Evaluation of Psychiatric Patients in the Emergency Department
OVERVIEW
People come to the emergency department (ED) with a wide variety of psychiatric and emotional concerns, from acute grief to first-break psychosis to medical illness masquerading as psychiatric disease. It is essential that the emergency physician begin with an open mind regarding the range of these possibilities, remain open throughout the process of working with the patient, and create communication that facilitates discussion of the patient’s concerns with the doctor.
As in all other aspects of medicine, a thorough history and an inclusive and accurate differential diagnosis are most crucial.
These in turn rest on:
Effective communication, in both directions, between doctor and patient (and often others who are involved)
Thoughtful and thorough history taking, mental status examination, physical examination, and laboratory studies
Effective use of ancillary sources of information
Effective negotiation about what is to be done about the problem
GENERAL APPROACH TO THE PATIENT
Preconceptions are almost always dangerous in the evaluation of psychiatric patients. Individuals with preexisting psychiatric disease often have new, nonpsychiatric problems that are easily overlooked by health professionals; new symptoms should not be attributed to old diagnoses. New symptoms appearing in the presence of a psychiatric diagnosis are not caused by that diagnosis until proved to be so.
Many psychiatric patients have negative perceptions regarding prior experiences in the ED—hours spent waiting, sometimes in restraints; sometimes treated against their will; sometimes treated in a patronizing, or otherwise disrespectful manner—not as adults with the same rights to courtesy and participation in treatment as anyone else. These experiences sometimes color the person’s expectations, and they may approach emergency personnel with wariness or hostility. It is wise to expect that anyone with a serious psychiatric disorder, who has had several ED visits, probably has had at least one such negative episode in the past. These perceptions are often accentuated by the physical environment and nature of the ED—lack of privacy, repeated questions, and personal questions asked by strangers. The emergency physician should engage the patient in a manner that preserves the patient’s dignity and emphasizes the physician’s respect for, and empathy with, the individual’s current and past problems. The following are simple, commonsense suggestions, but they are worth repeating.
Treat the person with at least as much courtesy as you expect in return.
Be open, friendly, and candid about your role and what you are doing.
Explain what you are doing and why.
Use nontechnical language.
If there have been undue delays in seeing the patient, or other problems have arisen, apologize—it works wonders.
Offer choices whenever possible, for example: Is there anyone you would like us to call, or to call yourself? Have I forgotten anything? Is there anything you would like to add? Anything you would like to ask me? If we need to give you medication, is there anything you prefer that we do or do not use?
PSYCHIATRIC HISTORY AND MENTAL STATUS EXAMINATION
Psychiatric History
General Considerations
The history taking comes first, and then the mental status examination, because most of the mental status examination can be inferred from the history. The function of the history taking, however, is to generate a differential diagnosis.
The heart of the history is the history of present illness: what is wrong now, when did it start, and what has the progress of the problem been to the current time. Frequently, when patients with a known psychiatric illness are evaluated in the ED, this step is skipped entirely, and the evaluation is based on the past psychiatric history. This can be a fatal error.
Under the time constraints of the ED, with multiple demands on the physician, there is a natural tendency to want to “cut to the chase.” This is one of the reasons that doctors so often jump to the conclusion that the current problem is caused by, or related to, psychiatric illness. It also sometimes causes physicians to use a communication style that drastically decreases self-exposure by the patient: rapid use of closed-ended, yes-or-no questions, and the use of symptom checklists (You have been depressed? Is your appetite low? Sleep poor? Suicidal ideas?). These questions may seem to lead rapidly to a ruled-in diagnosis, but they frequently obscure other important elements of the history. For example, the doctor may elicit that the patient is depressed, but not that depression exists now, or has significantly worsened, because of a completely new issue. For the patient to have just learned,
for example, that a spouse has been abusing their child, and it is this fact that has precipitated severe depression, has major significance in regard to prognosis, current treatment, and disposition options.
A time-saving, rapport-building suggestion: In general, it is wise to begin the history by offering to share with the patient what you already know. In doing this, the physician saves time, by obviating the need to repeat information already given; treats the patient in an unusual (and often engaging) way by offering to be the one who first exposes what she or he knows and who offers to share that mysterious document, “the chart”; and very often gives the patient a chance to correct some minor error or misinformation. This last interaction is often very helpful in establishing rapport, because the patient assumes a competent, helpful, and collaborative role—even if only to say he is 32, not 33, for example. This minor interaction validates the importance of the interaction and helps solidify the relationship. It also allows the doctor to demonstrate openness to input and correction, and to convey a respectful, kind, and down-to-earth tone. Even when the patient is in the ED totally against his or her will, this kind of openness and willingness to put the cards on the table on the part of the doctor can be very helpful.
After the patient starts to talk, try to be quiet for a minute or two and listen. On the average, doctors interrupt patients after less than 1 minute of the person’s speaking. Strive to hear what the person is saying, from his or her point of view. Then let the first thing you say be a summary of what you have heard so far, for example, “Let me see if I hear what you are saying…” As you summarize what you have heard, use as many of the same words as the patient to describe emotions and other important parts of the history, that is, if the person said he was “freaked out” because his pet died, do not say, “so, you were upset that your pet died.” The more exact your repetition, the more the person will feel heard; when you paraphrase or translate, the person tends to hear the difference between what she or he said and what you said, not the similarity. This decreases rapport.
The goal of the first part of the history taking is to get the “nod.” The nod is, literally, the person nodding to the doctor as the doctor reflects back what the person seems to be saying. If the doctor gets the nod, then the interview is off to a good and probably fruitful start. If there is no nod, there is almost certainly a communication problem, which the doctor needs to consider. It could be that the patient is so furious about being in the ED that there is nothing the doctor can do to establish rapport, although in such cases sometimes a candid acknowledgment of the person’s situation (“I understand that you feel it was a terrible mistake for the police to have brought you here”) can break through the person’s anger and fear. The lack of the nod could also be because the patient is too psychotic or delirious (a critically important distinction, as is elaborated herein) to communicate with the doctor. In either event, the absence of a nod is an important data point in further history taking and especially in negotiating about what to do.
History of Present Illness
As one begins to take the history of present illness, listen without interrupting at all in the first minute or so of the patient’s discourse; try to step back and take the patient in, as a whole person: the dress, bearing, tone of voice.
As discussed, begin the history with general, open-ended questions that invite elaboration, and then move gradually to more close-ended, yes-or-no questions about specific symptoms.
Be sure to focus on why the person is presenting for care now. Do not be misled by an extensive past history into overlooking current problems.
In interviewing psychiatric patients, one concern is that one does not want to overlook something that requires immediate action, such as an undisclosed overdose, or a silent serious medical problem. Pay particular attention to new physical symptoms and reports; these must be adequately explained in the differential. Pay particular attention to recent medication changes, psychiatric and nonpsychiatric.
If there is any concern about psychosis or impaired reality testing, be sure that you have established whether the person is delirious. This is a vitally important differential question. The evaluation of delirium is dealt with more fully below, but the hallmarks of delirium are the following:
Confusion about place, person, time, or situation
Impaired attention and concentration
Hallucinations other than auditory
Waxing and waning levels of consciousness
Rapid changes in psychiatric symptoms in a setting suggestive of physical or neurologic illness
Delirium is a medical emergency, not a psychiatric emergency. The underlying cause of delirium must be established as a priority.
If there is concern about psychosis or impaired reality testing, and the physician is satisfied that the person is not delirious, it is essential to inquire about hallucinations in all sensory modalities. Any hallucination in a nonauditory modality strongly suggests an encephalopathic cause—seizures, poisoning, withdrawal, etc. The differential diagnosis of psychosis is discussed more fully below. The presence of delusions and illusions should similarly be established.
If there is concern about the presence of depression, it is important to establish the time course, whether it is worsening or not, and whether it is accompanied by the so-called neurovegetative signs of depression. These can be remembered by the mnemonic device SIGECAPS: disturbances of sleep, interest, guilt, energy, concentration, appetite, psychomotor activity, and suicidal thoughts. The presence or absence of suicidal ideation requires separate consideration as well. This is dealt with more fully below. The number and intensity of the neurovegetative signs of depression are one measure of the intensity of depression and its likely response to pharmacotherapy.
If the problem concerns mainly relationships with important other people, take note of how the person is describing these people and relationships, to get a sense of how the person copes and what his or her strengths and weaknesses in relationships may be.
Take into consideration the course of treatment wherever possible—what has been tried and when.
Note the current, most proximate stressor, “the straw that broke the camel’s back,” as it were.
Note all current medications.
Psychiatric History
Note past treatment for conditions similar to the present problem, as well as unrelated psychiatric or substance abuse problems or previous treatment.
Medical History
For all psychiatric patients, it is essential to note the following:
Family History
A family history of psychiatric illness and substance abuse should be noted.
Social History
Note current living situation (with whom, nature of the relationship); current work or school situation; significant issues in the person’s current life.
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