Mental Health in the EDKane Guthrie

Learning Points

Overview of MH in ED Basic Mental Health Assessment Managing common disorders

Psych Resources in ED

24/7 Duty PLN & Psych Registrar 24/7 Oncall Psych Consultant Social worker Drug & Alcohol nurse SHACCS

ED’s Role

Stabilise aroused/frightened patient Manage acute behavioural disturbances Excluded medical causes Determine need for voluntary vs involuntary Arranging referral/disposition Family/carer support

Brief Assessment

Circumstances of referral /Presenting problem Social circumstances Previous treatment /Current mental health

service ETOH & drug use Mental state exam Medical/Risk assessment & investigations Provisional Dx Treatment & disposition

Medically Clearance

Contentious issue “Fit for psychiatric evaluation”

High risk: First time presenters Failure to take Hx Poor attention vital signs/ physical Ax

Screening for Medical Cause

Vital signs:Consider (case specific) FBC, U&E, TFT Paracetamol level ECG Urinalysis +/- Head CT/MRI +/- LP

Medical causes of Psychosis Epilepsy Hypo/hyper thyroidism Huntington’s disease Porphyria B12 deficiency Cerebral neoplasm Stroke Viral encephalitis AIDS Neurosyphillis

Medical causes Depressive symptoms

Hyperthyroidism Hypercalcaemia Pernicious anaemia Pancreatic Ca Lung ca Dementia

Drug Abuse = Psychosis

Amphetamines Cocaine PCP LSDWithdrawal: Alcohol Benzo’s

Mental State Exam

Mental State Exam

Appearance & Behaviour Speech Mood & Affect Form of thought Content of thought Perception Sensorium & Cognition Insight

Appearance & Behaviour

Appearance: Grooming, posture, clothing, build

Behaviour: Eye contact, cooperativeness Motor activity Abnormality of movement Expressive gestures

Speech

Articulation disturbances Rate Volume

Quantity of information: Pressured Loud Slurred Mumbled

Mood & Affect

Mood: Depressed, euphoric, suspiciousness

Affect: Restricted, flattened, inappropriate

Form of Thought

Amount of thought Rate of production

Flight of ideas Derailment

Continuity of ideas Disturbance in language & meaning

Content of Thought

Suicidal/ homicidal thoughts Delusions

A belief held with strong conviction despite evidence to the contrary.

Overvalued ideas, obsessions, phobias

Perception

Hallucinations A perception in the absence of apparent

stimulus that has qualities of real perception. Other perceptual disturbances:

Derealisation Depersonalisation Illusions

Sensorium & Cognition

Level of consciousnessMemory:

Immediate, recent, remote

Orientation: Time, place, person

Insight

Capacity to understand:

Own symptoms/illness Knowledge of medications Amenable to treatment Likelihood of compliance treatment

Documentation

NAB HECTOR• Name• Age• Build

Height Eyes Complexion Thatch (hair) Oddities (scars,

tattoos, deformities) Rig (clothing)

Suicide

Patients often prevent suicidal Overdose Self harm Plan

ED role Risk assessment Prevent suicide Offer support/disposition

Why do people self harm?

Significant proportion intend to die Escape intolerable situation No clear explanation “Loosing control” Punish someone “makes others feel guilty” Excess of life events

Bereavement Job loss Financial difficulties

Risk Factors for Suicide

Being single, divorced, widowed Unemployed Recent life stresses Having mental illness Previous self harm Substance abuse problem

Duty of Care

Duty of care needs to be enacted when: Risk to self (suicidal) Risk to others (homicidal) Under command auditory hallucinations Lack insight/capacity

The Big 5 Disorders

Depression Anxiety Bipolar Disorder Psychosis/Schizophrenia Borderline personality disorder

Case 1

55 male Wife left him Lost Job Increasing ETOH consumption

BIBP after calling mate saying was going to hang himself

Depression

Can be: Acute major depressive Chronic (dysthymia)

Affects 3-5% worlds population “Serotonin depletion”

Characteristics

Physical symptoms: Fatigue Nausea Headaches

ED Management

Kindness and reassurance Ensure patient safety (contain till risk Ax) Explore suicidal ideation Psych disposition (Admit vs O/P follow up) Antidepressant may be started in ED

SSRI or SNRI

Case 2

19 female Presents with palpitations/nausea Hyperventilating “I'm going to die”Social Hx: Doing uni exams Found out BF kissed another girl

Anxiety

More difficult emotion to handle: Compared to anger/depression

Cascade of symptoms often overwhelming Strong component of other psychiatric

illness’s

Panic/Anxiety Attacks

Overwhelming sense fear/doom Uncooperative/Irrational Often unable to process what is being said to

them

Characterised

Physical: Nausea Chest pain Shortness of breath Dizziness Headache

ED Management

Explore/rule out physical symptoms Listen & reassure Arrange follow up Benzo’s have limited role Antidepressants may help Coping techniques

Case 3

47 male Presents rambling Trashed house after loosing 5k at casino Hx of depression States all is find then goes of on tangents

Bipolar Disorder

aka- Manic depressive illness Disruption in brain chemistry Major mood swings

Characteristics

Extreme mood swings/behaviours Mania severe depression

Mania Grandiose Delusional thinking Rapid pressured speech Impulsive risk behaviours

ED Management

Low stimulus Keep directions/statements short simple

Medicate for agitation Assume unpredictable Often will require admission during acute

episode Lithium/Carbamazepine long term

Case 4

22 male Presents paranoid

Aliens & space ships are following him” Refusing to engage at triage

?hx of amphetamine use

Psychosis

Characterised by: Delusional Hallucinations Disorganisation of thinking

Psychosis vs Schizophrenia

Psychosis: Short term Drug induced or medical induced

Schizophrenia: Disruption in brain chemistry Onset typically adolescents/young adults

ED Management

Ensure safety Don’t feed into delusions Ask about voices/visual hallucinations Provide low stimulus environment Medicate for agitation

Case 5

26 female Presents with DSH to foramen/ paracetamol

OD 5th presentation in 5 weeks Hx of PTSD- child abuse Refuse's to cooperate Abusing staff – you don’t understand

Borderline Personality Disorder

Rigid fixed perception – world Often in pts with traumatic childhoods Extreme fear abandonment

Characteristics

Chaotic relationships Intense reactions to situations Dramatic-manipulative behaviours Attention seeking behaviour Self harm – manage intense feelings Often chronically suicidal

ED Management

Avoid power struggles Avoid punitive treatments, ultimatums Often require short period containment Medicate as appropriate to control behaviour Prepare for high risk behaviour (Self, others)

Questions

Take Home Points

Know the resources available These patients can be confronting Learn an approach Most are not violent Always ensure safety first yourself then your

patient

Thank You