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Psychiatry in the ED

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Dan Hackley

on 9 December 2015

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Transcript of Psychiatry in the ED

SEPARATE ELEMENTS
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Everything you
need to know about

Psychiatry
To survive in the e.d.
Dr dan hackley, consultant in liaison psychiatry
PHYSICIAN ASSOCIATE teaching programme, hairmyres hospital, 9 DEC 2015

PREVALENCE OF MENTAL DISORDER
COMMON REASONS FOR ATTENDANCE
AT THE EMERGENCY DEPARTMENT
* Primary mental health problem: 5%
* Mental health problem as a co-morbidity or contributory factor: far higher
* Primary alcohol use problem: 10% (RCPsych)

*
Delirium & acute psychosis
*

Self harm / personality disorder / low mood / suicidal thoughts
* Substance misuse
* Alcohol and self harm
* Physical disorder with concurrent mental disorder (25-33% in LTC)
*
Medically unexplained symptoms & factitious disorder
* Emotional response to trauma
* Learning disability & older people
Skills-based Training On Risk Management (in suicide)
- focus on self injury
Applied Suicide Intervention Skills Training
Half day, general
2 days, general staff
2 days, front-line staff
2 days, general staff, most widely used worldwide
Online, general staff
KEY POINTS
High prevalence, commoner in teenage years and females
Various kinds of self harm
Cutting, overdose, jumping, hanging, drowning
Cutting is the most common
Impulsive or compulsive component
Associated disorders include:
Borderline personality disorder
Eating disorders
PTSD, depressive and and anxiety disorders
SELF HARM
METHOD
FINAL ACTS
INFORM ANYONE, BEFORE OR AFTER?
EFFORTS TO
AVOID DISCOVERY
HOW DID THEY GET TO HOSPITAL
BACKGROUND
CURRENT
SOCIAL
STRESSORS
RELATIONSHIP
PROBLEMS?
C
O
N
T
E
X
T
TRIGGER?
INTOXICATED?
LETHALITY &
PHYSICAL DAMAGE
TIMESCALE
THE
PERCEIVED DANGEROUSNESS
PLANNED?
EXPECTATION
AMBIVALENCE?
DID THEY ACCEPT HELP IN HOSPITAL
INTENT AT THE TIME
MOTIVES?
PAST PSYCHIATRIC HISTORY
Mental health diagnoses
Mental illness, personality disorder, learning disability
Hospitalisations
Outpatient contact
GP treatment
Psychotropic medication
The patient's opinion on diagnosis
Previous self harming behaviours
Pattern? Escalating?
Basic mental state exam (objective assessment - behaviour, speech, mood, thoughts, etc) -

presence of mental disorder?
Capacity
Patient's current appraisal of situation
How do they feel about the event
How do they feel about still being here/alive
Any ongoing suicidal thoughts?
Guilt or hopelessness?
Any ongoing suicidal intent?
Plan?
Acted on the plan?
Protective factors?
Willingness to remain in the unit and engage?
Plans for the future (immediate and any longer term plans)
GENERAL POINTERS
Approach & attitude
Eye contact
Empathy, non-judgemental
Interview style
Use of silence
Give patient time
Paraphrase, reflect and summarise
LOSS?
ASSESSMENT OF
FACTS
AROUND
EVENT
REPORTED
INTENT
CONTEXT
PAST
PSYCHIATRIC
HISTORY
CURRENT
PRESENTATION
RISK
ASSESSMENT
&
FACTS
SECOND THOUGHTS?
RISK ASSESSMENT
Weigh up the information available
Seek senior or psychiatric advice when necessary; risk assessment should generally be multi-disciplinary
Be happy with the outcome
Should be done as part of a team
Inexact science
NHSL has a structured proforma for use by the EDs
RISK MANAGEMENT
An integral part of working in mental health and medicine in general
Wide variety of documents, reports and guidelines on the topic
In mental health, most often relates to risk to the safety of the individual
Susceptible to prevailing political climate
Culture of blame, defensive practice
Positive risk taking
Involves assessment of the magnitude of the risk, the acceptability of the risk and the protective measures in place
How to assess the magnitude of the risk?
Statistical evidence
Clinical impression
IN THE CLINICAL SCENARIO
Minimise the risk of harm to the patient
Minimise the risk of harm to you/the doctor
Minimise the risk of harm to the organisation
KEY POINTS 2
Motives behind self harm
Mental relief from distress via physical harm/pain
Self-loathing
Self-regulation of mood, dissociation
A sense of control
Influence of others
Impulsive or compulsive component
Can arouse various feelings in staff & influence staff attitud
Be calm, non-judgemental, practical & caring
RISK AND VULNERABILITY FACTORS
MANAGEMENT IN THE ED
Practical & environmental aspects
Offer safe and supportive environment whilst waiting, consider supervision
Enlist support of family and carers; obtain their viewpoints
Call for assistance from staff or police if necessary
Treat any physical sequelae of self harm
Adequate anaesthesia/analgesia
Screen for any other forms of harm or injury
Psychosocial assessment
Problem-solving; distraction techniques; mindfulness
Disposal & follow-up:
MANAGEMENT OF DELIRIUM
Treat underlying cause
Review medication
Supportive management - hydration, nutrition, oxygenation, analgesia, mobilisation
Environment - optimal sensory stimulation, remove unnecessary equipment
Skilled nursing care
PSYCHOTROPICS IN DELIRIUM
All sedatives can worsen delirium and delay recovery
Use only if significant risk or significant distress
Antipsychotics preferred to benzodiazepines, unless the presentation is a withdrawal or head injury
Monotherapy, lowest effective dose
Nice guidelines (2010): consider short-term haloperidol or olanzapine (though not in Lewy body dementia)
Haloperidol is generally the preferred antipsychotic
RCP recommend 0.5mg up to 2 hours with max 5mg in 24 hours, as as guide
Higher doses are often used; BNF maximum is 20mg daily oral, or 12mg daily IM
Consider ECG monitoring (risk of Torsades de Pointes, associated with prolonged QTc) and cardiology referral if QTc > 440ms (men) or 470ms (women)
NHSL Rapid Tranquillisation Guidelines provide some support though were intended for psychiataric inpatients
CLINICAL SCENARIO
22 year old male taken into the ED by his mother
Mother reports that her son has taken a paracetemol overdose
Patient seems very agitated though denies any overdose, stating that his mother is trying to have him "committed"
Patient then shouts "THIS IS DOING MY NUT!!" before storming out of the unit
Mother confides that she saw her son take tablets and found 3 empty strips of paracetemol in his bedroom
UK - IN ANY
ONE YEAR
UK - POINT
PREVALENCE
(Mental Health Foundation)
GP
CONSULTATIONS
Appearance
Behaviour
Affect
Speech
Thought form (e.g. thought disorder)
Thought content (e.g. delusions)
Perception (e.g. hallucinations)
Cognition (e.g. orientation, memory)
Insight
UK - REASON FOR
PRESENTING
TO THE ED
(RCPsych CR183)
INQUIRY: KEY MESSAGES
INQUIRY: KEY RECOMMENDATIONS
1.
Post-discharge followup
should be a priority
2.
HANGING SHOULD BE
RE-PORTRAYED IN THE MEDIA
3.
MENTAL HEALTH SERVICES SHOULD
PLAY A STRONGER ROLE IN PROTECTING
THE VICTIMS OF DOMESTIC VIOLENCE
4.
CRISIS/HOME TREATMENT SERVICES
SHOULD BE A PRIORITY FOR SUICIDE INTERVENTION (THOUGH MAY NOT BE SUITABLE FOR HIGH RISK PATIENTS)
5.
SERVICES SHOULD RECOGNISE & OFFER HELP WITH THE ECONOMIC PRESSURES
6.
SERVICES SHOULD WORK TO REDUCE THE NEED FOR RESTRAINT
FIRST 3 MONTHS POST
HOSPITAL DISCHARGE
IS A TIME OF PARTICULAR
RISK FOR SUICIDE
HANGING REMAINS
THE MOST COMMON
METHOD OF SUICIDE
INTIMATE PARTNER
HOMICIDE REMAINS
A PROBLEM -13%
BY MH PATIENTS
SUICIDE RATE FOR
PATIENTS UNDER CARE
OF CRISIS TEAMS IS
SUBSTANTIALLY HIGHER
THAN INPATIENTS
Overall fall if using old coding rules
Progress
5 themes
2002 Choose Life strategy & HEAT target
19% fall
2013 - 746
1. RESPONDING TO PEOPLE IN DISTRESS
- guidance document, training of staff in suicide prevention & the broader community, improving local & national data sources
2. TALKING ABOUT SUICIDE
- develop an engagement strategy to influence public perception, media guidelines to influence reporting, work to reduce stigma through the "See Me" campaign
3. IMPROVING NHS RESPONSE TO SUICIDE
- work to make mental health services safer, more regular review of those on long term treatment for mental disorder, improved detection & treatment of MH problems in those with long term conditions
4. DEVELOPING THE EVIDENCE BASE
- continue to fund ScotSID & National Confidential Inquiry
5. SUPPORTING CHANGE AND IMPROVEMENT
- continuation of Choose Life programme, monitoring of progress of all committments mentioned
3 quality ambitions
7 key themes
36 specific commitments
Health and care must be:
1. Person-centred - shared decision making
2. Safe - no avoidable harm
3. Effective - most appropriate input at the right
time with less wasteful variation
1. Working more effectively with families and carers
2. More peer to peer work and support
3. More support for self-management & self-help
4. Extending the anti-stigma agenda
5. Focus on patient's rights
6. Developing the outcomes approach to include personal,
social and clinical outcomes
7. Effective use of new technologies to provide information
and evidence-based services

IN THE GENERAL
HOSPITALS
(Centre for Mental Health)
Mental illness is one of the top public health
challenges as measured by prevalence, burden
of disease and disability
Evidence of need
High mental health needs in acute hospitals
Most common
: self harm, depression, delirium, dementia, adjustment reactions & alcohol related disorders
National drivers
Benefits
Improved quality of care and reduced risk & adverse events
Financial benefits; reduced readmissions, reduced unnecessary interventions, quicker discharges
Parity of physical and mental health care
Improved staff training & reduced stress
Service design & development
THE CASE FOR A LIAISON PSYCHIATRY SERVICE
MEDICALLY UNEXPLAINED SYMPTOMS
What are they?
Symptoms are common, tend to be persistent & are associated with distress
Risk of unnecessary medical interventions & iatrogenic complications
How to manage it?
Not generally an ED diagnosis unless patient known
Look at the bigger picture when eliciting symptoms
Ask about stress & childhood stressors such as abuse
Collaborative working between relevant physical health teams, psychiatry and primary care
Management plan encompassing both physical and mental healthcare
Consider depressive or anxiety disorders (common co-morbidity)
Rarely presents in older adulthood
What does "medically unexplained symptoms" mean?
An umbrella term meaning just that - but suggesting the likely absence of an underlying medical cause (or a strong assumption of psychological aetiology)
May present to any medical subspecialty
The term Includes a number of discrete conditions or aetiological theories:
SYMPTOM
- subjective and cannot be measured (cf. sign)
- a departure from normal feeling or function
- regarded as indicating an unusual state or a disease

SOMATOFORM
DISORDERS
The symptoms or pain are real to the patient and not created on purpose
Patients repeatedly present with physical symptoms and requests for investigations, in spite of negative findings and reassurances; symptoms may change over time
Inlcudes somatisation disorder,
hypochondriacal disorder
,
persistent somatoform pain disorder
Cause is thought to be stress-related
DISSOCIATIVE
(CONVERSION)
DISORDERS
Symptoms tend to involve an aspect of the CNS over which voluntary control is exercised - generally motor neurological symptoms though may be sensory
Patients do not consciously recognise the non-organic basis of the disease, though frequently demonstrate lack of concern for the deficit
Tends to be an antecedent stressor as well unconscious secondary gain
FACTITIOUS
DISORDERS
Intentional production or feigning of symptoms or disabilities
Motive is an internal secondary gain, e.g. the sick role
Previously termed Munchausen syndrome
May be "by proxy" - fabrication of symptoms in another, usually a child
MALINGERING
Intentional production or feigning of symptoms or disabilities
Motive is an external secondary gain, e.g. benefits, avoiding military service, etc
Not seen as a psychiatric disorder
CONSENT
&
CAPACITY
CONSENT
Agreement or permission to do or allow something
May be:
Implied
(e.g. by a person's actions or inactions)
Express/explicit
(clearly stated - in speech, non-verbal communication or writing)
Informed
(the person has a clear appreciation of the facts, consequences and risks of an action or inaction)
Voluntary
(the decision made by the patient - not under undue pressure from others)
Must be VALID - informed & voluntary with sufficient information given - the "broad terms of the nature of the procedure"
Has a duration and scope
A mentally competent person has an absolute right to refuse to consent to medical treatment for any reason, rational or irrational or for no reason at all, even when the decision may lead to his or her own death
CAPACITY
The ability to make and communicate an informed choice
A legal concept
Legal age of capacity in Scotland is 16 (Age of Legal Capacity (Scotland) Act 1991
Is presumed in adults
Decision-specific
Time-specific; may fluctuate e.g. in delirium
Can be impaired by temporary factors such as fear, pain or anxiety
Try and minimise these first if possible
1. Understand (and believe) the relevant information
2. Weight up the information and appreciate the consequences
3. Retain the relevant information
4. Communicate the decision
THE LEGAL TEST
LEGISLATIVE FRAMEWORKS TO CONSIDER
1. Informed consent
2. Common law
3. Mental Health (Scotland) Act
4. Adults with Incapacity (Scotland) Act
- section 47
- Guardianship Order
5. A legal guardian
COMMON LAW
SCOTS LAW
CIVIL LAW
COMMON LAW
Statutes
Case law or precedent
Doctrine of:
"Necessity" (emergencies) - necessary to save life or prevent deterioration
Acting in the patient's "best interests"
Under a "duty of care"
RIsk of "negligence" if no intervention
WHERE DO WE OBTAIN AUTHORITY FOR INTERVENTION?
AUTHORITY
TO
TREAT
MENTAL
HEALTH
ACT
ADULTS
WITH
INCAPACITY
ACT
WHICH
ACT TO
USE?
INCIDENCE
& PREVALENCE
SUICIDE
STATISTICS
IMPACT
Act of the Scottish Parliament relating to mentally disordered persons
Applies to people who have a "mental disorder";
Mental illness
Personality disorder
Learning disability
Sets out
When people can be treated against their will
When people can be taken into hospital against their will
What people's rights are and the safeguards for these rights
MH(S)A IN PRACTICE
The 3 main detention orders - EDC, STDC, CTO
The Emergency Detention Order
The 5 criteria for detention
The process of detention
The powers granted by the detention
Some important provisions
ALL
OF THE FOLLOWING MUST BE SATISFIED:
1. Mental disorder - likely
2. Lacking capacity - SIDMA - in relation to medical treatment for mental disorder, as a result of his or her mental disorder
3. Risk - likely - to self or others
4. Must be necessary - alternatives?
5. STDC would take too long
POWERS GRANTED BY DETENTION UNDER EDC
Detention for a period of 72 hours
If detained outside hospital, 72 hours allowed to transfer then further 72 hours begins on arrival
If detained in hospital, begins when certificate is granted
ED benefits from community timescales
But detention is not valid until form processed
Emergency medical treatment for mental disorder (section 243)
Essentially an assessment order
SOME IMPORTANT PROVISIONS REGARDING DETENTION
Millan principles - best interests, least restrictive option, etc
Advance statement
Named person
Views of carers and relatives
Act of Scottish Parliament
Concerns the welfare of adults who are unable to make decisions for themselves because they have a mental disorder or are not able to communicate
Covers power of attorney, guardianship orders, intervention orders, medical treatment and other areas
Principles: benefit, least restrictive option, past an present wishes, consultation with relevant others, encourage the person to use existing skills and develop new skills
Part 5 covers medical treatment
AWI(S)A - MEDICAL TREATMENT
Section 47 certificate
Cannot use force unless immediately necessary and only for as long as necessary
A welfare attorney or guardian may have power to consent on the patient's behalf
Some treatments carry special safeguards and require an independent opinion (e.g. abortion, ECT, sterilisation)
MHS(A) SHORT-TERM DETENTION ORDER
May only be granted with MHO permission
An AMP must do the detention (a senior psychiatrist)
Lasts for a maximum of 28 days
Does allow treatment for mental disorder
Does not allow treatment for physical disorder
Unless the physical disorder is a
direct cause or consequence
of the mental disorder
Note: test and threshold varies depending on the gravity of the decision
PRINCIPLE-BASED APPROACH
When considering detention or the use of force, a principle-based approach can be helpful;
Does the person lack capacity?
Is the treatment necessary?
Is force necessary?
Is the force required proportionate to the purpose of the intervention?
Is the use of force lawful?
Relatively new
Limited staffing
IS MENTAL DISORDER A RISK FACTOR FOR VIOLENCE?
Gender
Age
Poverty
Substance or alcohol abuse
Mental disorder?
Inaccurate and stigmatising portrayal in entertainment and the media
Methodological challenges in research
When the above factors have been controlled, rates are often equalised
A few more recent studies have reported a modest association between mental disorder and violence
Age
(Scotland)
(Scotland)
5 SUICIDE REDUCTION THEMES
Questioning style
Use open questions
Avoid compound questions
Avoid leading questions
Documentation
Be clear
Use quotes
Avoid jumping to conclusions e.g. "suicide attempt"
Deliberate self harm vs suicide attempt
Basic signposting
Liaison services do not necessarily have to be involved, though should be contacted if;
A new presentation or unknown patient
A suicide attempt
An acute mental disorder
Agree follow-up plan
Psychiatric review in ED
GP followup
CMHT referral
Ongoing CMHT input
Give contact numbers e.g. NHS-24, Breathing Space, etc
DISPOSAL AND FOLLOW-UP
*
*
SUICIDE RISK FACTORS
Male
Aged between 25 and 34
Recent discharge from hospital
BIOPSYCHOSOCIAL
Mental disorder
Physical disorder
Alcohol & substance abuse
Hopelessness
Impulsive or aggressive tendencies
History of trauma or abuse
Previous suicide attempt
Family history of suicide
ENVIRONMENTAL
Job or financial loss
Relational or social loss
Easy access to lethal means
Local clusters of suicide
SOCIO-CULTURAL
Social isolation
Stigma
Barriers to accessing healthcare
Certain cultural & religious beliefs
FOR ALL
DEPARTMENTS
DIAGNOSIS base on 3 domains:
1. Underlying cause - medical condition, intoxication or withdrawal
2. Course - acute onset, fluctuating, improvement with medical recovery
3. Clinical picture - disturbance of multiple higher functions (consiousness, cognition, perception, mood, psychomotor, sleep/wake cycle)
- SUBJECTIVE
CURRENT
PRESENTATION
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