In 2010 it was estimated that 21% to 23% of children have mental illness. By all estimates, the number of children with significant psychiatric emergencies presenting to the emergency department (ED) continues to rise and requires significant resources. The first priority in evaluating and treating psychiatric patients in the ED is to determine the risk the patients pose to themselves and others. This assessment guides how to best care for the patient. Safe rooms that have no equipment and are highly visible to staff are optimal for psychiatric patients. Some patients may need one-on-one supervision by staff, and some may need chemical or physical restraint.

Table 146-1 lists the historical information that should be obtained from a patient with psychiatric issues presenting to the ED. Emphasis should be placed on past psychiatric history with current medications taken, and a thorough social history to assess the home living condition, family and school relationship problems, and any history of substance abuse. It is important to ascertain the patient’s use of social networking (Facebook, etc.), as this can comprise a whole layer of social stressors. After collecting the history from the patient and parent in the examining room together, it is also vital to collect history from parents alone as well as from the child in the absence of the parents.

Examination of the psychiatric patient includes a full physical examination as well as complete neuro and mental status examination. The elements of a mental status examination are reviewed in Table 146-2. Attention should be paid to the caretakers as well as the patient. Assessment of the mental status of the caretaker can reveal much about the parent–child relationship and function.

ETIOLOGY/PATHOGENESIS

Biological correlations have been made with suicidal ideation. Low CSF levels of 5-hydroxy-indolacetic acid, low platelet imipramine binding, anomalies in the hypothalamic–pituitary–adrenal axis, sleep EEG abnormalities, and decreased REM sleep have been noted in patients with suicidal tendencies.² Most suicidal patients have psychiatric pathology, with the most common being major depressive disorder (MDD)/dysthymia, followed by disruptive behavior disorder, drug/alcohol abuse, and dependence and anxiety disorder.²

RECOGNITION

Many tools and psychiatric assessment modules have been designed to assess the suicidal patient. Usually patients present with a chief complaint of a suicide attempt that they confessed to or were confronted about. It is important to assess whether a patient with mental illness is at risk of suicide while in the ED. This can be ascertained in the interview. Horowitz and colleagues suggested a four-question (yes/no/don’t know) screening tool that yields the highest sensitivity and negative predictive value to rapidly detect suicide risk³: (1) Are you here because you tried to hurt yourself? (2) In the past week, have you been having thoughts about killing yourself? (3) Have you ever tried to hurt yourself in the past other than this time? (4) Has something very stressful happened to you in the past few weeks? The more “yes” answers, the greater the risk of the patient posing a threat to themselves.

MANAGEMENT

In the initial management of patients with suicidal tendency, it is vital that the interviewer be compassionate. The interviewer should ascertain: (1) the reason the patient desires to hurt him/herself, (2) the plan to do so, (3) whether the patient has the means necessary to carry out the plan, and (4) the timing of the plan’s execution. Recent data suggest increased urgency when suicidal patients have psychotic symptoms, as they are 20 times more likely to execute a plan of suicide as compared with their nonpsychotic counterparts.⁴ Hospitalization is warranted if there are any medical issues, or the patient is not deemed safe for discharge. Concerns for patient safety include the following:

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  Inability to maintain a safety (no-suicide) contract

  
  
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  Active suicidal ideation (plan and intent)

  
  
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  High intent or lethality of attempt

  
  
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  Psychosis

  
  
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  Volatile/unsafe family and home environment

Treatment of the patient with suicidal tendency may include both medical therapy and counseling. Multiple studies suggest that combining medical therapy (antidepressants such as a selective serotonin reuptake inhibitor [SSRI]) and cognitive behavioral therapy has the highest success rate. Treatment of depression with SSRI drugs has come under fire in recent years. In 2004, the FDA issued a black box warning for all SSRIs, warning that “antidepressants increased the risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of MDD and other psychiatric disorders.”⁵ Bridge et al. published a meta-analysis that showed antidepressant use in children, adolescents, and young adults causes greater benefit than harm.⁶ This study suggested close follow-up and evaluation of the patient, and that patients on SSRIs are not at a greater risk in the ED than those who are not on SSRIs. However, a more recent meta-analysis found evidence of increased suicidal ideation in child and adolescents on venlafaxine.⁷ Of paramount importance on discharge of a depressed or suicidal patient is counseling parents on means restrictions. This includes securing all home medications in a locked containment system and removing firearms from the home.

ANCILLARY STUDIES

If the patient’s mental status is altered, a toxicology screen and ethanol level are warranted. Many intoxicated suicidal patients are no longer suicidal once the intoxicant wears off. Organic disease must be ruled out. Thyroid disease, autoimmune disease, and other organic disease states can cause or augment a patient’s depression and tendency to commit suicide.

ETIOLOGY/PATHOGENESIS

Pediatric schizophrenia presents with psychosis at or before 12 years of age. Diagnostic and Statistical Manual of Mental Disorders (DSM)-5-criteria include: (1) delusions, (2) hallucinations, (3) disorganized speech, (4) grossly disorganized or catatonic behavior, and (5) negative symptoms. Of note, in the DSM-5 the patient must have at least two of these symptoms for at least a month, with one of them being delusions, hallucinations, or disorganized speech. Psychosis can be a feature of many other psychiatric diagnoses including MDD, bipolar disorder, and schizophreniform disorder.

Most pediatric patients present with a chief complaint of auditory and/or visual hallucinations. The etiology may be basic psychiatric illness, but again it is essential that organic disease be ruled out. There are many medical conditions that produce psychosis including infection, rheumatic disease, especially lupus,⁸ cerebral blood flow changes/hypoxia, temporal lobe epilepsy,⁹ toxicological conditions, vitamin deficiencies, metabolic and endocrine disorders, Reye syndrome, Wilson disease, and encephalopathy with varied etiologies from infectious to Hashimoto encephalopathy.¹⁰