Psychiatry Expert Questions

Psychiatry – Expert questions

Evaluation a) History E H b) Physical examination E H c) Mental state examination E H d) Investigations I H

Emergency Department Screening Assessment

Targeted History

 Focus on precipitating causes and circumstances that brought the patient to the emergency department.  Elicit information from multiple sources such as family, friends, or ambulance personnel.  Previous psychiatric treatment, seizure disorders, polysubstance abuse, and  Any recent suicidal attempts including possible ingestions.

Focused Physical Examination

 Thorough physical examination, including neurologic assessment.  Complete vital signs  Look for physical clues to the source of an altered mental status, such as evidence of head injury, drug use, or toxidromes.  Assess the patient for adverse consequences of his or her behavior such as malnutrition or dehydration.

Mental Status Examination

 Document the mental status examination in patients presenting with psychiatric emergencies.  Probe for global functioning, thought disorders, mood disorders, and personality disorders.

Global Functioning

 General orientation (person, place, time, reason for visit),  Memory (short and long term),  Judgment, and  Concentration.

Thought Disorders

 Abnormal thought content such as o hearing voices, o experiencing command hallucinations, or o paranoid thoughts

Mood Disorders

 Evidence of depression or mania.  Compare the appropriateness of the patient's stated mood with his or her overt affect.  Look for clues such as emotional lability or unbalanced emotional extremes. Personality Disorders

 A decompensation in his or her normal functioning or a representative sample of a maladaptive pattern of behavior derived from an underlying socially inappropriate personality matrix.

Screening Laboratory Tests

The following studies are often helpful in the evaluation of patients presenting with psychiatric emergencies:

 Electrolyte panel with glucose  Pulse oximetry  Toxicology screen  Liver function tests  Computed tomography (CT) scan of the head  Electrocardiogram (ECG)

 Thyroid function tests

The Psychiatric mental state examination:

The psychiatric evaluation addresses several dimensions of mental processes that are briefly discussed below. (LOABAAMMTPI)

 Level of Consciousness. o alert, o lethargic, o stuporous, or in o coma.  Orientation. This has four dimensions: person, place, time, and situation. o Does the patient know who he and others in the room are? o Does he know their names and roles? o Does he know where he is—the place, city, state, country? o Does he know the year, season, day, and date?  Appearance and Behavior. Close observation of the patient during the interview will provide important information. o How is the patient dressed and groomed? o How is the patient's personal hygiene? Does the patient make and sustain eye contact? o Does the patient answer questions promptly and fully? Are there areas of questioning that the patient avoids or tries to deflect? o What is the patient's body language? o Is the patient fidgeting or unusually still? o What is the patient's tone of voice, volume, and speech rhythm?  Attention. This is the ability to stay on task and follow the course of a conversation and interview avoiding distractions. o Attention deficits are the hallmark of confusional states and delirium and should alert the clinician to the possibility of a metabolic disorder. o Tests of serial 7s, serial 3s (subtract 3 sequentially, starting at 20), and attempting to spell "world" backwards are tests of attention. o Always consider the patient's level of education in interpreting these tasks. o A nonverbal task is the tap-no-tap test. Have the patient tap his or her hand twice when you tap once; if you tap twice they are not to tap.  Affect. This is the more transient state of emotion, which varies from minute to minute and day to day, depending upon the setting and types of social and personal interactions in which a person is engaged. Affect is the clinician's assessment of emotion and is assessed by facial expression, tone, and modulation of voice and specific questions about how the patient feels. Affect is also measured by considering intensity and range of expression. Affective states include o happy, o Sad, o angry, o fearful, o worried, and o wary.  Mood. Mood is the sustained affective state of the patient: how they feel. It is more like the tidal flow of emotion than the waves of affect. Mood is classified as normal, depressed, or elevated. Mood should be assessed, by asking the patient, how his or her mood has been over the last 2 weeks. Other questions used to evaluate mood include questions regarding how the patient feels about his or her life, the patient's thoughts of the future, the patient's confidence in his or her abilities, and the patient's hopes, and the intensity of these feelings. If depression is suspected, it is mandatory to inquire about suicidal thoughts or plans. Depressed patients may show blunted affect with little range.  Memory. This is the ability to register and retain material from previous experience. Memory is a complex phenomenon. It is usefully classified as immediate recall (registration), short- and long-term memory. o Immediate recall is the ability to register items presented. Short-term memory is the ability to recall the registered items within 5 to 10 minutes. o Long-term memory is the ability to recall events from the more distant past from days to years. o Specific tests of immediate recall and short-term memory are included in the MMSE. Short- and long-term memory is evaluated while taking the history. Find out what the patient is really interested in (such as politics, sports, cooking, etc.) and ask them, specific detailed questions about it, questions that demand specific quantitative, rather than vague qualitative answers.  Thought. This is how the brain communicates consciously with itself. Thought has several dimensions. o The content of thought is what the patient is thinking about. Is it appropriate to his or her situation and a reasonable perception of the world? o The sequence of thoughts is also important. How are they linked one to the next? Can the patient digress and get back to the original point? The logic a person uses to connect events and explanations should be evaluated. What is the nature of cause and effect in his or her life? What are the reasons he gives for seeking care? o Insight is the ability to look at one's self and situation with comprehension and understanding. Lack of insight into the nature or consequences of behaviors or thoughts is an important clue to mental illness. o Judgment is the ability to make reasonable assessments of the external world and choices between alternative actions. How are decisions made? How does the patient evaluate alternatives? How are potential benefits and risks considered?  Perception. This is a global term for the way in which a person experiences the world through the senses. Distortions of perception can be symptoms of either neurologic or psychiatric disease. o Hallucinations are sensory experiences perceived only by the patient, not by an observer. They may be auditory, visual, tactile, gustatory, or olfactory. . Auditory hallucinations are particularly common in psychosis, . Visual hallucinations are more common in delirium. . Gustatory and olfactory hallucinations are common in partial seizure disorders (temporal lobe epilepsy). o Illusions are the incorrect perception of objects seen by both the patient and the observer. These are particularly common with sensory impairment such as visual loss. o Structural perception is the ability to place objects and shapes in relation to one another. It can be tested by having the patient copy interlocked pentagons (MMSE) or perform clock drawing.  Intellect. Intellect is generally held to be an innate brain faculty, though it is difficult to separate deficits of intellect from deficits of education. The clinician must know the patient's educational and literacy level in order to properly evaluate his or her intellect. Culture greatly influences tests of intellect and it is hazardous to make assessments across cultures. There are several dimensions of intellect. o What is his or her information level? Does he know about important local, national, or international events? What are his or her sources of information? o Calculations, the ability to manipulate numbers are tested by simple and gradually more complex arithmetic tasks. o Abstraction is the ability to see general principles in concrete statements. Abstractions are tested by asking the patient to interpret proverbs, for example, "people in glass houses shouldn't throw stones" = "don't criticize others for things you have probably done yourself." Interpretation at the simplest level, for example, "they would break the windows," is indicative of a concrete thinking and a deficit in abstract thinking. Remember that proverbs are culturally bound and may not be recognizable to people from different cultural backgrounds. o Reasoning is the ability to solve problems involving simple logical sequences. o Language is what one brain uses to communicate with another brain. It is tested in the interview and by having the patient follow both written, verbal instructions and write a sentence (MMSE). Assess the patient's vocabulary and the complexity of the patient's spoken language. o Other dimensions of language are fluency of speech, body language, facial expression, and other nonverbal forms of communication; all should be thought of as language.

Organic brain syndrome DIS H Delirium, dementia, amnesia, and certain other alterations in cognition are subsumed under more general terms such as mental status change (MSC), acute confusional state (ACS), or organic brain syndrome (OBS). The term organic brain syndrome is used to distinguish changes in cognitive/behavioral functions due to physical (organic) causes from those due to psychiatric (functional) causes. Organic brain syndrome can be divided into 3 major subgroups:  Acute (delirium or acute confusional state) and  Chronic (dementia).  Encephalopathy (subacute organic brain syndrome), denotes a gray zone between delirium and dementia; its early course may fluctuate, but it is often persistent and progressive. The final common pathway of all forms of organic brain syndrome is an alteration in cortical brain function. This condition results from (1) An exogenous insult or an intrinsic process that affects cerebral neurochemical functioning or (2) Physical or structural damage to the cortex.

The end result of these disruptions of function or structure is impairment of cognition that affects some or all of the following: alertness, orientation, emotion, behavior, memory, perception, language, praxis, problem solving, judgment, and psychomotor activity.

Delirium Delirium is an acute organic brain syndrome, characterised by sudden onset (hours or days) of disordered attention and arousal - a reduced ability to focus, sustain or shift attention. It may be accompanied by disturbances of cognition, psychomotor behaviour and perception. It has a fluctuating course and lucid intervals may occur.

There are three main clinical categories of delirium:  Hypoactive: Easily missed or misdiagnosed as depression or fatigue. Quiet, passive, withdrawn, drowsy, can’t concentrate.  Hyperactive: Not missed. Irritable, vigilant, restless, agitated, has insomnia.  Mixed with fluctuations between hypo-active and hyper-active: the most common type of delirium.

Delirium can be misdiagnosed as dementia or depression. Use the Confusion Assessment Method (CAM) tool. Presence of (1) and (2) and either (3) or (4) is required to firmly diagnose delirium: (1) Acute onset, fluctuating course; and (2) impaired attention, impaired focus of concentration (initiating, maintaining, shifting focus at will); and either (3) confusion or any impaired cognition; or (4) altered consciousness: alertness/activity

Etiology of delirium and other cognitive disorders. Disorder Possible Causes Intoxication Alcohol, sedatives, bromides, analgesics (eg, pentazocine), psychedelic drugs, stimulants, and household solvents. Drug withdrawal Withdrawal from alcohol, sedative-hypnotics, corticosteroids. Long-term effects of Wernicke-Korsakoff syndrome. alcohol Infections Septicemia; meningitis and encephalitis due to bacterial, viral, fungal, parasitic, or tuberculous organisms or to central nervous system syphilis; acute and chronic infections due to the entire range of microbiologic pathogens. Endocrine disorders Thyrotoxicosis, hypothyroidism, adrenocortical dysfunction (including Addison's disease and Cushing's syndrome), pheochromocytoma, insulinoma, hypoglycemia, hyperparathyroidism, hypoparathyroidism, panhypopituitarism, diabetic ketoacidosis. Respiratory disorders Hypoxia, hypercapnia. Metabolic Fluid and electrolyte disturbances (especially hyponatremia, hypomagnesemia, and disturbances hypercalcemia), acid-base disorders, hepatic disease (hepatic encephalopathy), renal failure, porphyria.

Nutritional Deficiency of vitamin B1 (beriberi), vitamin B12 (pernicious anemia), folic acid, deficiencies nicotinic acid (pellagra); protein-calorie malnutrition. Trauma Subdural hematoma, subarachnoid hemorrhage, intracerebral bleeding, concussion syndrome. Cardiovascular Myocardial infarctions, cardiac arrhythmias, cerebrovascular spasms, hypertensive disorders encephalopathy, hemorrhages, embolisms, and occlusions indirectly cause decreased cognitive function. Neoplasms Primary or metastatic lesions of the central nervous system, cancer-induced hypercalcemia. Seizure disorders Ictal, interictal, and postictal dysfunction. Collagen-vascular and Autoimmune disorders, including systemic lupus erythematosus, Sjögren's immunologic disorders syndrome, and AIDS. Degenerative diseases Alzheimer's disease, Pick's disease, multiple sclerosis, parkinsonism, Huntington's chorea, normal pressure hydrocephalus.

Medications Anticholinergic drugs, antidepressants, H2-blocking agents, digoxin, salicylates (chronic use), and a wide variety of other over-the-counter and prescribed drugs.

Delirium always has an organic cause. Pathologic mechanisms are complex and are thought to involve widespread neuronal or neurotransmitter dysfunction. There are four general causes: 1. Primary intracranial disease 2. Systemic diseases secondarily affecting the central nervous system (CNS) 3. Exogenous toxins 4. Drug withdrawal

History For patients with delirium, attempt to obtain a current and past history from other sources, including prehospital workers, family or friends, and past medical records.  Look specifically for street drug, alcohol, and medication use; preexisting endocrine disorders; and recent activities that may have resulted in exposure to toxins or environmental injury.  Ask about prior psychiatric illness and similar episodes of confusion in the past. Physical Examination  General appearance -possibility of drug or alcohol abuse.  Smell for alcohol, the musty odor of fetor hepaticus, or the fruity smell of ketoacidosis.  Icterus and asterixis point to liver failure with an elevation of the serum ammonia level.  Agitation and tremulousness suggest sedative drug or alcohol withdrawal.  Close attention to vital signs  Fever may point to infection, heat illness, thyroid storm, aspirin toxicity, or withdrawal syndromes.  Focal neurological deficit s/o stroke.  Rapid respiratory rate - consider diabetic ketoacidosis (ie, Kussmaul respiration), sepsis, stimulant drug intoxication, and aspirin overdose.  Slow respiratory rate - consider narcotic overdose, CNS insult, or various sedative intoxications.  Rapid pulse rate is seen in patients with fever, sepsis, dehydration, thyroid storm, and various cardiac dysrhythmias and in overdoses of stimulants, anticholinergics, quinidine, theophylline, tricyclic antidepressants, or aspirin.  Slow pulse rate - elevated intracranial pressure, asphyxia, or complete heart block. Calcium channel blockers, digoxin, and beta-blockers also may produce altered mental status and bradycardia.  Blood pressure elevation is common in delirium because of resulting adrenergic overload.  In patients with hypertension and bradycardia, consider an elevated intracranial pressure (Cushing reflex). A brief bedside neurologic examination, including mental status testing, is an essential part of the workup of organic brain syndrome and altered mental status. The Mini-Mental Status Examination (MMSE): A score of less than 24 suggests the presence of delirium, dementia, or another problem affecting the patient's mental status and may indicate the need for further evaluation. Investigations: Bedside:  ECG – to rule out arrhythmias, ischemia and drug toxicities  BSL – to r/o hypo/hyper-glycemia  ABG and carboxyhemoglobin – to r/o acidosis and assess respiratory status  Urinalysis – to rule out dehydration, casts, infection and toxicology screen

Laboratory  FBC – rule out anemia, leukaemia  EUC – to look for sodium abnormalities, renal failure  CMP  LFT – to rule hepatic dysfunction and serum ammonia if indicated  Thyroid function tests – hypo/hyperthyroidism  Vitamin B12 and folate levels, iron studies  Coagulation profile  Serum ethanol, paracetamol and salicylate levels when indicated  Drug levels if on anti-epileptics to rule out toxicity or compliance issues  Serum cortisol In suspected CNS infection, the following may be ordered:  Lumbar puncture may be done for CSF studies Radiology  Chest x-ray – to rule out infection  CT scan of head to rule out IC disorders Dementia

Dementia is a progressive decline in general cognitive function, with normal consciousness and attention. Dementia is a disturbance of cognitive and higher cortical function. The hallmark of dementia is the loss of short term memory and evidence of global impairment. There is no clouding of consciousness and is typically of slow onset with normal attention. Epidemiology  <1% in <60yrs of age and >30% in >80yrs of age with increasing incidence Pathology  Plaques of amyloid beta tangles composed of hyperphosphorylated TAU  Neurodegeneration in Alzheimer’s starts >20yrs before manifestation  Earliest changes in medial temporal lobe, hippocampus and entorhinal cortex Clinical features  Memory loss  Apathy  Depression  Irritability  Aggression/ agitation in 25%  Delusions in 20%  Impairment of memeory and orientation with preservation of motor and speech abilities is said to be characteristic of the onset of AD.  Alzheimer’s dementia: o Early – complaints of memory loss, naming problems or forgetting items o Middle – progression of above problems + loss of reading, decreased performance in social situations and losing directions o Late – extreme disorientation, inability to dress or perform self-care and personality change. Causes

Degenerative Alzheimer disease, Huntington disease, Parkinson disease, others Vascular Multiple infarcts, Hypoperfusion (cardiac arrest, profound hypotension, others), Subdural hematoma, Subarachnoid hemorrhage Infectious Meningitis (sequelae of bacterial, fungal, or tubercular), Neurosyphilis, Viral encephalitis (herpes, HIV), Creutzfeldt-Jakob disease Inflammatory Systemic lupus erythematosus, Demyelinating disease, others Neoplastic Primary tumors and metastatic disease, Carcinomatous meningitis, Paraneoplastic syndromes Traumatic Traumatic brain injury, Subdural hematoma Toxic Alcohol, Medications (anticholinergics, polypharmacy) Metabolic

Vitamin B12 or folate deficiency, Thyroid disease, Uremia, others Psychiatric Depression Hydrocephalus Normal-pressure hydrocephalus (communicating hydrocephalus), Noncommunicating hydrocephalus

Diagnosis  H/o memory problems – usually slow progression without landmark occurrences  If specific dates of worsening are noted, possibility of vascular dementia increases – fluctuating course  Family history may be significant – Huntington disease – Autosomal dominant  Physical examination – usually normal o Focal neurologic signs – vascular dementia or mass lesion o Increased motor tone and extrapyramidal signs – Parkinson’s disease  Investigations o CBC, serum electrolytes, CMP, glucose, BUN, creatinine and LFT o TFT, serum vitamin B12 and folate o Serology for syphilis and HIV when indicated o Urinalysis, ESR, CXR o CTB and MRI when indicated o Lumbar puncture when diagnosis in doubt  Investigations for cause of acute deterioration of function should occur if the clinical presentation is sub-acute in nature  Normal pressure hydrocephalus should be suspected when C brain have excessively large ventricles and urinary incontinence and gait abnormalities occur early in disease Treatment  Environmental or psychosocial interventions  Antipsychotic drugs – o management of psychotic and non-psychotic behaviors o management of extreme disruptive and dangerous behaviors  vascular dementia – treatment of risk factors including hypertension  NPH – trial of ventricular shunting Disposition  Diagnosis of dementia needs in-depth diagnostic evaluation and may exceed the length of stay in ED and plans for admission or out-patient follow up should be made  Attention in ED should be directed toward presence of delirium or a treatable cause of dementia  Consideration for admission o Diagnosis in doubt o Atypical or rapid clinical course o Unsafe or uncertain home situation Differentiating delirium, dementia and depression Feature Delirium Dementia Depression Onset Acute/sub-acute depends Chronic, generally Coincides with life changes, on cause, often twilight insidious, depends on often abrupt cause Course Short, diurnal Long, no diurnal effects, Diurnal effects, typically worse fluctuations in symptoms progressive in the morning; situational symptoms; worse at yet relatively stable over fluctuations but less than acute night in the dark and on time confusion awakening Progression abrupt slow but even Variable, rapid-slow but uneven Duration Hours to less than 1 Months to years At least 2 weeks, but can be month, seldom longer several months to years Awareness Reduced Clear Clear Alertness Fluctuates; lethargic or Generally normal Normal hypervigilant Attention Impaired, fluctuates Generally normal Minimal impairment but is distractible Orientation Fluctuates in severity, May be impaired Selective disorientation generally impaired Memory Recent and immediate Recent and remote Selective or patchy impaired impaired impairment,'islands' of intact memory Thinking Disorganised, distorted, Difficulty with Intact but with themes of fragmented, slow or abstraction, thoughts hopelessness, helplessness or accelerated, incoherent impoverished, marked self-deprecation poor judgment, words difficult to find Perception Distorted; illusions, Misperceptions often Intact; delusions and delusions and absent hallucinations absent except in hallucinations, difficulty severe cases distinguishing between reality and misperceptions Stability Variable hour to hour Fairly stable Some variability Emotions Irritable, aggressive, Apathetic, labile, irritable Flat, unresponsive or sad; may fearful be irritable Sleep Nocturnal confusion Often disturbed; Early morning awakening nocturnal wandering and confusion Other Features Other physical disease Past history of mood disorder may not be obvious Hallucinations Common Late feature Uncommon until late Psychomotor Hyper or hypo Late Uncommon changes Depression

Depression is a common mental disorder that presents with depressed mood, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and poor concentration. These problems can become chronic or recurrent and lead to substantial impairments in an individual's ability to take care of his or her everyday responsibilities. At its worst, depression can lead to suicide. Pathophysiology The underlying pathophysiology of major depressive disorder has not been clearly defined. Research suggests a disturbance in CNS serotonin activity (5-HT) as an important factor. Other neurotransmitters implicated include norepinephrine(NE) and dopamine(DA). All available antidepressants appear to work by one of the following mechanisms:  Presynaptic inhibition of uptake of 5-HT or NE  Antagonist activity at presynaptic inhibitory 5-HT or NE receptor sites→ enhanced neurotransmitter release  Inhibition of monoamine oxidase, thereby reducing neurotransmitter breakdown Diagnosis Depressive disorders include major and minor depression. Major depressive disorder is defined by the presence of five or more symptoms from the DSM-IV criteria, while minor depressive illness is defined as presence of depressive symptoms without fulfilling criteria for major depression.

DSM-IV criteria for major depression Five or more symptoms persisting for over a 2 week period causing clinically important distress or impairing work, social or personal functioning. 1st criteria to be present compulsorily  Depressed mood most of the day, occurring most days (subjective or observed)  Markedly diminished interest or pleasure most of the day, nearly everyday  Significant weight or appetite change  Insomnia or hypersomnia  Psychomotor retardation or agitation (observable by others)  Fatigue or loss of energy  Feelings of worthlessness or inappropriate guilt  Diminished ability to concentrate or make decisions  Recurring thoughts of death or suicide plans

Mortality/ Morbidity  Major depressive disorder (MDD) carries significant morbidity and mortality due to: o Contributing to suicide o Medical illness o Disruption in interpersonal relationships o Substance abuse and o Lost work time  Risk factors for suicide include: o Male sex o Age >55yrs o Concurrent chronic medical illness o Social isolation e.g. divorced, widowed o Depression – severe melancholic or delusional symptoms o Substance abuse and dependence o Family h/o suicide and/or MDD o Command hallucinations o Access to firearms and options o White race Differential diagnosis Patients presenting with alterations of mood may have any of the extensive diagnosis but following should always be considered:  Mood disorders due to CNS conditions  Alzheimer disease  Neoplastic lesions of the CNS  Inflammatory conditions: SLE, vasculitis  Sleep disorders – especially OSA  Infectious diseases: syphilis, HIV  Pharmacologic agents – β-blockers, anti-HT medications, steroids, sex hormones (including OCP), H2 blockers, sedatives appetite suppressants, chemotherapy agents and OTC medications  Endocrinologic disorders – esp those affecting hypothalamus-pituitary-adrenal axis – Addison’s, Cushing’s, hyperparathyroidism, hypo or hyperthyroidism  Substance use, abuse or dependence  Anxiety disorders – panic disorders, OCD, PTSD, phobia and generalized anxiety disorder  Eating disorders  Personality disorders Physical findings No physical findings are specific for MDD. Diagnosis lies in history and MSE.  Appearance and affect o Normal appearance usually o Decline in grooming and hygiene in severe cases o Psychomotor retardation – slowing of spontaneous movement and reactivity o Flattening and loss of reactivity o Psychomotor agitation and restlessness  Mood and thought process o Dysphoric mood state – sadness, numbness, irritability or mood swings o Loss of interest or pleasure in usual activities o Difficulty concentrating or loss of motivation o Negative feelings, worthlessness, hopelessness and helplessness  Cognition and sensorium o complain of poor memory or concentration. o Most commonly, no significant deficits are found on cognitive examination. o Level of consciousness is normal o Fluctuating or depressed sensorium suggests delirium  Speech o Normal/slow/monotonic o Lacking spontaneity and content o Pressured speech – mania, disorganized speech – psychosis, racing thoughts – mania or hypomania  Thought content, suicidality and homicidality o Feeling overwhelmed, inadequate, helpless, worthless or hopeless o h/o suicidal attempt and violence are high risk factors for future attempts o hallucinations and delusions, including command hallucinations could be present  Depression screening tests o PDQ-9, mood disorder questionnaire o Hamilton and the Beck depression inventory Investigations Laboratory  FBC, EUC, CMP  Thyroid function tests  Vasculitic screen, ESR  Vitamin B12  HIV, syphilis serology when indicated  LFT  Blood alcohol and urine drug screen  ABG  Dexamethasone suppression test – Cushing disease  Cosyntropin stimulation test Imaging studies  CXR  CT and/or MRI brain Other tests: EEG, ECG, lumbar puncture

Management Mild depression – supportive care or counseling Moderate depression –  Antidepressant therapy, CBT and psychotherapy all equally effective  Most important factor is the therapeutic relationship with the provider  SSRIs usually first line in drug therapy  Fluoxetine – only AD with demonstrated efficacy in childhood and adolescent depression  TCAD  Other agents – SNRI – venlafaxine, NARI –reboxetine, RIMA – moclobemide  Pharm therapy improves symptoms in 50-70% of patients  Effects usually take 2-4 weeks to become evident  Alternative therapy if no effect in 4 weeks  50-70% of initial non-responders will respond to different agent Severe depression  Anti-depressant therapy +  Close therapeutic relationship and follow up  ECT

Some facts about pharmacologic anti-depressant therapy  All antidepressants on the market are potentially effective. Usually, 2-6 weeks at a therapeutic dose level are needed to observe a clinical response.  SSRIs include fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro). This group has the advantage of ease of dosing and low toxicity in overdose. Common adverse effects include GI upset, sexual dysfunction, and changes in energy level (ie, fatigue, restlessness).  Escitalopram has been shown to have superior efficacy to other antidepressants in the treatment of more severe depression. Escitalopram has also been shown to be at least as effective as SNRIs and better tolerated, even in severe depression.  Selective serotonin/norepinephrine reuptake inhibitors (SNRIs) include venlafaxine (Effexor) and duloxetine (Cymbalta). Safety, tolerability, and side effect profiles are similar to that of the SSRIs, with the exception that the SNRIs have been associated (rarely) with a sustained rise in blood pressure. SNRIs can be used as first-line agents, particularly in patients with significant fatigue or pain syndromes associated with the episode of depression. The SNRIs also have an important role as second-line agents in patients who have not responded to SSRIs.  St. John's wort (Hypericum perforatum), Research indicates that it acts as an SSRI and not as a monoamine oxidase inhibitor (MAOI) as previously believed.The dosage is 300 mg 3 times a day with meals to prevent GI upset. If no clinical response occurs after 3-6 months, encouraging the use of another medication is essential.  Atypical antidepressants include bupropion (Wellbutrin), nefazodone (Serzone), mirtazapine (Remeron), and trazodone (Desyrel). This group also shows low toxicity in overdose and may have an advantage over the SSRIs by causing less sexual dysfunction and GI distress. Bupropion is associated with a risk of seizure at higher doses, especially in patients with a history of seizure. Mirtazapine is a potent antagonist at 5-HT2, 5-HT3, alpha2-, and histamine (H1) receptors and, thus, can be very sedating.  Tricyclic antidepressants (TCAs) include amitriptyline (Elavil), nortriptyline (Pamelor), desipramine (Norpramin), clomipramine (Anafranil), doxepin (Sinequan), protriptyline (Vivactil), trimipramine (Surmontil), and imipramine (Tofranil). This group has a long record of efficacy in the treatment of depression and has the advantage of lower cost. They are used less commonly now because of the need to titrate the dose to a therapeutic level and because of their considerable toxicity in overdose. Adverse effects largely are due to their anticholinergic and antihistaminic properties and include sedation, confusion, dry mouth, orthostasis, constipation, urinary retention, sexual dysfunction, and weight gain. Caution should be used in patients with cardiac conduction abnormalities.  MAOIs include phenelzine (Nardil) and tranylcypromine (Parnate). MAOIs are widely effective in a broad range of affective and anxiety disorders. Because of the risk of hypertensive crisis, patients on these medications must follow a low-tyramine diet. Other adverse effects can include insomnia, anxiety, orthostasis, weight gain, and sexual dysfunction.

Non pharmacologic treatments:

Electroconvulsive therapy  Is a highly effective treatment for depression and may have a more rapid onset of action than drug treatments.  Advances in brief anesthesia and neuromuscular paralysis have improved the safety and tolerability of this modality.  Risks include those associated with brief anesthesia, postictal confusion, and, more rarely, short- term memory difficulties.  ECT is used when a rapid antidepressant response is needed, when drug therapies have failed, when there is a history of good response to ECT, or when there is patient preference.  ECT is particularly effective in the treatment of delusional depression. Other therapies with some proven benefit include:  Light therapy – efficacy in non-seasonal depression  Transcranial magnetic stimulation – investigational stages  Vagus nerve stimulation – some efficacy in treatment resistant MDD  Accupuncture therapy – significant symptoms reduction in pregnant patients.

Consultations  Psychiatrist referral necessary for severe symptoms with need for intensive care e.g. suicidal ideation, psychosis, mania and severe decline in physical health  Behavioural therapist or Psychologist can be a very useful adjunct  Whenever possible the primary medical practitioner should be involved closely in follow up plans for these patients Disposition  Indications for inpatient psychiatric care include o MDD with risk of harm to patient and others o Depression with psychotic features o Progressive inanition o Suicidality or inability to care for oneself at home o When ECT is indicated as therapy  Successful treatment of MDD requires good follow up care after resolution of the acute episode  Recurrences are common in 50-80% of patients with an episode of MDD  Treatment to continue for 6-12months after resolution of major episode.  If anti-depressant therapy needs to be discontinued, risk of relapse is 0.4 vs. 1 for tapering over 1-7 days compared to tapering over 7-14 days.  Psychotherapy – helpful once somatic and melancholic symptoms have improved. TRIAGE OF POTENTIAL MENTAL HEALTH PRESENTATIONS

Triage represents the first clinical contact with the patient to determine urgency of care and includes:  Initial risk assessment  Determination of observation level

People with mental health problems commonly:  Self-present  Are referred by health professionals  Are brought by concerned friends and relatives  Are escorted by others such as police or ambulance services Initial risk assessment should focus on:  Risk of aggression  Risk of suicide and self-harm  Risk of absconding  Risk of physical problem Triage is guided by the Australian triage scale (ATS) mental health and behavioural indicators. Need for triage:  High risk presentations are likely to require 1 to 1 nursing (specialling), close security presence and observation. Triage codes and expected management principles: Triage Treatment Description Typical presentation General management principles Code Acuity 1 Immediate -Definite danger to Observed Supervision self and/or others -violent behaviour Continuous visual observation or ATS states -Possession of weapon special 1:1 nursing -Severe behavioural -Self-harm in ED Action disorder with -Displays extreme agitation -Alert ED medical staff immediate threat of and restlessness immediately dangerous violence -Bizarre/disoriented -Alert mental health Reported liaison/service -Command hallucinations to -Provide safe environment harm -Ensure adequate personnel to -Recent violent behaviour provide restraint Consider -Call security ±Police if required -Intoxication with ETOH/drugs ↑risk of violence 2 Emergency -Probable risk of Observed Supervision Within danger to self or -Extreme Continuous visual or 1:1 10m others and/or agitation/restlessness observation -Physically restrained -Physically/verbally Action and/or aggressive -Alert medical staff immediately -Severe behavioural -Confused/unable to -Alert MH liaison disturbance cooperate -Provide safe environment ATS states -Hallucinations/delusions/ -Use defusing techniques Violent or aggressive paranoia -ensure adequate personnel to -Immediate threat to -Requires restraint provide restraint self/others -High risk of absconding Consider -Requires or has Reported -If defusing techniques fail, re- required restraint -Attempt/threat at self- triage to cat 1 -sever harm - Security presence until sedated agitation/aggression -Unable to wait safely -drug/ETOH intoxication ↑risk of violence 3 Urgent Possible danger to Observed Supervision Within 30 self or others -Agitated/restless Close supervision by staff or minutes -Moderate -Intrusive behaviour support person behavioural -Confused Do not leave alone in waiting disturbance -Ambivalence about room -Severe distress treatment Action ATS states -Not likely to wait for -Alert MH liaison -Very distressed, risk treatment -Ensure safe environment of self-harm Reported Consider Acutely psychotic or -Suicidal ideation -Re-triage if worsening thought disordered -Situational crisis -Restlessness -Situational crisis, Psychotic symptoms -Intrusiveness deliberate self-harm -Hallucinations/delusions -Agitation/aggression -Agitated/withdrawn -Paranoia/thought Increasing distress disordered -Intoxication ↑risk for violence -bizarre behaviour Mood disturbance -Severe symptoms of depression -Withdrawn/ uncommunicative -And/or anxiety -Elevated or irritable mood

4 Semi- Moderate distress Observed Supervision urgent ATS states -No agitation/restlessness Intermittent observation Within 60 -Semi-urgent MH -Irritable without aggression Action minutes problem -Cooperative Consult MH liaison -Under observation -Gives coherent history Consider and/or no immediate Reported -Re-triage if any worsening risk to self or others -Pre-existing MH disorder -Restlessness -Symptoms of -Intrusiveness anxiety/depression without -Agitation suicidal ideation -Aggressiveness -Willing to wait -Increasing distress -Intoxication ↑risk for violence

5 Non- No danger to self or Observed Supervision urgent others -Cooperative Routine observation Within 120 -No acute distress -Communicative and able to Action minutes -No behavioural engage in developing -Discuss with MH liaison disturbance management plan -Refer back to community MH ATS states -Able to discuss concerns team -Known patient with -Compliant with instructions -Refer to social worker chronic symptoms Reported -Refer to GP -Social crisis, -Known patient with chronic -Mobilise usual community clinically well patient psychotic symptoms support -Known patient with chronic un-explained somatic symptoms -Request for medication -Minor adverse effect of medication -Financial, social or relationship problems Features suggesting need for urgent assessment  Significant physical injury or illness e.g. poisoning, intoxication or injury  Patient with co-morbid physical and mental health presentation  Patient unaccompanied  First presentation  Dependants e.g. babies and children  If patient brought by Police, Ambulance or MH worker Risk factors for aggression include:  Act of violence, Threatened aggression  History of violence  Agitated, Angry/menacing  Persecutory ideation  Delusions or hallucinations with violent content  Intoxication – drugs or ETOH  Brought in by Police  Dependent children who are vulnerable  Confusion/disorientation  Increasing anger  Unwilling to communicate Risk factors for suicide/self-harm include:  Significant physical injury  Attempt or thoughts  Past attempt  Severe depression  Quiet and withdrawn, difficult to engage  Unable/unwilling to communicate  Unaccompanied  Overt suicidal ideation  Recent discharge from psychiatric unit  Agitation  Intoxication – alcohol or drugs  Corroborative history indicating recent suicidal ideation  Impulsive Patients who require mental health service consultation/review include those with:  Suicide attempt/ideation  Self-harm  Agitation  MH related aggression  Sever distress  Severe depression  Psychosis  Patients who request MH services  Patients with complex or difficult MH problems  Confusion with behavioural disturbance  Advice regarding sedation or medications Possible reasons for Psychiatric admission are a mental illness or disorder plus:  Danger to self/others  Unable to care for self  Extreme distress  Problems/diagnoses uncertain but behaviour causes concern – further assessment/observation needed  Need for stabilisation/treatment of condition  Treatment failure or resistance  Exacerbation of illness coupled with failure of usual supports General Approach to all Psychiatric patients /presentations SACCIT S – Safety A – Assessment C – Confirm provisional diagnosis C – Consult I – Immediate treatment T – Transfer of care

Common symptoms and presentations Self-harm suicidal behaviour or Ideation Detection Factors that increase or decrease risk of suicide Demographic factors that ↑risk Personal factors that ↑risk Protective factors that ↓risk -Unemployment -‘At risk’ mental status – -Strong perceived social supports -Alcohol/drug use hopelessness, despair, agitation, -Family cohesion -H/o physical and/or sexual abuse shame, guilt, anger, psychosis, -Peer group affiliation -Family discord psychotic thought process -Good coping and problem solving -Homelessness -Recent interpersonal crisis esp. skills -Incarceration rejection, humiliation -Positive values and beliefs -Mental health problems esp. -Recent suicide attempt -Ability to seek and access help depression -Recent major loss or trauma or anniversary -Alcohol/drug intoxication -Drug withdrawal state -Chronic pain or illness -Financial difficulties -Impending legal prosecution or child custody issues -Cultural or religious conflicts -Lack of social support network -Unwillingness to accept help -Difficulty accessing help – language barriers, lack of information, lack of support, negative experience with MH services

People at risk of suicide who present to ED should be triage according to their risk category using the Australasian Triage Scale (ATS) guidelines. High suicide risk is suggested by:  High intent  Definite plan  Hopelessness  Depression  Psychosis  Past attempts  Impulsivity  Intoxication  Male gender  Recent psychiatric hospitalisation  Access to means Approach to patient: SACCIT Safety  Ensure safety of patient and others,  Close observation. 1:1 nursing if high risk of absconding or harm  Prevent access to dangerous items  Search personal belongings to ensure lack of risky items e.g. medications, weapons etc Assessment  History o Mode of presentation o History of recent attempt if already occurred o Assess urgently as to need for urgent medical care – respiratory support, specific treatment or investigations o Assess for risk of overdose with minimal initial symptoms o Details of suicidal attempt o Intention of attempt – self-harm, suicide o What are patient’s intentions now? How do you feel about being alive now? o Risk for another suicide attempt o Suicidal plan and intent – preparations already made o Always ask about access to firearm – needs police notification o Look for evidence of covert suicidal ideation e.g. making a will, paying debts, verbal cues o Assess about risk for harm to others e.g. partners, family.  Past history/ social history o Corroborative history from family, police, ambulance, GP etc o h/o past suicide attempts o h/o psychiatric illnesses o family/social supports o children or dependents o drug and alcohol use  Mental state examination o Check for conditions associated with suicide/ self-harm . Depression, psychosis, command hallucinations, substance use disorders . Personality disorder (especially borderline/antisocial) o GFCMA: Got Four Clients Monday Afternoon . General appearance – agitation, distress, psychomotor retardation . Form of thought – is speech logical and making sense . Content of thought – hopelessness, despair, anger, shame or guilt . Mood and affect – depressed, low, flat or inappropriate . Attitude – insight, cooperation.  Assess coping skills, capacity and supports  Assessment for presence of high risk factors o Definite plan o High intent o Hopelessness o Recent bereavement/loss o Old age o Recent separation o Depression o Psychosis o Past attempts o Impulsivity o Intoxication o Current substance use or dependence o Recent psychiatric hospitalisation o Access to means? (e.g. to gun, medications, poisons, hose), preparation for attempt Confirm Provisional diagnosis – from information gained above Consultation  All patients presenting to ED with suicide risk should be referred wherever possible to MH service Immediate treatment  Of injuries, toxicity or other effects of current suicidal attempt  Sedation for acute anxiety, agitation etc. Transfer of care:  Transfer to in-patient unit – medical or psychiatric depending on most pressing issues at the time  Discharge to community o Develop management plan including appropriate follow up arrangements o Patient has suitable means of returning home or to suitable accommodation o Mental health team has suitable follow up plans o Relevant health provider informed about presentation, follow up plans and necessary actions o Contact family, friends or other staff closely involved with patient. Aggressive and/or threatening violence (agitated, angry patients) Behavioural disturbance can have many causes, and may or may not be related to a mental illness. Organic disorders, such as delirium, head injury, hypoglycaemia and epilepsy can cause aggression.

SACCIT

Safety  Ensure adequate back-up  Interview with staff nearby, if necessary security staff  Call security or police if needed  Do not attempt to disarm armed patient  Do not threaten or challenge  Approach in calm, confident manner and avoid sudden or violent gestures  Be respectful  Avoid prolonged eye contact, do not confront, corner or tower over patient  Focus on current issues  Allow patient time to settle if indicated Assessment  Assess for precipitants of behavioural disturbance o Fear – psychosis, anxiety, threat o Decreased inhibition – delirium, dementia, neurological disorders, intoxication, poor impulse control e.g. developmental disability o Anger, frustration – humiliation, rejection, personality disorder, extended waiting times, feeling neglected (by others, staff) o Stress – grief, frustration/helplessness e.g. parent of ill child, agitation  Assess risk factors for violence o H/o violence o Impulsiveness o Young men o H/o childhood abuse o Substance abuse/intoxication o Personality disorder o Psychosis – command hallucinations, persecutory delusions o Organic cause – head injury, delirium  Look for signs of impending aggression o Clipped or angry speech o Pacing, restlessness o Angry facial expression o Physical withdrawal o Threats or gestures o Physical or mental agitation o Loud voice, swearing o Abusive/derogatory remarks o Demanding , arguing o Persecutory ideation o Delusions or hallucinations of violent content o Intoxication  History o Ascertain patient’s main concerns o Assess threats of self-harm or to others o Assess patient’s access to potential weapons  Mental state examination o Sustained emotional disturbance – anger, stress, fear or frustration o Physical problem – delirium, head injury, epilepsy o Evidence of psychosis or mania o Confusion or intoxication o Patient reporting violent thoughts or making specific threats o Specific targets  Physical examination o Initially asses from a distance o Vitals signs – P,BP,T,RR,O2 sats and BSL o Once settled performed thorough physical including CNS examination o Check for extrapyramidal signs if on medications o Look for evidence of head injury, metabolic insult, substance abuse Confirming diagnosis  Corroborative history o H/o violence most significant best predictor of future violence o History from multiple sources looking for causes for current deterioration or presentation Investigations  Guided by history and examination  Consider o FBC,EUC o TFT o Urinalysis and drug screen o CT/MRI brain +/- LP Consultation  Mental health team referral and review Transfer of care  Will probably require inpatient admission to medical or psychiatric unit Management of severe behavioural disturbance

Management of severe behavioural disturbance includes the following:  Assessment in a safe environment  De-escalation/distraction  Legal issues  Medication/sedation  Physical restraint – manual and/or mechanical  Calling for security or police assistance

Assessment in a safe environment  Confirm police/security have searched patient for weapons or other potentially dangerous objects  Ensure patient does not have access to weapons or object with potential to be used as weapon  Ensure adequate back-up available  Have duress alarm at hand, if available  Approach at a safe distance, at least 2 metres – to avoid risk of sudden attack  Best environment – open area with at least two exits, observed by other staff  Remain near an exit, but do not block patients path to exit  Never turn your back on potentially violent patient  Approach in calm, confident manner and avoid sudden or violent gestures  Have non-aggressive stance  Allow patient ample personal space De-escalation/distraction  Empathic, confident manner  Non-aggressive stance with arms relaxed  Avoid prolonged eye contact, do not confront, do not corner or block exit  Emphasise desire to help  Offer patient time to state their concerns  Attempt to ascertain cause for violent behaviour  Try to identify problem and seek solution  Encourage person to think rather than react  Provide physical needs of person – water, lukewarm tea, phone etc.  Get relatives and trusted staff involved  Do not touch patient without permission to do so  Show of force with security and other staff may be required Legal issues  Involuntary sedation of acutely behaviourally disturbed patient in emergency situation to save a person’s life or save others from harm is covered under the common law principal of ‘Duty of care’. Sedation/ physical restraint  May be required if patient is too violent, or aggression is related to a delirium or psychosis and meaningful communication to de-escalate is impractical or impossible  Do not attempt restraint without adequate number of staff in attendance Sedation in ED for Behaviourally disturbed patients

Sedation may be required for patients whose behaviour puts them or others at immediate risk of serious harm, and which is unable to be contained by other means. Sedation should only be used when other methods of settling the patient have failed. Indications The most common reason for sedation in ED is severe behavioural disturbance manifested as:  Threatening or aggressive behaviour,  Extreme distress,  Self-harming behaviour or  Imminent suicide.

Speed of onset and reliability of delivery are two main factors to consider when selecting agents and route of administration for sedation. Oral sedation is indicated when: – Patients can be safely and quickly talked down – Are not at imminent risk of harm to self or others – Can be safely managed in the ED environment AND – They agree to take oral medications

Parenteral sedation: – Is indicated to control dangerous behaviour and to facilitate assessment and management. – The advantages of intravenous sedation are that the effect is immediate and the dose can be titrated. – The intramuscular route is preferred by some clinicians as it is may be quicker to administer, or particularly, where venous access is limited or difficult. – Should generally be titrated to the point of rousable sleep, not unconsciousness. – Benzodiazepines are generally the medications of first choice as they are more sedating and have fewer side effects than antipsychotics. – For more disturbed patients, a combination of benzodiazepine and antipsychotic, at the outset, is recommended. – Among the antipsychotics, droperidol is preferred over haloperidol in similar doses due to decreased incidence of extrapyramidal side effects as compared to haloperidol. Risk for dyrhythmia is similar if not more. – Lorazepam is now available IV and has an duration of action half way between midazolam and diazepam with a better side effect profile – Explain patient about the procedure even if they seem uncooperative – All personnel to remove potentially hazardous articles/possessions and be equipped with protective gloves and eyewear. – It may be useful for the ED to maintain an emergency sedation kit containing the necessary equipment and medication, – Always sedate in area with resuscitation and monitoring capability and always place patient on monitoring post-sedation Post sedation: – Check for O2 saturation >95% on RA, SBP >100mm hg and intact airway reflexes – Check for pregnancy, drug toxicity and adverse effects

Be aware of the risks associated with parenteral sedation for behavioural emergencies: – Respiratory depression, hypotension and dystonia – Excess pressure on neck/chest/abdomen – Biting, spitting, scratching and flailing limbs – Needle-stick injury Adults Medications Initial Notes Caution Route Dose IV Benzodiazepine (alone 5-10mg 5mg boluses q3-5mins (max Resp preferred) Diazepam or 60mg D , 8mg L) Depression lorazepam Benzodiazepine + anti- Diazepam as above + 5mg q RD + hypotension, psychotic 5-10mg of diazepam 20min droperidol dystonia and Droperidol IM Benzodiazepine (alone Midazolam 5-10mg Repeat q 20min up to 20mg RD preferred)

Benzodiazepine Midazolam + Midazolam as above + 5mg RD +hypotension + +antipsychotic Droperidol 5-10mg q20mins droperidol x3 dystonia each Oral Benzodiazepine (alone Diazepam 5-20mg Diazepam up to 60mg RD, 20-40mins to preferred) onset And/or Antipsychotic Olanzapine wafer 5- Maxm dose 20mg 10mg

Older Medications Initial Maximum dose in Caution Persons Dose 24hrs Route Oral BDZ alone preferred – 0.5- 7.5mg per vent RD, confusion, ataxia Lorazepam 1.25mg And/or Antipsychotic – Olanzapine 2.5-5mg 10mg per event Confusion, hypotension, Antipsychotic - Risperidone 0.5-1mg 4mg per event bradycardia, ataxia IM Antipsychotic – Olanzapine 2.5mg Titrate to 7.5mg Confusion, hypotension, ataxia

Children Medications Initial dose Maximum dose Caution Route Oral BDZ alone preferred Diazepam 0.2mg/kg Max dose 10mg RD, 20-40mins to And/or onset Antipsychotic Olanzapine wafer 2.5-5mg 20- Max dose 10mg Risperidone 40kg Max dose 2mg Hypotension, dystonia 0.02-0.04mg/kg Hypotension, dystonia IV BDZ alone preferred Diazepam Or 0.1-0.2mg/kg Boluses q2-3mins max dose RD BDZ + antipsychotic 10mg Diazepam + 0.1-0.2mg/kg As above RD droperidol 0.1-0.3mg/kg Max dose 10mg Hypotension, dystonia Documentation and reporting – Description of events that contributed to need for sedation – Results of physical examination of patient – Record of medications administered and response/ effectiveness – Record of vital signs post-sedation with regular charting – Record that explanation of the incident has been given to patient and carers – Any patient requiring more than IM/IV sedation on >2 presentations should have future management plan recorded on file. Operational guidelines for application of physical restraints

The use of mechanical devices requires authorisation of the treating doctor, and can only occur using a device specially approved by the relevant area health service of hospital patient care committee, and operated consistent with specifically approved policies and protocols.

Key operational standards for application of physical restraint Indications Clinician believes patient is likely to inflict physical injury on self or other persons and restraint is the least restrictive option Authorisation Usually treating medical officer; senior nurse on duty may authorise and notify MO immediately Medical -Unless in emergency, restraint to commence only after careful physical and mental assessment assessment of patient -In emergency, medical examination to occur as soon as possible after application of restraint Restraint -Restraints to be applied in accordance to specifically developed and approved procedures procedure -Each health service to set out own guidelines for application of manual restraint -Ensure physical restraint is clean and safe to use -Patient to be managed in supine position where possible Observations -P, T, RR, BP, GCS recorded on initiation of restraint, O2 sat if additionally sedated and vital signs -Monitor and document vital signs q15 mins -Continuous visual observation of patient during duration of restraint -Observe for adverse effects – limb circulation, skin condition, consciousness, comfort and pain -Observation to include verbal communication with patient Care -Adequate fluids, food and clothing/bedding -Access to toilet facilities offered to patient every 2 hrs Duration -Minimum time possible with safety, review at end of every hour -Restraints released for 10mins every hour, one limb at a time if needed Completion of -Patient may be released from restraints anytime when deemed fit by MO or senior nurse episode -Return to less restrictive care as soon as possible Documentation -Authorisation form- patient’s details, indication for restraint, alternatives considered, and forms name of authorising MO, vitals and observations during period of restraint and when ceased -Appropriate documentation in patient’s notes Training -Staff require adequate training and refresher courses for application of restraint and policies Reporting -Every episode should be recorded in patient files, at facility level and monitored at area level Facilities and -Restraints to meet approved standards equipment -Regularly checked for wear and tear and sharp edges etc. -Regularly cleaned and checked before each application -Staff to be provided with suitable protective clothing, gloves, facemasks and eyewear Confusion Assessment Method (CAM)

Consider the diagnosis of delirium if features 1 and 2 and either feature 3 or 4 are present. (AIDA)

ACUTE ONSET AND FLUCTUATING COURSE

1. Is there evidence of an acute change in mental status from the patient’s baseline?

INATTENTION

2. Did the patient have difficulty focusing attention, for example: easily distractible, having difficulty keeping track of what is being said?

a. None

b. Sometime during interview - mild

c. Sometime during interview – marked

d. Uncertain

3. Did this behaviour fluctuate during the interview?

a. Present

b. Absent

DISORGANISED THINKING

4. Was the patient’s thinking disorganised or incoherent

a. Rambling or irrelevant conversation

b. Unclear or illogical flow of ideas

c. Unpredictable switching from subject to subject

ALTERED LEVEL OF CONSCIOUSNESS

5. How would you rate the patient’s level of consciousness overall?

a. Alert (normal)

b. Vigilant (hyperalert, overly sensitive to environmental stimuli)

c. Lethargic (drowsy, easily arousable)

d. Stupor (difficult to arouse)

e. Coma (unrousable)

f. Uncertain Psychosis

Odd or Bizarre behaviour, ideas or speech

The patient is acting bizarrely or saying strange things but appears orientated and alert – the problem is most likely psychosis, but delirium, neurological problems and intoxication need to be considered and organic cause of psychosis need to be ruled out. Common precipitants of psychosis are:  Substance use  Non-compliance with medication  Psychosocial stressors

SACCIT – Safety, Assessment, Confirmation of provisional diagnosis, Consultation, Immediate treatment and Transfer of care.

After initial evaluation for safety of patient and others: Assessment  History – o Context of presentation – mode of presentation, description of behaviour and speech, does it make any sense, any mood symptoms. o Any precipitators – head injury, substance use, medical illness o Past history – similar presentation, psychiatric history  MSE – o Thought disorder . Delusions – messages from TV/radio, strange happenings, special powers or purpose . Persecutory ideation – safety, perceived danger, perceived spying or hurt from people . Auditory hallucinations – someone talking to patient when there is no one around, hear voices. . Command hallucinations – increased risk of violence  Rule out organic illness  Contact patient’s MH team or GP  Consult with MH team Possible early manifestations of psychosis in young person:  Declining work or academic performance  Decreased motivation  Withdrawal from family/friends  Reduced interest in social activities  Suspiciousness  Eccentric behaviour  Transient psychotic symptoms  Depressed mood  Irritability  Poor sleep and concentration Admission to be considered if:  Danger to self/others  Highly disturbed or disorganised behaviour  Patient distressed  Illness deterioration  Need for further investigation/ stabilisation/ observation  Diagnosis uncertain Mania

Hyperactive, loud, grandiose or elevated mood – though this presentation can be a result from many different causes, MANIA is archetype of this presentation.

SACCIT – Safety, Assessment, Confirmation of provisional diagnosis, Consultation, Immediate treatment and Transfer of care.

A corroborative history from relatives and carers is extremely important. People with mania may be good at ‘holding it all together’ for brief period. Always consider the potential for damage to patient’s reputation (or physical harm), if risk taking behaviour continues. Assessment: Key symptoms of mania: o Extremely happy mood o Irritable mood o Grandiosity o Decreased need for sleep o Increased energy/ risk taking/ sexual activity o Spending money o Increased goal directed activity o Rapid speech and racing thoughts Assess for other causes for elevated mood: o Intoxication – stimulant use o Psychosis – mood elevation less pronounced but psychosis can be a symptom of severe mania o Organic causes – steroid use o Personality disorder – histrionic, borderline or narcissistic o First presentation of mania in elderly is more likely to be secondary to neurological or physical illness. History o Context of presentation, precipitant, change from usual, substance use o Biological symptoms of mania – increased energy, decreased need for sleep o Asses potential harm for others o Harm to self-including financial o Past history – mania or psychiatric treatment MSE o Bright, garish ‘larger than life’ o Very active, unable to sit still o Good humoured interaction but irritable o Rapid speech, jumping from topic to topic o Delusions of grandeur o Impaired insight, poor judgement o Check physical condition for neglect, dehydration etc. o Evidence for intoxication Consult – o MH team o Beware of absconding patient o Patient usually uncooperative since they do not believe there is anything wrong with them and refuse treatment o Admission is usually necessary Discharge only after review by MHT and o Patient has insight and willing to take medication o Adequate and capable supports o Diagnosis clear with past similar episodes o Frequent follow up and review possible o Intensive follow up organised Anxiety disorders Nervous, anxious, panicky or excessively worried

Brief episodes of anxiety are part of a normal response to stress or threat.

Anxiety symptoms may be:  A primary anxiety disorder  Secondary to a medical disorder  Secondary to another psychiatric disorder – depression, schizophrenia, acute stress, adjustment disorder or personality disorder Symptoms of anxiety may be  Mental o Sense of apprehension, worry, fear or threat o Agitation, indecision o De-realisation, depersonalisation, obsessions And/or  Somatic o Tremor, palpitations, sweating, nausea o ‘tummy ache’, chest tightness or pain o SOB, dizziness, paraesthesia, choking sensation o Urinary frequency or hesitancy And/or  Behavioural o Avoidance of anxiety inducing situations o Compulsions Assessment Always consider possible physical causes or medical conditions which are commonly associated with anxiety symptoms.  Cardiovascular – angina, MV prolapse, tachycardia  Respiratory – asthma, PE, hypoxia, CAL  Endocrine – hypoglycaemia, hypo/hyperthyroid  Neurological – MS, epilepsy  Malignancy – pheochromcytoma, carcinoid  Medications – anti-depressants, bronchodilators, anticholinergics  Drugs – stimulants, sedative withdrawal, alcohol withdrawal  Exposure to noxious chemicals Anxiety always causes hyperventilation, which may produce unpleasant somatic sensations. Always consider medical causes first in a patient presenting to ED with symptoms. Always investigate for suicide risk and co-existent depression.  Thorough physical examination to exclude physical causes.  Breathing exercises if hyperventilation is a problem Consult  MH team and  GP  MH team review if depression or suicidal ideation present. Treatments  Cognitive Behavioural therapy (CBT)  Medications – antidepressants and sedatives rarely indicated.

Anxiety disorders include: Panic attacks: discrete episodes of intense fear accompanied by varied somatic and cognitive symptoms Agoraphobia: specific avoidance of situations that induce panic or anxiety. E.g. being in public, in queues, on public transport Generalized anxiety disorder: pervasive and excessive unjustified worry for at least 6 months, with symptoms such as insomnia, fatigue, edginess, irritability, muscle tension and concentration difficulties. Social phobia: exaggerated persistent and unreasonable fear associated with a social or performance situation. E.g. public speaking Post-traumatic stress disorder (PTSD): following exposure to a life threatening or shocking situation which the patient persistently re-experiences in nightmares and flashbacks. Avoidance, numbing and increased arousal (insomnia, anger, hyper-vigilance, easily startled) behaviours may also be present. Acute stress disorder: similar symptoms to PTSD, within a month of the event with dissociative symptoms. Obsessive Compulsive disorder: intrusive unwanted thoughts r images which cause marked anxiety, distress or urges to carry out repetitive behaviours or mental acts and interferes with person’s normal activities.