Pearls of Evaluating Psych Patients in the ER

In Medical Concepts by Nadim LalaniLeave a Comment

Psychiatry presentations comprise about 5-6% of total presentations,1,2 but account for way more work.
It’s a common mis-perception that psych patients require a one-hour intensive interview in order to ascertain what they need. Not true.
We got an inservice from one of our psychiatry faculty today. He allowed me to share his pearls on evaluating psych patients with the most important parts of a history that can be done in 15 minutes:

The Nuts and Bolts of Psychiatric Emergency Interviewing- Dr Gene Marcoux

Most important pearl:

You can run but you can’t hide from Psychiatry.  You may as well get good at it.

Rest of the pearls of evaluating psych patients in the ER

Diagnostics:

  • The Wise Men Questions:  ask Who, What, Why & When.
  • In or Out? Try and ascertain whether the patient is going to need admission [e.g. SADPERSONS score >8-9].
  • Function trumps symptoms in Psychiatric Evaluations. If they’re functioning – they don’t need to come in.
  • Psychosis does not necessitate a review,  poor choices as a result do.
  • Mania, Intoxication and Antisocial PD (in that order) predict violence.
  • “Can you keep yourself safe?”  Best single question to evaluate suicidal risk.
  • Is there mental illness in your family? Single best Functional History question to ask.

Therapeutics:

  • What meds are they on and their family on?  Best question to determine therapeutics in drug naive pts.
  • Increasing current meds, best stop gap strategy in ER vs. switching or starting.
  • Olanzapine/Quetiapine tabs: best/safest meds to send home in small quantities.
  • Bipolar Disorder: toughest Psychiatric Illness to treat, poorest meds, poorest outcomes.
  • Consultants are generally really receptive to phone calls in order to come up with a plan.
  • Antidepressants: Poorest Psychiatric Meds.
  • Antipsychotics: Best Psychiatric Meds.

Further reading for evaluating psych patients:

  • Suicide risk – good stuff from ERCAST [click here]
  • For Medical Students: A Neat [and concise] article by Bill Young U of Kentucky on Suicide Risk [click here]

Note: This post was originally published on the ERMentor Blog. It was revised by Sean Nugent and reposted on CanadiEM on

References

1.
Larkin G, Claassen C, Emond J, Pelletier A, Camargo C. Trends in U.S. emergency department visits for mental health conditions, 1992 to 2001. Psychiatr Serv. 2005;56(6):671-677.
[PubMed]
2.
Paltser G, Martin-Rhee M, Cheng C, et al. Care for Children and Youth with Mental Disorders in Canada. Healthc Q. 2016;19(1):10-12.
[PubMed]

Nadim Lalani

Nadim is an emergency physician at the South Health Campus in Calgary, Alberta. He is passionate about online learning and recently made a transition into human performance coaching. He is currently working on introducing the coaching model into medical education.