General psychiatric approach

Background

• Be wary of diagnostic overshadowing (e.g. erroneously attributing symptoms of medical illness to psychiatric disease)
  • Compared to overall population, patients with mental illness have significantly higher rates of stroke, CAD, DM, cancer, HIV, HCV

Clinical Features

Mental Status Exam

• General Appearance
• Orientation and Attention
• Speech
• Mood and affect
• Thought Patterns (process, content)
• Psychomotor behavior
• Insight and Judgement

Differential Diagnosis

General Psychiatric

• Organic causes
  • Delirium
  • Dementia
  • Overdose
• Psychiatric causes
  • Depression
  • Anxiety
  • Conversion disorder
  • Bipolar disorder
  • Acute psychosis
  • Panic attack
  • Schizophrenia

Evaluation

• Rule out medical pathology as cause or exacerbating factor for presentation

General ED Psychiatric Workup

• Point-of-care glucose
• CBC
• Chem 7
• LFTs
• ECG (for toxicology evaluation)
• ASA level
• Tylenol level
• Urine toxicology screen/Blood toxicology screen
• EtOH
• Urine pregnancy/beta-hCG (if female of childbearing age)
• Consider:
  • Ammonia (see Hepatic encephalopathy)
  • TSH (hypo or hyperthyroidism may mimic mental illness)
  • CXR (for Tb screen or rule-out delirium in older patient)
  • UA (for rule-out delirium in older patients)
  • Head CT (to rule-out ICH in patients with AMS)
  • Lumbar puncture (to rule-out meningitis or encephalitis)
• Sad person's score

ACEP Guidelines 2005

• Class B recommendations
• Routine laboratory testing is of low yield and unnecessary
• Routine urine toxicology need not be performed
• Pending results should not delay transfer or evaluation
• Patient’s cognitive abilities, rather than specific blood alcohol level, should dictate initiation of psychiatry evaluation

Risk Assessment

Use clinical judgment along with structured tools (e.g., SAD PERSONS, Columbia Suicide Severity Rating Scale) to assess:

• Suicide risk (plan, means, intent)
• Homicidal ideation or violent behavior
• Gravely disabled or unable to care for self
• Risk to others (e.g., psychosis, command hallucinations)
• Access to firearms or lethal means

Management

General ED Psychiatric Management

• Non-pharmacologic
  • Verbal de-escalation
  • Offer comforting items: blanket, meal, pillow, etc
  • Quiet room
  • Physical restraints (should administer medications if restraints used, as decreases restraint time)
• Pharmacologic: Goal is to calm patient without oversedation
  • No history of psychosis
    • Haloperidol 0.5mg-5mg +/- lorazepam 0.25-2mg (PO/IM/IV)
      • Consider adding benztropine 0.5-2mg or diphenhydramine 25-50mg (PO/IV/IM) (reduces dystonia or extrapyramidal reaction)
    • Consider risperidone 0.5-2mg PO or olanzapine 2.5-20mg (PO/IM/SL) or ziprasidone 10-20mg IM
  • Known or suspected underlying psychotic illness
    • Continue treatment with previous antipsychotic or
    • PO: olanzapine 5-10mg or risperidone 0.5-2mg +/- lorazepam: 0.5-2mg
    • IM: olanzapine 2.5-20mg or ziprasidone 10-20mg or
    • (PO/IM/IV) Haloperidol 0.5-5mg +/- lorazepam 0.5-2mg
      • Consider adding benztropine 0.5-2mg or diphenhydramine 25-50mg (PO/IV/IM) (reduces dystonia or extrapyramidal reaction)

Disposition

Disposition should be guided by clinical stability, psychiatric risk, support systems, and local resources. Consider:

Admit to Inpatient Psychiatry

• Active suicidal or homicidal ideation with intent or plan
• Severe psychosis, mania, or behavioral dysregulation that poses danger to self/others
• Unable to care for self due to psychiatric decompensation (gravely disabled)
• Failure of outpatient or partial hospitalization treatment with acute worsening
• Severe withdrawal or detox needs (e.g., alcohol or benzodiazepine)

Medical Admission

• Unstable vital signs, toxic ingestion, or altered mental status from organic cause
• Requiring ongoing medical treatment (e.g., infection, injury, metabolic derangement)

Observation or Crisis Stabilization Unit

• Milder psychiatric symptoms needing short-term containment
• Awaiting collateral or outpatient placement/clearance
• Requires reassessment after sobering, medication trial, or de-escalation

Potentially Safe for Discharge

• No suicidal/homicidal ideation, stable mental status
• Good insight and follow-up plan in place
• No grave disability and clear understanding of safety plan
• Collateral contact and outpatient psychiatric follow-up confirmed

Key Considerations Before Discharge

• Evaluate safety at home: living situation, family support
• Review access to weapons or harmful substances
• Provide printed discharge instructions and crisis resources (e.g., suicide hotline)
• Consider short-term outpatient bridge prescriptions if appropriate
• Document clearly: capacity, decision-making, and risk assessment