Mental Health in the EDDR IAN TURNER

Common Presentation Types

Self-harm

Mood disorders

Psychotic episodes

Acute behavioural disturbance

Personality disorders

Combinations

Challenges

Resource intensive

Delay in assessment can result in escalation

Safety

Legislation

Duty of care

ED Doctor’s Role?

STABILISE SITUATION

RISK ASSESS

SEEK MEDICAL ISSUES

DETERMINE LOCATION

What are your tools?

Clinical skills

Medications

Mental health teams

Legislation

Clinical Skills

History

Examination

Collateral

Relevant investigations

Mental state examination

historyexaminationcollateral

BACKGROUND

CURRENT TREATMENT

SOCIAL CIRCUMSTANCE

MEDICAL FINDINGS

RISK ASSESSMENT

mse

APPEARANCE / BEHAVIOUR

ATTITUDE

SPEECH

AFFECT / MOOD

THOUGHT

PERCEPTION

COGNITION

INSIGHT/JUDGEMENT

mse

VISUAL

LABILE

INCONGRUENT

RESTRICTED

APATHETIC

ALEXITHYMIC

ELEVATED

EUPHORIC

DEFENSIVEHOSTILE

INGRATIATING

EVASIVE

SEDUCTIVE

GARRULOUS

MONOTONOUS

ACCENTED

ECHOLALIA

PRESSURED

AGGRESSIVE

DISHEVELLED

STUPOR

GRANDEUR

OVERVALUED

OBSESSION

OLFACTORY

COMPULSIONS

PERSEVERATION

CONCRETE

TANGENTIAL

BROADCASTING

BLOCKING

mseEXAMPLE 1

EXAMPLE 2

EXAMPLE 3

risk assessment

90% OF SUICIDES HAVE A DIAGNOSABLE MENTAL DISORDER

RISK FACTORS

PROTECTIVE FACTORS

risk assessmentTRAAPPED SILO SAFE

TRAAPPED SILO = INCREASE RISK

SAFE = DECREASED RISK

risk assessment

T – TRIGGER

R – RATIONAL THINKING LOSS

A – AGE

A – ACCESS TO MEANS

P – PREVIOUS ATTEMPTS

P – PREVIOUS PSYCHIATRIC CARE

E – EXCESSIVE ETOH/DRUGS

D – DEPRESSION/HOPELESSNESS

S – SICKNESS

I – IDEATION

L – LACK OF SUPPORTS

O – ORGANISED OR SERIOUS PLAN

S – SOCIAL SUPPORT

A – AWARENESS

F – FUTURE ORIENTATED

E – ENGAGED

risk assessment

WORD YOUR ASSESSMENT USING RISK AND PROTECTIVE FACTORS RATHER THAN JUST QUANTIFYING LEVEL OF RISK

DOESN’T NECESSARILY REQUIRE A DIAGNOSIS

“

”

Mr. X presents with multiple suicide risk factors including daily drug use, depression with a sense of hopelessness and a concrete plan to hang himself, which he tried to hide. He had cleared space in his garage to carry out the hanging and was disappointed when the setup was discovered by his girlfriend.He also has limited social support and a chronic medical illness which limits his ability to work.There are some protective elements such as a willingness to engage in the therapeutic process. He also does not seem to be withholding information and shows no signs of agitation or psychosis. He does, however, demonstrate debilitating anxiety which has been unresponsive to treatment in the ED.I spoke with his mother who reports that Mr. X has been making suicidal statements over the past few days with increasingly erratic behavior. Considering the above, my conservative estimate of this patient’s suicide risk is high and I feel he warrants hospitalization.

“

”

Mrs. J presents with her third suicide attempt in the last year. Again, this was an overdose of 10 homeopathic sleeping tablets with the intent of not waking up, triggered by an argument with her husband relating to her alcohol intake. This has been a constant source of conflict between them over the last year with the patient binge-drinking at the end of stressful work weeks.She has a history of depression which is being managed with anti-depressants and weekly review with a psychiatrist. She has also been attending an alcohol support group. After sobering up in the ED, she regrets her actions and is glad no harm has come to her. She has work commitments this coming week which she doesn’t want to miss and is due to see her usual psychiatrist in 3 days.I have spoken with her psychiatrist and confirmed her upcoming appointment and that he will make phone contact with the patient tomorrow.Considering the above, I find Mrs J safe to go home with her husband today. She is able to contact her psychiatrist over the weekend if needed, and I have provided her with a 24-hour crisis phone line if she is feeling unsafe.

medicationsORAL

PARENTERAL

PHYSICAL

restraintBRIEF 5 POINT

PERMANENT PHYSICAL

CHEMICAL

medications

YOU

BENZODIAZEPINES

TYPICAL ANTIPSYCHOTICS

ATYPICAL ANTIPSYCHOTICS

NMDA RECEPTOR ANTAGONIST

SECURITY

mental health teams

MANY

REGIONAL VARIATIONAL

COLLATERAL INFO

legislationSTATE TO STATE

“AT RISK” DUE TO FRAME OF MIND

ASSIST IN DETAINING PATIENT

legislation

ASSESSMENT ORDER

MENTAL ILLNESS + SERIOUS HARM

NO OTHER LESS RESTRICTIVE MEANS

“clearance”

ENSURING AS REASONABLY POSSIBLE THAT NO UNDERLYING MEDICAL PROBLEMS ARE CONTRIBUTING TO THE PRESENTATION THAT WOULD PRECLUDE ADMISSION TO A PSYCHIATRIC FACILITY

“clearance” Established psychiatric diagnosis with:

Lack of specific medical complaint

Negative physical findings

Stable vital signs

You may not need to do anything if…

“clearance” Electrolyte disturbance

Endocrinopathies

Encephalopathies

Seizure disorder

Infection

Medication/drug effect/withdrawal

Otherwise consider:

Let’s play…SEDATE?

SECTION?

ADMIT?

72 male Found by passer-by in an empty field

In his car

Hose pipe attached to exhaust

Transferred for assessment

Looks well but agitated about being found

Happy to be assessed but does not want to be admitted

Sedate?

Section?

Admit?

17 female Found crying in bathroom by mother

Brought in by mum

8 Panadol tablets because boyfriend cheated on her

Worried how she will cope with upcoming exams

No psychiatric history

Superficial variably healed transverse incisions

Sedate?

Section?

Admit?

36 male

Brought in by concerned wife

Immigrated from Iran 1 year ago

Undertaking PhD in theoretical physics

1/12 odd behaviour

Reclusive, missing days at uni

Writing reams of equations at home

Solved the universal equation of life

“complex transcendental relationship between the 39 gods of the 13 universes”

“my job to inform the world”

Well dressed, vigilant, tactile

Sedate?

Section?

Admit?

23 male Police in ambulance bay with patient in divisional van

The van is rocking with louds bangs coming from inside

4 officers were required to restrain patient

Patient was running naked in street initially

Sedate?

Section?

Admit?

27 male

Arm laceration after falling through pub window

Wants to go home after suturing

Orientated to T/P/P

Knows his phone number and address

Smells of ETOH

Annoyed that you want to observe him for 4 hours

Wants to leave

Sedate?

Section?

Admit?

38 female

BIBA abusive and aggressive

Well known to your department

“bipolar and schiz but they can’t do a fuckin’ thing about it”

BAC 0.32, normal vitals

Initially co-operative, over familiar

Becomes rapidly violent when questioned about ETOH intake but you de-escalate her verbally

She now wants “to go for a smoke”

Sedate?

Section?

Admit?