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, which include the presence and severity of a major mental illness, substance use, impulsivity, family history of suicide, recent loss (social, occupational, or financial), and medical illness, including chronic pain.

The assessment of risk for violence is similar. Every patient should be asked about thoughts to harm others, as well as potential plans and intent. Observation of the patient's mental status, behavior, and impulsivity during the interview provides important information. Because previous violence is the strongest predictor of future violence, it is important to explore prior episodes of violence, triggers for those events, and the role of substance use. Questions about legal issues related to violence are also appropriate. In addition, any intended target(s) of future violence should be identified, if possible. If there is a likelihood of violence directed toward a specific person, there may be a duty to protect the identified target, potentially through containment and treatment of the patient or through warning the identified target. As jurisdictions differ in their approach to these duties, consultations with hospital legal counsel can be helpful when discharge is considered for a potentially violent patient.

Whenever possible, the safety evaluation should include contact with others who know the patient. Although civil commitment laws differ between states, most states have provisions for the containment of a patient who is deemed at acute risk for harm to self or others. In cases where the patient has expressed suicidal or homicidal ideation, which then resolves during the course of the assessment, a clear plan must be created for steps that the patient should take if these thoughts 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 Diagnostic and Statistical Manual of Mental Disorders , 5th edition (DSM-5) criteria can be difficult in the PES because patients are seen at a single point in time, often in crisis, whereas definitive diagnosis frequently requires a longitudinal assessment of symptoms. Nevertheless, consideration of the major diagnostic syndromes (e.g., mood disorders, psychosis, anxiety disorders, substance use disorders, and a change in mental status caused by a medical etiology, such as delirium) should be part of the emergency assessment. The following pages will outline some common psychiatric presentations.