The Evaluation and Treatment of the Emergency Psychiatric Patient
W. Scott Griffies, M.D.
LSUNO Department of Psychiatry
An ER Behavioral Healthcare Infrastructure
• ER physician assessment includes mental status exam.
• Crisis Assessment S.W., P.N.P., or P.R. include complete psychosocial assessment.
• Psychiatric Consultant rounds bi-daily.
(possible telepsychiatry)
• Social Service (S.W.) Discharge Plan/Resources.
CIU/BHETU
• Stabilization Units
• In Conjunction with ER
• 5-30% have medical illness
Disposition Evaluation
• Nature and duration of Illness
• Relationship to baseline
• Adequacy of self-care
• Level of social supports
• Risk of homicide/suicide
Differential Diagnosis
• Delirium
• Psychotic Disorders
• Mood Disorders
• Developmentally Disabled – have above diagnoses, but, since they are often nonverbal, diagnoses will be primarily based on behavioral observations and descriptions.
Medical Delirium
• Acute Onset
• Fluctuating, Altered Sensorium
• Abnormal MMSE
Life-Threatening - - WWHHIMP
• Drug withdrawal• Wernicke encephalopathy• Cerebral hypoxemia• Hypoglycemia• Hypertensive encephalopathy• Intracranial bleeding• Meningitis/encephalitis• Poisoning
An Option for Outpatient Psychosocial Planning of Substance Dependence
• Call AA/NA and have sponsor visit patient in ER
• Prescribe daily or bidaily NA/AA Group meetings for first 2 weeks post discharge.
• Follow-up with addiction disorder clinic.
• Register for Rehab Program.
Psychotic Disorders
• Clear sensorium
• Delusions
• Hallucinations
• Disorganized speech and behavior
• Flat or inappropriate affect
Psychosis Differential
• Substance – induced
• Due to medical condition
• Schizophrenia
• Mood Disorder (BMD/MDE)
• Dementia with delusions
Psychosis Differential (cont.)
• Brief Psychotic Episode
• Schizophreniform
• Delusional Disorder
Mood Disorders – BMD and MDE +/- Psychotic Features, Severe Agitation
• Mania - - Decreased need for sleep, increased energy, agitation, irritability, liability, projects, missions, hypertalkative, pressured, racing.
• R/o organic etiology, especially if acute.
Treatment of Acute Psychotic/Severe Agitation
• Haldol 5 mg, Benadryl 50 mg, Ativan 2 mg IM. (B52)
• Repeat Haldol 5mg IM +/- Ativan 1-2 mg q1-2h IM as needed until calm.
Other Guidelines
• Use 25-50% for elderly
• Monitor ECG when possible
• Most calm after 1-2 injections
Treatment of Acute Agitation Other Options
• Zyprexa 10 mg q 2 h X 1, then q 4 h not to exceed 30 mg/24 h. Do not give concomitant Benzos.
• Geodon 10 mg q 2 h or 20 mg q 4 h, not to exceed 40 mg/24 h.
• Use 25-50% for elderly/medically compromised.
• Not indicated for dementia-related psychosis.
Switching to Oral Antipsychotics for Schizophrenia, BMD, MDE with Psychoses
While Awaiting Admission.
• Haldol 2-5 mg po q daily --BID
• Zydis (melts in mouth): 10-15 mg po q daily initially.
• Seroquel 50 po BID. Increase by 100 mg/day to 600 mg/day in divided doses - - more at night.
Switching to Oral Antipsychotics for Schizophrenia, BMD, MDE with Psychoses
While Awaiting Admission. (Cont.)
• Risperidol 1 mg po BID. 1st day, 2 mg BID 2nd day, 3 mg 3rd day.
• Geodon 40 mg po BID (usually 2nd line)
• Abilify 10-15mg
• Use 25-50% for elderly/medically compromised.
Second Generation Antipsychotics: Long term Side Effects
• Zyprexa, -- most weight gain, metabolic syndrome (Relative cotraindication in D.M. Obesity, Cholesterol)
• Risperidol, Seroquel – Second-most metabolic syndrome issues.
• Geodon, Abilify – least weight gain and metabolic syndrome.
Second Generation Antipsychotics: Side Effects
• Risperidol – hyperprolactenemia
• Geodon – Relative QTC prolongation
Relative contraindication in patients with CVS history. If CVS history, perform EKG.
• Seroquel – most antihistaminic, sedating
Anxiety
• Adjustment d/o with anxious mood
• GAD
• Panic
• OCD
• Social Phobia
ER Treatment of Anxiety
• Ativan 1-2 mg po q 4-6 h
• Klonipin 0.5 – 1 mg po BID – TID
• Use SSRI long term.
Borderline P.D.
• Impulsivity
• Parasuicidal behavior
• Abandonment anxiety
• Labile affect
Agitation in Borderline P.D.
• Benzodiazepines may disinhibit
• Seroquel 50 po nightly/BID
Suicide
• Level of intent
• Level of lethality
• Prior attempts
• Late life white divorced male
• Living alone
• Lack of sleep/agitation
Major Depressive Episode (MDE)
• Depressed mood or loss of interest/pleasure x 2 weeks.
• Five/nine symptoms – depressed mood, interest/pleasure, or weight, insomnia/hypersomnia, psychomotor agitation/retardation, fatigue/ energy, selfworth, concentration, SI
Choice of Antidepressant – General Issues
• Needs weekly f/u x 4 weeks with new antidepressant
• Start low, go slow, especially in anxious, somatisizing patients.
• Early side effects usually diminish in 10-14 days. If tolerable, hang in there.
Choice of Antidepressant – General Issues
• Activating agent may need sleeping agent – Trazodone (Priapism), Ambien, Lunesta
• Don’t give if mania hx
Antidepressant Choices– Selective Variables
• Wellbutrin (150 mg) - norepinephrine/dopamine – activating, energy, concentration, no sexual SE’s.
• Effexor (75 mg) - combination serotonin, norepinephine – monitor BP, especially at higher dose – good for GAD also.
Antidepressant Choices– Selective Variables
• Cymbalta (30 mg) – combination norepinephrine/ serotonin – pain syndromes, start 30 mg for 7-14 days to mitigate nausea.
• Remeron (15 mg) – po q nightly – combination serotonin, norephinephrine, sedating
Antidepressant Choices – Selective Variables
• Prozac (10-20 mg) – in some, more activating, give in am, start 10 mg in panic/anxiety.
• Paxil (10-20 mg) – in some more sedating, more wt gain.
Antidepressant Choices – Selective Variables
• Zoloft (25-50 mg) – activating or sedating, can be nicely calming
• Celexa/Lexapro (10-20 mg) – most serotonin - receptor selective.
ER Physician
• R/O underlying medical causes for presenting delirium, psychosis, or mood disorder.
• PEC if S/H or G.D.
Mental Status Exam: ARTT SMAJIC
• Appearance – well dressed/disheveled
• Rapport – good/eye contact
• Thought Process – linear, goal
directed, looseness of associations (LOA), tangential, disorganized
• Thought Content – S/HI, A/VH
• Speech – N/R/R/V/T
Mental Status Exam: ARTT SMAJIC (Cont.)
• Mood – upset, angry, sad
• Affect – blunted, full range, depressed
• Judgment – good, poor
• Insight – good, poor
• Cognition – see MMSE
“MINI-MENTAL STATE EXAM”
Maxi-
mum
Score Score Orientation
5 ( ) What is the (year) (season) (date)
(day) (month)?
5 ( ) Where are we? (state) (country)
(town) (hospital) (floor).
MMSE (Cont.)Maxi-mumScore Score Registration 3 ( ) Name 3 objects: 1 second to say each. Then ask the
patient all after you have said them. Give 1 point for each correct answer. Then repeat them until he learns all 3.Count trials and record.
Trials_________
MMSE (Cont.)Maxi-mumScore Score Attention and Calculation 5 ( ) Serial 7’s 1 point for each
correct. Stop after 5 answers. Alternatively spell “world” backwards.
Recall 3 ( ) Ask for the 3 objects repeated
above. Give 1 point for each correct.
MMSE (Cont.)Maxi-mumScore Score Language 9 ( ) Name a pencil, and watch (2 pts)
Repeat the following “No ifs, ands or buts.” (1 point)
Follow a 3-stage command:“Take a paper in your right hand, fold it in half, and putit on the floor” (3 points)
Read and obey the following:
MMSE (Cont.)
Maxi-
mum
Score Score Close your eyes ( 1point)
5 ( ) Write a sentence ( 1 point)
Copy design (1 point)
Total Score________________
FIG 6-1. From Folstein MF, Folstein SE, McHugh PR: J. Psychiatr Res 1975, 12:189-198
Structured Diagnostic Interview with Psychosocial Assessment
• S.W./Psychiatric Nurse Practitioner/Psychiatric Resident
- HPI, DSM IV symptoms- Past psychiatric history- Family psychiatric history- Past medical history- Social history with current social
supports and resources. - MSE
Psychiatrist Consultant
• Confirm diagnosis
• Medication recommendations
Disposition and Treatment Recommendations
• Inpatient
• Outpatient
• ER medications
Withdrawal Delirium(alcohol, benzodiazepine, barbiturates)
• Fixed with symptom triggered schedule. Ativan 1-2 mg PO, IM or IV, Q 4-6 h; Ativan 1-2 mg PO, IM, IV; Q 1-2 h prn P>100, BP> 150/100; hold for sedation
• Or, give symptom – triggered alone, if more appropriate.
Alcoholism
• Thiamine 100 mg po q daily
• Folate 1 mg po q daily
• MVI 1 taken po q daily
Opiate Withdrawal Evaluation
• Positive Opiate UDS
• Positive history
• Dilated pupils, piloerection, muscle cramps
Opiate Withdrawal Treatment
• Clonidine 1 mg po TID – QID
with 1 mg po q 2 h for BP > 150/100,
p > 100
• Bentyl 20 mg po QID prn abdominal cramps.
• Pepto-Bismol, Imodium, Maalox, Mylanta
• Robaxin - muscle spasm.
Substance Dependence Disposition
• Medical admission for detoxification if unstable.
• Psychiatric admission if suicidal.
• Outpatient addiction follow-up and rehab.
Outpatient Detoxification Option
• Patients w/o history of prior seizures or withdrawal delirium.
• Valium 10 mg po TID-QID with 2-3 prn for agitation/tremulousness
• Taper over 5-7 days
• MVI
Ativan Outpatient Detoxification Option
• If patient has increased LFT’s
• Ativan 1-2 mg po q 4-6 h with 2-3 prn’s
• Taper over 10-14 days by dose, while preferentially maintaining frequency.
MEDICAL DELIRIUM TREATMENT ISSUES
• CBC, electrolytes, BUN, Cr, LFT’s, UDS, possible CT scan.
• Admit for medical stabilization of underlying causes.
Psychosis Due to Medical Condition
• Drugs and Toxins
• Intracranial masses (tumor, abscess, subdural)
• Anoxia
• Normal Pressure Hydrocephalous
Psychosis Due to Medical Condition (cont.)
• Neurodegenerative diseases
• Infection
• Nutritional (B12 , Folate)
• Metabolic/Endocrine
• Inflammatory/autoimmune
Mood Disorder Due to a Medical Condition
• Carcinoid• Pancreatic Cancer• Collagen-vascular disease• Endocrinopatheses (Cushings, Addison’s
hypoglycemia, hyper/hypocalcaemia, hyper/hypothyroid)
• Lymphoma• Viral illness (mono, hepatitis, flu)
Depressed Mood Due to a Pharmacologic Agent
• Clonidine
• Propanolol
• Corticosteroids
• Ibuprofen
• Indomethacin
• Ampicillin
• Teracycline
• Cimetidine
Mania Due to Pharmacologic Agent
• Baclofen
• Cimetidine
• Corticosteroids
• Disulfiram
• Isonazid
• Levodopa
