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