Introduction to Emergency Psychiatry

1. Introduction to Emergency Psychiatry Jack Rozel, MD, MSL

2. Conflicts of Interest Research Funding – Alexza, Janssen, NIMH Conference/Travel – Alexza, Eli Lilly, Janssen, Wyeth Ayerst Speakers’ Bureaus – Pennsylvania ACLU Stock Holdings – Johnson & Johnson, United Health

3. Agenda for the course • Introduction • Medical evaluation • Legal issues • Children • Suicide • Violence • Geriatrics (Dr. EJ Santos) • Addictions (Dr. Matt Tessena)

4. Agenda for today • Introduction to the course • Principles of emergency Psychiatry • Evaluation strategy & tactics • Medical evaluation and clearance

5. Key Points • Triage • Stabilization • Evaluation • Disposition • Prioritization

7. Recommended Reading • Glick et al., Emergency Psychiatry, 2008 ($70, if you are into it) • DSM-IV-TR (Buy it – live it – love it!) • Handouts will be given by topic as we go along • www.acutechildpsychiatry.com • BlackBoard @ Miner

8. Personal Safety

9. Be Aware of Yourself • “Dress Code” • Stable, non-slippery shoes • Nonrevealing clothing • Nothing around the neck! • Keep a safe distance • Avoid physical contact beyond shaking hands, etc. • Avoid personal disclosure • Trust your gut!

10. When in doubt, get out!

11. Be Aware of the Patient • Overt threats • Escalating volume • Increased physical tension • Intoxication • Psychosis • Mania • History of aggression • Antisocial Personality / Conduct Disorder

12. Be Aware of the Environment • General tone of the milieu • Who is behind you? • Don’t crowd a patient (and don’t let them crowd you) • Are you someplace visible? Does a staff know where you are?

13. When in doubt, get out!

14. On Emergency Psychiatry & Psychiatric Emergencies

15. On Emergency Psychiatry • American Association of Emergency Psychiatry (www.emergencypsychiatry.org) • No board certification; few fellowships • Attending-staffed PEDs – uncommon • PEDs staffed with a core team – downright rare! • “More like emergency medicine than psychiatry” – Rob Redondo

16. On Emergency Psychiatry • Less like psychiatry than any other subspecialty • Emphasis on triage, evaluation, stabilization and disposition (not treatment or therapeutic rapport) • “The crossroads” • Short attention-span friendly • “Most physical medical specialty”

17. Psychiatric Emergencies, an arbitrary definition • Any condition that requires rapid clinical assessment and differential diagnosis to confirm the presence (or absence) of a potentially life threatening situation. • A condition that requires immediate evaluation by a psychiatrist to determine the nature and severity of a condition.

18. What emergency psychiatrists do… • Triage. Who will be seen first? • Evaluation. What is going on with this patient? • Stabilization. What do I need to do to rapidly help the patient transition to the next LOC? • Disposition. Where is the best/most appropriate treatment setting? • Prioritization. What do I do next?

20. Common presenting complaints • Suicide attempt or intent • Violence • Severe eating disorders • Delirium • Withdrawal from some substances • Inability to care for self • Self injurious behavior • Imminent decompensation

21. Don’t forget to ask about domestic violence

22. Strategy without tactics is the slowest route to victory. Tactics without strategy is the noise before defeat. Sun Tzu

23. What Are the Goals of a Crisis Assessment? • Evaluate – Stabilize – Dispo • Assess for acute needs or safety concerns • Stabilize if in crisis • Arrange for beneficial interventions and/or definitive treatment • Proper diagnosis must precede treatment!

24. A one-size-fits-all strategy • What is the most efficient way • To determine the next step for this patient • That is clinically appropriate, • Ethically appropriate, • And takes into account the strengths and needs of the patient • And recognizes the realities of the psychosocial environment

25. Diagnosis & Risk Formulation

26. Confirmatory Bias Confirmatory bias is the tendency to emphasize and believe experiences that support one's views and to ignore or discredit those that do not

27. Hammer… If the only tool you have is a

28. And a hammer won’t work for everything…

29. Diagnoses should be accurate, precise and specific This takes time and has a cost How many specific figures are needed to solve the equation?

30. Practice Good Diagnosis • I. Bipolar, polysubstance abuse • II. MR, r/o Asperger’s d/o • III. No acute issues • IV. Abuse victim, noncompliance with treatment • V. 85 • The DSM has hundreds of diagnoses. You are not yet qualified to make up anything new.

31. Polysubstance abuse is not a diagnosis. Also, polysubstance dependence probably does not mean what you think it means

32. When you hear hoof beats…

35. Common disorders present more commonly than rare disorders • A common disorder is more likely to present with an atypical feature than a rare disorder is likely to present with a typical feature • But the ER is the at the crossroads of modern psychiatry…

37. Disposition(A Lumper’s Oversimplification) • The patient needs to come in for treatment, safety or intensive diagnostic workup • The suicide attempt, severely depressed, psychotic • The patient can safely go home with routine outpatient follow up • Needed to be linked to services, the one-day tantrum • The patient can probably go home safely with increased services… • But they should be admitted if they bounce back

38. Tactics, Tips & Tricks

39. Identify Agenda/Expectations • Whose idea was it to come in tonight? • How can we be most helpful to you tonight? • What was the MHA for? • What can we do to keep you safe until… • What could we be most helpful with here tonight • What do you think needs to happen right away to keep you/your child safe and healthy?

41. Trust No One • Everybody lies, or at least distorts • Selective memory and emphasis for a variety of motives • Sometimes comes down to he said/she said

42. Collateral, Collateral & More Collateral A page of history is worth a volume of logic. • Past records • Treatment team – current/recent mental health providers, also PCPs • Parents, children, spouses, paramours • Friends, coworkers

43. Asking About Psychiatric History • Ever been seen by a psychiatrist, psychologist or therapist before? Has it ever been recommended by? (What for, when?) • Ever been on medications for mood, behavior or anxiety disorders like Prozac or Ritalin? • What diagnoses have you had? Did those diagnoses make sense to you? Why or why not? • Does your behavior remind you of other people in you family?

44. Don’t Forget to Ask About (and Use) the Positive! • What are your strengths? What classes or activities do you do well in? • What coping skills work best for you? • Who are your supports? Who is there for you? • What are you looking forward to in life? • Is religion important to you? • What makes you proud of yourself? Why do your friends like you?

45. Treatment/Admission Criteria

46. When to Treat (versus cautious observation) • Impairment in development, functioning at home/work/school, socialization • Significant subjective distress • Dangerous symptoms or behavior • Prevention of anticipated symptoms or impairment (known pattern of pt) • When treating the disorder benefits the patient!!!

47. What Does Inpatient Hospitalization Provide? • Rapid, intense treatment • Close and skilled observation, e.g. regular vitals, medical exam, lab testing • Frequent evaluation by an MD • Individual and group therapy • Safe environment • Secured, locked unit • Intensive observation • Limited stimuli or access to drugs

48. Why Hospitalize? Not because of the evidence!

49. Why Hospitalize? • (Acutely) worsening symptoms of an identified/identifiable psychiatric illness • And imminent/serious danger to self or others • And a disorder amenable to inpatient treatment • And a situation that is unsafe to continue with a less intensive treatment setting

50. Key Points • Triage • Stabilization • Evaluation • Disposition • Prioritization