Abstract
Mental urgencies may present to urgent care centers with symptoms unexplainable by a thorough history and physical exam. This chapter examines mental urgencies such as depression and suicide, anxiety disorder, eating disorder, and conversion disorder and suggests the initial workup and reasons for referral to the emergency department for these conditions.
Keywords
anxiety, confidentiality, depression, eating disorders
1
A 14-year-old male with no significant past medical history presents to your urgent care center with a 6-month history of daily headaches and poor appetite. His parents are concerned because he has become more “withdrawn” recently, spending much of his day in his room alone, playing on his computer. On exam, he is sullen, unengaging, and says he “doesn’t want to talk about it.” His vital signs and physical exam are unremarkable. What signs and symptoms may lead you to consider depression in a child or adolescent?
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Isolation or withdrawing from friends and family
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Loss of interest in things he/she previously enjoyed
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Changes in sleep patterns (i.e., hypersomnia or insomnia)
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Decline in school grades or performance
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Somatic complaints: headaches, abdominal pain, chest pain
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Change in appetite: loss of appetite, weight loss or weight gain
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Irritability
3
What is an essential element to obtaining a psychosocial history in an adolescent?
In talking with an adolescent it is necessary to discuss confidentiality. When a medical provider has a discussion about confidentiality at the onset of the visit, adolescents are more likely to disclose information about sensitive topics. In addition, when confidentiality is not discussed, the adolescent is more likely to forgo care, or not disclose the information.
4
What is a “conditional” discussion of confidentiality?
Confidentiality is best discussed with the adolescent and family/guardian at the start of the encounter. The idea that confidentiality is “conditional” means that there are situations in which confidentiality will be breached. Under these circumstances, disclosure is required by law such as abuse or homicidal ideation, or when the provider has concern for risk or harm to the adolescent such suicidal ideation or high-risk behavior.
5
What are some of the risk factors for suicide attempt in adolescents?
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Male gender
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Age >16 years
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Homosexual orientation
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Parental mental health problems
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Family history of suicide or suicide attempts
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History of physical or sexual abuse
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Previous suicide attempt
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Mood disorder
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Substance use
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Pathologic internet use
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Access to firearms or lethal means
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Poor social support
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Bullying
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Recent psychosocial stressor
6
What questions can be asked to screen for suicide risk?
The Ask-Suicide Screening Questions (ASQ), which have a sensitivity of 96.9% and specificity of 87.6% in patients presenting to a pediatric emergency department. Answering yes to one or more of the four questions is considered a positive screen.
- 1.
In the past few weeks, have you ever felt that your family would be better off if you were dead?
- 2.
In the past few weeks, have you wished you were dead?
- 3.
In the past week, have you been having thoughts about killing yourself?
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Have you ever tried to kill yourself?
7
An 11-year-old female is brought to the urgent care clinic by her mother. The daughter has been complaining of stomachaches over the past 2 weeks since starting school. She is eating very little at lunch and cries every morning before leaving for school. She has never expressed any concerns about body image but says she is just not hungry. What signs may a child present with when exhibiting anxiety?
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School avoidance or refusal
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Avoidance of social situations or activities
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Somatic complaints (headache, chest or abdominal pain)
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Restlessness, nail biting, or hair pulling
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Declining school performance, inattentiveness
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Decreased appetite
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