The Evaluation and Treatment of the Emergency Psychiatric Patient

1
The Evaluation and Treatment of the Emergency
Psychiatric Patient

• W. Scott Griffies, M.D.
• LSUNO Department of Psychiatry

2
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.

3
CIU/BHETU

• Stabilization Units
• In Conjunction with ER
• 5-30 have medical illness

4
Disposition Evaluation

• Nature and duration of Illness
• Relationship to baseline
• Adequacy of self-care
• Level of social supports
• Risk of homicide/suicide

5
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.

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Medical Delirium

• Acute Onset
• Fluctuating, Altered Sensorium
• Abnormal MMSE

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Life-Threatening - - WWHHIMP

• Drug withdrawal
• Wernicke encephalopathy
• Cerebral hypoxemia
• Hypoglycemia
• Hypertensive encephalopathy
• Intracranial bleeding
• Meningitis/encephalitis
• Poisoning

8
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.

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Psychotic Disorders

• Clear sensorium
• Delusions
• Hallucinations
• Disorganized speech and behavior
• Flat or inappropriate affect

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Psychosis Differential

• Substance induced
• Due to medical condition
• Schizophrenia
• Mood Disorder (BMD/MDE)
• Dementia with delusions

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Psychosis Differential (cont.)

• Brief Psychotic Episode
• Schizophreniform
• Delusional Disorder

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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.

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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.

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Other Guidelines

• Use 25-50 for elderly
• Monitor ECG when possible
• Most calm after 1-2 injections

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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.

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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.

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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.

18
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.

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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

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Anxiety

• Adjustment d/o with anxious mood
• GAD
• Panic
• OCD
• Social Phobia

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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.

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Borderline P.D.

• Impulsivity
• Parasuicidal behavior
• Abandonment anxiety
• Labile affect

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Agitation in Borderline P.D.

• Benzodiazepines may disinhibit
• Seroquel 50 po nightly/BID

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Suicide

• Level of intent
• Level of lethality
• Prior attempts
• Late life white divorced male
• Living alone
• Lack of sleep/agitation

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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

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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.

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Choice of Antidepressant General Issues

• Activating agent may need sleeping agent
  Trazodone (Priapism), Ambien, Lunesta
• Dont give if mania hx

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Antidepressant Choices Selective Variables

• Wellbutrin (150 mg) - norepinephrine/dopamine
  activating, ? energy, ? concentration, no sexual
  SEs.
• Effexor (75 mg) - combination serotonin,
  norepinephine monitor BP, especially at higher
  dose good for GAD also.

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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

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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.

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Antidepressant Choices Selective Variables

• Zoloft (25-50 mg) activating or sedating, can
  be nicely calming
• Celexa/Lexapro (10-20 mg) most serotonin -
  receptor selective.

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ER Physician

• R/O underlying medical causes for presenting
  delirium, psychosis, or mood disorder.
• PEC if S/H or G.D.

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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

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Mental Status Exam ARTT SMAJIC (Cont.)

• Mood upset, angry, sad
• Affect blunted, full range, depressed
• Judgment good, poor
• Insight good, poor
• Cognition see MMSE

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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).

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MMSE (Cont.)

• Maxi-
• mum
• Score 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_________

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MMSE (Cont.)

• Maxi-
• mum
• Score Score Attention and Calculation
• 5 ( ) Serial 7s 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.

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MMSE (Cont.)

• Maxi-
• mum
• Score 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 put
• it on the floor (3 points)
• Read and obey the following

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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, 12189-198
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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

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Psychiatrist Consultant

• Confirm diagnosis
• Medication recommendations

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Disposition and Treatment Recommendations

• Inpatient
• Outpatient
• ER medications

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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 P100, BP 150/100 hold for
  sedation
• Or, give symptom triggered alone, if more
  appropriate.

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Alcoholism

• Thiamine 100 mg po q daily
• Folate 1 mg po q daily
• MVI 1 taken po q daily

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Opiate Withdrawal Evaluation

• Positive Opiate UDS
• Positive history
• Dilated pupils, piloerection, muscle cramps

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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.

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Substance Dependence Disposition

• Medical admission for detoxification if unstable.
• Psychiatric admission if suicidal.
• Outpatient addiction follow-up and rehab.

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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

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Ativan Outpatient Detoxification Option

• If patient has increased LFTs
• Ativan 1-2 mg po q 4-6 h with 2-3 prns
• Taper over 10-14 days by dose, while
  preferentially maintaining frequency.

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MEDICAL DELIRIUM TREATMENT ISSUES

• CBC, electrolytes, BUN, Cr, LFTs, UDS, possible
  CT scan.
• Admit for medical stabilization of underlying
  causes.

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Psychosis Due to Medical Condition

• Drugs and Toxins
• Intracranial masses (tumor, abscess, subdural)
• Anoxia
• Normal Pressure Hydrocephalous

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Psychosis Due to Medical Condition (cont.)

• Neurodegenerative diseases
• Infection
• Nutritional (B12 , Folate)
• Metabolic/Endocrine
• Inflammatory/autoimmune

53
Mood Disorder Due to a Medical Condition

• Carcinoid
• Pancreatic Cancer
• Collagen-vascular disease
• Endocrinopatheses (Cushings, Addisons
  hypoglycemia, hyper/hypocalcaemia,
  hyper/hypothyroid)
• Lymphoma
• Viral illness (mono, hepatitis, flu)

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Depressed Mood Due to a Pharmacologic Agent

• Clonidine
• Propanolol
• Corticosteroids
• Ibuprofen

• Indomethacin
• Ampicillin
• Teracycline
• Cimetidine

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Mania Due to Pharmacologic Agent

• Baclofen
• Cimetidine
• Corticosteroids
• Disulfiram
• Isonazid
• Levodopa