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Psychosocial Disorders SECTION CHAPTER Mental Health Disorders: ED Evaluation and Disposition Veronica Tucci Nidal Moukaddam INTRODUCTION AND EPIDEMIOLOGY This chapter is designed to provide the emergency provider with a gen eral approach to the psychiatric emergency patient, identify potential pitfalls, and provide strategies for successfully managing this difficult patient population. Psychiatric and behavioral emergencies have become a staple in every ED around the world. The busy emergency provider must successfully navigate encounters with patients who can exhibit a wide range of psychosocial pathology including substance use disorders, anxiety and agitation, depression and suicidal ideation, psychoses, neurocognitive disorders, and personality disorders, all of which can present with medical, psychiatric, or a combination of complaints. Globally, according to the World Health Organization, one in four people suffer from mental illness or neurologic disorders, with depression as the number one cause of disability worldwide. 1 The National Institute of Mental Health in the United States estimates that 1 in 5 Americans suffers from a mental, behavioral, or emotional disorder and 1 in 25 suffer from a severe mental illness. 2 The Centers for Disease Control and Prevention announced a 24% increase in the rate of suicide in the United States from 1999 to 2014. Psychiatric patients have a higher incidence of medical conditions 4-6 and a greater risk of injury7 than those without mental health or behavioral disorders. Fifty to 90% have at least one chronic medical condition and have a shortened life expectancy by anywhere from 8 to 30 years. Sixty percent of this shortened life expectancy is estimated to be due to physical illness. Moreover, the National Alliance on Mental Health reports that 26% of homeless people in the United States who live in shelters have a serious mental illness, and 24% of state prisoners had a “recent history of a mental condition. ” 9 This is of particular concern in urban, busy EDs and has special relevance for high ED users, discussed below. GOALS OF CLINICAL EVALUATION Anywhere from 7% to 10% of patients admitted to psychiatric wards have an organic condition that should have been identified, with higher figures often cited for patients at the extremes of life. 10,11 Examples of missed life-threatening organic pathology include meningitis; sepsis; delirium; toxicologic processes including acetaminophen toxicity; neuroleptic malignant syndrome; metabolic abnormalities including hepatic encephalopathy, myxedema coma, or DKA; and traumatic conditions including epidural or subdural hematomas. 12,13 The distinction between functional and organic causes is crucial because organic issues may be reversible with prompt intervention and failure to identify such pathology can have devastating outcomes. The evaluative process for identifying primary or comorbid medical conditions is often referred to as medical clearance. Little disagreement exists over the evaluation of patients with no known psychiatric history who present with altered mental status or new-onset psychosis. Such patients are presumed to have an underlying medical disorder or an “organic” cause until proven otherwise. Clinical evaluation is needed to identify any medical or surgical emergencies. Assuming a psychiatric condition for first-time episodes is ill advised because a psychiatric condition is a diagnosis of exclusion.

h patients are presumed to have an underlying medical disorder or an “organic” cause until proven otherwise. Clinical evaluation is needed to identify any medical or surgical emergencies. Assuming a psychiatric condition for first-time episodes is ill advised because a psychiatric condition is a diagnosis of exclusion. Evalua tion should include appropriate reassessment and observation periods which, realistically, may not be entirely completed in the ED. Controversy, however, arises on how in depth the ED evaluation needs to be for a patient with a known psychiatric history (with or without chronic medical problems) and who is presenting with a psychiatric or behavioral complaint. Because of missed organic pathology in patients admitted to psychiatric wards over the past 50 years, emergency providers have been tasked with completing a medical evaluation of patients with psychiatric or behavioral complaints. This initial medical evalua tion may be the only one that the patient will receive and, by design, is meant to ensure that potentially serious medical problems will not be left unaddressed and untreated. This thorough evaluation is more commonly referred to as medical clearance. As of this writing, there is still no interdisciplinary consensus on the necessary historical and physical examination elements, ancillary testing, and treatment that constitute an acceptable clearance process or medical stability examination. The lack of consensus is rooted in the fact that the term itself is ambiguous and means different things to different providers. 14-16 Regardless of the lack of interdisciplinary consensus, the medical clearance or medical stabil ity assessment is critical in evaluation and treatment of patients with psychiatric and behavioral emergencies. Two common situations are as follows: (1) Patients with chronic medical conditions can be viewed as stable as long as such conditions are not responsible for the patient’s psychiatric or behavioral issues or are incidental complaints. (2) Patients can be viewed as stable for psychiatric evaluation as long as medical illness has been treated and the patient’s condition has stabilized (e.g., diabetes, hypertension). For all patients, a thoroughly documented medical decision-making process, including specific ED treatment, further recommendations, and suggestions for follow-up, can facilitate placement in an inpatient facility. ED MEDICAL STABILITY OR CLEARANCE EVALUATION The end goal of the medical clearance or stability examination is to dis tinguish between an organic or psychiatric condition. Comorbid medi cal diseases may be causing or exacerbating psychiatric symptoms in 34% to 50% of patients who present with psychiatric emergencies. 10,18,19 The journey of the patient with mental health complaint is summarized in Figure 286-1.  ED ARRIVAL AND TRIAGE Paramedics or police typically provide advance notice to the ED regarding patients with serious mental health issues or severe agitation, so preparations can be made for the patient’s arrival. For patients who threaten harm to others or who have altered mental status or severe agitation, hospital security and ED nursing and medical staff can be prepared to search the patient for weapons, secure an appropriate ED room, and provide verbal de-escalation, restraints, or medication as needed. Place the patient in a room where there are no objects, liquids, or devices that can be used to harm the patient or others. Undress the patient and provide a hospital gown. If the patient has not already been screened for weapons, make sure it is done as soon as possible. Many EDs have systems in place to flag patients at risk of eloping or those who cannot be released until assessment is complete. Terms such Tintinalli_Sec24_p1933-1966.indd 1933 8/2/19 5:19 PM

nd provide a hospital gown. If the patient has not already been screened for weapons, make sure it is done as soon as possible. Many EDs have systems in place to flag patients at risk of eloping or those who cannot be released until assessment is complete. Terms such Tintinalli_Sec24_p1933-1966.indd 1933 8/2/19 5:19 PM 1934 SECTION 24: Psychosocial Disorders as protective custody or precautionary hold are sometimes used. Different color gowns, special area assignments, and special flagging of the chart are some means for identifying high-risk patients that are widespread. For other more stable patients, triage is accomplished in the usual manner as for medical patients, to identify high-risk versus lower-risk patients or situations. High-risk situations include suicidal or homicidal ideation, psychotic or violent behaviors, and risk for elopement. The Emergency Severity Index, the Canadian Triage Acuity Scale, the Manchester Triage System, the Australasian Triage Scale, and the South African Triage Scale are the most widely used ED triage systems worldwide.  HISTORY Obtain a detailed description of recent symptoms from the patient. Explore the severity of symptoms including any changes in behavior identified by the patient himself or herself or an alternative storyteller, any provoking and palliative features, similar previous occurrences, and the timing and duration of symptoms. Patients with psychiatric or behavioral issues may not be coopera tive or may offer tangential responses. Patients may provide diagnostic terms for their disorder that are technically inaccurate. It is best to ask the patient to describe symptoms rather than ask about a diagnosis. Ask openly about substance use disorders. Try to obtain collateral information from as many ancillary sources as possible. Additional sources can provide a baseline for the patient’s symptoms and confirm the story, especially if the patient’s mental capacity is impaired or not known or if the patient is uncooperative. Chart reviews can provide additional collateral. Table 286-1 lists historical features more likely to be characteristic of an organic pathology for psychiatric complaints. In one study, investigators found that 63% of patients with new psy chiatric symptoms had significant medical pathology, 42% of which could be diagnosed from a proper history alone. 25 Identify current infections and consider delirium when faced with an acutely psychotic or agitated patient. 26 See Chapter 288, “Mental Health Disorders of the Elderly, ” and Chapter 287, “ Acute Agitation, ” for further discussion of delirium, dementia, and agitation. Patients reporting any of the histori cal features noted in Table 286-1 should receive further focused testing.  REVIEW OF SYSTEMS The review of systems can be accomplished in a more structured manner than the rest of the interview and sometimes can help redirect the patient. Unfortunately, many avoid asking detailed questions on the review of systems because of concerns that the patient will endorse everything asked. Specific targeted yes or no questions in this part of the encounter can help hone the differential diagnosis. Focus on elements of the review of systems most likely to point to organic problems (e.g., recent fevers, productive cough, rashes, headaches, trauma).  PHYSICAL EXAMINATION The cornerstone of the medical stability assessment is the physical examination. Where the history and review of systems may prove troubling to decipher, the physical exam is more objective and can lead to an underlying medical disorder as the root or exacerbating cause of symptoms. First, obtain a full set of vital signs and address any abnormalities. Obtain vital signs in the agitated or hostile patient as soon as feasible, and recheck before discharge.

g to decipher, the physical exam is more objective and can lead to an underlying medical disorder as the root or exacerbating cause of symptoms. First, obtain a full set of vital signs and address any abnormalities. Obtain vital signs in the agitated or hostile patient as soon as feasible, and recheck before discharge. One study from 2008 noted a failure to document a complete set of vital signs in up to 50% of patients. Perform a head to toe examination. For psychiatric patients, like most medical patients in the ED, the patient’s complaints and known medical WALK-IN POLICE/LAW ENFORCEMENT and • SCREEN FOR WEAPONS TRIAGE • Assess risk • Place in protective custody or precautionary hold • Place in safe room • Place in hospital gown ASSESSMENT • Initial evaluation • Observation • Reassessment DISPOSITION • Discharge • Admit • Observation FIGURE 286-1. Elements of ED evaluation. TABLE 286-1 Historical Features Suggestive of Medical Causes for the Psychiatric Presentation20-24 •   No previous psychiatric history •   Recently hospitalized or with symptoms suggestive of possible infections •   Recent medication changes •   Sudden changes in behavior •   Visual hallucinations •   Extremes of life; age >40 y or <12 y •   New-onset seizure •   Recent memory loss •   History of substance abuse Tintinalli_Sec24_p1933-1966.indd 1934 8/2/19 5:19 PM

hospitalized or with symptoms suggestive of possible infections •   Recent medication changes •   Sudden changes in behavior •   Visual hallucinations •   Extremes of life; age >40 y or <12 y •   New-onset seizure •   Recent memory loss •   History of substance abuse Tintinalli_Sec24_p1933-1966.indd 1934 8/2/19 5:19 PM CHAPTER 286:  Mental Health Disor ders: ED Ev aluation and Disposition      1935 comorbidities dictate the order of the exam and the amount of attention given to each element. Patients with limited histories or who have selfinflicted injuries (especially adolescents) should receive a comprehen sive physical examination in a manner akin to a standardized trauma assessment. 28,29 Table 286-2 summarizes physical examination features that may help the emergency physician differentiate organic from primary psychiatric disease. Many inpatient psychiatrists expect the ED physical examination to include a mental status examination. 13,30 Common mental status examinations include the Mini-Mental Status Examination, the Brief Mental Status Examination, and Quick Confusion Scale. These tools generally focus on seven major areas: affect, attention, language, orientation, memory, visual-spatial ability, and conceptualization. 13 In the case of uncooperative or violent patients, a significant portion of the examina tion can be done by observing from the doorway.31  LABORATORY AND ANCILLARY TESTING Medical history, physical examination, review of systems, and tests for orientation have relatively high yield for detecting active medical prob lems, and routine laboratory testing is typically low yield. In general, testing is best left to the discretion of the emergency provider, with individualized assessments being the best guide to optimal evaluation. Most inpatient psychiatric facilities will still require extensive ancillary testing as part of the clearance process or otherwise will list specific test abnormalities as part of their exclusionary criteria in determining the patient’s suitability for admission. Most psychiatric facilities lack labo ratories and imaging suites on their premises and do not have access to immediate turnarounds. Therefore, in the interest of patient safety, they often require substantial testing as either part of the medical clearance process or as specific exclusionary criteria.  REASSESSMENT AND ANTICIPATION OF DECOMPENSATION Like the ECG or a FAST examination, the initial assessment is a snap shot in time. Reassess patients and document the reassessments for the following reasons: (1) patients can decompensate in the in-hospitable ED environment; (2) withdrawal or overdose symptoms may develop (indeed, one study asserted that one third of cases of severe intoxication were missed and that 12.5% of patients with withdrawal or delirium tremens and 12.5% of patients with a medication overdose had not been identified on initial assessment) 33; (3) a coexisting medical disorder will require attention (e.g., a diabetic requiring insulin or a patient with hypertension requiring twice-daily dosing of home medications); and (4) a coexisting medical disorder may reveal itself. SPECIAL CONSIDERATIONS  DEFICIENCIES IN THE INITIAL ASSESSMENT Although most impending medical disasters can be uncovered with a thorough history, review of systems, and physical examination includ ing attention to abnormal vital signs, studies over the past 40 years have demonstrated poor quality assessments performed on patients present ing with psychiatric symptoms in the ED (Table 286-3). One group of investigators found that over one third of medical clearance assessments lacked a history. 33 Another found that 8% of patients had no documented exam, 34 and even when present, many did not include critical components.

ts performed on patients present ing with psychiatric symptoms in the ED (Table 286-3). One group of investigators found that over one third of medical clearance assessments lacked a history. 33 Another found that 8% of patients had no documented exam, 34 and even when present, many did not include critical components. For example, complete sets of vital signs were often not documented, and even when abnormal, they were not reassessed or noted. Mental examinations (depending on whether they are defined as mini-mental or orientation status) are frequently missing, with statistics as high as 56%. Neurologic examinations were similarly neglected, with one study noting absence of cranial nerve testing in 50%, motor exam testing in 72% of cases, sensory exam testing in 88% of cases, and gait testing in 75% of cases.  INTERVIEWING TECHNIQUES Table 286-4 summarizes interviewing basics. Time constraints are common in the ED, and the time to conduct a detailed interview is often lacking. The recommended approach to the patient with mental health complaints focuses on safety first, followed by establishing and maintaining a therapeutic rapport.  VIOLENT RESTRAINTS In some cases, no matter how well trained the ED staff is in de-escalation techniques, physical restraints will need to be applied rapidly and safely to protect the patient from self-harm and/or the staff from harm. The term sometimes used is violent restraints. Application of violent restraints is ideally accomplished by a team of five staff members with one team leader and one person for each limb. Shows of force with multiple team members poised to act can at times be sufficient in themselves to subdue the patient without actually applying the restraints. As with all elements of care, the patient and any family members present should be provided with clear, ongoing explanations of the procedure and reasons for it. Place the patient on a bed or stretcher, and secure all four limbs with leather restraints (soft restraints are more commonly used in nonviolent settings). Be careful to avoid injury to the patient and personnel assisting in the process.

be provided with clear, ongoing explanations of the procedure and reasons for it. Place the patient on a bed or stretcher, and secure all four limbs with leather restraints (soft restraints are more commonly used in nonviolent settings). Be careful to avoid injury to the patient and personnel assisting in the process. Elevate the patient’s head, TABLE 286-2 Physical Examination Features Suggestive of Organic Causes of Psychiatric Complaints •   Abnormal vital signs •   Fluctuating level of consciousness/alertness (e.g., clouded sensorium) •   Significantly decreased level of consciousness (Glasgow Coma Scale score <8) •   Focal neurologic findings (e.g., new-onset seizures, inability to walk unassisted) •   Ophthalmologic abnormalities (e.g., rotary nystagmus) •   Evidence of trauma (e.g., raccoon eyes, Battle’s sign, septal hematoma, abrasions, lacerations) •   Abnormal dermatologic manifestations (e.g., rashes, purpura, jaundice, uremic frost, cool, mottled extremities) •   Abnormal mental examination or Quick Confusion Scale •   Presence of visual hallucinations TABLE 286-3 Medical Clearance Assessment Deficiencies •   Obtaining an incomplete or inaccurate history •   Failing to seek out collateral sources (e.g., family, EMS, police) •   Failing to acknowledge and address abnormal vital signs •   Failing to recognize immediate life and limb threats (e.g., respiratory failure due to narcotic overdose) •   Performing a cursory or incomplete physical examination •   Failure to develop and refine a differential diagnosis for the patient’s symptoms •   Anchoring on psychiatric diagnoses •   Failing to reassess the patient •   Applying a “kitchen sink” mentality in ordering laboratory and radiographic tests TABLE 286-4 Interview Techniques in the ED Safety •  Know  where the exits are before you talk to the patient; stand close to exit •  Leave  enough distance to avoid being physically hurt •  Wear  a badge clip that cannot be used to choke you Cooperation/rapport •  Always  introduce yourself clearly •  Establish  eye contact; smile if possible •   Reuse terms the patient uses to describe their condition before asking for clarification; this makes the patient feel heard •  Start  with open-ended questions because they are best to establish therapeutic rapport •  Transition  to close-ended questions if open-ended questions are not productive •  Last  resort: Yes or no and multiple-choice questions Tintinalli_Sec24_p1933-1966.indd 1935 8/2/19 5:19 PM

n; this makes the patient feel heard •  Start  with open-ended questions because they are best to establish therapeutic rapport •  Transition  to close-ended questions if open-ended questions are not productive •  Last  resort: Yes or no and multiple-choice questions Tintinalli_Sec24_p1933-1966.indd 1935 8/2/19 5:19 PM 1936 SECTION 24: Psychosocial Disorders TABLE 286-5 Sedation Assessment Tool and Treatment Suggestions* Sedation Assessment Tool Score Description Treatment 3+ Combative, violent, out of control with continual loud outbursts Physical restraint Lorazepam 1–2 milligrams IM AND Haloperidol 5–10 milligrams IM Olanzapine (Zyprexa®) 5–10 milligrams IM Droperidol 2 milligrams IM 2+ Very anxious and agitated with loud outbursts As above, or if will take PO, lorazepam 1–2 milligrams PO and haloperidol 5–10 milligrams PO Olanzapine orally disintegrating tablets (ODT) 5 milligrams 1+ Anxious and restless with normal to talkative speech If will take PO, lorazepam 1–2 milligrams PO and haloperidol 5–10 milligrams PO Olanzapine ODT 5 milligrams or 5 milligrams IM 0 Awake and calm, cooperative with normal speech Not applicable *Data from Calver LA, Stokes B, Isbister GK: Sedation Assessment tool to score acute behavioral disturbance in the emergency department. Emerg Med Australas 23: 732, 2011. [PMID: 22151672] if possible, to minimize risk of aspiration. Once the patient is restrained, offer medications, and if refused, administer medications involuntarily. Emergency providers must familiarize themselves with hospital poli cies and laws regarding the frequency of reassessment and the elements that they must document in their face-to-face assessment (e.g., vital signs; airway, breathing, and circulation; range of motion; skin integ rity; turning the patient as needed; attending to toileting and any other hygiene needs). The first face-to-face assessment is generally completed in the first hour after application. Computerized or written orders can specify the time limit for the restraint and protocols for removal. Many hospitals require a new order to maintain physical restraints at regular intervals for violent patients with restraints. Once the patient is calm and cooperative, the nursing or security staff under the direction of the emergency provider may remove the restraints. It is usually best to remove the restraints in a stepwise fashion, one at a time, while carefully monitoring the patient to ensure continued compliance and cooperation.  ASSESSING THE DEGREE OF AGITATION Some patients may require medications either before or after the appli cation of restraints. Pharmacologic treatment of violent or agitated patients is discussed in detail in Chapter 287, “ Acute Agitation. ” The Sedation Assessment Tool score is one method of grading behavior and assessing medication options. 12 Treatment options can be selected based on behavior (Table 286-5).  HIGH ED USERS High users are a group of patients who present to the ED at much higher rates than expected for their conditions or severity of illness. Pejoratively dubbed frequent flyers, and often accused of malingering, these indi viduals are some of the most challenging to deal with in the ED. High users typically consist of a mix of individuals with chronic conditions, a background of trauma, broken families/poor social support, and severe psychosocial stressors (e.g., homelessness). 36-38 They tend to elicit strong, often negative feelings in providers (discussed below). Families and communities are unable to take care of mentally ill individuals39 and ensure the necessary safety nets, and the ED becomes the go-to for crises and decompensations.

severe psychosocial stressors (e.g., homelessness). 36-38 They tend to elicit strong, often negative feelings in providers (discussed below). Families and communities are unable to take care of mentally ill individuals39 and ensure the necessary safety nets, and the ED becomes the go-to for crises and decompensations. “Bedless” psychiatry, embedded in outpatient and emergency care, has shown so many challenges that many have called for a return of long-term care, 40,41 and although psychiatric asylums are not the answers, they did fulfill a stabilizing function for a very difficult and fragile population. The advent of deinstitutionalization for psychiatric patients in the 1960s resulted in a dearth of inpatient psychiatric beds and outpatient and community outreach services, more hospital admissions, shorter hospital stays, and significant gaps in care. Many patients who would have previously been housed in long-term state hospitals or facilities were left with nowhere to live and nowhere to go to receive the kind of care to which they had become accustomed. Indeed, from 1970 to 2006, inpatient psychiatric beds decreased from an estimated 400,000 beds to less than 50,000. 42,43 The authors of the report “No Room at the Inn: Trends and Consequences of Closing Public Psychiatric Hospitals, 2005-2010” 43 found that the number of state psychiatric beds continued to dwindle by another 14% from 2005 to 2010, effectively decimating the number of public psychiatric beds available to treat both chronic and acutely decompensated psychiatric patients. 44 In 2016, Becker Hospital Review reported that the number of needed inpatient psychiatric beds in the United States is, at minimum, 123,300, and the number of beds actually available is 37,679. 45 With less than 30% of the needed inpatient beds available, demand for care for mental illness continues to reach new heights and is simply outstripping supply. Substance use disorders/ addiction, depression, anxiety, and psychoses in the general population have exploded, with more ED visits for disadvantaged populations. Consequently, the ED is the last beacon of hope and is a safety net for the community’s most vulnerable, with an estimated one in eight ED visits now involving mental and substance abuse disorders, according to the U.S. Agency for Healthcare Research and Quality. 47,48 There is no denying that high users sometimes derive emotional benefit from the ED visits,49-51 and there are (sadly not infrequent) anecdotal reports of patients who call their previous inpatient units on a regular basis to update on their progress. However, some strategies can help deal more effectively with this group. Factors to consider in managing high users include the following. First, most of the individuals in this category have unresolved symptoms and low treatment adherence, 52 as well as urgent social needs. Thus, social interventions such as supported housing may help more than purely medical interventions; providing housing reduces medical visits and EDseeking behavior. 53,54 Second, many of these patients have trouble navigating the health system and are often ignored or lack primary care resources. Programs that address these factors can reduce ED recidivism. 36,55,56 Third, chronic substance abuse and mental illness, alone or in conjunction, often have profound impacts on cognition. High ED users often present with an undisclosed or unexplored history of head trauma, 57 as victimization rates are elevated in both substance use dis orders and mental illness.58,59 The natural corollary of this is a decreased ability to recall and comprehend instructions given in the ED. Simplifying instructions and making sure the patient understood the explanation are crucial.

istory of head trauma, 57 as victimization rates are elevated in both substance use dis orders and mental illness.58,59 The natural corollary of this is a decreased ability to recall and comprehend instructions given in the ED. Simplifying instructions and making sure the patient understood the explanation are crucial. Provide a limited, singular-focused plan, without multiple steps or complicated follow-up provisions. Simple planning applies to verbal, written, or even E-health/mobile-based interventions. Beyond the social needs, however, high users often have unmet medical needs. To get to the point of providing proper medical care, the emergency provider must deal with the patient’s attitudes and behavioral difficulties. The difficult patient is a staple of every ED and every clini cal practice. Intense patients can provoke negative feelings in providers. Unconscious biases influence health decisions, cloud clinical judg ment, and can lead to discrepancies and disparities in health care. 61-64 Negative bias is an unconscious, automatic reaction to a patient’s pre existing attributes such as gender, race, obesity status, ED recidivism, socioeconomic status, or sexual orientation. Negative bias can alter care, even with the provider’s best intentions. Dealing with difficult patients can be improved by adherence to existing protocols to the extent possible. Discussion of difficult cases with colleagues and the ED team can be helpful to develop effective strategies and to decrease provider isolation and burnout. Tintinalli_Sec24_p1933-1966.indd 1936 8/2/19 5:19 PM