Acute Mental Health Emergencies- from the office to the ED

Transcription

1 Acute Mental Health Emergencies- from the office to the ED Jacqueline Grupp-Phelan, MD MPH Division of Emergency Medicine Cincinnati Children s Hospital Medical Center

2 Learning Objectives Be familiar with the common mental health emergencies that may result in an ED visit To examine strategies for risk assessment and crisis intervention To review examples of available tools and resources To outline the process of emergency department and inpatient psychiatric evaluation

3 Pediatric Mental Health Pediatric mental disorders affect 1 in 5 Begin early in life- 50% by age 14, 75% by 24 Surgeon General s Report 1999 A decade later less than half receive treatment Attitudinal barriers along with structural barriers remain significant Vary by SES, Ethnicity, Culture, Care Provider Most children with mental health problems in primary care are not referred, when referred may not attend

4 Crisis intervention General Approach Usual coping and adaptive patterns of child and family disrupted Risk to patient s health and wellbeing Risk to patient s safety Risk to others Assessment, treatment and disposition must include the child and the family Ensure physical and emotional safety of child Provide support and nurturance Set limits on behavior

5 The environment Everything should be done in a non-judgmental and caring manner Check your own pulse first Patients should be searched Removal of weapons or drugs that might be used to hurt self or others Place in a safe and quiet environment Decrease stimulation Minimize access to dangerous materials Chemical or physical restraints as necessary and appropriate

6 Orienting data Relevant history Evaluation Acute vs. sub-acute presentation Medical history and physical examination Assess for organic causes Mental status of the patient Assess for organic causes Family evaluation Disposition viability

7 Mental Status Exam Orientation Appearance Memory Acute and remote Cognition concentration Behavior Relating ability Speech Pressured? Affect Thoughts Looseness of associations Flight of ideas Hallucinations Insight and judgment Synthesis

8 Toxidromes Sympathomimetics Tachycardia/HTN/hyperthermia/euphoria/dilated pupils Opioids Pinpoint pupils/bradypnea/hypotension Anticholinergic delirium red as a beet, dry as a bone, blind as a bat, and mad as a hatter Cholinergic excess SLUDGE (salivation, lacrimation, urination, diarrhea, GI, emesis- add miosis) Marijuana- Dilated pupils

9 Common Mental Health Emergencies NSSI Suicidal behavior Homicidal Ideation Aggression Mania

10 Non-Suicidal Self Injury (NSSI) 10% of adolescents have engaged in self harm behaviors Self harm behaviors are often impulsive Range of motivations and intent (sometimes unclear) Regardless of intent, self harm is a risk factor for suicide attempts

11 Non-Suicidal Self Injury (NSSI) Cutting is the most common form Motivations may include escape, tension relief, punishment, cry for help Social transmission does occur Risk factors include female gender, psychiatric illness, substance abuse, bullying Greater number of events have higher suicide risk

12 Suicide Most acute aspect of psychiatric emergencies Greatest benefit from intervention Fleeting Suicidal tendencies are typically fleeting with increases after stressors, but decrease to zero within several weeks after the acute event in most adolescents

13 Suicide Epidemiology 2 million US adolescents attempt suicide each year 2000 succeed Suicide is 2nd leading cause of death for youth ages years 15.8% of high school students report they have seriously considered attempting suicide 7.8% report one or more suicide attempts during past 12 months Many youth at high risk go unrecognized; many who die by suicide have never received any mental health services Centers for Disease Control and Prevention (2012). "National Youth Risk Behavior Survey - United States, 2011." Retrieved October 22, 2012, from Centers for Disease Control and Prevention (2013). "Web-based Injury Statistics Query and Reporting System (WISQARS).". Retrieved July 8, 2013 from

14 Suicide Stats Rare before puberty, but not non-existent Age perceptions of death Increase in younger age group recently Attempts more common in females Ingestions most common method in attempts Completion more common in males Firearms most common method in completed attempts Neighborhood Rural-firearms Suburban-carbon monoxide Urban-jumping from buildings Suicide attempts via ingestion in age 5-14 years 5 times more common than all forms of meningitis

15 Socio-demographic Risk Factors for Suicide Male gender LGBTQ youth Homelessness Poor school functioning History of abuse Poor Supervision Parental Mental Health Problems Access to means (medications/weapons) Family Conflict Shain and AAP Committee on Adolescence, 2007

16 Psychiatric/Behavioral Risk Factors for Suicide Past history of attempts Passive vs. active suicidality Intensity of Thoughts Suicidal plans Suicidal intent Mood and Anxiety Disorder PTSD Insomnia Aggression and Impulsivity Substance Use Disorders Psychiatric Comorbidity Shain and AAP Committee on Adolescence, 2007

17 Protective Factors Desire and willingness to seek help Supportive family Peer support Established relationship with therapists Safety contracts have not been shown to be effective Asking about suicide does not raise risk suicidality Shain and AAP Committee on Adolescence, 2007

18 Suicide Risk Screens Columbia-Suicide Severity Rating Scale (C-SSRS) Suicidal Ideation Questionnaire (SIQ Jr) Ask Suicide Questions (ASQ) Columbia Suicide Scale

19 Ask Suicide Questionnaire 4 Items In the past few weeks, have you felt that you or your family would be better off if you were dead? In the past few weeks, have you wished you were dead? In the past week, have you been having thoughts about killing yourself? Have you ever tried to kill yourself? *Ballard et al., 2012

20 Clinical Assessment Interview child and parent separately Never worry alone refer for urgent assessment if concerned about imminent risk or if unsure Inform responsible third party Perception of lethality varies with developmental stage and cognitive level Don t take the child s word about medications ingested

21 Risk Assessment Frequency of thoughts about suicide Intensity of these thoughts Duration of these thoughts Specificity of plan Hopelessness Rapid denial in apparent significance of attempt worrisome Family support and supervision Connection with mental health treatment Reasonable safety plan

22 SADPERSONS Screen S ex A ge D epression and Affective Disorders P revious Attempts E thanol and Drug Abuse R ational Thinking Loss S ocial Supports Lacking O rganized Plan, access to means N egligent parenting, family stress S chool Problems

23 Acute Safety Concerns Referral to Emergency Department Mobile Crisis or Crisis Line

24 No Acute Safety Concerns Develop a safety plan Referral for mental health services (evidencebased) psychotherapy is usually a good first step Cultivate relationships with mental health providers in your area County health department can be a resource (especially for patients with Medicaid) Pediatricians can play a key role in coordinating, supporting, and providing mental health care Collaboration with child psychiatrists

25 Treatment Psychiatric consultation Never prescribe antidepressant medications Encourage family to tell patient they want him or her to live and that suicide is forbidden Tender, but firm with setting boundaries

26 Disposition Inpatient No studies exist that show a reduction in risk of future suicide attempts or completed suicides for patients hospitalized Outpatient Follow up within days Sanitized residence Contract for safety No evidence this prevents suicide

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28 Homicidal Ideation Risk assessment mirrors suicide assessment Passive vs. Active Homicidal Ideation Frequency and intensity of thoughts Past violent behavior Access to means Presence of risk factors Family support and supervision Connection with mental health treatment Reasonable safety plan

29 Aggression Characterizing Aggression Impulsive? Triggered? Red flags destructive behaviors, harm to self or others, cruelty to animals, fire setting, premeditation Risk Factors Prior aggression History of abuse Substance Use Exposure to violence

30 Acute Management of Aggression De-escalation Decrease environmental stimulation Remove obvious triggers Provide emotional support Call security personnel Parents should help calm patient Refer to ED

31 Psychosis and Mania Families may struggle to describe the symptoms Both can be associated with impulsivity, self harm behaviors, harm to others Consider medical causes, ingestions, substance abuse Both necessitate an urgent evaluation Both will likely require psychopharmacologic intervention

32 Psychosis Hallucinations Delusions Disorganized thinking Bizarre behaviors Severe functional decline Poor attention to self-care Psychosis and Mania Mania Elevated or irritable mood Pressured speech Racing thoughts Decreased need for sleep Pleasure-seeking, risk taking, impulsive behaviors Increased goal directed behavior Hypersexuality Grandiosity

33 Organic vs. Psychiatric Features Organic psychosis Psychiatric psychosis Onset Acute Gradual Pathologic autonomic signs May be present Absent Vital signs May be abnormal Normal Orientation Impaired Intact Recent memory Impaired Intact Intellectual ability May be impaired Intact Hallucinations Visual or Tactile Auditory

34 Other psychiatric disorders PTSD Reexperiencing, avoidance, hyperarousal Dissociative Disorders Extreme trauma leads to splitting of integrated functions of identity, memory and consciousness Includes conversion reactions, fugue states and multiple personality disorders School refusal Main goal is restoration of normal function Do not do excessive labs! Send them back to school!

35 ADHD Associated with depression and suicide attempts Associated with bipolar disorder Associated with antisocial personality disorder

36 Conduct Disorders Repetitive, socially unacceptable behavior, without evidence of medical or other psychiatric disorder Males 5 times more likely to develop than females High incidence of violence Usually seen in conjunction with law enforcement Firm control and detailed expectations with assistance of security and restraints when necessary Parents should be directed to assist with control of behavior in department

37 Emergency Department and Inpatient Psychiatric Evaluation Helping Families Know What to Expect

38 ED Mental Health Evaluations All children receive medical clearance before mental health evaluation begins Mental Health Social Worker or Mental Health Professional conducts the assessment Each case is discussed with the on call psychiatrist Primary focus of assessment is safety (not a comprehensive diagnostic assessment) Criteria for inpatient admission are limited (danger to self or others, grave disability)

39 ED Mental Health Evaluations Psychiatric medication evaluations are not available in the ED Psychiatric medication refills are not provided by the ED Any clinical/background information you can provide is very appreciated! Referrals are provided to children who are not psychiatrically hospitalized

40 Inpatient Psychiatric Admission Average length of stay is 5-7 days Includes family meetings, group sessions, psychiatric evaluation, safety planning, referrals to community resources Goal is stabilization (not necessarily resolution of symptoms) Psychopharmacologic treatment includes assessment, initiation of medication, observation for side effects. May not be able to assess benefit during short admission

41 Conclusions Mental health emergencies may arise in primary care settings Primary care providers can assess risk and triage to appropriate level of care There are tools available for screening and risk assessment It is important to become familiar with crisis resources available in your community Understanding the emergency department and inpatient mental health evaluation can help you counsel families during mental health emergencies

42 QUESTIONS? Back Up Slides