Emergency Mental Health Presentations

Presenters:Elizabeth Bennett – Team Leader Whyalla Community Mental Health Team Debra Papoulis – Nurse Practitioner Candidate Mental Health Country Health SA

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Outline

> Emergency mental health presentations to the ED> Recognition of distress> Assessment> Delirium> Treatment> Scenario> Suicidal Person> Questions

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What is an emergency mental health presentation?

> A mental health emergency is any disturbance in thoughts, feelings or actions for which immediate therapeutic intervention is necessary.

(Kaplan & Saddocks 2008)

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Emergency Dept. (ED) Presentations

> An equal number of men and women attend the ED with a mental health emergency

> More single people present than married people

> About 20% of these people are suicidal and approx. 10% are violent

(Kaplan & Saddocks 2008)

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ED Presentations

> About 40% of ED presentations require hospitalization

> Most visits occur during the night hours

> Contrary to popular belief studies have found there to be no increase in mental health presentations during a full moon.

(Kaplan & Saddocks 2008)

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ED Presentations

Emergency presentations may include:

> People with suicidal ideation> People experiencing psychosis> People in situational crisis> People with a delirium> People Intoxicated with Substances

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Recognition of distress

Situations which may cause distress:

> Relationship issues> Conflict> Trauma> Bereavement> Loss of friends, job, home or health

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People react differently to stressors and may present as

> Anxious> Depressed> Suicidal> Angry> Tearful> Agitated> Aggressive> Confused

(MH First Aid)

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Signs of acute distress

> Highly aroused> Wide eyed, agitated> Tearful> Wringing hands> Hysterical> Screaming> Yelling> Frightened> Frantic

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Signs of acute distress

OR

> Pale> Feels faint> Weak> Jelly-legged> Looks blankly> Seems unable to comprehend circumstances> Shivering> Feelings of numbness and emptiness

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Respond appropriately

> Always assess the risk to yourself and others

> If able to do so ask the person how you can help them

> If they are very disturbed, agitated summon help as the person can be very unpredictable

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Assessment

The most important question at the beginning of a mental health assessment in the ED is;

Is this presentation due to a medical condition, a mental health condition or both?

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Assessment

Medical conditions such as diabetes mellitus, thyroid disease, acute intoxications, withdrawal states, head traumas and infection can present with prominent changes to mental status that mimic psychiatric illness.

These conditions may be life threatening if not treated promptly

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Primary Survey

> A – airway> B – breathing> C - circulation

> A – appearance / affect> B – behaviour> C – cognition / conversation

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History> Personal history i.e. accommodation, employment, family and

relationships etc

> Past and present medical / surgical / psychiatric history

> Medication past and present, including prescription, over the counter, alternative and black market

> Health questions i.e. diet, cigarettes, alcohol, other substances, exercise, health screens

> Collateral history from family/friends, other health professional, other service providers

( Talley & O’Connor,2010)

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Physical Examination

> Vital Signs> Finger-prick blood glucose level> Dipstick urinalysis> Urine drug screen> Look for any obvious signs of injury or

illness> Laboratory Tests i.e.

CBE, TFT, EUC, LFTs > CT head

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Mental State Exam

> Appearance> Behaviour> Conversation / speech> Affect / mood> Perception> Cognition> Insight / Judgement> Rapport

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Neuro Vegetative symptoms

> Sleep> Appetite> Energy> Concentration > Motivation

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Risk Assessment

> Risk of harm to self> Risk of harm to others> Level of problem with functioning> Level of support available> History of response to treatment> Attitude and engagement to treatment

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Risk assessmentWhat is the nature of the risk

• Suicide• Exploitation / vulnerability• Self neglect• Violence and aggression• Absconding• Criminal activity

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Risk of harm to selfWhat are the static factors

> Previous suicide attempt> Previous high lethality suicide attempt> Family history of suicide> Long term unemployment> Long standing physical illness or pain> Male – under 35 years

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Risk of harm to selfWhat are the dynamic factors

> Intent / plan / thoughts> Current suicide attempt> Distress or anger> Isolated / lonely> Hopelessness / perceived lack of control over own life> Stressors over the last six months> Psychotic symptoms> Command hallucinations> Content of delusional belief

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Risk of harm to othersWhat are the static factors

> Under 25 years of age> History of violence> Criminal history> Conduct disorder> History of substance abuse

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Risk of harm to othersWhat are the dynamic factors

> Impulsivity> Anger> Fear / anxiety over MH service contact> Intoxication / withdrawal> Cognitions supporting violence> Recent threats> Recent aggressive actions / thoughts> Carries weapons> Psychotic symptoms> Command hallucinations> Content of delusional beliefs

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Risk of Vulnerability/Exploitation/Self Neglect/Absconding

> At risk of being sexually abused by others> At risk of domestic/family violence> At risk of being financially abused by others> Cognitive / intellectual disability> History of absconding> Refusal of treatment> Frustration regarding hospitalisation> Breach of limited community treatment order

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What does Delirium look like?

> Confusion > Altered consciousness > Clouding of consciousness - not due to a pre-

existing dementia> Acute onset over several hours or perhaps days> Disorientation> Inattention> Aggitation> Possible slurred speech> Disturbed sleep (reversal of sleep pattern)> Visions or illusions> Hallucinations

(Talley & O’Connor 2010)

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What causes Delirium?

> Substance intoxication or withdrawal> Medication> Exposure to toxins> Metabolic disturbance> Infection> Head injury> Nutritional / fluid deficiency> Epilepsy> Intracranial lesions / raised intracranial

pressure

(Talley & O’Connor 2010)

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Treatment of MH Emergencies

Psychotherapy> Speak calmly and clearly in short sentences and

don’t shout> You may need to repeat what you have said

several times in order to help them understand> Use open, relaxed body language > Show empathy> Tell the person you want to help> Encourage the person to tell their story> Listen carefully to what the person is saying

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Treatment of MH Emergencies

Psychotherapy

> Provide verbal reassurance > Try to make them feel safe and secure > Stay with them if safe to do so> Offer practical assistance i.e. warmth, drink,

contacting a support person/significant other for them> Do not make promises you can not keep> Offer oral medication sooner rather than later if

clinically indicated

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Pharmacotherapy

> Medication is used to relieve the distress a person is experiencing

> If the person usually takes psychotropic medication it is preferable to use that medication

> Often people who are acutely disturbed present either psychologically or behaviourally disturbed

> In these situations sedation is often required> Sedation is the deliberate lowering of central

nervous system arousal for therapeutic purposes

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Pharmacotherapy> Oral medication is always first line therapy

> Benzodiazepines are generally the drug of first choice as they are more sedating and have less side effects than antipsychotics

> Diazepam 10 – 20mg as a single dose this may be repeated every 2 to 6 hours, up to 120mg in 24 hrs, depending on the response

and/or

> olanzapine tablets or wafers 5-10mg up to 40mg max in 24

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Pharmacotherapy> quetiapine 50 to 100mg as a single dose: up to

400mg max in the first 24 hours

> If the oral route of administration is not possible, parenteral administration may be indicated if circumstances allow for its safe use:

> Midazolam 2.5 to 10mg as a single dose

> Patients should be constantly monitored for 4 hours in case of excessive sedation, respiratory depression or hypotension

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Pharmacotherapy

> Midazolam may be repeated, titrated to response every 20 mins up to 20mg max per sedation event

> Midazolam has a very short half life (<6 hrs) and may be limited in its usefulness in patients who are acutely disturbed over an extended period.

> Often a combination of IM midazolam and an IM antipsychotic may be required if the desired effect is not achievable with midazolam alone.

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Scenario

> The mother of a 29 year old male telephones the team.

> Informs the intake worker that her son has just returned from visiting his children interstate a week prior to Christmas.

> He has relationship issues with his current partner and has been taking time off work.

> She believes that he has been using alcohol and drugs to cope with how he is feeling.

> She thinks he may have had depression in the past. > His mother is concerned for his safety as he was

hinting at not being around much longer. > We are given a contact phone number by his mother

who lives in another rural town.

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Where to from here?

> Intake worker rings the son (no answer)> Ascertains his address > Organise an home visit to client> Assessment of client (mental state, neuro- vegetative

and risk assessments)> Client assessed, identified as being high risk requiring

hospitalisation due to suicidal ideation with set plan and intent

> Client refused to attend hospital or GP surgery for review

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Why at high risk

> 29 year old male > No family close by > Relationship issues with his current partner > Taking time off work (out of character) > Using alcohol and drugs to cope > Possible depression in the past > Hinting at not being around in the future

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What Now?

> SAPOL contacted by CMHT requesting assistance> SAPOL attended assessed client as high suicide risk

and transported client to hospital under section 23 of the Mental Health Act for medical review

> GP attended A&E assessed client to be extreme risk of suicide

> For involuntary admission to an approved treatment centre under Mental Health Act

> Transported to approved treatment facility by RFDS

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Suicidal Person

> People who see no future and feel totally overwhelmed with life events may think of suicide

> Many people do not want to discuss these very personal thoughts and feelings

> Asking if a person feels suicidal will not encourage them to suicide, but signal care, concern and a genuine desire to help

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Signs of a person with possible suicidal ideas

> No longer making plans> Feels life is not worthwhile> Seems to have given up, no longer discussing

or trying to sort out problems> Expressing hopelessness or helplessness> Talking about what life will be like without them> Tidying up personal affairs> Becoming secretive about actions> Has written goodbye note

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Suicide Rates in Australia> The highest age-specific suicide death rate for males in

2005 was observed in the 30-34 years age group (27.5 per 100,000 )

> The lowest was in the 15-19 years age group (9.5 per 100,000).

> For females the highest age-specific suicide death rate in 2005 was observed in the 35-39 years age group (6.9 per 100,000)

> The lowest in the 15-19 years age group (3.6 per 100,000).

(Australian Bureau of Stats 3309.0 - Suicides, Australia, 2005)

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References

Kaplan and Sadock, J 2008, Concise Textbook of Clinical Psychiatry, 3rd edn. Lippincott Williams & Wilkins, USA

Myhill, K and Tobin, M 2001, Mental Health First Aid for South Australians, DHS, Government of SA

Talley, N and O’Connor, S 2010, Clinical Examination, 6th edn. Elsevier, Australia

Beyondblue

htt://www.beyondblue.org.au

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