Emergency Treatment of Acute Psychiatric Symptoms
Emergency Treatment of Acute Psychiatric Symptoms
Chief of Psychiatric Emergency Services, Alameda County Medical Center, Oakland, California
First published in Psychiatry Weekly, Volume 6, Issue 1, January 17, 2011.
Emergency department (ED) presentations of psychiatric problems continue to rise, placing a strain on ED resources, but also creating a growing subspecialty of psychiatric treatment in emergency settings. Practitioners of emergency psychiatry can help resolve suicidal feelings, quell agitation, lessen the severity of psychosis and mania, and assist in the stabilization of the troublesome symptoms of many mental health crises.
There were 53 million mental health-related ED contacts in the US from 1992 to 2001, an increase from 4.9% to 6.3% of all ED visits.1 EDs and psychiatric emergency services have become the primary acute care settings where patients seek mental health care in the US, because adequate alternatives are seldom available.
Treatment Goals for Emergency Psychiatry
There are several treatment goals for emergency psychiatry. First, medical etiologies must be excluded for symptoms that appear similar to endogenous psychoses, mania, or other acute psychiatric states, prior to psychiatric treatment. (Table) Distinguishing delirium from psychosis is especially important; misdiagnosing delirium as a psychosis and treating it as such can be life threatening. A good history and visual evaluation by a qualified medical professional, along with vital signs, are frequently sufficient to make a determination that urgent medical—rather than psychiatric—intervention is indicated. In patients with no known previous history or with new-onset symptoms, head computerized tomography and laboratory data also might be indicated.
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Second, acute crises should be rapidly stabilized following medical clearance. This will frequently involve medications. Prompt crisis counseling can also assist with stabilization.
Third, practitioners in the emergency setting are often the first contact a patient will have with mental health care, so establishing a strong patient alliance is critical. A bad experience on an initial mental health contact may lead to long-term problems in which consumers might fear, distrust, or dislike psychiatrists and other providers. Beauford and colleagues2 found that the better the early therapeutic alliance the lower the likelihood of a patient becoming violent during psychiatric hospitalizations. In emergency psychiatry it is essential that a patient be provided with an appropriate care plan for post-discharge, including appointments with outpatient providers (when possible), referral to mental health clinics and/or substance abuse treatment programs, and instructions on what to do if crisis symptoms recur.
Types of Psychiatric Emergencies
Perhaps the most common psychiatric emergency, and one unfortunately increasing in number, involves suicidal thoughts or behavior. In the period between 1992 and 2001, US emergency room encounters for suicide attempt and self-injury increased by 47%.3 Patients may arrive in an ED after surviving a suicide attempt, being stopped from making a suicide attempt, in the wake of suicidal threats, or after reporting suicidal ideation.
Although suicidality alone can be a justification for psychiatric hospitalization, inpatient care may be avoided when suicide risk is mitigated. American Psychiatric Association guidelines4 permit release from an ED without inpatient admission in cases where after a suicide attempt or suicidal ideation is (1) a reaction to precipitating events (eg, exam failure, relationship problems); (2) the plan and intent have low lethality; (3) the patient has a stable and supportive living situation; and (4) the patient is able to cooperate with follow-up recommendations.
Other presentations, such as malingering or contingent suicidal ideation for secondary gain, suicidal ideation in context of substance intoxication or withdrawal that dissipates with detoxification, may frequently be dischargeable from the ED.
Agitation in psychiatric conditions can be a major concern in the ED, with the potential for violence and harm to the patient, staff, or others. Up to 10% of patients seen in psychiatric emergency settings may be agitated or violent during their evaluation.5 The traditional response of many EDs to serious agitation would be to restrain such patients and forcibly sedate them with powerful medications. There are many drawbacks to this approach: it is very coercive to patients; oversedated patients cannot participate in treatment, nor can dispositions be determined for them while they are obtunded; and many of the medications used in these situations can have severe and/or unpleasant side effects which will be quite disturbing to patients and interfere with opportunities for therapeutic alliance. The preferable intervention is to combine verbal de-escalation techniques with the offer of oral medications. This collaborative approach is successful in the majority of cases and reduces untoward outcomes and injuries, while often taking less time to efficacy than restraint and injection.
Most intoxication states are usually not difficult to diagnose, but intoxications from cocaine and amphetamines can mimic the delusions, paranoia, hallucinations, and agitation from decompensated psychotic illnesses. In such cases, the use of benzodiazepines is indicated, allowing patients to calm and detoxify. In pure stimulant intoxications without underlying psychiatric illness, this is typically sufficient to relieve symptoms of psychosis benignly.
By combining the compassionate and interpersonal therapeutics of psychiatry with the fast-paced assessment and treatment approach of emergency medicine, emergency psychiatry clinicians can make positive and prompt interventions for those individuals suffering from acute mental health disturbances.
Disclosure: Dr. Zeller is consultant to Alexza Pharmaceuticals and on the speaker’s bureau of Eli Lilly and Pfizer.
1. Larkin GL, Claassen CA, Emond JA, Pelletier AJ, Camargo CA. Trends in U.S. emergency department visits for mental health conditions, 1992 to 2001. Psychiatr Serv. 2005;56(6):671-677.
2. Beauford JE, McNiel DE, Binder RL. Utility of the initial therapeutic alliance in evaluating psychiatric patients’ risk of violence. Am J Psychiatry. 1997;154(9):1272–1276.
3. Larkin GL, Smith RP, Beautrais AL. Trends in US emergency department visits for suicide attempts, 1992-2001. Crisis. 2008;29(2):73-80.
4. Suicidal behaviors. In: American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders: Compendium 2004. Washington, DC: American Psychiatric Association, 2004:31.
5. Huf G. Alexander J, Allen MH. Haloperidol plus promethazine for psychosis induced aggression. Cochrane Database Sys Rev. 2005;(1):CD005146.