Emergency psychiatry

Emergency psychiatry

Emergency psychiatry is the clinical application of psychiatry in emergency situations and care may be given a specialised Psychiatric Emergency Setting (PES) or in a general emergency room. An emergency serves as the gateway for patients to receive mental health services (Woo, 2009). What constitutes a mental health emergency? As with any medical emergency, a mental health emergency can be life-threatening. Most of the time mental health emergencies are those involving the threat of suicide or the occurrence of an actual suicide attempt. Other types of mental health emergency may involve the threat of harm to another person. In a situation where a patient is decompensating or becoming psychotic and is being guided by audio/visual hallucinations it is sometimes possible that there is a threat posed to another person. This is relatively rare but it can happen if someone is extremely agitated, on hallucinatory drugs or is in the grip of an extremely serious psychotic episode with paranoid thoughts that others are planning to harm the individual. Reasons for visits by patients vary and notable ones include:  psychiatric emergencies in the form of aggression, confusion, depression, homicidality, suicidality and substance abuse, Disruptive Behaviour Disorders (DBD), Conduct Disorder (CD), and Oppositional Defiant Disorder. Conditions requiring psychiatric interventions may include attempted suicide, substance abuse, depression, psychosis, violence or other rapid changes in behaviour. Psychiatric emergency services are rendered by professionals in the fields of medicine, nursing, psychology and social work.

Care for patients in situations involving emergency psychiatry is complex. Health workers attending to people who may be living with a mental disorder are usually under a high risk of violence due to the mental state of their patients. Individuals may arrive in such a setting through their own voluntary request, a referral from another health worker, or through involuntary commitment. Care of patients requiring psychiatric intervention usually encompasses crisis stabilization of many serious and life-threatening conditions which could include acute or chronic mental disorders or symptoms similar to those conditions.

Symptoms and conditions behind psychiatric emergencies may include:

•  Attempted suicide,
• Substance intoxication
• Acute depression,
• Acute psychosis
• Presence of delusions,
• Violent behaviour,
• Panic attacks and severe psychological stress,
• Significant, rapid changes in behavior
• In addition, several rapidly lethal medical conditions present themselves with common psychiatric symptoms.
• Suicide attempts and suicidal thoughts

 Severe Changes in Moods

Patients who present with severe changes in mood, thoughts, or behaviour and those experiencing severe, potentially life-threatening drug adverse effects need urgent psychiatric assessment and treatment. Nonspecialists are often the first care providers, but whenever possible, such cases should be evaluated by a health worker.

 Suicide attempts and suicidal thoughts

As of 2000, the World Health Organization estimated one million suicides each year in the world. There are countless more suicide attempts. Psychiatric emergency service settings exist to treat the mental disorders associated with an increased risk of completed suicide or suicide attempts. Health professionals in health settings are expected to predict acts of violence patients may commit against themselves (or others), even though the complex factors leading to a suicide stem from so many sources, including psychosocial, biological, interpersonal, anthropological and religious. These mental health professionals will use any resources available to them to determine risk factors, make an overall assessment, and decide on any necessary treatment.

Violent behaviour

Aggression can be the result of both internal and external factors that create a measurable activation in the autonomic nervous system. This activation can become evident through symptoms such as the clenching of fists or jaw, pacing, slamming doors, hitting palms of hands with wrists, or being easily startled. It is estimated that 17% of visits to psychiatric emergency service settings are homicidal in origin and an additional 5% involve both suicide and homicide. Violence is also associated with many conditions such as acute intoxication, acute psychosis paranoid personality disorder, antisocial personality disorder, narcissistic personality disorder, and borderline personality disorder. Additional risk factors have also been identified which may lead to violent behaviour. Such risk factors may include prior arrests, presence of hallucinations, delusions, or other neurological impairment, being uneducated, unmarried, poor or male. Mental health professionals complete violence risk assessments to determine both security measures and treatments for the patient.

Psychosis

Patients with psychotic symptoms are common in psychiatric emergency service settings. The determination of the source of the psychosis can be difficult. Sometimes patients brought into the setting in a psychotic state have been disconnected from their previous treatment plan. While the psychiatric emergency service setting will not be able to provide long term care for these types of patients, it can exist to provide a brief respite and reconnect the patient to their case manager and/or reintroduce necessary psychiatric medication. A visit to a crisis unit by a patient suffering from a chronic mental disorder may also indicate the existence of an undiscovered precipitant, such as change in the lifestyle of the individual, or a shifting medical condition. These considerations can play a part in an improvement to an existing treatment plan.

An individual could also be suffering from an acute onset of psychosis. Such conditions can be prepared for diagnosis by obtaining a medical or psychopathological history of a patient, performing a mental status examination, conducting psychological testing, obtaining neuroimages, and obtaining other neurophysiologic measurements. Following this, the mental health professional can perform a differential diagnosis and prepare the patient for treatment. Like with other patient care considerations, the origins of acute psychosis can be difficult to determine because of the mental state of the patient. However, acute psychosis is classified as a medical emergency requiring immediate and complete attention. The lack of identification and treatment can result in suicide, homicide, or other violence.

 Substance dependence, abuse and intoxication

Another common cause of psychotic symptoms is substance intoxication. These acute symptoms may resolve after a period of observation or limited psychopharmacological treatment. However the underlying issues, such as substance dependence or abuse, is difficult to treat in the emergency room. Both acute alcohol intoxication as well as other forms of substance abuse can require psychiatric interventions. Acting as a depressant of the central nervous system, the early effects of alcohol are usually desired for and characterized by increased talkativeness, giddiness, and a loosening of social inhibitions. Besides considerations of impaired concentration, verbal and motor performance, insight, judgment and short term memory loss which could result in behavioural change causing injury or death. Beyond the dangerous behavioral changes that occur after the consumption of certain amounts of alcohol, idioyncratic intoxication could occur in some individuals even after the consumption of relatively small amounts of alcohol. Episodes of this impairment usually consist of confusion, disorientation, delusions and visual hallucinations, increased aggressiveness, rage, agitation and violence. Chronic alcoholics may also suffer from alcoholic hallucinosis, wherein the cessation of prolonged drinking may trigger auditory hallucinations. Such episodes can last for a few hours or an entire week. Antipsychotics are often used to treat these symptoms.

Patients may also be treated for substance abuse following the administration of psychoactive substances containing amphetamine, caffeine, tetrahydrocannabinol, cocaine, phencyclidines, or other inhalants, opioids, sedatives, hypnotics, anxiolytics, psychedelics, dissociatives and deliriants. Health workers assessing and treating substance abusers must establish therapeutic rapport to counter denial and other negative attitudes directed towards treatment. In addition, the clinician must determine the substances used the route of administration, dosage, and time of last use to determine the necessary short and long term treatments. An appropriate choice of treatment setting must also be determined. These settings may include outpatient facilities, partial hospitals, residential treatment centers, or hospitals. Both the immediate and long term treatment and setting is determined by the severity of dependency and seriousness of physiological complications arising from the abuse.

Anxiety

Patients suffering from an extreme case of anxiety may seek treatment when all support systems have been exhausted and they are unable to bear the anxiety. Feelings of anxiety may present in different ways from an underlying medical illness or psychiatric disorder, a secondary functional disturbance from another psychiatric disorder, from a primary psychiatric disorder such as panic disorder or generalized anxiety disorder, or as a result of stress from such conditions as adjustment disorder or post-traumatic stress disorder. Health workers usually attempt to first provide a "safe harbour" for the patient so that assessment processes and treatments can be adequately facilitated. The initiation of treatments for mood and anxiety disorders are important as patients suffering from anxiety disorders have a higher risk of premature death.

Disasters and Post disaster Emergencies

According to the World Health Organization, 30-50% of victims from large-scale disaster are psychologically distressed in the acute phase after disaster. Despite the high chance of natural

recovery for some, around 5 to 10% of the affected population will have a more serious and long-term mental health problems including Major Depression, Anxiety Disorders and Post-traumatic Stress Disorders. The burden of disability attributable to these mental health problems is no less than those caused by physical handicap. Natural disasters and man-made hazards can cause severe psychological stress in victims surrounding the event. Emergency management often includes psychiatric emergency services designed to help victims cope with the situation. The impact of disasters can cause people to feel shocked, overwhelmed, immobilized, panic-stricken, or confused. Hours, days, months and even years after a disaster, individuals can experience tormenting memories, vivid nightmares, develop apathy, withdrawal, memory lapses, fatigue, loss of appetite, insomnia, depression, irritability, panic attacks, or dysphoria. Due to the typically disorganized and hazardous environment following a disaster, mental health professionals typically assess and treat patients as rapidly as possible. Unless a condition is threatening life of the patient, or others around the patient, other medical and basic survival considerations are managed first. Soon after a disaster health workers may make themselves available to allow individuals to ventilate to relieve feelings of isolation, helplessness and vulnerability. Dependent upon the scale of the disaster, many victims may suffer from both chronic and acute post-traumatic stress disorder. Patients suffering severely from this disorder often are admitted to psychiatric hospitals to stabilize the individual.

 

Abuse

Incidents of physical, sexual abuse or rape can result in dangerous outcomes to the victim of the criminal act. Victims may suffer from extreme anxiety, fear, helplessness, confusion, eating or sleeping disorders, hostility, guilt and shame. Managing the response usually encompasses coordinating psychological, medical and legal considerations. Dependent upon legal requirements in the region, mental health professionals may be required to report criminal activity to a police force. Mental health professionals will usually gather identifying data during the initial assessment and refer the patient, if necessary, to receive medical treatment. Medical treatment may include a physical examination, collection of medicolegal evidence, and determination of the risk of pregnancy, if applicable.

Treatment

Treatments in an emergency room are typically transitory in nature and only exist to provide dispositional solutions and/or to stabilize life-threatening conditions. Once stabilized, patients suffering chronic conditions may be transferred to a setting which can provide long term psychiatric rehabilitation. Prescribed treatments within the emergency service setting vary dependent upon the patient's condition. Different forms of psychiatric medication, and psychotherapy may be used in the emergency setting.

The introduction and efficacy of psychiatric medication as a treatment option has reduced the utilization of physical restraints in emergency settings, by reducing dangerous symptoms resulting from acute exacerbation of mental illness or substance intoxication.

Medications

With time as a critical aspect of emergency psychiatry, the rapidity of effect is an important consideration. Pharmacokinetics is the movement of drugs through the body with time and is at least partially reliant upon the route of administration, absorption, distribution and metabolism of the medication. A common route of administration is oral administration, however if this method is to work the drug must be able to get to the stomach and stay there. In cases of vomiting and nausea this method of administration is not an option. Suppositories can, in some situations, be administered instead. Medication can also be administered through intramuscular injection, or through intravenous injection. The amount of time required for absorption varies dependent upon many factors including drug solubility, gastrointestinal motility and pH. If a medication is administered orally the amount of food in the stomach may also affect the rate of absorption. Once absorbed medications must be distributed throughout the body, or usually with the case of psychiatric medication, past the blood-brain barrier to the brain. With all of these factors affecting the rapidity of effect, the time until the effects are evident varies. Generally, though, the timing with medications is relatively fast and can occur within several minutes. As an example, physicians usually expect to see a remission of symptoms thirty minutes after haloperidol, an antipsychotic, is administered intramuscularly.

Psychotherapy

Other treatment methods may be used in psychiatric emergency service settings. Brief psychotherapy can be used to treat acute conditions or immediate problems as long as the patient understands his or her issues are psychological, the patient trusts the physician, the physician can encourage hope for change, the patient has motivation to change, the physician is aware of the psychopathological history of the patient, and the patient understands that their confidentiality will be respected. The process of brief therapy under emergency psychiatric conditions includes the establishment of a primary complaint from the patient, realizing psychosocial factors, formulating an accurate representation of the problem, coming up with ways to solve the problem, and setting specific goals. The information gathering aspect of brief psychotherapy is therapeutic because it helps the patient place his or her problem in the proper perspective. If the physician determines that deeper psychotherapy sessions are required, he or she can transition the patient out of the emergency setting and into an appropriate clinic or centre. 

PART 2- SUMMARY

Emergency psychiatry involves the application of psychiatry in emergency situations, and care may be provided in either a specialized Psychiatric Emergency Setting (PES) or in a general emergency room. Patients can receive mental health services through the emergency department. Mental health emergencies can be life-threatening, and most of the time, they involve the threat of suicide or the occurrence of an actual suicide attempt. Other types of mental health emergencies may involve the threat of harm to another person. In rare cases, patients may become psychotic, which could result in a threat to others. Common reasons why patients seek emergency psychiatric services include psychiatric emergencies in the form of aggression, confusion, depression, homicidality, suicidality, substance abuse, Disruptive Behaviour Disorders (DBD), Conduct Disorder (CD), and Oppositional Defiant Disorder. Conditions requiring psychiatric interventions may include attempted suicide, substance abuse, depression, psychosis, violence, or other rapid changes in behavior. Psychiatric emergency services are rendered by professionals in the fields of medicine, nursing, psychology, and social work. Providing care for patients in situations involving emergency psychiatry is complex. Health workers who attend to patients with mental disorders are usually at high risk of violence due to their patients' mental state. Individuals may arrive in such a setting through their own voluntary request, a referral from another health worker, or through involuntary commitment. Care of patients requiring psychiatric intervention usually encompasses crisis stabilization of many serious and life-threatening conditions which could include acute or chronic mental disorders or symptoms similar to those conditions. Symptoms and conditions behind psychiatric emergencies may include attempted suicide, substance intoxication, acute depression, acute psychosis, presence of delusions, violent behavior, panic attacks, severe psychological stress, and significant, rapid changes in behavior. Additionally, several rapidly lethal medical conditions present themselves with common psychiatric symptoms. Suicide attempts and suicidal thoughts are prevalent in the world, with an estimated one million suicides each year as of 2000, and countless more suicide attempts. Psychiatric emergency service settings exist to treat mental disorders associated with an increased risk of completed suicide or suicide attempts. Health professionals in these settings predict violent behavior that patients may commit against themselves or others, even though the complex factors leading to suicide stem from many sources, including psychosocial, biological, interpersonal, anthropological, and religious. These mental health professionals use all available resources to determine risk factors, make an overall assessment, and decide on necessary treatment. Aggression can be the result of internal and external factors that create a measurable activation in the autonomic nervous system. This activation can become evident through symptoms such as clenching fists or jaw, pacing, slamming doors, hitting palms of hands with wrists, or being easily startled. Homicidal behavior accounts for 17% of visits to psychiatric emergency service settings, and an additional 5% involve both suicide and homicide. Violence is also associated with conditions such as acute intoxication, acute psychosis, paranoid personality disorder, antisocial personality disorder, narcissistic personality disorder, and borderline personality disorder. Mental health professionals complete violence risk assessments to determine both security measures and treatments for the patient. Patients with psychotic symptoms are common in psychiatric emergency service settings. The determination of the source of the psychosis can be difficult. Sometimes, it is caused by substance use, while other times, it may be the result of a severe mental disorder. Regardless of the cause, mental health professionals use various resources to determine the best course of action for the patient.

Psychiatry: The Disturbed Patient Mental state examination:

ABC-SMITH

The mental state examination is a structured way of collecting and presenting information about patients with psychiatric symptoms.

Appearance grooming/hygiene/dress/eye contact

Behaviour agitation/withdrawn/gestures/co-operation

Cognition inattention/orientation/reasoning

Speech speed/fluency/pressure/volume

Mood sad/happy/angry/flat/labile/apathetic

Insight presence/degree

Thought process content/possession/speed/flow

Hallucinations/delusions presence/organisation/system

When treating acutely disturbed patients in the Emergency Department (ED), healthcare providers must be equipped to handle a range of possible underlying causes of the patient's condition. These causes may include drug or alcohol use or withdrawal, personality disorder, acute mental illness, or delirium from an organic disease process. Given the complexity of these cases, a robust treatment system is essential. Here are the key principles and practices for managing acutely disturbed patients:

Prediction and Prevention

·        Screening: Patients with a risk or history of violence should be searched by hospital security before being seen by clinical staff.

·        Observation: Monitoring patients can help identify warning signs of agitation or aggression.

·        Environment: Patients should be interviewed in a quiet room with outward-opening doors and an alarm system. Adequate numbers of staff should be nearby to ensure safety.

De-escalation and Observation

·        De-escalation: Using verbal and non-verbal communication techniques to calm potentially confrontational situations.

·        Seclusion: Consider seclusion if a suitable room and staff for observation are available.

·        Honesty and Respect: Being honest and respectful can positively influence patients' behavior, offering them choices and limited negotiation.

·        Negotiation: Attempt to persuade the patient to take an oral benzodiazepine while ensuring both sides understand that non-compliance may lead to restraint. A credible 'show of force' can support negotiations.

Restraint

·        When Necessary: If de-escalation fails, restraint is necessary to protect the patient, others, and staff.

·        Physical Restraint: A minimum of six trained staff members are required for physical restraint to minimize injury risks.

·        Pharmaceutical Sedation: Follow physical restraint with pharmaceutical sedation if needed.

·        Monitoring: Close clinical and physiological monitoring is crucial for patient safety during restraint and sedation.

Review

·        Assessment: After restraint or sedation, the patient should undergo a thorough examination for signs of organic disease.

·        Screening Tests: Perform bedside tests such as urine/glucose, blood work (FBC, U+E, LFTs, Ca2+, TFTs), and imaging (chest X-ray, CT brain) as needed, based on the patient's history.

Sedation

·        Benzodiazepines: Examples include lorazepam, midazolam, and diazepam. They are generally safe and predictable but may be less effective in routine users due to tolerance.

·        Neuroleptics: Examples include haloperidol, chlorpromazine, and droperidol. These provide prolonged sedation and are preferred for patients with psychotic features.

·        Combination: Benzodiazepines and neuroleptics can be combined for agitated patients.

·        Administration: Favor lorazepam and/or haloperidol, administered orally if the patient is cooperative or via intramuscular injection otherwise.

Differentiating Delirium (Organic) and Psychiatric Symptoms

·        Delirium: Characterized by cognitive and consciousness impairment from organic disease, such as sepsis, drugs, or metabolic disorders. Features include rapid onset, fever, non-sensory neurological abnormalities, disorientation, and visual hallucinations.

·        Psychiatric Disease: Indicators include chronic symptoms, previous psychiatric history, delusional beliefs, paranoia, disorganized thought processes, and auditory hallucinations.

·        Overlap: Patients with psychiatric illness may also have organic diseases, and alcohol/drug use or withdrawal may complicate diagnosis.

Factitious Disorders

·        Characteristics: Factitious disorders or Munchausen's syndrome involve symptoms with no organic basis. Patients may appear unconcerned despite dramatic symptoms, and vital signs are typically normal.

·        Challenges: Differentiating true factitious illness from malingering or drug-seeking behavior with an obvious secondary gain can be difficult.

·        Approach: Use minimum necessary investigations and involve a senior doctor early on. Challenging these patients may lead to them leaving rapidly without engaging in psychiatric services.

Managing acutely disturbed patients requires a combination of assessment, prediction, prevention, de-escalation, restraint when necessary, and continuous review. Proper care and monitoring are essential to ensure the safety and well-being of both patients and healthcare staff.