Textbook of Adult Emergency Medicine, 4th Edition

SECTION 20. Psychiatric Emergencies

Edited by George Jelinek

OUTLINE

20.1 Mental state assessment 656

20.2 Distinguishing medical from psychiatric causes of mental disorder presentations 661

20.3 Deliberate self-harm/suicide 666

20.4 Depression 674

20.5 Psychosis 684

20.6 Pharmacological management of the aroused patient 691

20.1 Mental state assessment

George Jelinek and Sylvia Andrew-Starkey

Essentials

1 Prevalence of mental health disorders appears to be increasing in Western society.

2 Regardless of diagnosis and presentation, three brief risk assessments must be performed within the first few minutes of an individual’s arrival in the emergency department (ED). These are:

suicide risk assessment

violence risk assessment

absconding risk assessment.

3 The role of organic illness presenting as a behavioural disorder should not be forgotten.

4 Substance use/misuse resulting in presentations to EDs also appears to be increasing in the general population.

Epidemiology

Mental health disorders are one of the three leading causes of total burden of disease and injury in Australia, alongside cancer and cardiovascular disease [1–3]. In middle age, it is the leading cause of non-fatal disease burden in the Australian population. There is no doubt that mental health disorders have a high prevalence, are disabling and are high cost in both human and socioeconomic terms [1,2].

In terms of disability, it has been estimated that having moderate to severe depression is the equivalent of having congestive cardiac failure [3], chronic severe asthma or chronic hepatitis B [2]. Severe post-traumatic stress syndrome was comparable to the disability from paraplegia and severe schizophrenia was comparable to quadriplegia, in terms of disability [2]. Over the 10 years to 2007, emergency department (ED) presentations rose 8% in the USA, whereas mental health presentations for the same time period rose 38%, contributing significantly to ED overcrowding [4]. This trend has been mirrored in Australia.

Contributing to this may be:

lack of private health insurance

lack of social supports

lack of alternatives to care

24-hour accessibility of the ED [4].

The Australian Institute of Health and Welfare report into Mental Health Services in 2012 estimated that there were nearly a quarter of a million occasions of service to Australian EDs in 2009/10 where the primary problem was thought to be due to a mental health disorder, with an average annual increase of 3.6% between 2005–06 and 2009–10 [1]. A little over 3% of Australian public hospital ED presentations are for mental health related problems, correlating well with other studies and US figures, which estimate 2–6% of emergency medicine presentations are primarily due to mental health disorders [4–7].

Two-thirds of these people are between the ages of 15 and 44 years (compared to 42% for the general population presenting to a suburban ED); 29% have anxiety and neurotic disorders, 21% mental and behavioural disorders due to psychoactive substance abuse, 19% mood disorders and 17% schizophrenia or delusional disorders [4].

This is a significant underestimate of the prevalence of mental health disease in the ED as many patients remain undiagnosed and many have active medical conditions and a mental health diagnosis may be secondary [6].

It is estimated that 17.7% of adult Australians admitted to hospital report a mental health issue in the previous 12 months. An estimated 0.4–0.7% of the adult population suffer from a psychotic episode in any 1 year [2]. Mental health issues are highly prevalent and relevant.

Introduction to the mental state examination

The mainstreaming of mental health patients into general EDs has brought problems and anxieties for staff. Staff often feel a lack of confidence because they are dealing with a population of patients unfamiliar to them. They can also feel inadequate due to poor assessment skills [7,8].

Recent Australian studies have shown ED clinicians are most concerned about knowledge gaps in risk assessment, particularly related to self-harm, violence and aggression, and distinguishing psychiatric from physical illness [9]. ED clinicians routinely report the need for more education on mental health related presentations [10]. A high proportion of mental health patients have drug and alcohol intoxication. This confounds the evaluation and treatment, lengthens the stay of these patients within the ED and delays their disposition.

Mental health patients can be assigned lower triage categories and longer waits to be seen by staff than mainstream patients and there is more variation in triage categorization for mental health patients [11]. They have a higher chance of leaving before assessment has begun or is complete and the overall increase in length of assessment time has the potential to increase violence in the ED [7,8].

With this in mind, there has been much work over the last 10 years on the assessment of mental health patients in a general ED.

Bias and discrimination

It is important for health professionals assessing the mentally ill to be aware of their own potential biases. An interviewer’s past history and personal beliefs can influence a mental state assessment and the interviewer should be aware of this. These beliefs may stem from past personal or professional experience (Table 20.1.1).

Table 20.1.1

Factors which may influence an objective MSE

ABC of the MSE

A mental state examination (MSE) is analogous to the management of severe trauma. There is an initial risk assessment looking for immediately life-threatening risks to the patient or staff. The triage nurse and the treating doctor should then obtain a brief collateral history from the emergency services or carers and initial management is based on this assessment. Regardless of threat, all assessments should balance the safety of both patient and staff with privacy and dignity [7].

Assessment should be based on [12]:

appearance and affect

behaviour

conversation

drug and/or alcohol intoxication.

If the situation is relatively controlled, the formal mental health assessment should then take place. Further information is gathered from the community. A provisional assessment and management plan is developed in conjunction with the mental health team and appropriate disposition is arranged (Fig. 20.1.1).

FIG. 20.1.1 The mental health assessment process.

Triage

The Mental Health Triage Scale (Table 20.1.2) has been developed and modified to be included into the Australian Triage Scale (ATS) [7,13,14]. It is very broad and asks the triage nurse to make four assessments: risk of suicide/self-harm, risk of aggression/harm to others, risk of absconding and whether the patient is intoxicated. From this, the triage nurse determines the ATS and urgency of initial treatment. It is also helpful to determine if the patient is known to a mental health service.

Table 20.1.2

The mental health triage scale

Many centres have developed a triage risk assessment proforma. For ease of use, many of these have included ‘tick box’ areas. A compilation of multiple assessment tools used throughout Australia is shown in Tables 20.1.3–20.1.5[2,5,12–15].

Table 20.1.3

Brief screening suicide risk template

Table 20.1.4

Aggression risk tool

☑ Alert on chart

☑ Previous history of violence/threatening behaviour: verbal or physical

☑ Aggressive behaviour/thoughts

☑ Homicidal ideation

☑ Use of weapons previously

☑ Access to weapons

☑ Intoxicated

☑ Middle-aged male

Patients then stratified into high, medium or low risk

Table 20.1.5

Risk of absconding

Mode of arrival

☑ Police

☑ Handcuffed

☑ Family/carer coercion

☑ Voluntary

☑ Past history of absconding behaviour

☑ Alert on chart

☑ Verbalizing intent to leave

☑ Lack of insight into illness

☑ Poor/non-compliance with medication

Patients then stratified into high, medium or low risk

It is recommended that any patient who scores ‘high risk’ in any one area or ‘medium risk’ in two areas is treated as a ‘high-risk’ patient. Ensuing management of ‘high-risk’ patients depends on: local protocols, levels and presence of security, police intervention, restraint and sedation guidelines and guidelines for the urgent assessment by ED and/or by mental health services.

Aims of mental health assessment

The aims of the formal mental health assessment are to determine the following:

Does the patient have a mental illness?

Is there a question of safety for the patient or for others?

Does the patient have insight into the illness?

Will the patient comply with suggested treatment?

Can the patient be managed in the community or is hospitalization required?

Only if all of the above are answered, can management and appropriate disposition be considered.

The formal psychiatric interview

Introduction

The environment in which the mental state assessment is conducted is important. Behaviourally disturbed people tolerate noise poorly and have short concentration spans. The interview room should be quiet, private, make the patient feel safe and the interviewer should avoid all interruptions. These prerequisites are increasingly difficult to attain in current access-blocked environments.

The interviewer should sit at the same level as the patient and impart empathy. The voice should be quiet and calming. The interviewer should use non-judgemental language and open-ended questions [13,16]. It is important that the interviewer also feels safe and secure. If any risk is felt, the interviewer should have security or police present in the room or just outside. Depending on state legislation and hospital policy, the interviewer may request to have the patient searched. The interviewer should also note the nearest duress alarm and may choose to wear a personal alarm. The interviewer should sit within easy access of an exit and should never be boxed into a corner. If an interviewer begins to feel uncomfortable, there is always the option of leaving and returning to complete the assessment at a later stage. All threats, attempts and gestures suggestive of violence should be treated seriously.

First part of the interview: direct questioning

Basic demographic information

The formal interview has become less diagnosis focused and more problem based. Management is centred around the alleviation of symptoms and return to function. Thus, the psychiatric interview has become somewhat less structured.

It is wise to establish rapport with the patient by personal introduction and explaining the purpose of the interview. The interviewer can begin by asking a series of non-threatening questions, such as demographics. This information is often required as many mental health services rely on an appropriate post code to determine follow-up management.

These questions assist by building a profile of lifestyle, relationships and thought processes. Likelihood of success or failure of particular treatment modalities may be assisted by knowledge of previous hospital admissions, both general hospital and mental health (Table 20.1.6).

Table 20.1.6

Demographic information required

The process of obtaining a mental health assessment is different to that of a general medical assessment. In a general medical history, a series of questions is asked and the response is written. In a mental health assessment, responses are also interpreted. The interviewer is asked to form an opinion as to how thoughts are processed, based on observations. The interviewer is asked to interpret the patient’s thought patterns by what, and how, the patient tells the interviewer.

Presenting complaint

The patient is asked to recall the sequence of events prior to presentation to the ED. The interviewer should explore the circumstances of the behaviour, reasons for it, degree of planning or impulsivity and its context. Were drugs and alcohol involved? Was there a recent precipitating event? It is often useful to get the patient to recall the previous 48–72 hours leading up to the event.

This usually leads to questioning regarding current difficulties. The interviewer should explore the nature of current problems. They may be financial or legal problems, isolation, bereavement, impending or actual loss, or diagnosis of major illness. Have there been any recent changes and who are their usual support people? An exploration of significant relationships is important along with the depth and duration of these relationships. It is useful to explore the patient’s usual coping methods when under stress.

Mood and affect

There should be formal questioning regarding the patient’s mood (internal feelings) and whether it is in keeping with affect (external expression). The mood may be incongruent with affect, swing wildly between extremes (labile) or be inappropriate.

Usually mood is assessed by asking about the patient’s ability to cope with activities of daily living, such as eating, weight loss or gain, sleep disturbance (early morning wakening or trouble getting to sleep) and general hygiene. The patient’s ability to concentrate may also diminish with increasing mood disturbance, reflected by the ability to perform normal work duties.

This may lead to direct questioning regarding mood and thoughts of suicide. It is important to be direct in asking the patient about suicide and whether there is a formulated plan. A well thought out plan with clear means of carrying out threats is of great concern.

Delusions and hallucinations

Delusions and hallucinations are often personal and the patient may not want to disclose intimate thoughts and beliefs to the interviewer. Hallucinations may be auditory, visual, tactile, olfactory, somatic or gustatory. The context in which they occur should be explored. Hypnagogic (occurring just before sleep) and hypnopompic (occurring on wakening) hallucinations are more benign than others. Common themes for all types of hallucinations include suicide, persecution, religion, control, reference, grandeur or somatization.

Insight and judgement

Insight is the degree of understanding of what is happening and why. This may be:

denial of illness

awareness of being sick and needing help but denying it at the same time

awareness of being sick but blaming it on external factors

awareness that illness is due to something unknown within the patient

intellectual insight: admission that the patient is ill and that symptoms are due to irrational feelings, but inability to apply this to the future

true insight: being aware of motives and feelings and being aware of what can lead to changes in behaviour.

It is important to determine the patient’s level of insight. This determines appropriate treatment and management, level of supervision required and the likelihood of compliance with treatment.

Second part of interview: observation

Key elements

The second part of the MSE can be more difficult to conceptualize. It relies on the interviewer actively observing the patient’s behaviour and conversation and interpreting thoughts. A summary is given in Table 20.1.7.

Table 20.1.7

Overview of mental state examination

This part of the interview can be difficult to remember and different services have developed a multitude of acronyms for remembering the various elements of the remaining mental health assessment. Listed below are two.

ABC of Mental Health Assessment [12]:

Appearance

Affect

Behaviour

Conversation and mood.

GFCMA – ‘Got Four Clients on Monday Afternoon’ [13]:

General appearance

Form of thought

Content of thought

Mood and affect

Attitude.

Appearance, attitude and behaviour

This determines the patient’s ability to self-care. Table 20.1.8 lists features that may require particular attention. Attitude is important as it may indicate whether a patient is compliant with management and treatment. Abnormal posturing or repetitive behaviours should be noted. These may indicate increasing thought disturbance. With increasing aggression and agitation, there may be motor restlessness, pacing and hand wringing. Tension may escalate rapidly and steps should be taken early to diffuse the situation.

Table 20.1.8

Appearance, attitude and behaviour

The interviewer should note the rate, volume and rhythmicity of speech. This can range from completely mute, through monosyllabic answers, to rapid, loud speech indicative of pressure of speech. The tone, inflection, content and structure of speech should be noted. The interviewer should determine if the speech is fluent, if the thoughts behind it are logical and whether it flows appropriately for the situation.

Thought disorder

This is speech that does not reach its goal, is not fluent and is interrupted often with many pauses or changes in direction. A list with explanations is given in Table 20.1.9.

Table 20.1.9

Thought disorders

Circumstantiality	Delays in reaching goals by long-winded explanations, but eventually gets there
Distractible speech	Changes topic according to what is happening around the patient
Loosening of associations	Logical thought progression does not occur and ideas shift from one subject to another with little or no association between them
Flight of ideas	Fragmented, rapid thoughts that the patient cannot express fully as they are occurring at such a rapid rate
Tangentiality	Responses that superficially appear appropriate, but which are completely irrelevant or oblique
Clanging	Speech where words are chosen because they rhyme and do not make sense
Neologisms	Creation of new words with no meaning except to the patient
Thought blocking	Interruption to thought process where thoughts are absent for a few seconds and are unable to be retrieved

Thought content

There are often recurrent themes in the speech of an acutely disturbed patient. These may revolve around suicide, persecution, control, reference, religion or somaticism (the extremes of which are nihilistic delusions – the belief that part of the self does not exist, is dead or decaying) or they may be grandiose in nature.

Perception

A patient may be actively hallucinating despite denying this on questioning. It is important to note if the patient’s eyes suddenly switch direction for no apparent reason or they appear to be listening to a voice. These movements are often quite subtle and easily missed if observation is not active.

Cognitive assessment and physical examination

A formal examination of cognitive function and a thorough physical examination complete the full psychiatric assessment. The interviewer should ensure that the patient does not have an acute confusional state secondary to a physical condition that may account for a behavioural problem.

A number of tools are available to assess cognitive functioning. These comprise assessments in orientation, concentration, memory, language, abstraction and judgement. An assessment of a patient’s cognitive functioning and intelligence may assist in deciding the best way to deal with problems.

Approximately 20% of mental health patients have a concurrent active medical disorder requiring treatment and possibly contributing to the acute behavioural disturbance [6]. Investigations depend on physical findings but may include creatine kinase, urine drug screen, electroencephalogram, computed tomography and lumbar puncture. Only after this can an emergency medicine practitioner plan the most appropriate management.

Conclusion

Although time consuming, a good mental health assessment is vital for the appropriate management and disposition of what is an increasingly large group of patients in the ED. If able to formulate an opinion on the risk assessments regarding suicide, violence and flight risk and the aims of the MSE, the emergency clinician will be able to present to mental health services a comprehensive picture of the patient.

The mental health professional is then able to administer mental health first aid [2], the principles of which are:

assess the risk of suicide/harm to others

listen non-judgementally

give reassurance and information

encourage getting professional help

encourage self-help strategies.

Controversies

Whereas most general hospitals have integrated the assessment of mental health patients within the ED, there is now a growing trend towards the development of stand-alone psychiatric emergency centres – a separate area attached to the ED where mental health patients are assessed after initial triage. This is staffed by dedicated mental health professionals and has the potential to deskill emergency medicine personnel, both nursing and medical. It is uncertain whether this model or mainstreaming is more effective in the management of mental health patients.

Despite an overall improvement in assessments, mainstreaming of mental health patients has exposed them to the increasing levels of access block within general hospitals and increasing overcrowding in EDs. This has resulted in mental health patients spending prolonged periods of time in the ED while waiting for inpatient beds to become available. This has the potential for increased violence, unnecessary use of sedation and increased morbidity and mortality of mental health patients while placing other patients, their carers and staff members at unnecessary risk.

References

1. The Australian Institute of Health and Welfare. Mental health provided in emergency departments (updated Aug 2012). Canberra: Australian Institute of Health and Welfare; 2012.<http://mhsa.aihw.gov.au/services/emergency-departments/>[Accessed Mar. 2013].

2. Kitchener B, Jorm A. Mental health first aid manual Melbourne: Orygen Research Centre; 2002.

3. Clinical Practice Guidelines Team for Depression, Royal Australian and New Zealand College of Psychiatrists. Australian and New Zealand clinical practices Practice guidelines for the treatment of depression. Aust NZ J Psychiatr. 2004;38:389–407.

4. Larkin GL, Classen CA, et al. Trends in US Emergency Departments Visits for mental health conditions, 1992–2001. Psychiatr Serv. 2005;56:671–677.

5. Crowe M, Carlyle D. Deconstructing risk assessment and management in mental health nursing. J Adv Nurs. 2003;43:19–27.

6. ACEP Clinical Policies Subcommittee.. Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med. 2006;47:79–99.

7. Smart D, Pollard C, Walpole B. Mental health triage in emergency medicine. Aust NZ J Psychiatr. 1999;33:57–66.

8. Happell B, Summers M, Pinikahana J. Measuring the effectiveness of the national Mental Health Triage Scale in an emergency department. Internatl J Mental Hlth Nurs. 2003;12:288–292.

9. Jelinek GA, Weiland T, Mackinlay C, et al. Knowledge and confidence of Australian emergency department clinicians in managing patients with mental health-related presentations: findings from a national qualitative study. Internatl J Emerg Med. 2012;6:2.

10. Weiland T, Mackinlay C, Hill N, et al. Optimal management of mental health patients in Australian emergency departments: barriers and solutions. Emerg Med Australas. 2011;24:667–688.

11. Gerdtz MF, Hill N, Weiland TJ, et al. Perspectives of emergency department staff on the triage of mental health related presentations: implications for education, policy and practice. Emerg Med Australas. 2012;24:492–500.

12. McSherry B. Risk July 2004 Assessment by mental health professionals and the prevention of future violent behaviour. Australian Government: Australian Institute of Criminology.

13. NSW Department of Health. Framework for suicide risk assessment and management. Emergency Department Online.<www.health.nsw.gov.au>; 2004.

14. Department of Health and Ageing. Emergency triage education kit. Australian Government; 2007; 37–48.

15. Department of Human Services, Victorian Emergency Department. Mental health triage tool.<www.health.vic.gov.au/emergency/mhtriagetool.pdf>[Accessed Mar. 2013].

16. Meyers J, Stein S. The psychiatric interview in the emergency department. Emerg Med Clin N Am. 2000;18:173–183.

20.2 Distinguishing medical from psychiatric causes of mental disorder presentations

David Spain

Essentials

1 Morbidity and health costs are reduced by correct distinction of medical from psychiatric causes of mental disorder in presentations to emergency departments.

2 The question of whether any medical condition exists in addition to the psychiatric complaints should be asked. This will identify most medical causes of mental disorder.

3 Missed medical diagnosis is most commonly associated with failure to undertake an adequate medical history, mental state examination and physical examination.

4 Substance-related disorders are most easily identified on direct or collateral history.

5 The presence of delirium or other significant cognitive defects makes an organic or substance-related illness almost certain.

6 The diagnosis of delirium may require repeated assessments over time.

Introduction

Emergency physicians often assess patients who have suspected mental disorder. The critical question posed is: what is the cause of this? Causes are many but broadly include psychiatric, medical, intoxication and behavioural. Identifying the likely cause and careful consideration of the capability of local facilities usually leads to correct disposition, reducing medical costs and morbidity [1]. In practice, emergency physicians need a simple classification defining the principal diagnosis of the presenting mental disorder consistent with the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) terminology. This allows us to communicate with psychiatric colleagues and should assist diagnostic, management and disposition accuracy. Table 20.2.1 is such a suggested classification.

Table 20.2.1

A simple classification of principal diagnosis of mental disorder for emergency physicians

DSM-IV terminology	Broad traditional clinical grouping	Likely principal management and disposition
Axis 1
Clinical disorder due to a general medical disorder	Organic	Medical
Delirium, dementia and amnestic and other cognitive disorders	Organic	Medical
Substance-related disorder – intoxication or withdrawal disorder	Organic	Medical
Substance-related disorder – substance induced persistent disorder	Organic	Psychiatric
Clinical disorder (not identified to above or axis II principal diagnosis)	Psychiatric	Psychiatric

This patient group is diverse and many factors increase the difficulty of assessment including poor cooperation, intoxication, violence and minimal information referrals. Additionally, many presentations are subtle, can mimic other conditions and may not have absolute or clear distinguishing criteria. The historical approach of ‘medical clearance’ aims to screen for emergent medical causes that are unsuitable for psychiatric care. Medical issues are traditionally called organic. That terminology persists but is increasingly challenged by a postulated medical basis for some psychiatric disorders. Medical clearance has been used for over 30 years, but there is still no accepted universal agreement of what that means or should entail. Overall, the process should be considered an imperfect risk reduction strategy.

General approach

Patients with abnormal behaviour labelled as psychiatric after routine medical and psychiatric assessment frequently have a final diagnosis of a medical cause or precipitant for the mental disorder. The incidence of missed medical diagnosis ranges between 8 and 46% [1–3]. One study of first psychiatric presentations found a higher rate of medical diagnosis of 63% [4]. Deciding whether a particular presentation of mental disorder is medical or psychiatric is often difficult, as there are very few absolutes that distinguish medical from psychiatric illness. Careful collection and weighting of appropriate information commonly only leads to a differential diagnosis.

Some diagnoses and dispositions can be determined quickly after a medical and psychiatric history, with the addition of a mental state and full physical examination. This may sometimes take place without expensive diagnostic procedures. Other presentations are difficult and require extensive and intensive evaluation, repeat evaluation, observation in hospital and significant investigations before the diagnosis is clear.

Medical clearance in emergency departments (EDs) can be inaccurate due to the presence of intoxicating substances or patient factors that limit necessary assessments. A non-judgemental approach with prudent intervention based on known or likely risks, close monitoring in a safe environment and repeated reassessment of physical and mental state over time are often necessary to obtain an accurate diagnosis and optimal outcome.

Studies on medical clearance by ED staff, primary-care physicians and psychiatrists have repeatedly shown a poor ability to discover medical conditions. This failure is commonly due to one or more of the following factors: inadequate history; failure to seek alternative information from relatives, carers and old records; poor attention to physical examination, including vital signs; absence of a reasonable mental state examination; uncritical acceptance of medical clearance by receiving psychiatric staff; and failure to re-evaluate over time [5]. One study noted that medical conditions were most easily identified in the ED by the triage nurse or medical officer asking whether any medical conditions existed in addition to the patient’s psychiatric complaints [6].

Evaluation requires a thorough approach and a commitment of time and effort. Special skills are required for medical clearance and psychiatric interview. A coordinated and focused medical and psychiatric assessment has the highest yield of correct diagnoses [1]. Proformas or clinical pathways may improve compliance and documentation of important details, but have not been clearly demonstrated to improve patient outcomes [7].

National Emergency Access Targets (NEAT) in Australia will change the management of mental disorder clients. The approaches will vary dependent on institutional capabilities and local agreements. Universal medical clearance for every patient presenting will be unlikely, with many known psychiatric patients being triaged directly for psychiatric assessment. Additionally, medical processing when required will need to occur concurrently with psychiatric assessments, thus replacing traditional sequential processing where medical assessment and often investigation precedes psychiatric involvement. High yield presentations for organic disease will be directed to Medical Assessment Units when available to allow investigations, observation and reassessment over a reasonable period of time.

Triage

Triage is vital, as many patients presenting with apparent psychiatric problems have medical conditions. Correct identification at the point of entry by nursing staff facilitates correct management and reduces morbidity and mortality. Many patients with psychiatric illness are also a significant risk to themselves or others and require urgent intervention. Questions regarding safety should always be raised (Table 20.2.2) [8].

Table 20.2.2

Triage safety questions [8]

Is the patient a danger to him- or herself?

Is the patient at risk of leaving before assessment?

Is the patient a danger to others?

Is the area safe?

Does the patient need to be searched?

Pollard C. Psychiatry reference book – nursing staff. Hobart: Department of Emergency Medicine Royal Hobart Hospital; 1994 with permission.

Nursing staff should use a triage checklist to identify likely organic presentations (Table 20.2.3). These are indications for urgent medical assessment. If these are absent and a psychiatric diagnosis is likely, then an appropriate urgency rating by Australasian Triage Scale for psychiatric presentations should be applied. This triage categorization for psychiatric presentations has been developed and verified and allows reasonable waiting time standards for urgency to be applied in Triage Category 2–5 (Table 20.2.4) [9]. A Triage Category 1 when there is severe behavioural disturbance with immediate threat of serious violence has been sensibly added to that scale by the Australasian College for Emergency Medicine.

Table 20.2.3

High-yield indicators of organic illness

First presentation of mental disorder or distinctly different mental disorder in patient with known psychiatric illness

Delirium

Abrupt onset change in mental state

Hours to days

Fluctuates

Change in cognition

Disorientation

Memory deficit

Language disturbance

Disturbance of consciousness

Fluctuating or decreased

Poor attention

Perceptual disturbance

Hallucinations (especially visual)

Illusions

Misinterpretations

Drug or alcohol use

Recreational/illicit

Overdose

Prescribed or over-the-counter

Recent or new medical problems

Neurological signs or symptoms

Abnormal vital signs

Table 20.2.4

Guidelines for Australasian Triage Scale coding for psychiatric presentations [9]

Emergency: Category 2

Patient is violent, aggressive or suicidal or is a danger to self or others or requires police escort

Urgent: Category 3

Very distressed or acutely psychotic, likely to become aggressive, may be a danger to self or others. Experiencing a situation crisis

Semi-urgent: Category 4

Long-standing or semi-urgent mental health disorder and/or has a supporting agency/escort present (e.g. community psychiatric nurse*)

Non-urgent: Category 5

Long-standing or non-acute mental disorder or problem, but the patient has no supportive agency or escort. Many require a referral to an appropriate community resource

Smart D, Pollard C, Walpole B. Mental Health triage in emergency medicine. Aust NZ J Psychiatr 1999;33:57–66 with permission.

*It is considered advantageous to ‘up triage’ mental health patients with carers present because carers’ assistance facilitates more rapid assessment.

Triage should consider patient privacy issues if the history obtained is to be accurate. Collateral information from the carers with the patient should always be diligently obtained, carefully considered and documented. This information should allow the patient to be placed in an appropriate and safe environment where continuing visual and nursing observations can occur while further assessment occurs. An emerging trend is to use nursing triage immediately to refer likely psychiatric presentations to mental health clinicians without formal medical clearance. This method identifies clients who have presented with an aggravated or past similar psychiatric condition, who have normal vital signs, without recent medical concerns and who are not under the influence of drugs or alcohol. This streaming will become more widespread with National Emergency Access Targets and appears effective and efficient for both patient and clinicians. These triage referral systems require a medical safety net if referral was inappropriate. They have been operating now for some years without obvious increase in adverse outcomes. They are yet to be validated by scientific studies.

The interview environment

A climate of trust is very important, as many details of the psychiatric interview are quite sensitive. The psychiatric interview should take place in as quiet and private an environment as possible. The choice of the interview site may be limited in emergencies to ensure safety for both patient and staff.

History

A careful traditional medical history is the most common identifier of medical illness as a cause of a mental disorder presentation. Substance-related disorders are also most easily identified on history. A careful drug history, including prescribed, recreational and over-the-counter medications, should always be included. A slow onset and a previous psychiatric history are more commonly associated with psychiatric illness. Conversely, rapid onset, no premorbid decline and no past psychiatric history favour a medical cause. Poor recall of recent events may indicate delirium.

Family history is often a key indicator of psychiatric or medical cause. For example, a newly depressed 30-year-old man with a family history of Huntington’s disease or porphyria is more likely to have a physical cause. Conversely, an 18-year-old man with a hypomanic presentation and a strong family history of bipolar disorder is more likely to have a psychiatric cause. Suicidal and homicidal risk should be assessed routinely to ensure safety. Escalating immediate risk can often be recognized by combining patient perceived lethality and inquiry about any transition from thoughts, to actual plans and finally to actions. For patients with previous psychiatric illness, the system review is a useful screen for organic illness.

HIV is an increasingly important area as HIV-related illness becomes the new great mimic of modern psychiatry and medicine. Practices likely to have put the patient at risk should be explored. These may have been in the distant past. Known positive HIV status always warrants assessment for an organic cause of any new behavioural disturbance. Clinically, these problems often initially present with symptoms of mild anxiety or depression. Many treatable medical causes are only evident after significant investigations.

Delirium, a highly specific but not absolute indicator of medical or substance-induced disorders, should always be sought. By definition, this requires a history of recent onset and of fluctuation over the course of the day. Classically, there will be subtle changes in level of consciousness or the sleep–wake cycle. Patients may not be able to attend sufficiently to give this history if delirious. The psychiatric history, including life profile, may give evidence of the presence or absence of premorbid decline. An abrupt onset of abnormal behaviour with no premorbid decline is more suggestive of an organic cause.

Collateral history

Collateral history is important as the patient is not always capable of or willing to give full information. This history often crystallizes a diagnosis that would otherwise be uncertain or completely missed. Previous discharge summaries may provide relevant information regarding alcohol and drug use, previous behaviour and diagnosis. The family should be asked to bring in all medications, including over-the-counter items. Family, friends and caregivers may give more rapid access to collateral history than waiting for past admission details. Family and friends may be the only source for obtaining a history of a patient’s fluctuating mental status suggesting delirium, even when the patient appears quite lucid in the ED.

Examination

Lack of attention to important details of the examination is a frequently identified cause of missed medical illness. Areas that commonly yield positive findings, but which are frequently omitted, are the neurological examination, a search for general or specific appearances of endocrine disease, the toxidromes, examination for signs of malignancy, drugs or alcohol abuse and vital sign examination. Poor cooperation can prevent detailed examination and should be documented so that future consulting clinicians are aware of a deficient entry examination.

Vital signs

Abnormal vital signs are frequently the only abnormality found on examination of patients with serious underlying medical disease. They must always be acknowledged and explained. Pulse oximetry should be included rapidly to exclude hypoxia. A bedside blood sugar level should be routine for patients with abnormal behaviour.

Mental state examination

This is an account of objective findings of mental state signs made at the time of interview. It is the psychiatric equivalent of the medical examination and specifically details the current status. Observations made by other staff in the department, such as hallucinations, may be very significant and can be included with the source identified. Careful consideration of the mental status frequently clearly distinguishes medical from psychiatric illness and guides further investigation and management. For example, the presence of delirium or other significant cognitive defects make an organic illness almost certain. Disorientation is highly suggestive of delirium. Delirium can be very subtle. Sometimes, owing to the fluctuating nature, the patient may appear normal on a single interview. Other less obvious features, such as lability of mood, variability of motor activity or lapses in patient concentration making the interview more difficult, can be the only clues and can be easily overlooked. The importance of formulation using collateral history and repeated mental state examination is stressed. Documentation is important so that mental status changes with time during repeat assessment can be appreciated.

Examination tools

Cognitive defects may be rapidly and reliably identified in the ED during mental status examination by the use of Folstein’s Mini Mental State Examination (MMSE) [10]. A score of less than 20 suggests an organic aetiology. A fall of two or more points on serial MMSE is highly suggestive of delirium. Elderly patients with delirium or cognitive defects are frequently not recognized by emergency physicians. These patients are at high risk of morbidity and mortality [11]. Simple assessment methods, such as the confusion assessment method (CAM), are rapid, reliable methods of identifying delirium in older patients, suitable for ED use[12]. Use of such simple methods should be encouraged to reduce inappropriate disposition. The tests above are suitable screening tools for EDs but are not intended to replace formal neuropsychological assessment. Proformas of medical history, mental state examination and physical examination may improve thoroughness of assessment and documentation.

Investigations

Investigations should always be guided by clinical findings and must be tailored to each individual presentation. A combined Massachusetts Emergency Physician and Psychiatry Task Force in 2009 identified criteria for low medical risk. Patients must meet all criteria. The criteria were adults aged 15–55, no acute medical complaints, no new psychiatric or physical symptoms, no evidence of substance abuse pattern, normal vital signs, normal gait and speech with normal memory and concentration. Patients with low medical risk were not recommended for any routine testing in the ED as they are of very low yield.

First presentations and suspicion of a medical cause that needs to be confirmed or excluded are the major indications for emergency investigations. Baseline blood tests, such as full blood profile, blood sugar level, electrolytes, liver function tests, calcium and thyroid function tests, may at times detect clinically unsuspected problems. Examination and culture of urine and cerebrospinal fluid should be undertaken if occult infection is considered a possible cause. A urine drug screen may on occasion be the only way to confirm clinical suspicions of drug-related illness. Time delays for results, low specificity from cross-reactivity and uncertainty caused by drugs with long half-lives limit their usefulness. Newer drug-screening stat tests at the bedside may improve their usefulness in the ED. Mandatory brain computed tomography (CT) is not indicated, but the threshold for imaging in first presentations of altered mental state without obvious cause should be low. HIV and syphilis testing should be done on all patients with significant risk profile. Herpes encephalitis may not produce imaging changes but should be considered when fever, delirium or cognitive changes are present with sudden alterations in behaviour. Newer imaging modalities, such as magnetic resonance imaging, magnetic resonance spectroscopy, positron emission tomography and single-photon emission CT, continue as research tools but may have a role in the future. Electroencephalogram examination is rarely a current ED test for psychiatric patients.

Diagnostic formulation

Emergency physicians should suspect organic disease until proved otherwise. In particular, reversible medical causes of abnormal mental state should be sought. Proformas improve documentation and summation. Consideration of the factors in Table 20.2.5 may help to determine doubtful cases. There are few absolutes that distinguish organic from psychiatric patients. Use of the five-axis DSM-IV system improves the ability to look at the patient’s presentation in the context of total functioning. It also allows emergency physicians to communicate with psychiatric peers in the recognized language.

Table 20.2.5

Factors influencing the likelihood of medical or psychiatric illness as the principal diagnosis

FH: family history.

Some patients require periods of observation, re-examination and further investigations before a definitive answer is obtained. Intoxicated patients frequently are not assessable till sober. NEAT will pressure hospitals to look for safe disposition sites for this often difficult patient group. Interim care and disposition varies depending on presentation, prior history and facilities available. A common expectation of emergency physicians for patients referred to psychiatrists is to document that the patient is ‘medically cleared’. The assessment is known to be imprecise and difficult [1–4,7]. Better documentation is to state that the ED assessment has revealed no evidence of an emergent medical problem that would preclude admission to psychiatric care.

Conclusion

A thorough medical history, psychiatric history, collateral history, physical examination, mental state examination and judicious specific investigation will identify most patients likely to have an underlying physical cause for a mental disorder presentation. Omission of any of these steps may lead to missed medical diagnosis and incorrect disposition.

Controversies and future directions

Where and when assessment of mental disorder ideally occurs is somewhat controversial. Urgent assessment in the traditional hospital-based general ED with strict medical clearance is ideal and safest for rapid and new onset illness. Patient volume and time demands with resource restraints are forcing alternative models for entry to care. Many EDs are triaging patients in crisis as likely medical, emergent psychiatric or non-emergent psychiatric. Depending on local service availability, early streaming based on this triage allows many psychiatric clients (some emergent and most non-emergent) to be directed away from the ED to appropriate community mental health services. Additionally, community-based psychiatric services are increasingly managing acute episodes of behaviour disorder in the community without the need for hospitalization or emergency department involvement. Hard outcome studies are yet to be undertaken on these new models.

Driven by new access targets, there is some pressure for early referral to an acute care psychiatric team after triage, rather than all mental disorder patients receiving medical clearance by a doctor. Many believe that this has produced significant benefits to patients, with shorter waiting times and better psychiatric assessments by psychiatric trained nurses and psychologists when compared to junior medical staff. Experience to date indicates they need ready access to safety net medical systems and consultant psychiatric supervision to operate effectively and safely.

Providing adequate resources and a safe physical environment for assessment, management and disposition of the rapidly escalating number of patients with substance-related disorder is a major ED challenge. Assessments during intoxication are typically unhelpful. Intoxication may last hours to days and require medical therapy. NEAT targets will likely force new care pathways for this patient group. Some health services are exploring memorandums of understanding with local police services to care for selected high-risk clients until sober.

References

1. Hoffman RS. Diagnostic errors in the evaluation of behavioural disorders. J Am Med Assoc. 1982;248:964–967.

2. Koranyi EK. Morbidity and rate of undiagnosed physical illnesses in a psychiatric clinic population. Arch Gen Psychiatr. 1979;36:414–419.

3. Hall RC, Popkin MK, Devaul RA, et al. Physical illness presenting as psychiatric disease. Arch Gen Psychiatr. 1978;35:1315–1320.

4. Henneman PL, Mendoza R, Lewis RJ. Prospective evaluation of emergency department medical clearance. Ann Emerg Med. 1994;24:672–677.

5. Tintinalli JE, Peacock FW, Wright MA. Emergency medical evaluation of psychiatric patients. Ann Emerg Med. 1994;23:859–862.

6. Olshaker JS, Browne B, Jerrard DA, et al. Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med. 1997;4:124–128.

7. Zun LS, Downey L. Prospective medical clearance of psychiatric patients. Primary Psychiatr. 2008;15:60–66.

8. Pollard C. Psychiatry reference book – nursing staff Hobart: Department of Emergency Medicine Royal Hobart Hospital; 1994.

9. Smart D, Pollard C, Walpole B. Mental health triage in emergency medicine. Aust NZ J Psychiatr. 1999;33:57–66.

10. Folstein MF, Folstein SE, McHugh PR. ‘Mini Mental State’: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–198.

11. Trzepacz P, McIntyre, Charles SC, et al. Practice guideline for the treatment of patients with delirium. Am J Psychiatr. 1999;156:1–20.

12. Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion The confusion assessment method A new method for detection of delirium. Ann Intern Med. 1990;113:941–948.

20.3 Deliberate self-harm/suicide

Jennie Hutton, Grant Phillips and Peter Bosanac

Essentials

1 Deliberate self-harm is a frequent presentation to emergency departments and is a symptom of diverse underlying problems, be they biological, social or psychological.

2 Patients with deliberate self-harm form a heterogeneous group, most of whom do not have ongoing suicidal behaviour.

3 Assessment of suicide risk following deliberate self-harm is to inform treatment, to identify risks amenable to intervention and protective factors. It involves assessment of background demographic, psychiatric, medical and psychosocial factors.

4 There is no ‘gold standard’ for suicide risk assessment and level of risk can change quickly.

5 The most consistent factors predicting fatal and non-fatal repetition following deliberate self-harm are psychiatric illness, personality disorder, substance abuse, multiple previous and types of attempts, hopelessness, social disconnectedness and intoxication.

6 Management requires coordinated care with emergency, mental health and primary care clinicians, as well as carers.

7 A planned strategy to deal with these patients should address triage, restraint and observation, medical and suicide risk assessment, treatment and disposition.

8 The legal framework for the location in which individuals practice should be known and considered.

Introduction

Suicide is a deliberate act of intentional self- inflicted death. It is the most extreme manifestation of deliberate self-harm, where the spectrum also comprises suicidal ideation, plans and intent. Although suicide is uncommon, 10% of people who commit suicide are seen in an emergency department (ED) in the month prior to death, with a substantial proportion not having psychosocial assessment, thus providing an opportunity for intervention [1,2]. The major ED impact, however, is in the identification and assessment of large numbers of patients potentially at risk of suicide, with initial management of co-morbidities and modifiable risk factors.

Deliberate self-harm (DSH) is a maladaptive response to internal distress and may not have suicidal intent; it may, however, indicate a risk for suicide. Deliberate self-harm is a common ED presentation (approximately 0.4% of all ED visits [3]) and the goals of management include treatment of the physical health sequelae, assessment of risk of non-fatal or fatal repetition and diagnosing and commencing treatment of potentially reversible psychosocial causes.

Epidemiology

In Australia, there were approximately 2300 deaths per year from suicide in 2010, with age-standardized rates of approximately 16.4 per 100 000 in males and 4.8 in females (Table 20.3.1) [4]. Suicide accounts for 1.6% of deaths in Australia. Suicide remains the leading cause of death among Australians between 15 and 34 years of age. Despite some decreases in suicide rate over the past decade, suicide remains a major external cause of death, accounting for more deaths than road traffic crashes [5].

Table 20.3.1

Suicide summary statistics, Australia, 2001–2010 [6]

OECD Factbook 2009. [Internet homepage] [cited 2012, Nov 4].<http://www.oecd-ilibrary.org/economics/oecdfactbook-2009/suicide-rates_factbook-2009-graph162-en>

Across OECD (Organisation for Economic Cooperation and Development) countries, suicide rates were lowest in Greece, Mexico, Italy, the UK and Spain at less than 7 deaths per 100 000. They were highest in Hungary, Japan, Korea, Finland and Belgium at more than 19 deaths per 100 000 [6]. WHO estimates the low and middle income countries account for 84% of global suicides with India and China accounting for 49%. In these countries, rural young women are at an increased risk of suicide [7].

The trends involving completed suicide vary internationally, as well as subnationally, in addition to variance over time. Figure 20.3.1 shows this change over 62 years for New Zealand. Some inconsistencies across reporting systems should also be considered when interpreting suicide rates.

FIG. 20.3.1 New Zealand suicide age-specific death rates, by life-stage age group, 1948–2010 as an example of changing rates over time in a developed country. Notes: The rates in this figure are age-specific rates, measuring the frequency of suicides per 100 000 population relative to particular population age groups. (With permission from Ministry of Health, New Zealand Government. New Zealand Mortality Collection.)

Hospital presentations for DSH are at least 10 times higher than suicide rates [4]. In the 2007 Australian National Survey of Mental Health, 0.3% of males and 0.5% of females reported they had made a suicide attempt in the previous 12 months. Most of these are not reported or are reported as accidents. Hence, unrecognized DSH is at least as frequent as that recognized. The same survey reported 1.9% of males and 2.7% of females experienced suicidal ideation within 12 months [8]. This rate may be as high as 25% in certain populations and age groups [9,10].

Risk of suicide

An episode of DSH is one historical risk factor predictive of future suicide attempts. Approximately 1–2% of patients commit suicide during the year following an attempt and in approximately 40% of suicides there is a history of a previous self-harm. A systematic review of fatal and non-fatal repetition of self-harm reported a suicide rate of 2% at 1 year and 7% after 9 years [11]. In a prospective Finnish 14-year follow-up study and a UK 18-year follow-up study, the rate of suicide after an episode of DSH was 6.7% [12,13]. A 10-year follow-up study in New Zealand documented a suicide rate of 4.6% in patients admitted for DSH [14]. An emergency centre-based retrospective cohort study in New Zealand demonstrated an 18% re-presentation and a 1.1% suicide rate at 1-year follow up [15]. Hospitalization and aftercare decrease short-term risk of suicide, but have little impact on long-term risk of suicide. However, this may be due to undertreatment of psychiatric illness [16–18].

Exposure to suicide in adolescents tends not to cause an increased risk of suicide among friends, but may cause an increased incidence of depression anxiety and post-traumatic stress disorder [19].

Repeated episodes of DSH

DSH usually invokes help from friends, family and the medical profession so that the patient’s social situation and psychological well-being tends to improve [20]. This effect is prominent in younger patients, but may not occur in patients aged over 60 years [21]. The risk of repetition is 12–16% in the following year, with 10% of these occurring in the first week [11]. This is more likely in females who are unemployed, have cluster B (e.g. borderline, narcissistic and histrionic) personality traits or have substance-abuse problems. A younger age at first attempt, presence of long-standing affective disorders, drug/alcohol misuse disorders and anxiety all correlate with repeated attempts. Some patients have chronic suicidal ideation and multiple repetitions of DSH. They often suffer from personality disorders, psychotic disorders, chronic medical conditions, alcohol or drug use, a history of childhood sexual abuse [22,23] and violent behaviour. They use DSH as a means of fighting off anxiety, hopelessness, loneliness or boredom, or for inter-personal secondary gains with regard to family, friends or healthcarers. These patients are at increased risk of eventual suicide. Reversible potentiating factors should be addressed where possible.

Patients with DSH who leave the ED prior to a psychosocial assessment may have a higher risk for repeat DSH, probably associated with lack of specialist follow up and treatment of reversible factors [18,24].

Increased mortality

A suicide attempt is associated with a severe risk of premature death with the increased mortality rate not entirely due to suicide [25]. There is a higher than expected rate of accidents, homicides and death from other medical conditions. This may indicate social disadvantage, disengagement with the health system, underlying chronic illnesses or lifestyle factors.

Patient characteristics

Demographic factors

Age

Suicide and DSH are rare in children under 12 years of age. Australian data suggest similar rates of suicide from the age of 20–50, with a peak at 40–44 years in males (27.7 per 100 000) and 45–49 years in females (7.6 per 100 000) [4]. There is another peak in the elderly, with suicide rates increasing with age from 65 years. This bimodal distribution is also evident from USA and New Zealand data, with males aged over 80 years having the highest age-specific rates of suicide.

The incidence of DSH increases throughout puberty, reaching a peak at 15–24 years of age and decreasing thereafter. The ratio of rates of DSH to suicide decreases markedly with age. DSH is uncommon in the elderly, who have a high ratio of successful to unsuccessful attempts [26].

Gender

In Australia, the overall rate ratio of M:F suicide is 3.4 in 2010 compared with 2.7 in New Zealand and 3.2 in the UK in the same year [27,28]. The rate for male DSH has been increasing in Western countries recently with the male to female ratio approximately 1:2. Females choose methods that are less likely to be fatal and may be more likely to present to hospital following DSH.

Employment

Unemployment increases the risk of DSH by 10–15 times, with the risk increasing with duration of unemployment. This may not be a cause or effect, but may be due to some underlying factor, such as psychiatric illness, personality disorder or substance abuse. There is a more pronounced increased in the risk factors of unemployment rate and lower socioeconomic status for young men in Australia [29].

Social and cultural factors

Suicide rates are higher in those who live alone or are in a lower social group, especially in urban areas characterized by social deprivation and overcrowding. Being single, separated, divorced or widowed increases the risk of suicide two- to threefold in the high- income countries [7]. In these countries, being partnered reinforced by children decreases the risk of suicidal behavior. In India and China, there is a reduced risk of suicide versus other causes of death in women widowed, divorced or separated compared with married women and men [7].

Recent data in Australian Aboriginal people report substantially higher suicide rates that commence at a lower age than in the non-Aboriginal population [4]. Suicide has become more common in recent years; in 2010 the percentage of deaths by suicide among Aboriginal and Torres Strait Islander people was 4.2% compared with non-indigenous Australians 1.6% (does not include states of Victoria, Tasmania and Australian Capital Territory data). It is of concern that the age-specific suicide rate for Aboriginal males aged 25–29 was 90.8 deaths per 100 000 in a combined 10-year period 2001–2010 [4]. A higher suicide rate is seen in indigenous groups of other developed countries, for example, in New Zealand, the age standardized rate was 16 per 100 000 in 2010 compared with a rate of 10.4 in the non-Maori population [28].

Suicide rates of migrants initially reflect rates in the country of origin and converge toward the Australian rate over time. Rural areas in Australia and New Zealand and remote areas in the UK have a higher rate than urban areas [4,28,30]. Incarceration is a risk factor for suicide; in any form of custody, the suicide rate is three times that of the general population [31].

Some social groups, such as doctors, dentists, musicians, lawyers and law-enforcement officers, are more prone to suicide [32]. Most adults (75%) with DSH have relationship problems with their partners and teenagers with their parents. A major argument or separation often precedes the act on a background of ongoing social difficulties or substance use.

Medical factors

There is an increased risk of suicidal ideation in people with chronic ill health, terminal illness or chronic pain and epilepsy. The majority of such patients have sought medical advice in the 6 months before suicide. Most patients with DSH have good health.

Psychiatric factors

There is a pre-existing psychiatric disorder in 90–100% of cases of suicide, with depression accounting for 66–80%, but this rate may be based on retrospective psychological autopsy and therefore be open to dispute. The lifetime rate of suicide among psychiatric inpatients is 3–12 times higher than in the general population and involves a greater proportion of more violent methods, such as jumping from buildings, hanging or jumping in front of vehicles. One-third of these episodes occur after self-discharge from hospital, with another third occurring during approved leave. The high-risk time is the first week of admission and during the first 3 months after discharge [33].

Psychiatric disorders are present in up to 60% of patients who commit DSH, but may be transient and secondary to acute psychosocial difficulties. Da Cruz et al. examined the cases of 286 individuals who died within 12 months of mental health contact in North West England; 43% of the sample attended the ED on at least one occasion and 12% of the sample attended an ED on more than three occasions and could be considered ‘frequent attenders’. Most frequent attenders had a history of self-harm (94%), 68% had a history of alcohol abuse, 63% were unemployed at the time of deaths and 49% had a history of drug abuse [34].

Affective disorders

The psychiatric diagnosis that carries the greatest risk of suicide is mood disorder, particularly major depressive disorder if associated with borderline personality disorder, anxiety or agitation [35]. Fifteen per cent of these high-risk patients commit suicide over a lifetime. Depression correlates well with the occurrence of suicidal desire and ideation, but may not be as strong a predictor of planning and preparation (intense thoughts, plans and capability) and, therefore, suicide completion [36]. Hopelessness is the most important factor associated with suicide completion and may be of greater importance than suicidal ideation or depression itself [36]. Depressed patients should, therefore, have their attitudes towards the future carefully assessed.

Substance abuse

Individuals with alcohol use disorders have an overall approximately 7% lifetime risk of dying by suicide, with women being at greater risk than men. Fifteen per cent of alcohol-dependent persons eventually commit suicide. The majority of these are also depressed. The risk is higher if associated with social isolation, poor physical health, unemployment and previous suicidal behaviour. The increased risk may be more pronounced in males aged below 35 years [37]. Young males dependent on heroin have 20 times the risk of the general population. Chronic alcohol dependence is uncommon in DSH, but alcohol intoxication is involved in 50–90% of suicide attempts. Wyder found that 65% of people presenting with deliberate self-harm in Australia were substance affected at the time [38]. Acute alcohol ingestion is found in approximately 35% of people who die by suicide and between 15 and 60% of people who die by suicide have been found on psychological autopsy to have lifetime alcohol-use disorders [39].

Schizophrenia

Up to 10% of people with schizophrenia die by suicide. Young adult males are at high risk, especially if there is associated depression with feelings of hopelessness, previous DSH or suicide attempts, unemployment or social isolation.

Personality disorders

Patients with cluster B personality disorders are at high risk of DSH and suicide, especially if associated with labile mood, impulsivity, alienation from peers and associated substance abuse. This may be due to precipitation of undesirable life events, predisposition to psychiatric and substance-abuse disorders and social isolation. Adjustment disorders are associated with 25% of adolescent suicide [23].

Frequent attenders

Frequent attenders to EDs (defined as greater than three presentations in a year) are also at high risk. This group has seven times the risk of the general population and rates of suicide similar to clinical psychiatric populations. This risk is particularly pronounced in patients who present with panic attacks, especially if associated with depressive symptoms.

Aetiology

No specific psychological or personality structure is associated with suicide and patients who commit suicide or DSH do so for many unrelated reasons. The precipitant may be a personal crisis or life change amplified by poor social support, substance abuse or psychiatric disorder. Intoxication may decrease inhibitions enough to allow an act to proceed. A study by Wyder interviewed 112 people following a deliberate self-harm attempt. She found that 51% had considered deliberate self-harm for 10 minutes or less, but of those who had been affected by alcohol that number jumped to 93% [40].

The most frequent methods of suicide in Australia are hanging, strangulation and suffocation, these modes being used in 56% of all suicide deaths in 2010 in Australia. Poisoning by drugs was used in 12% of suicide deaths in 2010, followed by poisoning by other methods including alcohol and motor vehicle exhaust (10%). Firearms accounted for 7% of suicide deaths in Australia in 2010, a rate which has declined from 20% a decade prior, possibly due to firearm restriction legislation [5]. Proportions due to each method vary according to region, residence, age and sex [1,41]. In the USA, firearms accounted for 57% of male and 32% of female suicide deaths. In trauma centres in the USA, stab wounds are a far more common method of deliberate self-harm than gunshot wounds and people (more often men) at the extremes of age are more likely to use firearms with fatal consequences [3]. In many developing countries, organophosphate or antimalarial poisoning and charcoal burning are more common methods of suicide [42]. One-third of patients with DSH express a wish to die, but most do so to communicate distress. DSH may serve many functions for the person. At its most simple, it serves an integrative function calming the person at a time of great distress. It may also be a way of mobilizing assistance for someone who is feeling overwhelmed by circumstances. Many patients threaten suicide or magnify being at risk of suicide to increase the likelihood of admission to hospital. These patients are more likely to be substance dependent, have personality diatheses (for example, marked borderline, antisocial or dependent traits or disorder) or homelessness and be unpartnered and in legal difficulty. However, these instances of goal directed behaviour should not be discounted and the behaviour should be taken seriously. A presentation to an ED is a declaration that the person is in a self-defined crisis for which they are using maladaptive coping measures.

Most cases of medically serious DSH are due to self-poisoning, with 90% associated with alcohol intoxication. The most common drugs are non-prescription analgesics and psychotropic drugs. Many overdoses are related to alcohol or illicit substance intoxication and may be accidental rather than deliberate, although this distinction is often difficult to ascertain. Self-injury may involve cutting of the skin in various sites about the body but may also involve self-inflicted cigarette burns, excoriation of the skin or hitting themselves or other objects. More violent forms of self-injury are less common and suggest serious suicidal intent. Bizarre self-mutilation may occur in psychotic patients who may not necessarily have an intention to die but are acting in accordance with delusional beliefs or in response to command hallucinations.

Assessment

A person who expresses suicidal ideation or engages in DSH is sending a distress signal that emergency physicians must acknowledge. Suicidality should also be assessed in patients with symptoms or signs of depression, unusual behavioural changes, substance abuse, psychiatric disorders, complainants of sexual violence [27] and those who present with injuries of questionable or inconsistent mechanism, such as self-inflicted lacerations and gunshot wounds or motor vehicle accidents involving one victim. Many would argue that assessment of suicidality should be a routine part of any ED assessment. A retrospective study by Da Cruz et al. found that 40% of persons who died by suicide had presented to the ED at least once during the year prior to their death [34]. Assessment in the emergency department ideally will contain elements that provide the person with the opportunity to discuss psychosocial aspects of their life. Within this discussion, it may be that suicidal ideation or thoughts of deliberate self-harm may be elicited. This may allow early referral to psychosocial supports thereby providing the person with holistic care to help address their needs.

Assessment requires a systematic, multidisciplinary approach involving prior staff education, appropriate triage, observation and restraint procedures (in the setting of imminent risk and the absence of less restrictive options) and a planned strategy for assessment followed by treatment and disposition. The priorities are to define the physical sequelae of the act, risk of further DSH behaviour, psychiatric diagnoses and acute psychosocial stressors. These aspects are those that can then be targeted for short-term interventions.

Triage

In a patient who has attempted DSH, initial management involves resuscitation, treatment of immediate life threats and preventing complications. The patient should be triaged according to the physical problem as well as current suicidality, agitation and aggressiveness and mental state. The mental health triage scale can be used for this purpose [43]. A triage score of 2 or 3 should be applied if patients are violent, actively suicidal, psychotic, distressed or at risk of leaving before full assessment can occur. Constant observation is required at this point and nursing staff, security or police may be needed. In Australia, a number of different triage scales can be used. There is some evidence that a mental health triage scale improves outcomes; however, the accuracy of the assessment can be limited by a number of environmental, staff and patient factors [44].

Medical assessment

The patient’s safety in the ED should be optimized by limiting availability of drugs, removing sharp implements, removing car keys, ropes, belts or sheets and securing nearby windows. Other concurrent and concealed methods of self-harm should be sought. This may be facilitated by changing into hospital gowns, whereby the patient is more easily identified if they abscond. In addition, other means to increase visibility, such as security cameras, high visibility cubicles or assigning a special nurse, should be considered. Assessment of the patient may be difficult, either due to a general medical cause or being unsettled from the precipitant of the act, or from not wanting to be in hospital or allow medical intervention. This may necessitate the therapeutic utilization of anxiolytic medication; the use of physical restraint may be considered if at high risk or unable to be fully assessed and wanting to self-discharge. This may be done under a duty of care to the patient or the local mental health act may be utilized in extreme situations. Emotional support of patient, friends and relatives is required during and after this phase, with clear explanation of the rationale and the procedures. Distinguishing medical from psychiatric causes of mental disorder presentations is discussed elsewhere in this book (see Chapter 20.2).

Suicide risk assessment

Initially, an assessment needs to be done in the ED so as to determine patient disposition, but a more comprehensive psychiatric assessment may need to wait until substance or anxiolytic medication effects wear off. Other sources of information need to be accessed since patient history can be unreliable or incomplete. Friends, family, local doctor, ambulance officers, helping agencies already involved and previous presentations documented in the medical record can all add useful information in order to advise an assessment. A therapeutic relationship should be formed and the clinician should be non-judgemental, non-threatening and clearly willing to help. A positive attitude has been shown to improve outcomes with this group of patients [45]. People presenting in crisis are hypersensitive to any negative transference. This may intensify the patient’s already low self-esteem, increasing future suicide potential and making a therapeutic relationship difficult to establish [46]. When managing a patient who may be suicidal, the suicidal ideation should be discussed openly. Expressions of self-harm carry individual meaning for each person. It is important, in a therapeutic relationship, to explore the meaning that this carries for the person and alternatives.

Risk factors may be divided into two main categories, namely static and dynamic. Static factors have been historically identified by Durkheim [47] who showed some, less socially integrated groups within society to be at greater risk of suicide than others. These static factors are enduring and in context of a person’s developmental history and social circumstances. Hence, being male, unemployed, single, poorly educated, from a lower socioeconomic group, with a history of mental disturbance and substance-use disorders would all place someone in a higher risk group.

Dynamic factors are the more fluid day-to-day factors that intensify the risk posed by the static factors. Flewett [48] divides these factors into internal and external factors. The internal factors include current feelings of abandonment, desperation, hopelessness, co-morbid depression, current drug use or physical illness. External factors are those of increased social dislocation, including homelessness, bereavement, intoxication, adverse life event, such as the recent loss of a job or relationship.

The role of dynamic risk is highlighted by Rosenman [49] when he states:

for conditions with multiple risk factors… each factor adds a little to the risk, but only when it interacts with other factors. No single predictor or combination of predictors is present in every individual, and membership of the high risk group changes from moment to moment. Half a bottle of whiskey may create a high suicide risk within an hour.

Assessment of suicide risk involves assessing background demographic, psychiatric, medical and social factors, these are the static factors that underlie any presentation and will determine the chronic suicidal risk that the person presents. Dynamic risk factors as well as the current circumstances and risk of suicidal behaviour itself are outlined in Table 20.3.2. There are epidemiological differences between people who attempt suicide and those who complete suicide. Although the groups are different, there is an important overlap. The more an individual’s characteristics resemble the profile of a suicide completer, the higher the risk of future suicide or suicide attempts. Despite this, in long-term follow-up studies very few of these factors have been shown to be good independent predictors of suicide following DSH. The most consistent factors are psychiatric illness, personality disorder, substance abuse, multiple previous attempts and current suicidal ideation and hopelessness. Guidelines are available to assist in suicide-risk stratification and describe characteristics associated with suicide-risk levels and the appropriate further assessment and disposition for each group [50].

Table 20.3.2

Factors associated with suicide [1]

Variable	High risk	Low risk
Static factors
Gender	Male	Female
Marital status	Separated, divorced, widowed	Married
Employment	Unemployed or retired	Employed
Medical factors	Chronic illness, chronic pain, epilepsy	Good health
Psychiatric factors	Depression, bipolar, schizophrenia, panic disorder, previous psychiatric inpatient, substance abuse	No psychiatric history
Social background	Unresponsive family, socially isolated or chaotic, indigenous background, refugee from conflict areas, past history of trauma, developmental trauma	Supportive family, socially stable and integrated
Dynamic factors
Suicidal ideation	Transient, intense suicidal ideation, plan and intent, intoxication and impulsivity with impaired judgement	Infrequent, transient
Attempts	Multiple	First attempt
Lethality	Violent, lethal and available method	Low lethality, poor availability
Planning	Planned, active preparation, extensive premeditation	No realistic plan, telling others prior to act
Rescue	Act performed in isolation, event timed to avoid intervention, precautions taken to avoid discovery	Rescue inevitable, obtained help afterwards
Final acts	Wills, insurance, giving away property
Coping skills	Unwilling to seek help, feels unable to cope with present difficulties	Can easily turn to others for help, can plan to overcome present difficulties, willing to become involved in aftercare
Current ideation	Admitting act was intended to cause death, no remorse, continued wish to die, hopelessness or helplessness	Primary wish to change, pleased to recover, suicidal ideation resolved by act, optimism
Precipitant	Similar circumstances can recur, acute precipitant not resolved	Stressful but transient life event, acute precipitant addressed

Salter A, Pielage P. Emergency departments have a role in the prevention of suicide. Emergency Medicine 2000; 12: 198–203 with permission.

Use of scales

Many screening tools have been devised to identify high-risk groups within those presenting with DSH. PATHOS [51], the Suicidal Intent Scale [52], the Sad Persons Scale [53] and other scoring systems have been devised to complement medical assessment of suicide risk. However, many of these scales use outdated risk factors and patient populations unrepresentative of EDs. Scales need to be sensitive, but this misclassifies a large number of individuals as potentially at risk of suicide. These deficiencies need to be considered when applying suicide risk scales in the ED and these scales should not be used as an absolute assessment of suicide risk or of the need for psychiatric admission [54,55]. In addition to validated questionnaire assessment, there are a number of validated interview assessment tools, such as the Suicide Attempt Self-Injury Interview [56]. Problems clinicians report in using these tools is that of the time taken to administer them. In any event, these tools have been shown to be as accurate as a mental health clinician’s global assessment [9].

The problems associated with suicide-risk assessment are summarized in Table 20.3.3.

Table 20.3.3

Problems in assessing suicide risk

Suicide is rare, even in high-risk groups, so it cannot be predicted without a high rate of false-negative or false-positive errors

Suicidality presents in heterogeneous ways that may not be recognized

Suicidality is transient and affected by intoxication, stress and being in hospital

The patient may be reluctant, oppositional or manipulative

The patient may present in an atypical fashion, especially the elderly with physical complaints

Suicide risk factors identify high-risk subgroups but not individuals

The demographic factors associated with suicide have changed recently, thus changing the make-up of risk groups

Risk factors are based on studies of long-term follow up and, therefore, long-term risk

Subtle changes in mental status and behaviour may be missed if not assessed by the usual doctor

Unexplained improvement in psychological status may be the result of increased motivation to die

Patients may deny their true intentions due to embarrassment, fear of being stopped in carrying out their own wishes, fear of being institutionalized or fear of the confidentiality of the interview

Patients may say life is not worth living or that they feel they would be better off dead, but not necessarily have an increased risk of suicide, unless they have made suicidal plans or attempts, or if they have pervasive hopelessness

Correlation between medical danger and suicidal intent is low unless the patient can accurately assess the probable outcome of their attempts if treatment had not been received

Definitive treatment and disposition

Following necessary medical treatment and suicide-risk stratification, disposition may involve involuntary or voluntary admission to a psychiatric or medical ward, short-term observation or discharge with appropriate follow up. Restraint and involuntary admission may be necessary for the high-risk patient who wishes to self-discharge. Approximately 30% of DSH patients are admitted for psychiatric inpatient care, but the factors involved in the decision for psychiatric hospitalization following DSH involve a complex evaluation of risk, potential for treatment and social supports [57].

Patients who are intoxicated with alcohol can be both behaviourally disinhibited and emotionally labile and, as discussed, are at higher risk of intentional self-injury. Short-term observation allows intoxication to resolve so that more comprehensive and longitudinal psychiatric assessment can take place. A short-term stay in hospital can also help resolution of many acute areas of conflict and make psychiatric evaluation more accurate. ED short-stay wards or psychiatric assessment and planning units are appropriate for these admissions, especially if a multidisciplinary team is available to review the patient and institute management and follow up.

Important elements of management involve addressing the modifiable elements of the precipitating problem, treatment of psychiatric illness and environmental interventions, such as family counselling, encouraging a support network and developing coping and problem-solving skills [58]. Adaptive solutions to the current crisis should be reinforced utilizing short-term solutions. Factors that should be addressed while patients are in hospital include referral to services to help address the dynamic risk issues, such as problems with relationships, employment, finances, housing, legal problems, social isolation, bereavement, alcohol and drug abuse and dependence. In this regard, social workers or mental health nurses are invaluable [59]. For greatest effect, these should be available after hours and on weekends since the majority of DSH presentations are after hours [60]. For repeat attenders who are often socially isolated, hospitalization should not be a substitute for social services, substance-abuse treatment and legal assistance, although admission may be necessary while appropriate supports are put in place [61].

Dispositional decisions need to be taken, weighing up the relative and potential iatrogenic harm generated by hospitalization and the now common legal mandate for treatment in a least restrictive environment. Discharge will be with referral to community agencies with responsibility for supporting the person in the community and, according to risk assessment, may include community mental health teams, GPs, non-government support agencies, etc. The aim of disposition is to minimize risk factors while empowering the person to develop more positive and capable coping styles for future crises.

Pharmacotherapy has been shown to be useful in addressing the debilitating symptoms of a major depressive disorder and, along with psychotherapy, can help the person regain their previous level of functioning. Once risk and disposition have been addressed, the pharmacotherapeutic management and ongoing assessment can be by the local medical officer, who can refer as necessary to mental health specialists. Pharmacotherapy involves the treatment of the underlying psychiatric disorder. Antidepressants decrease the risk of attempting suicide, although the lethality of suicide attempts is increased if tricyclic antidepressants are taken in overdose. Selective serotonin reuptake inhibitors and other newer classes of antidepressants (including SNRIs, NasSa, NRI, etc.) may have a more selective effect in decreasing suicidal behaviour and are less toxic in overdose than tricyclic antidepressants – the latter are no longer prescribed as first-line antidepressant medications by psychiatrists. These factors make the newer class of drugs an attractive choice for depressed patients who are suicidal.

Prevention

Comprehensive strategies for prevention of suicide have been or are being developed in Finland, Norway, Sweden, Australia and New Zealand [62]. Suicide prevention focuses on psychiatric, social and medical aspects and usually involves public education, media restrictions on reporting of suicide, school-based programmes with teacher education, training of doctors in detection and treatment of depression and other psychiatric disorders, alcohol and drug abuse information, enhanced access to the mental health system and supportive counselling after episodes of DSH. Decreasing the availability of lethal methods may involve legislative changes, such as more stringent gun control, restricting access to well-known jumping sites or changes to availability or packaging of tablets [63]. Overall, studies into the effectiveness of suicide-prevention strategies have shown inconsistent reductions in suicide rates following interventions [64]. Approaches to reduce DSH repetition have also shown disappointing results [65]. Improved recognition and treatment of mental illness, improved social services and drug and alcohol-support services may be of greater benefit than specific suicide-prevention strategies.

Ethical considerations

In assessing and managing patients with deliberate self-harm and suicidality, the patient’s desire for autonomy and self-determinism (e.g. declining recommended or reasonable treatment options, follow up or support) must be considered in terms of their mental state, static and imminent dynamic risk factors, protective factors and available support (e.g. social, family, carer, accommodation, financial, etc.) These considerations must also be balanced with the patient’s capacity to provide informed consent and their human rights and dignity, against that of the paternalism of clinicians initiating immediate treatment or restricting immediate care to the emergency department or other inpatient setting (e.g. psychiatric inpatient unit).

Often, in circumstances of imminent risk to self, the patient’s requests or demands for confidentiality may not be absolute, in so far as it is often necessary to obtain collateral history from others (e.g. general practitioners, psychiatrists, family, carers, etc.) and communicate with others about the immediate assessment and management of risk. Other aspects of confidentiality include local governance around accessing electronic mental health databases or clinical records that record service contact data about patients.

The framework of care in which the above issues and dilemmas are considered is also informed by relevant local mental health, medical treatment and human rights legislation. Emergency department clinicians should familiarize themselves with the relevant local legislation and the processes of invigilation.

The disposition of emergency department patients who have presented with deliberate self-harm or a suicide attempt must also be considered through the prism of the health service’s key performance indices. For example, such key performance indices may cover response times for triage and target times for disposition from the department. Accordingly, the patient’s disposition must also be considered in terms of balancing non-maleficence with utilitarianism (the ‘greater goods’ of accessibility, responsiveness and quality of healthcare for a community) in the context of these indices.

Conclusion

Assessment of suicide risk is an important skill in emergency medicine, since many patients present to EDs with suicidal thinking or behaviour. Although the risk of suicide for an individual patient is difficult to predict, emergency physicians can provide a system for assessment and identification of risk groups. Acute interventions can attempt to prevent short-term completion of suicide or repetition of DSH, since emergency physicians are predominantly involved in the care of these patients, often using short-stay wards. It is during this period in the emergency department that linkage to ongoing support services can be effected. A team approach involving psychiatry and social work is necessary in most cases, with many problems resolved by a short-term hospital admission, brief crisis intervention and intensive short-term follow up.

Controversies

The legal position is clear in not assisting suicide, meaning we have a duty of care for people who are suicidal.

Dispositional decisions need to be taken, weighing up the relative and potential iatrogenic harm generated by hospitalization and the now common legal mandate for treatment in the least restrictive environment.

Consideration must be given to the issue of competency when taking into consideration patients’ preferences for disposition.

Clinical trials of ED assessment and brief intervention strategies, including short-stay admissions, need to occur since more patients are managed entirely in EDs.

Currently available guidelines and triage scales need to be validated and refined.

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20.4 Depression

Simon Byrne

Essentials

1 Clinical depression is common, affecting 2–5% of the population at any time.

2 Depressive symptoms can be accurately assessed through a systematic interview.

3 The diagnosis of depressive syndrome depends on the severity, pervasiveness and persistence of the symptoms.

4 Management decisions include inpatient admission and referral to appropriate community outpatient services.

Introduction

The need to determine the presence and severity of a depressive syndrome is a very frequent task in the emergency department (ED). Assessment of depression is necessary in relation to a variety of patient presentations. The classic ED situation is the overdose or other attempted suicide or self-harm, where the assessment of depression forms part of further evaluation after the patient has been medically stabilized.

It is also becoming more common for patients to present to the ED complaining of depression (often on the advice of family, friends or crisis help lines) without having harmed themselves. Patients with a variety of medical conditions, especially conditions which are chronic or disabling, also often develop a depressive syndrome that can form a major part of the reason behind an ED attendance. Some patients who present to EDs with personal crisis or self-harm may have been identified as suffering from a personality disorder but, nevertheless, need assessment for co-morbid depression. The evaluation of depressive symptoms is also an important aspect of the assessment of patients seen in the ED with alcohol and drug abuse problems.

In these assessments, it is very important to have a clear concept of the syndrome of ‘clinical depression’. This syndrome is called ‘depressive episode’ in The International Classification of Disease – 10th edition [1] (ICD-10) and ‘major depression’ in the Diagnostic and Statistical Manual of Mental Disorders – 4th edition (DSM-IV) [2]. The importance of diagnosing a depressive episode lies principally in determining the presence of a clinical syndrome which is in need of treatment, is likely to respond to treatment and is likely to persist without treatment. The clear delineation of a depressive episode is also an essential basis for differential diagnosis from other medical and psychiatric conditions and for distinguishing between the clinical syndrome of depression and the day-to-day fluctuations of mood and states of dejection, pessimism, frustration and disappointment which are the lot of all human beings.

The diagnosis of a depressive episode depends on the pervasive presence of enduring mood change, marked loss of interest in usual activities or marked loss of energy and drive, as well as a number of other associated symptoms. The list of symptoms contributing to the depressive episode syndrome in ICD-10 is shown in Table 20.4.1. The DSM-IV syndrome of major depression has the same list of symptoms, with the exception of ‘loss of confidence or self-esteem’. An adequate number of these symptoms must be present for at least 2 weeks before the diagnosis of depressive episode can be made. The pervasiveness of the symptoms is defined principally by the specifications that they must be present ‘most of the day’ and for ‘nearly every day.’

Table 20.4.1

Symptoms contributing to the diagnosis of a depressive episode in ICD-10 [1]

1. Depressed mood, most of the day, nearly every day, largely uninfluenced by circumstances

2. Markedly diminished interest or pleasure in all, or almost all, activities, most of the day, nearly all day

3. Loss of energy or fatigue, nearly every day

4. Loss of confidence or self-esteem

5. Unreasonable feelings of self-reproach, or excessive or inappropriate guilt, nearly every day

6. Recurrent thoughts of death or suicide or any suicidal behaviour

7. Diminished ability to think or concentrate or indecisiveness, nearly every day

8. Psychomotor agitation or retardation, nearly every day

9. Insomnia or hypersomnia, nearly every day

10. Change in appetite (decrease or increase with corresponding weight change)

ICD-10 further classifies depressive episodes into mild, moderate and severe, according to the total number of symptoms present (mild=4/10 symptoms, moderate=6/10 symptoms and severe=8/10 symptoms). However, it is important to note that, even in mild or moderate depression, the patient must have at least two of the first three symptoms; that is the patient must have two of depressed mood, loss of interest or loss of energy, most of the day, nearly every day, for at least 2 weeks. The diagnosis of severe depressive episode requires the presence of all three of the first three symptoms.

The diagnosis of a depressive episode does not in any way depend on the presence or absence of a precipitating life event or situation. The ICD-10 also has a category of brief depressive reaction (one of the ‘adjustment disorders’), which forms part of the differential diagnosis of a depressive episode. This syndrome is defined by the presence of a precipitating life event and depressive symptoms. However, if the depressive symptoms are of sufficient number, pervasiveness and duration as to qualify for the description of a depressive episode, then this diagnosis should be made regardless of the presence of a precipitant. The notion that ‘this patient’s depression is understandable given the circumstances’ should never detract from a proper evaluation of the severity and duration of the symptoms.

Epidemiology

Clinical depression, defined as ‘major depression’ or an ICD-10 ‘depressive episode’, is a very common condition. Extensive epidemiological community surveys in many populations around the world have established that the 6-month prevalence rate of major depression is in the range of 2–5% in any population [3]. The epidemiological research has also shown that only a minority of persons with current depressive syndromes are receiving active treatment [3].

The age onset of the first depressive episode is typically in the third decade, but can be at any age. The male to female ratio is 1:2. A person who has had one episode of clinical depression has an 80% chance of recurrence and patients with recurrent depression have an average of four episodes in their lifetime [4].

Incomplete recovery is common. Studies of hospitalized patients have shown that, while at least 50% of patients recover from an index episode within 6 months, 30% remain symptomatic for more than a year and 12% for more than 5 years [5].

There is some evidence for an increase in the prevalence of major depression and a younger age of onset, over the last 40 years [6].

Aetiology

The aetiology of depression is complex, involving both genetic and environmental factors. Important environmental factors include childhood experiences of adversity or neglect and stresses in adult life. The effect of genetic factors may be mediated in part through inherited predispositions to excessive worry and anxiety [3].

Precipitating life events, especially those involving loss, are known to play a part in triggering individual episodes of depression [7]. This effect is greatest for the first episode of depression. Second and subsequent episodes are more likely to occur without identifiable precipitating events [8], suggesting that the first episode has a neurobiological priming effect [9].

Neurobiological changes in depression are also complex. Based in part on the supposed mechanism of action of antidepressant medication, early work focused on evidence of depletion of amine neurotransmitters in the central nervous system [10]. More recent research has suggested depression may involve alterations in neural cell populations, especially in the hippocampus [11].

Prevention

Depression is a major public health problem. The World Health Organization has determined that, in 1990, depression was the fourth leading cause of disease burden in the world and that by 2020 it would be the second leading cause of disease burden [12]. Public health measures have included campaigns to raise awareness of depression both in the general public and in healthcare providers. ED staff can play a very significant role in case identification and in ensuring referral for effective treatment.

Clinical features

The syndrome described as a ‘depressive episode’ (or ‘major depression’) is defined principally by its symptoms and, to a lesser extent, signs. As the severity of the depressive episode is also dependent on specific characteristics of the individual symptoms and signs (as well as the total number of symptoms), it is also important to understand the varieties of their manifestations.

Symptoms

It is useful to start the history with an exploration of the problem that has brought the person to the ED. This problem may be an overdose or other attempted suicide or self-harm, a personal or relationship crisis, a period of alcohol or other drug abuse, an exacerbation of a chronic medical condition or chronic pain or some other complaint. It is also important during the clinical assessment to begin to form some picture of who the patient is, including whether he or she lives alone or with others, the nature and quality of his or her personal relationships and his or her daily occupation, interests and activities. These inquiries assist in building rapport through demonstrating an interest in the patient, but also elicit information that is necessary for understanding the patient’s symptoms in context.

At some point, the patient can be told that the interviewer would now like to explore the symptoms of depression in more detail. It may be helpful to group the symptoms of the depressive episode (see Table 20.4.1) into various domains of the patient’s experience. The first group (‘depressed mood’, ‘markedly diminished interest’ and ‘loss of energy’) refers to the pervasive mood state and the quality of the patient’s spirits or enthusiasm for life. The second group (‘loss of self-esteem’, ‘unreasonable self-reproach or guilt’ and ‘recurrent thoughts of death or suicide’) refers to the cognitive contents of the patient’s thoughts. The third group (‘diminished concentration’ and ‘psychomotor agitation or retardation’) refers to the degree of agitation or lethargy associated with the patient’s thought processes and physical activity. The final group (‘insomnia or hypersomnia’ and ‘change in appetite’) refers to physiological changes.

Both the pervasiveness and duration of these symptoms should be assessed. The syndrome is, by definition, one in which the symptoms have become persistent and inescapable, not the occasional or sporadic experience of these symptoms which nearly everybody endures sometimes. Duration is important because the syndrome must be present for at least 2 weeks before the diagnosis can be made, although often the patient may have been unwell much longer than this.

The timing of onset of a depressive episode can be difficult to establish because the onset is often very gradual and insidious (although it can be relatively rapid). The patient may have experienced previous episodes which become confused with the present one and patients often confuse long-term feelings of low self-esteem with the current episode. Hence, the question ‘How long have you been feeling like this?’ is often unproductive. It is more useful to ask the patient to describe the presence and pervasiveness of each of the symptoms ‘during the last 2 or 3 weeks or so’ and, in particular, to try to identify some recent time at which there has been a change in the clinical state or function of the patient.

The pervasiveness and duration criteria taken together imply a diminished ability to carry out normal activities and meet responsibilities. Although many depressed patients push themselves to keep going, careful enquiry reveals that this has become more arduous. Difficulty in attending to tasks may range from diminished effectiveness at work, child care or study to, eventually, neglect of self-care and nutrition. Thus, impairment in function is another indicator of the severity of the episode.

‘Depressed mood, most of the day, nearly every day’ is perhaps the most difficult of the symptoms to characterize. ‘Mood’ refers to a person’s underlying emotional state, the emotional baseline that permeates each day. It is useful to ask not only ‘Do you feel depressed?’ but also ‘What is that like for you?’ Some patients describe feeling much more unhappy than usual or sad all the time or unexpectedly tearful; others report feeling more irritable with others or more inclined to worry. The severity of the mood change may be shown in a loss of mood reactivity, which can be elicited by asking ‘Can you cheer yourself up, take your mind off your worries?’ and ‘Do you find that the things which normally make you happy don’t seem to cheer you up as much as usual?’

‘Markedly diminished interest or pleasure in all, or almost all, activities, most of the day, nearly every day’ is somewhat easier to assess, especially if the interviewer takes the time to build up a picture of the patient’s usual day. With careful inquiry, a nuanced picture can be built up of the extent of the patient’s withdrawal from his or her usual activities. Included within this criterion is a lack of pleasure or interest in sexual activity which, in more severe cases, can be experienced as a profound loss of sexual feelings.

‘Loss of energy or fatigue, nearly every day’ is an important symptom which is sometimes overlooked. The emphasis should be on the loss of energy, that is, whether the patient is aware of having much less energy or drive than usual. In severe cases, the patient may describe feeling the body is heavy or thoughts sluggish, at which point this symptom overlaps with ‘psychomotor retardation’. Loss of energy is an important symptom in differential diagnosis, which may point to such conditions as anaemia, hypothyroidism, diabetes or other undiagnosed medical conditions.

The cognitive symptoms of depression (‘loss of self-esteem’, ‘unreasonable self-reproach or guilt’ and ‘recurrent thoughts of death or suicide’) can to some extent be observed in listening to the patient’s spontaneous comments and, as such, form a part of the mental state examination. However, patients who are more introspective have some awareness of a change in thought processes and are able to describe the ways in which their thoughts have become more gloomy than usual. This insight is lost when depression becomes more severe and the patient tends to regard the self-reproach or thoughts of suicide as entirely justified.

In assessing ‘loss of confidence or self-esteem’, the emphasis should be on the loss or change in the person’s self-concept. It can be helpful to approach the issue with suggestive questions, such as ‘Tell me about a time when you felt better about yourself’, ‘Did you used to feel more confident at work?’ or ‘Was there a time when you felt more adequate as a parent?’

‘Unreasonable feelings of self-reproach or excessive or inappropriate guilt, nearly every day’ is probably one of the most consistently reliable symptoms pointing to a diagnosis of depressive episode. Sometimes, a very conscientious person may habitually find fault with him- or herself without being clinically depressed. However, a person who is not depressed will usually be able to consider other points of view, to debate the sense of culpability internally and to consider whether the sense of guilt may be ‘excessive’, ‘inappropriate’ or ‘unreasonable’. This capacity to rationalize about thought processes becomes progressively more impaired as the patient becomes more severely depressed, until the patient’s guilt appears unquestionable.

In psychotic forms of depression, the sense of guilt may take on bizarre dimensions in which the patient can feel responsible for all the evil in the world or for distant events. A not uncommon experience is for the patient to see a report on the television of a calamity, such as an earthquake, and to feel responsible for the event.

‘Recurrent thoughts of death or suicide’ can arise in a depressive episode in a variety of ways. Not uncommonly, the thoughts may simply come into the patient’s mind; the patient reports having thoughts of being dead, wanting to be dead or thoughts of suicide that are uncharacteristic, unbidden and unwanted, without any intention to act on these thoughts. Sometimes the suicidal thoughts are directly linked to excessive or delusional guilt, in which the patient feels his or her death to be necessary and inevitable; here the risk of suicidal action is very high.

In other cases, the suicidal thoughts are a logical consequence of a sense of hopelessness, a lack of faith in the future. This last type of suicidal ideation is less specific for the diagnosis of depressive episode, as it may also reflect an apparently realistic appraisal of life circumstances, an attitude of philosophical pessimism or poor coping skills in a person with impaired personality function. These distinctions are important because the suicidal ideation, which is a part of a depressive episode, may be expected to resolve with treatment of the depression, whereas the other forms may not.

‘Diminished ability to think or concentrate or indecisiveness, nearly every day’ is a relatively straightforward symptom to assess and is useful as an indicator of the severity of the depressive episode. It can be assessed by asking about ability to focus on work or a recreational activity, such as watching television or reading a book. Some patients report that their mind is easily distracted or restlessly inattentive. Many report the intrusion of negative ruminations (concerning lack of worth, sense of failure or guilt, thoughts of suicide or other worries) which go round and round in their minds. Progressive impairment in the capacity to concentrate will demonstrate increasing severity of depression; a severely depressed patient may not even be able to focus on one newspaper story and take in the contents.

‘Psychomotor agitation or retardation, nearly every day’ refers to abnormalities of movement, facial expression, speech and thought processes which are directly assessed in the mental state examination and are discussed more fully below. However, this can also to some extent be assessed through the history from the family. ‘Psychomotor agitation’ includes restless, fidgety behaviour, inability to sit still or attend to a task and anxious, repetitive speech or even perseveration. ‘Psychomotor retardation’ includes lack of spontaneous bodily movement, lack of facial expression, lack of verbal communication and slowness of response. Retardation is the more common and the patient or family may report progressive withdrawal and decrease in activity to the point where the patient sits for long hours apparently doing nothing. The presence of significant psychomotor agitation or retardation is usually indicative of a severe depressive episode.

Changes in sleep pattern (‘insomnia or hypersomnia, nearly every day’) are very common in depression, even in mild episodes. It is worth enquiring in detail about the specific changes in sleep pattern, as these relate to the severity of the depressive episode. Initial insomnia or delay in the onset of sleep is not specifically associated with depression, as it can be strongly associated with anxiety or primary insomnia. Middle insomnia (waking after 2 or 3 hours of sleep) and early morning waking are more specific to depression. The extent of difficulty the patient has in going back to sleep and the mood and thought content when awake during the night are also relevant.

Change in appetite may involve an increase or decrease with corresponding weight change. Severe loss of appetite with marked loss of weight, in the absence of medical illness or deliberate dieting, is associated with severe depression.

Signs

The most important signs are:

signs of psychomotor agitation or retardation

the affective state of the patient

the thought content

the degree of insight.

The patient with psychomotor agitation demonstrates, in milder forms, fidgety or repetitive behaviours, such as hand wringing or sighing. This can progress to an inability to sit still and, eventually, continuous pacing. The patient may say little while looking very apprehensive and preoccupied or may importune all the staff with repetitive, anxious questions, apparently seeking reassurance which is never achieved. In severe cases, speech becomes perseverative.

By contrast, the psychomotor-retarded patient maintains a relative immobility, lying in bed or sitting in a chair for long periods, with infrequent changes in posture. The face may be relatively expressionless, look sad or show an anxious dread. Both the facial expression and the body language show diminished reactivity during interview. There is little spontaneous speech and, if responses to questions can be elicited, the responses lack richness, depth or elaboration. Slowness of thought processes is shown especially by a marked increase (sometimes as long as several minutes) in the time taken to supply an answer to a question. In severe cases, the patient may be mute.

The affective state of the depressed patient during the interview is most often sad, but sometimes anxious or even hostile. As the depression becomes more severe, the patient tends to show a diminished range of affects and has an impaired affective reactivity (for example, the patient does not smile in response to social cues).

During the interview it is important to observe the themes evident in the patient’s spontaneous conversation. Themes of despair, failure, guilt and death are typical of a depressive episode. The degree of insight may be a marker of the severity of the depressive episode.

Variants

Melancholic (somatic) depression

Some severe depressive episodes can be distinguished which have severe mood symptoms, marked changes in physiological function and significant psychomotor agitation or retardation.

This form of the depressive syndrome is designated ‘major depression with melancholia’ in DSM-IV and ‘depressive episode with somatic syndrome’ in ICD-10. The ICD-10 criteria for the ‘somatic syndrome’ are shown in Table 20.4.2. At least four of the eight symptoms must be present to make the diagnosis. Most ‘depressive episodes with somatic syndrome’ are also likely to meet the criteria for ‘severe depressive episode’.

Table 20.4.2

ICD-10 criteria for the ‘somatic syndrome’ (melancholia) [1]

1. Marked loss of interest in activities that are normally pleasurable

2. Lack of emotional reactions to events or activities that normally produce an emotional response

3. Waking in the morning 2 hours or more before the usual time

4. Depression worse in the morning

5. Objective evidence of marked psychomotor retardation or agitation

6. Marked loss of appetite

7. Marked loss of libido

The clinical significance of making the diagnosis of melancholic depression is that this form of depression is likely to require intensive biological treatment.

Most of the symptoms contributing to the diagnosis of the ‘somatic syndrome’ are more severe and more specific forms of the symptoms of a ‘depressive episode.’ It is not just any sleep disturbance, but marked early morning waking which is important. Similarly, it is not just a change in appetite, but a significant (more than 5% of body weight) loss of weight which is important. The presence and severity of the psychomotor agitation or retardation is the most important sign, since these phenomena can be objectively and systematically observed and rated [13].

Psychotic depression

This is discussed in Chapter 20.5. The patient with a psychotic depression will usually meet the criteria for a severe depressive episode, often with the ‘somatic syndrome.’

Mild and moderate depressive episodes

In clinical practice, it is usually not difficult to recognize a ‘severe’ depressive episode.

Greater uncertainty may be associated with making the diagnosis of ‘mild’ or ‘moderate’ depressive episode, especially in patients who have a long-term history of poor self-esteem or are temperamentally inclined to worrying, moodiness or irritability. Some research evidence [14] suggests that these temperamental factors can affect the presentation of the depressive syndrome. Thus, a person who is a habitual worrier who develops a depressive episode is likely to worry more and perhaps to withdraw from social contact or abuse alcohol or anxiolytic drugs. A person who tends to be moody or irritable is likely to become more so in a depressive episode and may appear demanding, complaining and unreasonable.

Nevertheless, the essential and salient characteristic of even a mild or moderate depressive episode is that the patient has a persistent mood change for at least 2 weeks. The interviewer should focus on the symptoms of depressed mood, loss of interest and loss of energy because it is the enduring presence of these symptoms which makes the diagnosis clear. Of the additional symptoms contributing to the diagnosis of depressive episode, probably the most common are difficulty with sleep and diminished ability to think and concentrate.

A patient with persistent depressed mood and impaired concentration almost certainly has some functional impairment. A useful approach to this question is to ask the patient about normal daily activities and then assess the extent to which these activities are disrupted by the symptoms. Can the patient do household chores? Does this require unusual effort? Can the patient go to work? Is the patient functional at work? Are even simple leisure activities like watching television disrupted by the patient’s mood state? It is this evidence of change in function that permits the identification of a mild or moderate depressive episode, regardless of pre-existing temperamental vulnerabilities.

Depression in the elderly

The symptoms of depression in older people are generally very similar to those in younger age groups and should be assessed in a similar way [15]. Symptoms, such as loss of energy, insomnia or change in appetite, may also be influenced by co-morbid medical illness, but a persistent mood change or loss of interest should prompt consideration of a depressive episode. Older people may tend to minimize their feelings of depression and, in these cases, a collateral history of loss of interest in usual activities may be found. Not uncommonly older people are seen in the ED following an overdose that may appear medically trivial. These patients should always be carefully assessed for the presence of a depressive syndrome.

‘Pseudo-dementia’ is a term used to describe patients with a depressive syndrome who present with an apparent change in cognitive function. The patient with depressive pseudo-dementia is likely to have a relatively recent and relatively abrupt change in concentration and memory. In contrast to the patient with dementia, the patient with pseudo-dementia usually shows a great awareness of having memory difficulties and will tend to demonstrate the impairment to the interviewer with considerable anxiety. In addition, the patient with depressive pseudo-dementia manifests other symptoms of a depressive episode.

Differential diagnosis

The differential diagnosis of the depressive syndrome is important because there are several other clinical disorders involving depressed mood or other symptoms of depression which have a different prognosis and treatment.

Brief depressive reaction

A brief depressive reaction (also called ‘adjustment disorder with depressed mood’ in DSM-IV) can be diagnosed when a person experiences some depressive symptoms without meeting the full criteria for a depressive episode, following stressful life events. Typically, the person describes a depressed mood which is not persistent, that is there are good days and bad days and the depressed mood can be relieved by distraction or pleasant activities. Common stressful life events include relationship crises or other interpersonal conflicts.

This is often the diagnosis in patients who are seen in the ED following overdose, although care should be taken to inquire about symptoms of a depressive episode. Treatment involves brief psychotherapy aimed at helping the person achieve some resolution of the personal crisis. If the hospital has a crisis counselling service, the patient can be referred to that service for brief therapy. Alternatively, the patient can be referred to their GP or other community counselling service. Social work staff in the ED often have good knowledge of local crisis counselling services.

Grief

The symptoms of acute grief can be mood disturbance, guilt, impaired concentration, sleep and appetite disturbance, impaired function in daily activities and preoccupation with memories of the deceased [16]. There is a considerable overlap with the symptoms of a depressive episode. However, it is customary to respect the feelings of the bereaved and to recognize that it is usually beneficial for the person to be supported through the natural process of grief, preferably by family, friends or other familiar persons, such as the family GP.

However, if the symptoms become more severe or more prolonged (such as beyond 6 months), it is appropriate to consider the diagnosis of a depressive episode. Symptoms suggestive of the development of a depressive episode include persistent and progressive lowering of self-esteem, persistent thoughts of death and suicide, markedly impaired concentration and psychomotor retardation.

Bipolar depression

ICD-10 specifies that in a person who has a history of bipolar disorder, a diagnosis of ‘depressive episode’ should not be made even if the patient meets the criteria for a depressive episode. Instead, the diagnosis of ‘bipolar affective episode, current episode mild, moderate or severe depression’ should be made. The distinction is important because of the treatment and prognosis. In particular, antidepressant medication should be used very cautiously in the person with bipolar disorder because of the risk of provoking a switch to mania.

The symptoms of a bipolar depressive episode are in themselves not different from the symptoms of any other episode of depression. The distinction therefore rests on a previous history of treatment for bipolar disorder or a history of a manic episode that may not have been treated.

A manic episode, as defined in ICD-10 [1], involves an elevated or irritable mood sustained for at least a week and at least three (or at least four if the mood is only irritable) of the signs shown in Table 20.4.3. Mania is discussed in more detail in Chapter 20.5.

Table 20.4.3

Signs contributing to the diagnosis of a manic episode in ICD-10 [1]

1. Increased activity or physical restlessness

2. Increased talkativeness (‘pressure of speech’)

3. Flight of ideas or subjective experience of thoughts racing

4. Loss of normal inhibitions, resulting in behaviour that is inappropriate to the circumstances

5. Decreased need for sleep

6. Inflated self-esteem or grandiosity

7. Distractibility or constantly changing activity or plans

8. Behaviour that is foolhardy or reckless

9. Marked sexual energy or sexual indiscretions

The depressed patient seen in ED who is suspected of having a bipolar disorder should usually be referred to a psychiatrist for assessment and treatment. Bipolar disorder is a life-long condition, with a high rate of recurrent episodes, which requires specialized pharmacological and psychological management.

Organic mood disorder

Many medical conditions (Table 20.4.4) are especially associated with a typical depressive syndrome. Because the medical condition is considered likely to have a pathophysiological significance in the development of the depressive syndrome, these conditions are termed ‘organic mood disorders.’

Table 20.4.4

Medical conditions associated with depressive syndrome

Hypothyroidism

Hypercalcaemia

Pernicious anaemia

Pancreatic cancer

Lung cancer

Stroke

Alzheimer’s dementia

Vascular dementia

Parkinson’s disease

Huntington’s disease

AIDS

Central nervous system tumour

Multiple sclerosis

Neurosyphilis

Brucellosis

Occasionally, the depressive syndrome may be the first presentation of a previously undiagnosed medical illness. Clinical or laboratory evidence of hypothyroidism was found in 5% of patients with a depressive syndrome in one series [17]. Hypercalcaemia due to unsuspected hyperparathyroidism very occasionally presents with depressed mood, lethargy or cognitive change as the presenting symptoms [18]. The first presentation of pancreatic cancer with a depressive syndrome is well recognized [19]. A depressive syndrome may be the first presentation of Huntington’s disease, before the onset of the movement disorder and the diagnosis will only be suggested by the family history [20]. Some patients with HIV infection have been found to present with a mood disorder before manifesting other symptoms of AIDS [21]. Because many medical conditions associated with depressive symptoms involve central nervous system disease, any neurological signs should prompt investigation for, for example, unsuspected cerebral tumour.

However, more commonly the depressive syndrome presents in a patient with an already recognized medical illness. In these cases, it is important to evaluate carefully the severity and persistence of the depressive symptoms and not dismiss them as an understandable reaction to the illness. Symptoms, such as loss of energy, sleep disturbance and anorexia, may be difficult to evaluate as they may be related to other pathophysiological change, but the patient with persistent depressed mood, loss of pleasure in activities, marked loss of self-esteem and feelings of guilt or hopelessness is likely to be experiencing a depressive episode. If such a depressive episode is diagnosed and treated, the patient will experience relief of suffering and a greater ability to deal effectively with other medical problems.

Many drugs have been associated with depressive symptoms, often based on only a few case reports [22]. Medications with a particularly strong association with depression include interferon, isotretinoin, methyldopa, benzodiazepines, digitalis, β-blockers, oral contraceptives and corticosteroids. A useful approach is to consider drugs which have recently been introduced in relation to the time course of the depressive symptoms.

Mood disorder due to psychoactive substance use

Chronic alcohol misuse is frequently associated with depressed mood, low self-esteem and feelings of guilt and hopelessness. Severe sleep disturbance can also be precipitated by rebound wakefulness as blood alcohol levels fall during the night. The person who regularly abuses alcohol is also likely to experience fatigue, impaired concentration, appetite disturbance and loss of sex drive. These symptoms may mimic those due to a depressive episode, such that it is not possible to make a differential diagnosis of a depressive episode while the patient continues to drink, nor is it likely that the depressive symptoms will remit without abstinence. Patients with alcohol-induced mood disorders should be encouraged to attend alcohol detoxification and rehabilitation programmes. There is some evidence that antidepressant medication may help to reduce both depressive symptoms and alcohol consumption [23].

Amphetamine withdrawal is often associated with a markedly depressed mood which usually improves within a few days if the patient remains abstinent.

The abuse of alcohol and other drugs is sometimes an attempt to self-medicate for a pre-existing depressive syndrome. This history should be especially sought in the patient whose abuse of alcohol or other drugs is of recent onset or follows important life change, such as bereavement or divorce. Even if a pre-existing depressive syndrome is identified, however, the patient should be informed that abstinence is necessary for recovery.

Depressive stupor, catatonia and hysterical stupor

Sometimes a patient with profound psychomotor retardation presents with ‘depressive stupor’, that is the patient is mute but alert and lacking spontaneous bodily movement. This presentation can give rise to a diagnostic uncertainty in the ED. Neurological conditions, such as pontine haemorrhage causing a ‘locked-in syndrome’, may have to be considered. Collateral history, if available, generally reveals that the patient with depressive stupor has a preceding history of the gradual onset of a depressive syndrome. Occasionally, the condition of depressive stupor may be confused with the catatonic form of schizophrenia. However, in catatonia the patient is likely to display ‘waxy flexibility’ (maintenance of an uncomfortable posture, such as an arm held up for a prolonged period against gravity), echopraxia (imitation of movements) and bizarre posturing and grimacing. These specific motor abnormalities are not usually associated with depressive stupor. Furthermore, the catatonic form of schizophrenia is now quite rare, especially as a first presentation. A final differential diagnosis of depressive stupor is hysterical stupor: in this condition, the collateral history shows that the patient was well preceding the abrupt onset of apparent paralysis and mutism. There will usually be a history of a markedly stressful event.

Dysthymia

Dysthymia refers to a chronic form of depression in which the patient experiences symptoms, such as lack of enjoyment in life and a gloomy or pessimistic outlook, without meeting the full criteria for a depressive episode. The depressed outlook tends to become interwoven with the personality of the patient, who tends to be sombre, self-critical and lacking in confidence and motivation. Dysthymia often has onset in early adult life and can persist for many years. The disorder has been well characterized [24] and found to be relatively common (about 3% of the general population) in epidemiological studies [25].

Sometimes, patients with a dysthymic disorder develop further symptoms indicating a superimposed depressive episode, which can be termed a ‘double depression’.

Patients with dysthymia may present to EDs as a consequence of suicidal ideation or behaviour. The condition should be regarded as serious because of its chronicity. The patient should be referred to a psychiatrist or mental health service as the treatment can be difficult [26].

Anxiety

Anxiety disorders include panic disorder (recurrent panic attacks), generalized anxiety disorder (persistent worrying associated with muscular tension and autonomic symptoms), obsessive–compulsive disorder and phobic disorders, such as agoraphobia or social phobia. Any of the symptoms of each of these anxiety disorders may occur as part of the symptoms of a depressive episode if a person with a pre-morbid anxious temperament becomes depressed. However, primary anxiety disorders are also common. In these cases, the patient gives a history of typical anxiety symptoms usually extending over many months or even years. Many patients with primary anxiety disorder go on also to develop a depressive syndrome.

Because of both the overlap in symptoms and the frequent co-morbidity, it may be difficult to distinguish primary anxiety disorders from primary depressive disorders in the emergency setting. Probably the most important symptoms are persistent depressed mood and suicidal ideation, which may require inpatient treatment. Patients who do not have persistent depressed mood and suicidal ideation, but who have a mixture of other depressive symptoms and anxiety symptoms, can be safely directed to their GP or to an outpatient mental health service for further evaluation.

Personality disorder

The concept of personality disorder refers to enduring patterns of behaviour, including especially interpersonal behaviours, which are well outside the usually sanctioned range of behaviours in a particular culture and which are associated with substantial subjective distress or conflict with others. The diagnosis of personality disorder should only be made if the behaviour patterns are persistent, relatively inflexible and have been present since a young age, often beginning in childhood or adolescence.

Although a variety of specific personality disorders have been described, the two most common forms in the ED are antisocial personality disorder and borderline personality disorder.

Persons with antisocial personality have a long-term history of disregard for social rules, usually resulting in a chequered employment history, broken relationships and often violent or criminal behaviour. As a result of personal crisis precipitated by these behaviours, persons with antisocial personality not infrequently present to ED with acute brief depressive reactions, helplessness and suicidal ideation or behaviour. Assessment should be especially directed at clarifying if a superimposed persistent depressive episode is present and the severity of this episode.

Inpatient psychiatric treatment is problematic because the patient often has difficulty adhering to ward rules and expectations. If the depressive symptoms are not severe and seem to be reactive to recent stressors, it is preferable to try to engage the patient in a realistic discussion of the current problems and, if possible, make a referral to crisis counselling. In some cases, however, when the depressive symptoms are more severe and the risk of suicidal behaviour is high, it may be necessary to arrange inpatient admission.

The person with borderline personality disorder displays persistent severely immature interpersonal behaviour, as well as considerable impulsivity and recklessness. The interpersonal behaviours include a strong tendency to see others in ‘all good’ or ‘all bad’ terms and to blame others for the patient’s own feelings and behaviours. Reckless and impulsive behaviours include abrupt breaches in relationships, alcohol and other drug abuse and self-damaging acts, such as cutting. Persons with borderline personality often describe chronic feelings of emptiness and loneliness, often associated with suicidal ideation. These features are sometimes misdiagnosed as depression when they may actually represent the patient’s usual way of feeling rather than a discrete depressive episode. Because borderline personality disorder is a long-term condition, intervention with the patient who presents in the ED in crisis should, if possible, be directed towards facilitating or enhancing the patient’s engagement with outpatient treatment services.

As many as 50% of patients with borderline personality may also meet the criteria for a depressive episode at any one time [27]. Although a diagnosis of borderline personality may have been made on the basis of the longitudinal history, it is therefore also important to try to assess the severity, persistence and duration of current depressive symptoms. If the patient is already engaged with an outpatient mental health clinician, it is useful to liaise with the therapist regarding recent symptoms and function.

Assessment

The assessment of the patient for depression should cover:

the current social circumstances of the patient

recent stressors or precipitating events

thorough evaluation of the symptoms of the syndrome of clinical depression and their severity

consideration of previous depressive or manic episodes

mental state examination

risk assessment

consideration of possible medical illness as cause of symptoms

detailed evaluation of alcohol and other drug use

identification of treatment services already available to patient.

It is generally a good idea to start the interview with some basic social information. Does the patient live alone? How is he or she occupied or employed? Is there a supportive relationship or other family? This information assists in understanding the context of the symptoms and helps with treatment planning.

Exploration of precipitating events is important partly because these worries are likely to be occupying the mind of the patient and discussion of these issues helps to build rapport in the interview.

Identification of the presence and severity of the depressive symptoms is the most important part of the assessment. Unfortunately, it is often not done systematically and the ‘diagnosis’ of depression is made only on the basis of a patient’s statement about ‘being depressed’ and one or two other symptoms, such as sleep and appetite disturbance. Systematic evaluation requires detailed exploration of the symptoms described above. Particular attention should be paid to the persistence, pervasiveness and duration of the symptoms. If this systematic approach is taken it is possible to determine:

if the syndrome of clinical depression is present or not

the severity of the syndrome.

The proper diagnosis of a depressive syndrome and the assessment of the severity of the syndrome are of major importance in treatment planning.

There may be insufficient time in an emergency interview to explore fully the previous psychiatric history. However, it is useful to ask if the patient has been depressed before, whether or not any previous episodes were treated and what was the response to previous treatment. It is also important to identify any previous episodes of mania in case the depressive episode may be a presentation of bipolar disorder.

Mental state examination focuses on the signs described above. Persistently sad affect and noticeable psychomotor agitation or retardation are indicators of more severe depression. Similarly, if the patient’s conversation is very preoccupied with themes of failure, despair, guilt or death, the depression is likely to be more severe. Inquiry about these matters should be extended to look for delusional beliefs. Useful questions may include ‘Do you feel responsible for bad things happening?’, ‘Do you feel there is something drastically wrong with you?’ or ‘Do you believe you deserve punishment?’ Understanding the patient’s level of insight into his or her condition is also important to treatment planning, particularly if involuntary treatment should become necessary due to the risk of suicide.

Risk assessment is multifaceted. If the patient has attempted suicide through overdose or other means, inquiry should be made about the circumstances of this attempt, the patient’s understanding of the lethality of the attempt and whether or not the patient sought help afterwards or made an effort to conceal the attempt. The patient’s current thoughts about suicide and his or her attitude to suicide are also relevant. Many patients admit to having thoughts of suicide but indicate that they would be deterred from suicidal action by, for example, having responsibility for dependent children. The disappearance of these ‘protective factors’ from a patient’s considerations is an indicator of worsening risk. Patients with psychotic depression may be at higher risk because they lack such ‘emotional’ constraints on suicidal behaviour. Other factors associated with increased suicide risk include lack of supportive relationships, living alone, being unemployed and current alcohol abuse.

A primary medical condition causing depressive symptoms is likely to be suggested by other symptoms and signs or be pre-existing. There are no mandatory investigations for the assessment of a depressive episode, although checking thyroid biochemistry is sensible.

Inquiry should be made about alcohol and other drug-use patterns and, especially, recent changes in pattern use. A person with long-standing alcohol or other drug abuse is likely to have a substance-induced mood disorder and needs to address this as the major focus of treatment. A recent marked increase in alcohol or other drug use may indicate an attempt to self-medicate for a depressive syndrome.

It is always useful to ask the patient if she or he is currently seeing a psychiatrist, psychologist or other mental health therapist or has a good relationship with a trusted GP. These existing healthcare professionals can often be the natural starting point in planning treatment interventions.

Treatment

Treatment for a depressive episode involves the prescription of specific antidepressant medication or a specific course of psychotherapy or both.

Medications

Commonly used first-line antidepressant medications are shown in Table 20.4.5. Because no one of these medications has been shown consistently to have superior efficacy, choice of medication is based on the acceptability of the side-effect profile and previous treatment response.

Table 20.4.5

Commonly used antidepressant medications

SSRI: selective serotonin re-uptake inhibitor; SNRI: serotonin and noradrenaline re-uptake inhibitor; RIMA: reversible monoamine oxidase inhibitor.

The selective serotonin re-uptake inhibitors (SSRIs) are usually well tolerated and are a good first choice. Some patients experience agitation, nausea or gastrointestinal hypermotility when they start SSRI medications. These symptoms usually settle in a week or two. The most troublesome long-term side effect of SSRIs is sexual dysfunction (especially delayed ejaculation or anorgasmia). These side effects sometimes require a change of medication. The side effects of venlafaxine are similar to SSRIs, with the addition of excessive sweating and itch at high doses.

Mirtazapine has useful sedating properties and can be very helpful in a patient with marked insomnia or agitation. Because it stimulates appetite, its use is limited in patients with a weight problem. Mirtazapine, reboxitine and moclobemide are useful alternatives for patients who experience sexual dysfunction with SSRIs or venlafaxine.

Tricyclic antidepressants (e.g. imipramine, amitriptyline and dothiepin) and irreversible monoamine oxidase inhibitors (MAOIs; phenelzine and tranylcypromine) continue to be prescribed for some patients, but they tend not to be first-line drugs. The use of tricyclics has decreased because of side effects (especially anticholinergic) and because of their cardiac toxicity in overdose. Irreversible MAOIs are generally inconvenient to take because of the need for dietary restrictions.

Psychotherapy

The psychotherapies commonly used for depression include supportive psychotherapy, cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT). Most psychiatrists and clinical psychologists have appropriate training and skills to offer one or more of these therapies. Many GPs and other health professionals, such as social workers, nurses and occupational therapists, have also often received training in these therapies.

Supportive psychotherapy is the least well defined of the psychotherapeutic treatments. The core of the treatment is a supportive relationship, education about the nature of depression and practical advice. CBT is a structured psychotherapy, usually involving 10–20 sessions. The behavioural techniques include reversing social isolation, scheduling relaxing or pleasurable activities and working with family members to provide incentives for helpful behaviours. The main part of the therapy involves ‘cognitive restructuring’, a systematic exploration of the patient’s unhelpful thought patterns, followed by collaborative work to help the patient substitute more positive responses [28].

IPT is also a structured psychotherapy, typically of about 16 sessions. The therapy focuses on helping the patient to make changes in his or her interpersonal relationships which may be contributing to the depressive syndrome [29].

Evidence

All currently available antidepressants have been shown to achieve better symptom reduction than placebo, with no one antidepressant consistently demonstrating superior efficacy [30]. In drug trials, up to 40% of patients in the placebo arm show improvement, which may include the non-specific effects of supportive interventions, as well as spontaneous remissions [31]. As the natural history of depression in a community sample (which includes relatively minor, untreated cases) shows a median episode duration of 12 weeks, spontaneous remission appears to be not uncommon [32]. Patients with psychotic depression respond better to the combination of an antidepressant and an antipsychotic medication than to an antidepressant medication alone [33].

Both CBT and IPT have been shown to be effective in achieving symptom reduction compared to pill placebo control [34,35]. CBT and IPT have been shown to be as effective as medication for mild-to-moderate depression [35]. For a severe depressive episode, psychotherapy alone is not as effective as medication alone or a medication–psychotherapy combination [36].

There are no systematic data regarding supportive psychotherapy (as it is not a standardized treatment) but substantial clinical experience attests to its efficacy.

Mild-to-moderate depressive episodes

As long as the suicide risk is containable, the great majority of these patients can be treated as outpatients. The most important part of treatment planning in the ED is therefore to identify an appropriate referral pathway. If the patient is already in contact with a mental health professional or has a trusted GP, it is preferable to refer the patient back to these persons and, if possible, make phone contact with that doctor or therapist with advice regarding the emergency presentation. If the patient does not have their own doctor or mental health professional, it is appropriate to refer the patient to an outpatient mental health service.

Patients with mild-to-moderate depressive episodes can improve with either medication or psychotherapy and can be advised to discuss these treatment options with the follow-up doctor. It is not essential to start the antidepressant medication in the ED; it is probably more appropriate to leave this to the follow-up doctor who can monitor for efficacy and side effects.

Some patients may only have mild-to-moderate symptoms but, nevertheless, be at significant suicidal risk, associated with recent suicidal behaviour and persistent suicidal ideation. The risk is increased if the patient lives alone. Such patients require admission to a psychiatry ward, where the options for medication and psychotherapy can be further explored.

Severe depressive episodes

Most patients with severe depressive episodes will be admitted because of significant suicide risk or substantial functional impairment. The evidence suggests that these patients require treatment with antidepressant medication and are often initially too symptomatic to engage in psychotherapy. Classical indications for electroconvulsive therapy are psychotic depression and severe retarded depression (especially if the patient has inadequate oral intake).

Controversies and future directions

Population-based studies indicate that clinical depression is very common, possibly increasing in prevalence and significantly undertreated.

A major challenge for all health services is to improve the rate of case identification.

Equally important will be the further development of effective referral pathways to appropriate treatment.

References

1. World Health Organization. The ICD-10 classification of mental and behavioural disorders Geneva: WHO; 1993.

2. American Psychiatric Association.. Diagnostic and statistical manual of mental disorders 4th ed. Washington DC: American Psychiatric Association; 1994.

3. Joyce P. Epidemiology of mood disorders. In: Gelder M, Lopez-lbor J, Andreasen N, eds. New Oxford textbook of psychiatry Oxford. Oxford University Press 2000; 695–701.

4. Judd J. The clinical course of unipolar major depressive disorders. Arch Gen Psychiatr. 1997;54:989–991.

5. Katz M, Secunda S, Hirschfeld R, et al. NIMH clinical research branch collaborative program on the psychobiology of depression. Arch Gen Psychiatr. 1979;36:765–771.

6. Cross National Collaborative Group. The changing rate of major depression Cross national comparisons. J Am Med Assoc. 1992;268:3098–3105.

7. Tennant C. Life events, stress and depression: a review of recent findings. Aust NZ J Psychiatr. 2002;36:173–182.

8. Frank E, Anderson B, Reynolds C. Life events and research diagnostic criteria endogenous subtype. Arch Gen Psychiatr. 1994;51:519–524.

9. Kendler K, Thornton L, Gardner C. Stressful life events and previous episodes in the etiology of major depression in women: an evaluation of the ‘kindling’ hypothesis. Am J Psychiatr. 2000;157:1243–1251.

10. Schildkraut J. The catecholamine hypothesis of affective disorders: a review of supporting evidence. Am J Psychiatr. 1965;122:509–522.

11. Jacobs B, Praag H, Gage F. Adult brain neurogenesis and psychiatry: a novel theory of depression. Mol Psychiatr. 2000;5:262–269.

12. Murray C, Lopez A. The global burden of disease and global health statistics Boston: Harvard University Press; 1996.

13. Parker G, Hadzi-Pavlovic D. Melancholia: a disorder of movement and mood Cambridge: Cambridge University Press; 1996.

14. Parker G, Hadzi-Pavlovic D, Roussos J, et al. Non-melancholic depression: the contribution of personality, anxiety and life-events to subclassification. Psychol Med. 1998;28:1209–1219.

15. Musetti L, Perugi G, Soriani A, et al. Depression before and after age 65: a re-examination. Br J Psychiatr. 1989;155:330–336.

16. Lindemann E. The symptomatology and management of acute grief. Am J Psychiatr. 1944;101:141.

17. Gold M, Pottash A, Extein I. Hypothyroidism and depression. J Am Med Assoc. 1981;245:1919–1922.

18. Watson L. Clinical aspects of hyperparathyroidism. Proc Roy Soc Med. 1968;61:1123.

19. Joffe R, Rubinow D, Denicoff K, et al. Depression and carcinoma of the pancreas. Gen Hosp Psychiatr. 1986;8:241–245.

20. Folstein S, Abbott M, Chase G, et al. The association of affective disorder with Huntington’s disease in a case series and in families. Psychol Med. 1983;13:537–542.

21. Atkinson J, Grant I, Kennedy C, et al. Prevalence of psychiatric disorders among men infected with human immunodeficiency virus. Arch Gen Psychiatr. 1988;45:859–864.

22. Hales R, Yudofsky S. The American psychiatric publishing textbook of clinical psychiatry 4th ed. Washington: American Psychiatric Publishing; 2003; 462–3.

23. Cornelius J, Salloun I, Ehler J, et al. Fluoxetine reduced depressive symptoms and alcohol consumption in patients with co-morbid major depression and alcohol dependence. Arch Gen Psychiatr. 1997;54:700–705.

24. Akiskal H, Cassano G, eds. Dysthymia and the spectrum of chronic depressions. New York: Guildford Press; 1997.

25. Waintraub L, Guelfi J. Nosological validity of dysthymia Part 1, historical, epidemiological and clinical data. Eur Psychiatr. 1998;13:173–180.

26. Haykal R, Akiskal H. The long-term outcome of dysthymia in private practice Clinical features, temperament and the art of management. J Clin Psychiatr. 1999;60:508–518.

27. Gunderson J. Borderline personality disorder: a clinical guide Washington: American Psychiatric Publishing; 2001.

28. Seligman M. Learned optimism New York: Random House; 1991.

29. Weissman M, Markowitz J, Klerman G. Comprehensive guide to interpersonal psychotherapy New York: Basic Books; 2000.

30. Nemeroff C, Schatzberg A. Pharmacological treatment of unipolar depression. In: Nathan P, Gorman J, eds. A guide to treatments that work New York. Oxford University Press 1998;212–215.

31. Paykel E, Scott J. Treatment of mood disorders. In: Gelder M, Lopez-lbor J, Andreasen N, eds. New Oxford textbook of psychiatry Oxford. Oxford University Press 2000;724–726.

32. Eaton W, Anthony J, Gallo G, et al. Natural history of diagnostic interview schedule/DSM-IV major depression: the Baltimore epidemiologic catchment area follow-up. Arch Gen Psychiatr. 1997;54:993–999.

33. Schatzberg A, Rothschild A. Psychotic (delusional) major depression: should it be included as a distinct syndrome in DSM-IV? Am J Psychiatr. 1992;149:733–745.

34. Dobson K. A meta-analysis of the efficacy of cognitive therapy for depression. J Consult Clin Psychol. 1988;57:414–419.

35. Elkin I, Shea M, Watkins J, et al. National Institute of Mental Health treatment of depression collaborative treatment programme. Arch Gen Psychiatr. 1992;46:971–982.

36. Thase M, Greenhouse J, Frank E, et al. Treatment of major depression with psychotherapy or psychotherapy pharmacotherapy combinations. Arch Gen Psychiatr. 1997;54:1009–1015.

20.5 Psychosis

Simon Byrne

Essentials

1 In the age of community mental health treatment, emergency departments have become major sites for the assessment of patients with psychosis.

2 It is important to distinguish psychiatric causes of psychosis from psychosis due to medical conditions or to drug abuse.

3 Attention must be given to the proper management of the patient with psychosis in the emergency department environment.

4 Disposition decisions, including community referral or hospitalization, depend on the collection of information about treatment history, community supports and risk assessment, as well as assessment of the mental state of the patient.

Introduction

Psychotic illness is a frequent cause of presentation to the emergency department (ED), accounting for 0.5–1.0% of all visits and 10–20% of all mental health presentations [1,2]. Because these patients are usually severely mentally unwell, they also account for a significant share of the workload of EDs.

The tasks of the ED staff in relation to patients with psychotic illness are complex and varied. Initially, there is usually a need for containment and stabilization of an aroused and frightened patient with impaired reality testing. The patient is often in the hospital unwillingly and frequently following a major crisis in the community or at home. There is often a need to manage behavioural disturbance, potentially involving risk of harm to the patient, staff or others, while the patient remains in the ED for often lengthy periods of assessment and for the implementation of disposition plans. It is also important to exclude medical causes for the psychotic symptoms and to consider the presence of co-morbid medical conditions. In determining disposition, consideration must be given to the need for voluntary or involuntary admission or, alternatively, referral to an array of community-based treatment services. Finally, it is often useful to involve families and other carers in both the assessment phase and in treatment planning. These tasks are summarized in Table 20.5.1.

Table 20.5.1

Tasks of the ED in relation to the patient with psychosis

ED, emergency department.

Classification

Traditionally, psychotic illnesses were classified into ‘functional’ (i.e. non-organic) psychoses and ‘organic’ psychoses. Developments in psychiatric nosology have expanded this classification and the ICD-10 Classification of Mental and Behavioural Disorders [3] now contains at least 16 different diagnoses, many with several subtypes, which could be used to describe patients with psychotic symptoms.

In emergency practice, however, the differentiation of the specific psychiatric syndrome is not always possible. The pragmatic classification shown in Table 20.5.2 is based on:

excluding medical causes for the psychotic presentation

considering the role of alcohol and other drugs of abuse

making a provisional psychiatric diagnosis as a guide to initial management and

considering the possibility that the symptoms may be related primarily to psychological stress.

Table 20.5.2

Pragmatic classification of patients with psychotic symptoms

A description of each of these categories is given in the section on clinical features.

Epidemiology and prognosis

The two principal ‘non-organic’ conditions which involve psychotic presentations are schizophrenia and bipolar affective disorder.

The prevalence of schizophrenia is 0.2–0.5% of the population. It is not a rare disorder. The male:female ratio is 1:1. Onset can be at any age, but mostly before the age of 30 [4].

Schizophrenia is usually a chronic condition, but with a variable course. In the long term, about 20% of cases have a good recovery, 20% have recurrent episodes with good recovery between episodes, 40% have recurrent episodes with incomplete remission and 20% have a severe chronic course [5]. The 20-year suicide rate may be as high as 14–22% [5].

The prevalence of bipolar disorder (which by definition means that the patient has had at least one manic episode) is about 1.0% of the population. The male:female ratio is 1:1. The onset is often in late adolescence and 95% of cases have onset before the age of 26 [6].

A patient who has had one episode of mania has about an 80% chance of a recurrence within 5 years. Although there is usually a good recovery between episodes, there is a very high rate of recurrence, with an average of one episode of mania or depression every 2 years, although the frequency of episodes in the individual case varies greatly [7]. The 22-year suicide rate is 13% [7].

Aetiology and prevention

The aetiology of schizophrenia and bipolar disorder is not well understood, despite intensive research. Both disorders involve genetic and environmental factors. A person who has one parent with schizophrenia has about a 10% chance of developing the disorder; this is similar for bipolar disorder. There is insufficient knowledge about the aetiology of either disorder to suggest effective strategies for primary prevention.

There is considerable scope for secondary prevention, which is early diagnosis and prompt treatment, especially in relation to recurrent episodes. Strategies include education of patients and families, the identification of early warning signs of relapse and the use of maintenance and prophylactic medication [8]. ED staff can make a major contribution to this preventative work by emphasizing the importance of continuing treatment and facilitating engagement with generalist and specialist mental health services.

Clinical features

Psychotic symptoms due to a general medical condition

Delirium

Delirious patients often manifest psychotic symptoms. Visual illusions (misperception of real objects, such as mistaking an innocuous object for a malevolent figure or animal) and delusions of persecution (such as the patient believing he is being poisoned by the doctors and nurses) are particularly common. Other symptoms include auditory hallucinations, affective lability, apparent formal thought disorder and grandiose or religious delusions.

The pathognomonic features of delirium are disorientation (especially for time and place) and a fluctuating conscious state. Not uncommonly, the patient plucks at the air or the bedclothes in apparent response to visual illusions or hallucinations. The abnormalities of mental state can fluctuate widely over the course of a day from relative lucidity to marked disturbance.

The delirious patient usually has a history or symptoms of a medical disorder and manifests abnormalities of vital signs or other abnormalities on physical examination or laboratory investigation.

The differentiation of medical and psychiatric causes of altered mental state is discussed in detail in Chapter 20.2.

Dementia

Psychotic symptoms in dementia can include auditory and visual hallucinations, delusions (often persecutory) and delusional misidentification (e.g. the delusion that a person closely related to the patient has been replaced by a double). These psychotic symptoms are common in dementias of all types, including Alzheimer’s and vascular dementias. A mean prevalence of 44% has been found across several cross-sectional samples [9]. The diagnosis of dementia depends on the presence of multiple cognitive deficits and will usually be evident from other features of the history and presentation. A change in the mental state of a patient with dementia should prompt consideration of superimposed delirium.

Psychosis in clear consciousness without cognitive impairment

Occasionally, patients present with psychotic symptoms of organic cause, without features of delirium or dementia. The variety of medical conditions associated with psychotic presentations is shown in Table 20.5.3. Although these disorders are relatively rare as the cause of psychiatric presentation, they should be especially considered in relation to a patient with new-onset psychosis over the age of 40 (i.e. older than the usual age of onset of the much more common schizophrenia and bipolar disorder).

Table 20.5.3

Medical causes of psychotic presentations

Epilepsy

Hypo- or hyperthyroidism

Huntington’s disease

Wilson’s disease

Porphyria

B12 deficiency

Cerebral neoplasm

Stroke

Viral encephalitis

Neurosyphilis

AIDS

In emergency practice, the psychoses associated with epilepsy are probably those most likely to be associated with uncertainty in management. These psychoses are of two types. Some patients with established epilepsy develop chronic inter-ictal psychosis, that is, a psychosis without specific temporal relationship to seizure activity. The clinical picture is often like schizophrenia and the disorder should be treated in its own right with antipsychotic medication [10]. The second presentation is of a post-ictal psychosis, usually following a cluster of seizures and sometimes with a lucid interval of 1 or 2 days. The patient can present with both schizophrenia-like and mood symptoms. The mental state spontaneously returns to normal within a few days, as in the more common post-ictal delirium [11].

Psychoses caused by prescribed medications

A long list of medications, many based on sporadic case reports, can sometimes be associated with psychotic symptoms [12]. The two most common are corticosteroids and dopamine agonists.

Steroid psychosis usually presents a manic-like picture and can show florid psychosis. It is most often associated with doses greater than 40 mg equivalents of prednisolone per day [13].

Dopamine agonists used in the treatment of Parkinson’s disease like levodopa and bromocriptine are associated with auditory and visual hallucinations, persecutory delusions and hypomania. The psychotic symptoms are dose-related but dose reductions may be associated with severe exacerbation of Parkinsonian symptoms [14].

Acute and chronic schizophrenia

The symptoms of schizophrenia include the ‘positive’ symptoms of acute psychosis and the ‘negative’ symptoms, such as apathy and social withdrawal.

Positive symptoms involve delusions, hallucinations and formal thought disorder. The content of delusions may include beliefs that the patient is an important person (grandiose), that the patient has special communication with deities or spirits (religiose) or that there is something awry with the patient’s body or the world (hypochondriacal and nihilistic). The most common delusions are beliefs that other persons or the TV or radio are making special reference to the person (delusions of reference) and beliefs that certain persons or agencies are engaged in conspiracies to harm the patient (delusions of persecution).

Hallucinations are usually auditory but can be in any sensory modality. The specific types of auditory hallucinations first described by Schneider [15], although not specific to schizophrenia, are strongly supportive of the diagnosis. These include a voice making a running commentary on the patient’s actions, two or more voices discussing or arguing about the patient and a voice repeating the patient’s thoughts aloud.

Sometimes the most obvious positive symptom of psychosis is formal thought disorder. This usually takes the form of loosening of associations (lack of logical connection between statements) and tangential (off the point) replies to questions. The effect of these symptoms is to make it difficult or impossible to take a sequential history. In more severe cases, the language itself becomes incoherent as grammatical conventions are abandoned and invented words (‘neologisms’) are used. In the emergency setting, the less severe forms of formal thought disorder may also be shown by highly anxious, delirious or intoxicated patients.

The negative symptoms include blunting of affect (lack of emotional response), apathy (loss of volition), poverty of speech (severely diminished verbal communication) and autistic withdrawal from social interaction. These symptoms can be difficult to distinguish in the acute setting from the effects of co-morbid depression or from the bradykinesia caused by antipsychotic medications.

In emergency practice, the three most common types of presentation of schizophrenia are the first psychotic episode, acute psychotic relapse of an established illness and a social crisis in a patient with chronic schizophrenia. It is useful to distinguish these types of presentation because of the management implications.

The patient with a first episode of psychosis is typically a young adult who has been brought to the ED by family or police often following months of concern about deterioration in the patient’s mental state or behaviour. Sometimes there will have been an acute episode of bizarre, suicidal or aggressive behaviour. Exclusion of medical causes of psychosis is important in the first episode, especially in the older patient. It may be difficult to be certain whether the syndrome is one of mania (see below) or schizophrenia, but this distinction is not crucial in emergency assessment. More important is the fact that the patient is likely to be frightened and confused, as is also the family. The patient may require involuntary hospitalization.

The acute relapse of an established illness can also involve considerable distress to the patient and family. In these cases, it is useful to look for changes in medication, problems in compliance, changes in the treatment system, such as absence of the treating doctor, alcohol and other drug abuse and recent stressful events. It may be possible to avoid hospitalization.

Patients with chronic schizophrenia are now treated most frequently through community mental health services. They may present with an exacerbation of the psychosis for the reasons outlined above. However, the presentation is often related to social problems, such as conflict with family or difficulties with accommodation or finances. In these cases, it can be very useful to communicate with the community mental health services to clarify the patient’s baseline level of function and current problems. Some patients with chronic illness are effectively homeless and have poor engagement with community services, irregular medication use and ongoing drug abuse. Although it is difficult in a busy ED, these patients ideally need some work towards establishment of continuity of care and long-term treatment plans.

The term ‘schizo-affective disorder’ has been used to describe an illness in which patients show typical symptoms of schizophrenia as well as having definite manic or depressive episodes. In practice, in the ED, such patients can be assessed and managed in a similar way to patients with schizophrenia.

Mania with psychotic symptoms

The manic syndrome is one form of presentation of bipolar disorder, the others being a depressive episode and mixed affective psychosis.

The typical manic syndrome is very distinctive. The patient presents with euphoric or irritable affect, pressure of speech (rapid, continuous speech which is difficult to interrupt), distractibility and disinhibited or over-familiar behaviour. If delusions are present, they are grandiose (that the patient has an important mission) or persecutory (e.g. that other persons are engaged in a conspiracy to prevent the patient fulfilling his or her destiny). Collateral history will usually show that the patient has been well until the last few days when the patient has become overactive and disorganized with a markedly decreased need for sleep.

In mixed affective psychosis, the patient often shows typically manic arousal and irritability, but may have a depressive theme evident in the content of speech. Depressive psychosis is discussed below.

Sometimes a delirious patient with affective lability, irritability, disinhibition and distractibility may be misdiagnosed as manic. The diagnosis should be considered in the older patient without previous history of bipolar disorder. The distinction can be made on the basis of the impairment of cognitive function (disorientation, fluctuating conscious state and memory impairment) in delirium and clinical or laboratory evidence of medical illness.

It may be difficult to distinguish acute mania from acute schizophrenia in the emergency setting, especially in first episode cases. Being certain of the diagnosis is not crucial, as the short-term management is similar (see below).

Major depression with psychotic features

Patients who exhibit psychotic features during a depressive syndrome are severely depressed. The content of delusions and hallucinations relates to the patient’s feelings of worthlessness or guilt and may include the conviction that the patient should die. Because the patient is unable to evaluate these beliefs rationally, the risk of suicidal actions is high and these patients should be closely supervised.

The patient with a depressive psychosis will show the other typical features of a depressive syndrome. Most often, the mental state assessment will show a patient who lacks spontaneity and is withdrawn and sad. Occasionally, however, the patient may be agitated and irritable.

The differential diagnosis and management of depressive syndromes are discussed in Chapter 20.4.

Substance-induced psychosis

Drugs of abuse are associated with psychotic presentations in several ways: psychosis as a manifestation of acute intoxication, psychosis during withdrawal reactions, chronic psychosis following prolonged use and the exacerbation of pre-existing psychotic illness due to drug abuse. Drugs of abuse which may contribute to psychosis are listed in Table 20.5.4.

Table 20.5.4

Drugs of abuse associated with psychosis

Amphetamine and methamphetamine

Methylenedioxymethamphetamine (MMDA, ecstasy)

Cocaine

Phencyclidine

Ketamine

LSD

Cannabis

Alcohol

Benzodiazepines

The psychosis associated with intoxication may include auditory and visual hallucinations and persecutory or grandiose delusions. The patient is usually agitated, highly anxious and incoherent and often shows autonomic signs, such as dilated pupils. Some drugs, such as phencyclidine, are particularly associated with disinhibited rage. Management is focused on ensuring safety and maintaining vital functions in the expectation that the psychosis will clear when the intoxication resolves.

Alcohol and benzodiazepines can lead to psychotic symptoms (most commonly visual hallucinations) in the context of withdrawal delirium. The psychotic symptoms resolve through management of the withdrawal with benzodiazepines.

Amphetamine (and amphetamine derivatives), phencyclidine and lysergic acid diethylamide (LSD) have all been associated with chronic psychosis which can persist for weeks or months after cessation of drug use [16–18]. Whether or not the patients who develop these chronic psychoses may have been predisposed to psychotic illness is controversial but, nevertheless, the psychosis should not be regarded purely as an intoxication effect but treated in its own right. Amphetamine dugs are most frequently associated with this chronic psychosis, usually following prolonged heavy amphetamine abuse. The clinical picture can be quite distinctive, including beliefs that the patient is being watched or followed or that thoughts may be monitored with an implanted device. ‘Running commentary’ auditory hallucinations may occur as well as tactile hallucinations, which may lead the patient to excoriate the skin in pursuit of a supposed infestation with insects.

The role of cannabis as a cause of chronic schizophrenia-like psychosis is uncertain, although cannabis frequently exacerbates psychotic symptoms in patients with an existing illness [19].

Alcoholic hallucinosis is a relatively uncommon condition found in some patients with long-term alcohol abuse histories. The patient experiences auditory hallucinations of a derogatory or ‘running commentary’ type in clear consciousness, without being in a withdrawal state. This disorder may persist for weeks or months and the symptoms may respond to antipsychotic medications.

Because alcohol and drug abuse can exacerbate psychosis in patients with an established schizophrenic or bipolar disorder, inquiry should be made into their use with every patient.

Psychotic-like reactive states

Patients with histories of severe personality disorder, post-traumatic stress disorder and dissociative disorder sometimes present with quasi-psychotic states [20,21]. These episodes usually follow acute stress, such as a relationship or other social crisis, or events which trigger recall of traumatic experiences. The patient is usually extremely anxious and may have impaired verbal communication, further complicating assessment. Psychotic-like experiences can include intense subjective experiences of a derogatory internal monologue, which can seem like auditory hallucinations or intense fears of being harmed which mimic persecutory delusions. Some patients’ recall of traumatic experiences is so persistent and vivid that it seems as if it is actually happening again.

When such patients are seen in emergency settings, they often need containment and assessment in a similar manner to patients with true psychoses. Benzodiazepines and sedative antipsychotic medications (see below) are often useful in reducing the high level of arousal.

Assessment

Objectives and sources of information

The assessment of the psychotic patient in ED has several objectives. The basic questions are:

Is the altered mental state primarily due to a medical condition?

To what extent are drugs or alcohol contributory?

Can a primary psychiatric diagnosis be made?

Can the patient be treated at home or is hospitalization necessary?

Should the patient be detained under the mental health act?

These questions cannot be answered by considering only the clinical state of the patient. Decisions about risk assessment and disposition depend on a careful consideration of the social circumstances of the patient, recent events that have led to the emergency presentation and past and current engagement with community mental health treatment services. Diagnostic clarification is often greatly assisted by previous treatment records, which can usually be fairly quickly accessed.

Information should be sought from family and community mental health teams about recent function, symptoms, dangerous behaviours and alcohol and other drug use. The police who sometimes bring patients with psychosis to ED can often give important information about the circumstances that led to the presentation.

The assessment process is not a single one-off review of the patient’s mental state, nor is it a linear process in which the various objectives of assessment can be serially addressed. It tends rather to be a back and forth process as multiple lines of inquiry are simultaneously pursued and the clinical data re-evaluated in the light of new information.

At the end of the assessment process, it should be possible to record a summary of the various parameters of assessment as outlined in Table 20.5.5, which can then form the basis for management planning.

Table 20.5.5

The psychotic patient – brief assessment schedule

Initial stabilization of the patient

In order that conditions can be created for an adequate assessment, there is an immediate need to stabilize the patient. The acutely psychotic patient has distorted understanding and may be an unwilling participant in the process. It is preferable to try to engage the patient in a calm manner with straightforward and clear explanation of the need for assessment. The patient’s own concerns and perceptions of the problem are worth listening to without initially trying to seek answers to specific questions. This attention is reassuring to the patient and provides an opportunity for observation of the mental state, even if the patient’s account lacks coherence.

Patients who are aroused and agitated, intoxicated or have persecutory delusions may pose a risk of violent or aggressive behaviour. In these cases, it is important to monitor safety by having security staff present, by not assessing the patient in a confined space and by remaining out of striking distance and not turning one’s back on the patient. Sometimes the patient may have to be sedated before much assessment can be made. Sedating the aroused patient is discussed in Chapter 20.6.

Moderate use of benzodiazepines need not significantly complicate the mental state assessment, although these drugs may exacerbate delirium. High doses of benzodiazepines (especially diazepam which has active metabolites with long half-lives) can produce a prolonged delirium, which will delay the assessment process.

Mental state assessment

Especially in the aroused patient, it is often difficult to carry out a formal mental state examination. Nevertheless, it is possible to collect a lot of information by simple observation. The general appearance can give clues to the patient’s level of self-care. The rate and mode of speech can suggest the presence of formal thought disorder. Hostile or euphoric affects may suggest a manic syndrome or intoxication. Patients may spontaneously reveal delusional ideas or auditory hallucinations or may admit to these on specific questioning. Orientation to time and place and recent events should always be assessed because of the strong association of disorientation with delirium. Although detailed cognitive assessment is usually not possible, an attempt should be made to assess short-term memory function and attention and concentration.

As with all aspects of assessment, the assessment of mental state should not be based on a single evaluation but on serial assessments by medical staff and the observations of the nursing staff throughout the time the patient is in the ED.

Risk assessment

It is important to inquire directly about suicidal and homicidal ideation and to record the patient’s statements. However, risk assessment depends on an objective evaluation of the whole situation. A patient with persistent persecutory beliefs may be at significant risk of behaving aggressively towards perceived persecutors, even though he or she may deny hostile intent. Conversely, a patient’s expression of suicidal ideation may reflect long-standing frustration and dissatisfaction (which may be alleviated by receiving help) rather than intent to act in a suicidal manner. The degree to which the patient can exercise judgement is also important. A floridly psychotic or grossly disorganized patient is at greater risk than a patient with chronic symptoms who presents with a social crisis. The home situation and the views of family should also be considered and taken very seriously. Inquiry should be also made into the provision of care for dependent children.

Decisions about hospital admission and involuntary detention usually focus appropriately on danger to self and others. Uncertainty may sometimes arise regarding the use of mental health act detention powers in relation to manic (and some schizophrenic) patients who clearly deny any intent to harm themselves or others, but who are clearly in need of treatment, lack insight and are very unlikely to receive treatment unless compulsorily detained. Most jurisdictions, however, make some provision in their mental health legislation for such patients to be detained in the interests of their health or to prevent other ‘harms’, such as harm to reputation. The decision to detain involves balancing the patient’s right to autonomy against the probable risks of not receiving treatment. In general, such a patient has only been brought to ED because family, friends or other carers have been concerned about the behaviour or mental state of the patient and it is therefore wise to consult with these concerned others if there is doubt about the decision to detain.

Medical evaluation and investigation

Medical evaluation has three goals: excluding delirium (or dementia), considering other organic causes of psychosis and assessing for the presence of co-morbid medical illness.

The practice of ‘medical clearance’ prior to psychiatric evaluation may detract from a comprehensive evaluation of the patient. A more satisfactory process is to compile an adequate history of the presenting illness, assess the mental state, review the medications and alcohol and other drug use, consider previous medical history, check vital signs and carry out as comprehensive a physical examination as possible, with particular attention to signs of injury, poisoning or intoxication [22]. In services where both emergency physicians and psychiatrists are available, direct discussion about cases of uncertain diagnosis is useful.

Medical causes for an altered mental state will usually be suggested by the history, mental state assessment, abnormal vital signs and physical examination. As noted above, particular consideration should be given to medical causes in a first presentation of psychosis, especially in an older patient.

Investigations should be driven by history and examination findings, such as neurological signs or signs of infection. Nevertheless, because of the difficulties in compiling comprehensive medical histories, it is often appropriate to do a number of ‘screening’ investigations as indicators of unsuspected medical illness. The range of suggested tests varies, but usually includes urea and electrolytes, full blood count, liver function tests, random blood sugar, blood alcohol level, thyroid function tests and B12 and folate levels [23].

The availability of computed tomography (CT) scanning in more centres has facilitated the use of neuroimaging as an aid to diagnosis. This investigation is likely to be indicated in patients where stroke, neoplasm, haemorrhage or central nervous system infection may be suspected. It is also appropriate to consider a CT scan of the brain in first episode psychosis cases to assess further the possibility of neurological disease presenting with only psychotic or affective symptoms. However, the yield of positive results with this investigation is low [24], especially in the younger patient [25], and neuroimaging is therefore generally not required as an emergency investigation if the patient is otherwise medically well.

It is well established that patients with chronic psychotic illness tend to have poorer physical health than the general population [26]. Common conditions include obesity, late onset diabetes, hypertension, arteriosclerotic disorders, smoking-related disorders and alcohol and other drug-related disorders. The prevalence of these problems can be related to lifestyle factors, the side effects of medication and difficulties in making effective use of primary medical care. It is worth considering the possible presence of these common conditions as they sometimes need acute treatment or contribute to an exacerbation of the mental state.

Treatment

Management in the ED

Once medical causes have been excluded, the primary psychiatric diagnosis is likely to fall into one of the following groups:

drug-induced psychosis

acute schizophrenia

mania

chronic schizophrenia

psychosis-like reactive state

depressive psychosis.

Patients with psychotic illness often stay in the ED for prolonged periods. Sometimes this is due to delays in the assessment process, but it is also significantly a result of access block, that is the lack of ready availability of beds in psychiatric wards. In some hospitals, these circumstances have resulted in the establishment of specific psychiatric ‘holding beds’, within or closely related to the ED, where patients may be observed and treated for up to 48 hours while further management and disposition plans are being made [27,28]. The availability of such specialized psychiatric observation units is likely to reduce the need for reliance on sedative medications to manage behavioural disturbance. The patient can move around more freely, preferably with access to an outside secure area and specialized mental health staff can provide assessment, supervision, explanation and reality orientation.

In the more conventional ED setting, behavioural management is more difficult as a balance must be achieved between imposing restrictions on the patient and maintaining the safety of all patients and staff. Psychotic patients should be in areas which can be easily observed and often one-to-one supervision will be necessary, preferably with trained mental health nurses. If possible, this should be in a quiet area without too much coming and going. Engagement of the patient in reality-based conversation (explanation of what is happening, attention to personal concerns) is often useful. It may be possible to enlist the help of family members in providing reassurance and comfort.

The use of specific medications will depend in part on the diagnostic picture. Patients with drug-induced psychosis are usually quite aroused and require significant levels of sedation. Benzodiazepines, such as midazolam and diazepam, are usually preferred as they are less likely to lead to medical complications (especially arrhythmias) in a person who has already taken other drugs and has a high sympathetic drive. The period of sedation may become prolonged for several hours (or even days if high doses of diazepam are used). The mental state needs to be reassessed for the presence of persistent psychosis when the sedation abates.

Patients with acute schizophrenia, mania or persistent psychosis following drug use all have similar management in the short term. These patients tend to be aroused and agitated and to have considerable difficulty in coping with the restrictions and the stimulation of the ED environment. If the patient will take oral medications, sedative antipsychotics (such as olanzapine) or benzodiazepines (such as lorazepam) can be used. These are better prescribed as regular doses (e.g. olanzapine 5 mg tds or 7.5 mg qid or lorazepam 1 mg qid or 2 mg qid) than on a pro re nata (PRN) basis to ensure consistency in dosing. Repeated divided doses to maintain a more constant level of sedation are preferable to infrequent large doses. Estimates of the probable appropriate dose can be made on the basis of the size of the patient and degree of arousal and then titrated upward or downward on the basis of response in the first 24 hours.

If the patient refuses oral medication, lorazepam (if available) or clonazepam can be used intramuscularly or intravenously. Olanzapine can also be used effectively intramuscularly. Patients who are likely to stay in the ED for more than 24 hours can be given zuclopenthixol acetate 50–150 mg IM (dose dependent on the size of the patient). This is a medium-acting depot antipsychotic preparation which will last for 3–4 days. However, the onset of action is delayed for 6–8 hours, and this medication should be avoided in neurolept-naïve patients because of the risk of prolonged dystonia.

The patient who presents with acute schizophrenia who is not aroused may benefit from explanation and only small doses of medication, such as olanzapine 5 mg at night. Similarly, the patient with chronic schizophrenia should be maintained on usual medications, possibly with the addition of a PRN benzodiazepine if very anxious.

Patients with psychotic depression can be quite agitated, but also may be quiet and withdrawn. They should be considered at high risk of suicidal behaviour and need close supervision. Their mental anguish may be helped in the short term with the use of benzodiazepines or sedative antipsychotics (olanzapine or quetiapine). Regular doses are better than PRN, although smaller doses are needed than in the treatment of the acutely schizophrenic or manic patient. It is not essential to commence an antidepressant medication during the time the patient is in the ED.

The patient with severe personality disorder or a history of severe trauma who presents with a psychosis-like reactive state often requires similar treatment to a patient with acute schizophrenia. The patient may require containment in a place of safety and will benefit from explanation and reassurance. Benzodiazepines and sedative antipsychotics can be very useful in lowering arousal.

Admission to inpatient care

The decision to admit the patient for inpatient psychiatric care depends on the acuity of the presentation, the supports available at home, the degree of risk and the availability of community mental health services.

Patients with an acute episode of schizophrenia, especially a first episode, often require admission because they are often very disorganized, lack insight and are likely to be non-compliant with medication and may be at risk of suicide or aggressive behaviour. However, the increasing availability of mobile crisis teams (community mental health teams with the capacity for rapid and intensive follow up in the home) has made it more possible to treat even these acutely unwell patients at home. This is usually preferred by the patient and sometimes by the family, especially where the patient is an adolescent or young adult still living with their family. In these cases, careful assessment of potential risks to the patient or others and frank discussion of these issues with the family is advisable.

The acutely manic patient who has been brought to the ED almost certainly requires admission. Once established, the manic syndrome is likely to persist for several weeks if untreated. In some cases, especially those involving recurrence of a previous bipolar disorder, the patient presents relatively early in the relapse and with sufficient insight to accept advice about increasing or changing medications. If such a patient is discharged to outpatient care, specific arrangements should be made with the family and the community mental health services for monitoring and follow up.

The patient with an acute psychotic depression almost always requires admission because of the high risk of suicidal behaviour.

On the other hand, patients with chronic schizophrenia who present with a mild exacerbation of symptoms or family or social crisis should generally be managed in the community if possible. These are chronic conditions analogous to diabetes or asthma and quality of life can be enhanced if the patient can be helped to engage with community treatment services, achieve stability of accommodation and daytime activity and learn to self-manage the condition [29].

For patients with reactive psychoses in the context of personality disorder or trauma history, the individual circumstances vary widely and the decision to admit depends on careful assessment of the risk factors. Every effort should be made to return the patient as quickly as possible to reality-based perceptions of the world and to restore a sense of autonomy and personal responsibility. It is sometimes not possible to achieve this during the course of an ED stay and a brief crisis admission to a psychiatric unit may be necessary.

Criteria for involuntary treatment

When inpatient admission is considered desirable but refused by the patient, consideration should be given to the use of mental health act powers for referral and detention. Contemporary mental health legislation requires the person considering this option (which may be a doctor or other authorized mental health practitioner) to review options for less restrictive treatment before making this decision.

Mental health acts generally stipulate that persons can only be referred under the act if they suffer from a ‘mental disorder’ and are also at some ‘risk’. Risks involving danger to self through suicidal intent or behaviour and danger to others as a result of aggression or persecutory delusions are usually straightforward grounds for referral and detention. The decision may be more difficult in relation to the mildly manic patient or the schizophrenic patient with partial insight. The need for detention involves weighing up the potential consequences of not receiving treatment, the possibility of access to community services and the availability of family or other social supports.

Where mental health specialists are not readily available to the ED, ED doctors may appropriately refer a patient under the mental health act so that assessment by a psychiatrist can take place at another location. Especially in cases where the need for involuntary treatment is uncertain, it is good practice for the ED doctor to make this referral to ensure that the decision to detain or release can be made by a psychiatrist, who is in a clearer position to take medico-legal responsibility.

Community referral

The range of potential community treatment options is now wide. Patients may receive outpatient treatment through GPs, private psychiatrists and psychologists, community mental health clinics, public and private drug and alcohol services, relationship counselling agencies and various other specialized services (e.g. non-government community support services, services for indigenous persons and services for victims of trauma). In planning outpatient care, a good approach is to determine initially what service providers may be already involved in helping the patient and the strength of the patient’s relationship with those services. Direct communication between the ED staff and the community service providers is very desirable, especially if the patient is a new referral to those services.

Some of the more effective psychiatric emergency services work in close liaison with mobile crisis teams or acute care teams, who actively and intensively follow up discharged patients in their own homes or in crisis accommodation [28,30].

Controversies and future directions

As a result of the contemporary mental health community focus, EDs will continue to have a major role in the assessment and stabilization of patients with psychosis.

Should this assessment occur within traditional EDs or should EDs facilitate the development of co-located psychiatric emergency services?

The models of care which will achieve the best integration of emergency mental health assessments with community services require better definition.

References

1. Gregory LL, Claassen CA, Edmond JA, et al. Trends in US emergency department visits for mental health conditions, 1992 to 2001. Psychiatr Serv. 2005;56:671–677.

2. Kalucy R, Thomas L, King D. Changing demand for mental health services in the emergency department of a public hospital. Aust NZ J Psychiatr. 2005;39:74–80.

3. World Health Organization. The ICD-10 classification of mental and behavioural disorders Geneva: WHO; 1993.

4. Jablensky A. Epidemiology of schizophrenia. In: Gelder MG, Lopez-lbor JJ, Andreasen NC, eds. New Oxford textbook of psychiatry. London: New Oxford Press; 2000.

5. Jablensky A. Course and outcome of schizophrenia and their prediction. In: Gelder MG, Lopez-lbor JJ, Andreasen NC, eds. New Oxford textbook of psychiatry. London: New Oxford Press; 2000.

6. Joyce PR. Epidemiology of mood disorders. In: Gelder MG, Lopez-lbor JJ, Andreasen NC, eds. New Oxford textbook of psychiatry. London: New Oxford Press; 2000.

7. Angst J. Course and prognosis of mood disorders. In: Gelder MG, Lopez-lbor JJ, Andreasen NC, eds. New Oxford textbook of psychiatry. London: New Oxford Press; 2000.

8. McGorry PD. The concept of recovery and secondary prevention in psychiatric disorders. Aust NZ J Psychiatr. 1992;26:3–17.

9. Douglas S, Ballard C. Psychotic symptoms in dementia. In: Hassett A, Ames D, Chiu E, eds. Psychosis in the elderly. London: Taylor Francis; 2005.

10. Bredkjoer SR, Mortensen PB, Parnas J. Epilepsy and non-organic non-affective psychosis: national epidemiologic study. Br J Psychiatr. 1998;172:235–238.

11. Logsdail SJ, Toone BK. Post-ictal psychoses. Br J Psychiatr. 1988;152:246–252.

12. Hales RH, Yudofsky SC. Textbook of clinical psychiatry 4th ed. Washington: American Psychiatric Publishing; 2003; p. 462–3.

13. Boston Collaborative Drug Surveillance Program. Acute adverse reactions to prednisolone in relation to dosage. Clin Pharmacol Ther. 1972;13:694–698.

14. Young BK, Camicioli R, Ganzini L. Neuropsychiatric adverse effects of antiparkinsonian drugs: characteristics, evaluation and treatment. Drugs Aging. 1997;10:367–383.

15. Mellor CS. First rank symptoms of schizophrenia. Br J Psychiatr. 1970;117:15–23.

16. Flaum M, Schultz SK. When does amphetamine-induced psychosis become schizophrenia? Am J Psychiatr. 1996;153:812–815.

17. Javitt DC, Zukin SR. Recent advances in the phencyclidine model of schizophrenia. Am J Psychiatr. 1991;148:1301–1308.

18. Abraham HD, Aldridge AM, Gogia P. The psychopharmacology of hallucinogens. Neuropsychopharmocology. 1996;14:285–298.

19. Hall W. Cannabis and psychosis. Drug Alcohol Rev. 1998;17:433–434.

20. Chopra HD, Beatson JA. Psychotic symptoms in borderline personality disorder. Am J Psychiatr. 1986;143:1605–1607.

21. Butler RW, Mueser KT, Sprock J, et al. Positive symptoms of psychosis in post-traumatic stress disorder. Biol Psychiatr. 1996;39:839–844.

22. Olshaker JS, Brown B, Jerrard DA, et al. Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med. 1997;4:124–128.

23. Thienhaus OH. Physical evaluation and laboratory tests. In: Hillard JP, ed. Manual of clinical emergency psychiatry. Washington: American Psychiatric Press; 1990.

24. Rock DJ, Wynn Owen P. An investigation of criteria used to indicate cranial CT in males with schizophrenia. Acta Neuropsychiatr. 2003;15:284–289.

25. Adams M, Kutcher S, Antonio E, et al. Diagnostic utility of endocrine and neuroimaging screening tests in first-onset adolescent psychosis. J Am Acad Child Adolesc Psychiatr. 1996;35:67–73.

26. Phelan M, Stradius L, Morrison S. Physical health of people with severe mental illness. Br Med J. 2001;322:443–444.

27. Allen MM. Level 1 psychiatric emergency services: the tools of the crisis sector. Psychiatr Clin N Am. 1999;22:713–733.

28. Frank R, Fawcett L, Emmerson B. Development of Australia’s first psychiatric emergency centre. Austral Psychiatr. 2005;13:266–272.

29. Bennett C, Fumall J, Fossey E, et al. Assessing and responding to the needs of people with schizophrenia and related disorders. In: Meadow G, Singh B, eds. Mental health in Australia: collaborative community practice. Melbourne: Oxford University Press; 2001;283–312.

30. Breslow RE. Structure and function of psychiatric emergency services. In: Washington: American Psychiatric Press; 2002;1–34. Allen MH, ed. Emergency psychiatry review of psychiatry. Vol 21.

20.6 Pharmacological management of the aroused patient

Mark Monaghan and Simon Byrne

Essentials

1 Benzodiazepines and antipsychotics, often used most effectively in combination, are the first-line drugs for sedation of the aroused patient.

2 As much information as possible should be collected before the patient is sedated.

3 The risks involved in giving sedative drugs need to be considered, particularly at higher doses.

4 Dose adjustments are necessary in the older or medically compromised patient.

Introduction

Aroused patients who present to the emergency department (ED) of their own accord can generally be best assisted by verbal reassurance and prompt mental health evaluation. Reducing the waiting time and arriving quickly at an action plan will provide the best response to the patient’s anxiety and agitation.

For highly aroused patients who have been brought to the hospital reluctantly, the immediate need is to gain control of the situation to permit further evaluation, while ensuring the safety of the patient, staff and the public.

Where possible, it is desirable to collect some information about the patient before sedation. The patient should be approached in a calm manner in a safe, observed area of the ED, with security staff in the background if necessary. The patient should be asked about his or her understanding of the problems and listened to attentively, even if the account is incoherent. This attention will be reassuring to the patient and helps in building rapport. During this process observations can be made about the mental state. If possible, vital signs should be recorded and a brief physical examination carried out, with particular attention to signs of injury, intoxication or overdose.

In the hostile or frightened uncooperative patient, it will often be necessary to proceed to rapid tranquilization. This is a familiar procedure to the emergency physician and the practice can be enhanced by attention to the basic principles of care, an awareness of the risks and knowledge of the characteristics of the available drugs.

Pharmacological management should always be tailored to the particular patient. The medically compromised patient will be at greater risk of the complications of sedation. In elderly patients, decreased and delayed metabolism and elimination can result in prolonged therapeutic and adverse effects. Dose adjustments and agents with shorter half-lives and more favourable side-effect profiles must be considered for these patients.

General principles of rapid tranquillization

The general principles of care are:

Use sedative benzodiazepines and/or antipsychotics as the first-line agents.

Should the situation allow, oral dosing is the least distressing approach for patients and staff.

Treating physicians should use agents with which they are familiar. In particular, they should be aware of maximal safe dosing and expected adverse effects.

The endpoint should be a calm cooperative patient. Sedation to the point of loss of airway protection is dangerous.

The patient should be nursed in a quiet, calm and gently lit environment if possible.

Sedated patients should be monitored with basic observations; a 12-lead ECG should be performed on any patient being administered repeat doses of antipsychotics.

Supportive care, such as hydration, indwelling catheterization, pressure care and deep vein thrombosis prophylaxis, are essential for patients requiring ongoing sedation. This is particularly relevant in overcrowded EDs and if patients are detained in the ED for prolonged periods.

Maintenance of patient dignity by using single rooms and limiting visual exposure of the patient to the public is often forgotten but should be a basic standard of care.

Risks of rapid tranquillization

There are inherent risks in attempting to gain control of the aroused patient, including risks of injury to the staff and patient. If physical restraint is necessary to administer parenteral medication, adequate staff, trained in restraint procedures should be on hand. Sometimes mechanical (padded strap) restraint may be necessary in the early stages or to limit the dose of medication if the patient is developing toxic effects. Mechanical restraint should not be maintained in the absence of chemical sedation due to the risks of physical injury and rhabdomyolysis, as well as for ethical reasons.

The risks of adverse events from medication administration are well recognized.

Over-sedation and resultant respiratory depression and pulmonary aspiration are relatively common and for the most part avoidable with proper care.

Sudden cardiac death, particularly with agents that prolong the QT interval and precipitate torsade des pointes and ventricular tachycardia (VT), is a rare but catastrophic complication of rapid tranquilization [1,2]. This risk is heightened in the aroused patient with increased circulating catecholamines and in patients with pre-existing heart disease or conduction disturbance. Antipsychotics combined with other medications that prolong the QT interval pose an increased risk. The agents most associated with risk of sudden death are thioridazine and clozapine. Droperidol and haloperidol are associated with QT prolongation but rarely with the risk of torsade des pointes. Quetiapine and chlorpromazine are associated with QT prolongation but this is probably less clinically significant than with the above agents. The atypical agent olanzapine appears to be relatively safe from this perspective.

Hypotension can occur with administration of any agent with alpha blockade effects, but is especially associated with chlorpromazine (particularly when given intravenously). Dystonic reactions are seen with all antipsychotics, most frequently with the butyrophenones, such as haloperidol, and less commonly with atypical agents, such as olanzapine. Neurolept malignant syndrome is a risk with any antipsychotic agent, even following a single dose.

Anticholinergic effects, such as delirium and urinary retention, are risks with virtually all antipsychotics and are generally seen at high doses. Delirium is also caused by high doses of benzodiazepines, particularly diazepam, which accumulates with recurrent dosing. All antipsychotics have the potential to lower the seizure threshold.

Elderly patients are at significantly greater risk of drug accumulation and adverse effects. They are also at far greater risk of delirium, particularly with the combination of possible underlying cognitive impairment and environment change. Age-related reductions in hepatic metabolism and renal function make it reasonable to assume that all agents will have prolonged elimination half-lives in these patients. Even small doses of benzodiazepines can produce significant and prolonged respiratory depression in the elderly. Standard doses of antipsychotics, such as haloperidol, may result in prolonged extrapyramidal effects that impair mobility for days to weeks post-administration.

Specific agents

Benzodiazepines

Midazolam

This water-soluble benzodiazepine has major benefits over diazepam in that it produces fewer site reactions and can be given intramuscularly. It has a rapid effect by intramuscular or intravenous injection (2–5 minutes), with a half-life of 1–3 hours. The active metabolite has a similar half-life. The elimination half-life is significantly prolonged in the elderly. The major adverse effect is respiratory depression. It is available in ampoules (5 mg/mL, 15 /3 mL, 5 mg/5 mL and 50 mg/10 mL).

Diazepam

Diazepam can be used orally or intravenously. It is not recommended for intramuscular use due to unpredictable absorption. Diazepam demonstrates biphasic elimination with rapid redistribution of 1–3 hours, followed by a prolonged terminal elimination phase of up to 20 hours. Hepatic metabolism produces active metabolites and excretion is renal. Elimination is significantly prolonged in the elderly. Major adverse effects are respiratory depression and accumulation causing delirium. It is available in ampoules (10 mg/2 mL), tablets (2 mg and 5 mg) and elixir (10 mg/10 mL).

Clonazepam

Clonazepam can be used by oral, intravenous or intramuscular routes. Clonazepam has a prolonged elimination half-life (20–50 hours) with hepatic metabolism and renal excretion. The major adverse effects are excessive sedation and risk of accumulation. It is available in ampoules (1 mg/mL), tablets (0.5 mg and 2 mg) and oral liquid (2.5 mg/mL).

Lorazepam

In Australia, lorazepam is only used orally as the parenteral preparation is not available. However, in other countries, it is widely used intramuscularly in the sedation of psychotically aroused patients. It is well absorbed orally, with an elimination half-life of 12–15 hours. The hepatic metabolites are non-active. The major adverse effect is excessive sedation, but it is less likely to accumulate than diazepam or clonazepam. It is available in tablets (1 mg and 2.5 mg).

Antipsychotics

Droperidol

Droperidol can be administered intramuscularly or intravenously. Clinical effects are seen within 3–10 minutes, maximum at 30 minutes and the elimination half-life is approximately 2 hours. It is significantly more sedating than haloperidol, which makes it an attractive choice for the aroused patient. It is also a potent antiemetic. The black box labelling of droperidol is highly controversial as there appears to be little evidence that there is greater cardiovascular risk with this agent than with haloperidol. QT prolongation is seen with greater frequency at higher dose, but deterioration to torsade de pointes is rare. The risk is greater when combined with agents that prolong the QT interval or in patients with pre-existent QT prolongation. As with haloperidol, there is risk of dystonic reactions and neurolept malignant syndrome. (Ampoules 2.5 mg/mL.)

Haloperidol

Haloperidol can be given by oral, intramuscular or intravenous routes. Peak plasma levels occur 20 minutes after intramuscular injection and 2–6 hours post-oral dose. Mean elimination half-life is 20 hours, but this includes initial rapid elimination followed by a prolonged elimination over days. Hepatic metabolites are renally excreted. Major adverse effects are extrapyramidal effects that may persist for days (particularly in the elderly), prolongation of QT interval with risk of torsade and neurolept malignant syndrome. It is available in tablets (0.5 mg, 1.5 mg and 5 mg), liquid (2 mg/mL) and ampoules (5 mg/mL).

Olanzapine

Olanzapine is licensed for oral, sublingual (SL) and intramuscular use. There are also common reports in the literature of intravenous use. It is an atypical antipsychotic that is well absorbed orally with peak plasma levels 2–5 hours post-oral dose and 30 minutes post-intramuscular injection. It has a half-life of approximately 33 hours and is hepatically metabolized to inactive metabolites that are renally and faecally excreted. There is also now a long-acting preparation with a half-life of 30 days. Major adverse effects include excessive sedation, mild anticholinergic effects and neurolept malignant syndrome (NMS). Extrapyramidal side effects, including dystonias, are rare. Cardiotoxicity is also rare. It is available in tablets (2.5 mg, 5 mg, 7.5 mg and 10 mg), dissolvable tablets, wafers (5 mg and 10 mg) and ampoules (10 mg).

Risperidone

Risperidone is for oral and sublingual use. It is an atypical antipsychotic that is well absorbed orally with a peak effect in 1–2 hours. It is hepatically metabolized to an active metabolite that is renally excreted. The half-life of the parent compound is 3 hours in extensive metabolizers and 17 hours in poor metabolizers; the active metabolite elimination half-life is 24 hours. Risperidone’s adverse effect profile is benefited by the absence of anticholinergic effects, but includes postural hypotension with initial dosing, extrapyramidal effects and NMS. Extrapyramidal reactions, including dystonias, are less frequent with risperidone than with haloperidol. There has been an increased mortality associated with risperidone and elderly patients on frusemide, so caution should be taken to ensure adequate hydration in these patients. It is available in tablets and sublingual ‘quicklets’ (0.5 mg, 1 mg, 2 mg, 3 mg and 4 mg) and solution (1 mg/mL).

Chlorpromazine

Chlorpromazine is for oral, intramuscular or intravenous use. It has variable and incomplete absorption and a large first-pass metabolism, with peak plasma levels 1–4 hours after oral and 30 minutes after intramuscular administration. Metabolism is hepatic with many metabolites that are renally excreted. Elimination is complicated with early (2–3 hours), intermediate (15 hours) and late (60 days) elimination phases. Major adverse effects are postural hypotension, strong anticholinergic effects, excessive sedation and the risk of NMS. Extrapyramidal effects are relatively uncommon. It is available in tablets (10 mg, 25 mg and 100 mg), syrup (25 mg/mL) and ampoules (50 mg/2 mL).

Zuclopenthixol acetate (‘Acuphase’)

This is given intramuscularly. Zuclopenthixol acetate is a medium-acting depot preparation of a typical thioxanthene antipsychotic. Maximal plasma levels are achieved 24–36 hours post-intramuscular injection, declining to 30% of maximum levels by day 3. It is hepatically metabolized to inactive metabolites and faecally excreted. Zuclopenthixol acetate should be avoided in neurolept-naïve patients and those with organic brain disorders, cardiac disease and lowered seizure threshold. This is because any adverse effects, including NMS, will be prolonged because of the slow absorption and elimination. The usual dose is 50–100 mg.

Dexmedetomidine and clonidine

These central alpha-agonists have a significant sedative effect. Dexmedetomidine is used as an infusion, primarily in the ICU setting. Clonidine has a recognized role in opiate and, to a lesser extent, alcohol withdrawal. It may be administered by the oral, SC, IM or IV route. It has a rapid onset of action when given parenterally and a half-life of greater than 12 hours. There is the potential for both these agents to have an increasing role in the emergency department for the management of hyperaroused patients. Both have a risk of bradycardia and hypotension and should be avoided in patients with pre-existent cardiac conduction abnormalities and used with caution in patients on rate lowering agents.

A rapid tranquillization algorithm

There are a variety of published algorithms for rapid tranquillization [3–15]. The following is a reasonable approach in terms of effectiveness, risk of adverse effects and availability. This algorithm applies to the management of a previously well adult patient. It must be remembered that, in general, the risk of adverse events is increased the greater the doses used. Elderly patients as a general rule should have lower initial doses and smaller daily doses.

First-line treatment

Try to develop rapport with the patient and use oral medication if possible. Oral agents of choice include:

benzodiazepines: diazepam 10 mg, clonazepam 2 mg or lorazepam 2.5 mg (elderly: lorazepam 0.5–1 mg)

and/or:

antipsychotic: olanzapine 5–10 mg oral/SL (elderly: olanzapine 2.5 mg oral/SL or risperidone 0.25–0.5 mg oral/SL).

Second-line treatment

If oral therapy is not achievable or is not effective, parenteral medications must be given. Agents of choice include:

benzodiazepines: midazolam 2.5–5 mg IV/IM repeated as required to a maximum of around 100 mg (elderly or compromised patients may develop respiratory depression with as little as 1 mg midazolam, so 0.5–1 mg is a safer initial dose, with maximal dose many times lower than 100 mg)

and/or:

antipsychotic: olanzapine 10 mg IM, which can be repeated up to a maximal daily dose of 30 mg (elderly patients can be given olanzapine in doses of 2.5 mg IM, but may be better managed with sublingual olanzapine 2.5 mg or sublingual risperidone 0.5 mg)

or:

droperidol 2.5–5 mg IM/IV, up to max of 25 mg/24 h. Risks include dystonic reactions, QT prolongation, anticholinergic delirium and NMS, with QT prolongation risk greater with increasing dose or if combined with QT prolonging agents. Doses less than 10 mg seem to be relatively safe from this persepective [15]. It would seem sound clinical advice to obtain a 12-lead ECG in any patients treated with droperidol or haloperidol, particularly if doses exceed 10 mg.

There is evidence of more rapid onset of sedation and less adverse events when a combination of midazolam and antipsychotics is used rather than midazolam alone [12].

Third-line treatment

If the maximal doses of the above agents have been reached with the first- or second-line drugs without adequate effect, it is necessary to try other options. Sometimes also the first- or second-line drugs may have to be avoided because of previous adverse effects. The maximum doses described here are based on the likelihood of very limited greater benefit (and the probability of greater adverse effects) of exceeding these doses.

Third-line agents include:

diazepam 2.5–5 mg IV, up to a maximum of around 100–150 mg. (Risks include accumulation, delirium and respiratory depression; should not be given intramuscularly)

clonazepam 1–2 mg IM/IV up to a maximum of 8 mg per day. Clonazepam can also be given as an infusion at a rate of 4–6 mg/24 h; the rate of the infusion can be varied according to the arousal level of the patient. (Risks include accumulation, delirium and respiratory depression)

haloperidol 2.5–5 mg IM/IV, up to a maximum of around 30–50 mg/24 h. Risks similar to droperidol

chlorpromazine can also be given as an intravenous infusion, with an initial rate of 6.25–12.5 mg/h to gain initial control and then reduced to a maximum of around 200 mg/24 h. (Risks include anticholinergic effects, hypotension, delirium, accumulation, QT prolongation and NMS.)

Aroused patients with amphetamine intoxication should be managed with benzodiazepines and supportive care, sometimes requiring large doses for initial control. Both intravenous midazolam and oral/intravenous diazepam are reasonable first choices. Severe intoxication with hyperthermia and rigidity requires paralysis and intubation. In patients who present with paranoid psychosis associated with amphetamine abuse, addition of an antipsychotic, such as olanzapine (oral or intramuscular), is appropriate.

Maintenance therapy

Following initial rapid tranquillization, the patient will remain sedated for several hours, during which collateral history may be obtained. When the patient awakes, a further psychiatric assessment should be made, especially with a view to deciding whether the patient needs to be admitted to a psychiatric unit.

If the patient does need to remain in hospital, consideration must be given to further appropriate medication. A general approach is to use lorazepam (1 or 2 mg three times a day) or sedative antipsychotics (olanzapine 5 or 10 mg three times a day). It is better to prescribe regular medication (rather than ‘PRN’) to ensure consistency of dosing. The appropriateness of the prescribed medication and the side effects should be reviewed at least daily.

If the patient remains uncooperative, intravenous benzodiazepines or intramuscular olanzapine can be used on an as needed basis. If adequate facilities are available for monitoring respiratory function, the use of an infusion of clonazepam or chlorpromazine can help to achieve control. Alternatively, some patients who are likely to remain in the ED for more than 24 hours may benefit from a one-off dose of zuclopenthixol acetate.

Controversies and future directions

The role of butyrophenones versus atypical antipsychotics is controversial from a drug safety perspective.

There is debate about the appropriateness of prolonged restraint and sedation of patients ‘stranded’ in emergency departments.

The role of the central alpha-2 agonists in the management of hyperaroused patients in the emergency department is yet to be determined.

References

1. Abdelmawla N, Mitchell AJ. Sudden cardiac death and antipsychotics Part 1: risk factors and mechanisms. Adv Psychiatr Treat. 2006;12:35–44.

2. Abdelmawla N, Mitchell AJ. Sudden cardiac death and antipsychotics Part 2: monitoring and prevention. Adv Psychiatr Treat. 2006;12:100–109.

3. McAllister-Williams RH, Ferrier IN. Rapid tranquillisation: time for a reappraisal of options for parenteral therapy. Br J Psychiatr. 2002;180:485–489.

4. MacPherson R, Dix R, Morgan S. A growing evidence base for management guidelines. Adv Psychiatr Treat. 2005;11:404–415.

5. Battaglia J, Moss S, Rush J, et al. Haloperidol, lorazepam or both for psychotic agitation? A multicentre, double-blind, emergency department study. Am J Emerg Med. 1997;15:4335–4340.

6. Atakan Z, Davies T. ABC of mental health: mental health emergencies. Br Med J. 1997;314:1740–1742.

7. Pilowski LS, Ring H, Shine PJ, et al. Rapid tranquillisation: a survey of emergency prescribing in a general psychiatric hospital. Br J Psychiat. 1992;160:831–835.

8. Alexander J, Tharyan P, Adams C, et al. Rapid tranquillisation of violent or agitated patients in a psychiatric emergency setting: pragmatic randomized trial of intramuscular lorazepam versus haloperidol plus promethazine. Br J Psychiatr. 2004;185:63–69.

9. TREC Collaborative Group. Rapid tranquillisation for agitated patients in emergency psychiatric rooms: a randomized trial of midazolam versus haloperidol plus promethazine. Br Med J. 2003;327:708–713.

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