The evaluation of the psychotic patient in the emergency setting begins the moment the patient arrives at the hospital, if not before. The clinician should carefully note the circumstances of the patient’s arrival at the hospital and the patient’s appearance upon arrival in order to determine how to safely proceed with the assessment.
Mode of Presentation
Psychotic patients present by a number of means and under a variety of cir-cumstances, all of which are relevant to evaluation and treatment. A patient can come to the emergency room by ambulance, arrive under his or her own volition, or be brought to the emergency room by family, friends, strangers, or law enforcement personnel. Whatever the circumstances surrounding pa-tients’ arrival to the emergency room, much information can be gleaned from the events leading up to arrival at the hospital, including the manner of their arrival (Dhossche and Ghani 1998).
Patients who self-present to the emergency room for psychosis fall generally into one of three major categories: 1) those who present with medical/somatic complaints, 2) those who present with social complaints, and 3) those who present with psychiatric complaints. Of those patients who have psychiatric complaints, the subjective chief complaint of the psychotic patient often is unrelated to psychosis. Common reasons for such a patient to request help are hallucinations, feelings of persecution or paranoid ideation, mood symptoms, or social stressors. Patients often present complaining of homelessness, finan-cial difficulties, or other sofinan-cial issues, only to reveal themselves to be flagrantly psychotic as well; a patient who requests a social intervention or appears to have secondary motives for presenting to the emergency room requires a full eval-uation.
Psychotic patients are often referred to the emergency room by someone else. Behavior intolerable to the community, such as violence, aggression, ag-itation, and disorganized or inappropriate behavior, will commonly result in the involvement of either law enforcement or emergency medical services. Pa-tients with persecutory delusions may make frequent complaints about others to law enforcement agencies and end up being referred for evaluation, thanks usually to a concerned law enforcement officer. Families of psychotic individ-uals may bring their loved ones to emergency services for aggressive behaviors, or they may report that the patients have stopped eating, are not sleeping, are behaving oddly, or are otherwise unable to care for themselves. After some change in their baseline behavior occurs, patients already connected within the mental health system may be referred for evaluation by health care provid-ers, case managprovid-ers, counselors, social workprovid-ers, staff in shelters or prison sys-tems, or other public agencies.
Choosing a Setting for Initial Patient Evaluation
Having considered the psychotic patient’s mode of presentation, a clinician needs to determine the appropriate setting for patient evaluation. In many hospitals, patients are seen in the medical emergency department, and psychi-atric consultation is available at the request of emergency department staff.
Larger tertiary care centers may have a designated psychiatric emergency room that is separate from the medical emergency room. In such cases, staff must decide whether to evaluate a patient in the psychiatric or medical emer-gency room.
The initial contact is often a triage nurse, who briefly interviews the pa-tient, obtains a set of vital signs, and determines whether the chief complaint is primarily medical or psychiatric. This is a juncture at which mistakes com-monly occur, because this cursory physical assessment may overlook signifi-cant medical signs and symptoms (Allen 2002). Vital sign abnormalities, somatic complaints, physical signs, marked intoxication, disorientation, rapid onset of psychotic symptoms, or a waxing and waning mental status are all strong indications for evaluation in the medical emergency department, at least until the patient is determined to be medically stable. Kishi et al. (2007) found that 1) almost half of cases ultimately determined to be delirium that are referred for psychiatric consultation are initially mistaken for psychiatric
illness by the referring doctor and 2) delirium is more likely to be missed in those patients with preexisting psychiatric illness. Current or past diagnoses of psychiatric disorders should not influence clinicians in assessing patients for the presence of medical illness (Duwe and Turetsky 2002). Even when no clear physical abnormality is present, patients who are experiencing psychotic symptoms for the first time, elderly patients, and patients with a history of trauma, falls, or significant medical comorbidities warrant a thorough workup in a medical emergency department to rule out a life-threatening medical condition (Marco and Vaughan 2005).
The clinician in the psychiatric emergency department plays a critical role in the medical management of psychiatric patients. The ability to generate a differential diagnosis that takes into account possible medical etiologies for psychosis and to effectively communicate specific concerns about a patient’s presentation to other physicians, nurses, and hospital staff can save lives. In ter-tiary care centers with designated psychiatric emergency departments, a high index of suspicion that a general medical condition may be causing a patient’s psychosis will often prompt referral of psychiatric patients to the medical emergency department for further evaluation. In such cases, the psychiatric clinician’s role is to assist the medical team in building a differential diagnosis, and therefore he or she should be prepared to address specific concerns and ask specific questions tailored to the individual patient’s presentation. Under no circumstances should a potentially medically ill patient be simply referred to the emergency room for “medical clearance” without a conversation between psychiatrist and emergency room physician that addresses the exact nature of the concern.
Two other points bear mentioning about the initial decision regarding the appropriate setting for evaluating a psychotic patient. First, patients with a clear psychiatric history and etiology for their symptoms often present with or develop medical comorbidities significant enough to warrant deferring a thorough psychiatric evaluation until more serious medical concerns are ad-dressed. In fact, a growing body of evidence supports the contention that peo-ple with primary psychotic disorders such as schizophrenia have a much higher rate of medical comorbidity (e.g., cancer, heart disease, diabetes) than the general population (Newcomer 2006). When such medical conditions exist, their mortality is also well above the average. Second, when a patient is seen in the psychiatric emergency room, if there is any concern that he or she
may have a condition that warrants urgent imaging or lab work, the psychia-trist treating the patient has a responsibility to communicate with the appro-priate departments, to ensure that the workup is done in a timely manner, and to follow up the results.
Initial Assessment and Management
The next decision to be made is whether the patient can wait to be fully eval-uated or must be seen immediately. If the patient is being evaleval-uated in a med-ical emergency department, either because the patient is medmed-ically unstable or because the facility does not have a designated psychiatric emergency room, the patient should be seen as quickly as possible.
The initial psychiatric assessment is separate from the full interview that will follow, and it has one primary purpose: to assess danger and maintain a safe environment. Any patient who is physically violent on arrival to the emer-gency room requires immediate assessment and may require urgent behav-ioral and/or pharmacological intervention. Conversely, a patient who arrives in the psychiatric emergency room in some form of restraint may no longer require it. Patients brought in by emergency medical services, for example, who may have been agitated and dangerous at the time of their initial point of contact, may have calmed sufficiently in transit. For this reason, any pa-tient arriving in physical restraints should be assessed immediately, and a de-cision needs to be made as to whether physical restraint is absolutely necessary to avoid imminent danger; almost always a less restrictive intervention is avail-able. Other patients who require immediate assessment include those who ap-pear frightened or paranoid, those verbally responding to internal stimuli, those who are verbally aggressive or threatening, those with psychomotor ag-itation (e.g., pacing or shadowboxing), and those attempting to leave the area without being evaluated.
Special care must be taken in the initial assessment of psychotic patients who present to the emergency room setting involuntarily. A safe and well-run psychiatric emergency department will have adequate staff available to rapidly and effectively deal with any sudden violent outburst with a certain amount of sensitivity to the special needs of this patient population. The psychiatrist should not approach an agitated patient to perform an initial assessment without support staff in the room. On the other hand, the psychiatrist should
not leave the initial assessment to the support staff; a team approach works best, and an adequate “show of force” will often be enough to defuse a poten-tially dangerous situation. The psychiatrist should approach the patient and introduce himself or herself as the doctor who will be performing the evalua-tion. Patients should be given information about what to expect in language they can understand. It may be appropriate to explain the emergency room procedures, such as performing a search, holding personal valuables in a safe place, or changing into hospital clothes, with emphasis on the fact that these are standard procedures. Any reasonable wants or needs of the patient, such as hunger or thirst or the need for a bathroom, should be addressed. Often, offering food or drink even when the patient has not asked for it may have a calming effect. Patients who want to contact their family or legal services should be given the opportunity to do so.
Unfortunately, some acutely psychotic patients will not respond to verbal interventions or show of force. In such cases, the next step to ensure the safety of both patients and staff and to deescalate potentially dangerous situations generally involves the use of pharmacological interventions, physical re-straints, or both. The subject of seclusion and restraint is covered more fully in Chapter 11, “Seclusion and Restraint in Emergency Settings.”
The treating physician has several choices to make in determining the best pharmacological intervention for the acutely agitated psychotic patient:
which medications to use, what doses to give, and by what route. Most emer-gency departments use either the intramuscular or oral form of medications to manage psychosis. Unless a patient is physically violent or in imminent danger of becoming so, a good practice, which may assist in establishing a bet-ter rapport with the patient, is to offer even the most seemingly agitated pa-tient the option of taking medications by mouth (Currier et al. 2004). When intramuscular medication is required, it is advisable to first have the necessary staff on hand to restrain the patient physically, if necessary, because attempt-ing to give an injection to an unwillattempt-ing agitated patient without at least tem-porary restraint poses a significant risk of needlestick or other injury to all involved. In our experience, a show of force is typically enough to encourage the patient to cooperate without the use of force.
Traditional treatment of agitation and psychosis in emergent settings in-volved high doses of typical antipsychotics such as haloperidol (Hillard 1998). Over time, these doses were reduced due to the risks of side effects
such as acute dystonia. Antipsychotics remain the mainstay of treatment for acute agitation and psychosis in many emergency departments. Benzodiaz-epines, such as lorazepam, are also frequently used. More recently, atypical an-tipsychotics have been used to treat psychosis in the emergency department;
olanzapine, ziprasidone, and aripiprazole are available in a short-acting intra-muscular form. If a patient’s agitation or acutely psychotic state can be man-aged with oral medications, clinicians have a larger field to choose from.
The choice of which medications to use for agitation, and in what doses, should be tailored to the individual. Patients already maintained on an anti-psychotic medication as outpatients, and who have tolerated and responded to that particular medication, can be treated accordingly (Hillard 1998). In the absence of any further clinical information, a psychotic but otherwise healthy patient with no known allergies may be given a combination of halo-peridol and lorazepam, although olanzapine is increasingly popular in the emergency setting. Patients who are naïve to antipsychotics are likely to be more quickly and heavily sedated, and may require less medication. As with all medications, doses used in elderly patients are typically much less than the dose for a typical adult. It is often best to avoid the use of benzodiazepines in elderly patients because of the potential for falls, respiratory compromise if the patient is medically ill, and paradoxical reactions such as disinhibition particularly in patients with underlying dementia. If a patient has been agi-tated and required medication shortly after arrival at the emergency room, it is of vital importance that the physician try to garner as much information from the patient as possible, because he or she may soon be too sedated to an-swer questions, sometimes for a number of hours. If nothing else, informa-tion about medical history, substances used, allergies, current medicainforma-tions, any recent trauma, and family to contact in case of an emergency are all im-portant to obtain.
All antipsychotic medications have the potential to cause side effects. The patient in the emergency setting is at particular risk for two reasons: patients may at times need to be medicated without sufficient knowledge of medical comorbidities or previous reactions to medications, and patients treated in the emergency department and subsequently discharged are often lost to fol-low-up. Patients treated with typical antipsychotics in the emergency room should be observed for signs of acute dystonia, such as muscle spasm or stiff-ness. Acute dystonia is treated with intramuscular injection of anticholinergic
drugs, such as diphenhydramine or benztropine. Patients treated in the emer-gency department with an atypical antipsychotic, such as olanzapine, should have a fingerstick performed to assess blood sugar levels. Other potential side effects are akathisia (i.e., the subjective sense of being unable to sit still or stop moving) and tardive dyskinesia (i.e., abnormal choreiform movements than can often be observed in patients with a history of treatment with typical an-tipsychotics; these are unlikely to be caused or significantly worsened by a sin-gle antipsychotic dose in the setting of agitation.)
Case Example (continued)
Mr. S arrived on a stretcher to the psychiatric emergency room. A cursory ex-amination of his property revealed a veteran’s identification card. He was ag-itated and paranoid during the interview, refusing to answer the majority of questions. He reported that he was in a car with President Bush just 2 weeks ago but said that it would be too dangerous to say why. He asked the medical students present during the interview, “Which one of you jokers grabbed me this morning?” When asked what war he is a veteran of, Mr. S replied, “I’m at war now!” He was malodorous, disheveled, and continually scratching his skin. Mental status examination revealed that he was disoriented to place and time. Because of his agitation, he received prn medications.