Psychiatric symptoms are often the cause of, or the effect of many toxicologic-presentations. Suicide attempts and aggressive behaviors are commonly associated with toxicity and can be uniquely difficult to assess and manage in the emergency department. Patient factors, clinician bias, and a lack of coordination of care exacerbate the difficulties and make evaluating and treating patients with psychiatric symptoms uniquely challenging in the medical setting. Patients are unable or unwilling to communicate adequately. They are frequently disorganized, psychotic, and engaged in self-injurious and/or dangerous behaviors. Mental illness, personality disorders, delirium, intoxication and withdrawal are frequently the underlying etiology of these behaviors and can interfere with treatment. The combative, threatening, and/or violent patient requires special consideration as the safety of the patient and staff is imminently jeopardized. The individual’s medical condition and/or behavior can be life threatening, disruptive, and/or destructive. Patient behaviors are viewed dichotomously as deliberate, totally “out of control,” and irrational. The truth is more complex, with some aspects occurring within the awareness and control of the patient and other aspects either unknown, out of the patient’s control, and/or overwhelming to the patient. Coordination with and availability of psychiatric care is difficult and inaccessible.
Substances of abuse, overdose, and toxicity or adverse effects of psychiatric medications are the most obvious commonalities between the fields of psychiatry and toxicology. However, psychiatric symptoms overshadow other toxic or metabolic conditions and are confused for primary mental illnesses. In addition, the adverse effects or toxicity of xenobiotics mimics various symptoms of mental illness. Given the increased rates of suicide attempts and substance abuse among people with severe mental illness, distinguishing cause and effect is complex.
This chapter will review some of the special considerations that should be recognized when dealing with the overlap between psychiatry and toxicology. The chapter will start with an overview of the capacity assessment and its formal components. Then there is a discussion of the components of the medical evaluation of psychiatric patients for admission to a psychiatric facility. The third section is devoted to suicide and the suicidal or self-injurious patient. And finally substance use disorders are addressed. Principles of workplace violence and the violent patient will we addressed in Special Considerations: SC4.
“Decision-making capacity is the ability to understand relevant information and to appreciate the reasonably foreseeable consequences of the decision.”3 Every consent form requires documentation of some aspects of a capacity assessment. Physicians are legally and ethically obligated to obtain informed consent for treatment and procedures. The initial presumption when evaluating capacity is that all people have decisional capacity.2 Depriving a patient of his or her decision-making rights is a serious infringement on his or her liberties that has legal and ethical implications. Yet, only a patient with capacity can legally consent to medical treatment. Allowing a patient without capacity to consent to medical treatment is also problematic and has legal and ethical implications.
Physicians are constantly evaluating capacity, although they are not always cognizant of this fact. Capacity assessments are done quickly and implicitly in every patient encounter. Physicians ask themselves, “Can my patient make a decision?” “Does my patient understand the seriousness of the illness?” “Does the patient understand the treatment being offered and why?” “Does the individual understand the implications of the treatment and/or the implications of refusing the treatment?” “Does this patient have a problem that is interfering with his or her ability to understand or make a good decision?” If the patient appears to be making a poor decision, the physician may ask, “Why is the patient making this decision?” These are essential questions in patient care, a fundamental part of shared decision making and the basis of the capacity assessment.27
It is when there are impasses, ambiguity, or murky ethical situations that a patient’s capacity comes into question, such as when a patient refuses a treatment that is clearly beneficial or life-sustaining. Another example occurs when a patient refuses treatment in the setting of a recent suicide attempt, such as refusing a treatment for a potentially lethal ingestion. In these scenarios, having a systematic approach to assessing capacity and good documentation is necessary.
It is important to note that capacity assessments occur at a specific moment in time regarding a specific medical decision. The assessment is not a “global” determination that persists throughout the hospitalization but rather it is a temporary determination that requires reassessment as factors change with time and/or situation. Capacity fluctuates with a change in the patient’s mental status, medical or psychiatric condition, the time of day, amount of pain, level of anxiety, perceived support, recent medication administration, or in the context of withdrawal from a xenobiotic.
When assistance from a psychiatry consultant is requested, the primary physician should first perform his or her own capacity assessment. This should be done clearly and in the patient’s native language. The physician should take into consideration the patient’s health literacy, level of education, and cultural background. The information should be tailored to the patient’s ability to understand. For example, it is not productive to refer to percentages to describe outcomes with a patient who has never learned basic math. The physician should be certain to address the medical condition, the procedure, the risks and benefits, and the option of “doing nothing.”
The patient must engage in the evaluation. Refusal to engage indicates a lack of capacity by default.
The general legal standard for capacity requires assessment of 4 basic skills. They should be clearly documented.2
The patient must clearly indicate a preference or choice. This choice should be consistent long enough for the choice to be implemented. The physician could ask the question, “Have you decided what you would like to do?” A patient with capacity can alter their decision over time for a variety of logical reasons such as changes in their medical condition or as additional information becomes available. However, when an individual changes his or her decision repeatedly or is unable to come to a decision despite sufficient time and information, it suggests the individual lacks capacity to make that specific decision. These cases often occur in patients who have a high degree of ambivalence, have poor short-term memory, a thought disorder, or who are delirious.
The patient must comprehend the fundamental information communicated by the care team.3 The physician could ask, “Can you tell me about your medical problems?” “Can you tell me the procedure that is being offered to you?” “What are the risks and benefits?” This portion is preferably done by the primary physician who best understands the nuances of the procedure.
Often physicians assume that if the patient repeats these factors adequately, that is, the risks, benefits, and alternatives, then the patient has capacity and the assessment is complete; however, this is not always the case. The patient should be able to understand and manipulate the information independently, which can be demonstrated by asking the patient to paraphrase the physician’s explanations rather than repeat verbatim. Difficulties in this domain can arise from deficits in attention, intelligence, or memory.
The patient must be able to incorporate the relevant information. The medical condition in question must be acknowledged, and the individual must demonstrate awareness that the risks and benefits being discussed apply to him or her specifically, and will have implications in the individual’s life. The physician can ask, “How will this procedure affect you?” If a patient is unable to answer this question, then he or she does not demonstrate capacity. A statement such as “The doctors say I could die from a heart attack if I do not get this stent placed right now, but I know that’s not going to happen to me” would call the patient’s capacity into question. Difficulties in this area often arise from denial, mistrust of the physician, cognitive or affective impairment, or delusional/paranoid thought processes.
The patient must be able to demonstrate how, in a logical progression, he or she arrived at the decision. This is a synthesis of all the other requirements. The physician should ask, “How did you come to this decision?” “Why are you willing or unwilling to have the procedure?” The patient should be able to compare treatment options and consequences, and be able to explain how he or she arrived at the decision, including the reasoning involved. Patients can make “unreasonable,” “wrong,” or “bad” decisions and still have capacity; poor judgment is not equivalent to a lack of capacity. Furthermore, despite the physician’s best intentions, every attempt should be made to honor a patient’s decision if he or she meets the threshold for capacity. The patient’s autonomy should prevail. Difficulties in this domain often occur in patients with delirium, dementia, extreme phobia, panic, anxiety, psychosis, depression, or anger.
If the patient is unable to perform one or more of these steps then he or she lacks capacity. Once a patient has been deemed to lack capacity he or she should be so informed. An assessment of why the patient lacks capacity should follow. Then, every effort to restore capacity and, as such, patient autonomy, should be attempted. For example, a patient with a substance use disorder who is experiencing withdrawal and therefore demands to leave the hospital and unwilling to participate in any discussion would lack capacity. Treatment of an individual’s withdrawal will result in significant relief and rapid re-establishment of capacity. A patient experiencing opioid withdrawal feels the need to leave the hospital to use heroin; a dose of methadone to relieve withdrawal symptoms will allow this patient to participate in capacity evaluation and provide a rationally articulate reason for his or her choice, and it often leads to a more reasonable decision to continue the recommended treatment. On the other hand, in a patient who lacks capacity due to an irreversible process such as dementia, capacity cannot be restored.
When a patient is determined to lack capacity in life-threatening situations, physicians need to treat the patient over patient objection. The physician should continue to consider the patient’s autonomy.2 Efforts should always be made to impose the least restrictive measures while still providing appropriate care.
When patients lack capacity, every effort to find an alternative decision maker should be made. When there is no designated health care proxy and family members are not in agreement about what treatment choice the patient would want if he or she had the capacity to make that decision, most states have determined a specific hierarchy to identify which family member should make the decision.3
The hierarchy is state dependent. For example, in New York State, the alternative decision maker is determined by the Family Healthcare Decision Act of 2010 which states the hierarchy as: spouse or domestic partner, adult child, parent, adult sibling, friend, or extended family”.19
Although it is important to know what a capacity assessment is, it is equally important to understand its limitations. It does not determine what, if any, treatment should be initiated. It is not a psychiatric evaluation, nor is it a judgment of soundness.
A well-researched scale for determining decisional capacity is the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), which is a semi-structured interview that requires 15 to 20 minutes to administer and is designed for use in a clinical setting (Table 26–1).34
| Interview Process (15–20 minutes): |
| • Clinician discloses patient’s disorder, recommended treatment, risks, benefits, and alternative treatments |
| • Patient expresses a treatment choice and explains how the choice was made |
| Questions embedded in the interview process assess patient’s abilities in 3 areas: |
|
An important concept is the sliding scale of capacity, which has been supported by both expert consensus guidelines and the legal system. This “sliding scale” concept indicates that the threshold for deeming a patient to lack capacity changes depending upon the seriousness of the consequences. Refusing life- or limb-saving procedures requires the patient to demonstrate a very high level of understanding and reasoning. On the other hand, even if a patient shows limitations in one of the 4 basic skills during a capacity assessment and the risks of refusal are low, then the patient is thought to have capacity and the patient’s autonomy prevails.
Decisional capacity is often part of a larger question about how to proceed with treatment for a particular patient. Once a patient is found to lack capacity, ethical questions arise about the appropriateness and practicality of imposing treatment. For example, should a patient who is refusing a necessary blood draw be sedated for the procedure? Sedating a patient has its own inherent risks, and psychological distress to the patient cannot be discounted. In these situations, it is often helpful to have a discussion involving the psychiatrist, and a general consensus can usually be reached weighing the risks and benefits of proceeding with treatment against a patient’s will. In cases of life-threatening refusal of treatment, how to proceed is usually clear, but physicians often encounter situations in which the medical necessity of an intervention is urgent but not emergent. For example, for a patient who needs an amputation for an infected limb that is currently stable but will inevitably proceed to sepsis, the physician has a responsibility to petition the court for treatment over objection. These cases require a team approach involving psychiatry, risk management, legal services, and bioethics.
MEDICAL EVALUATION OF THE PSYCHIATRIC PATIENT PRIOR TO ADMISSION TO A PSYCHIATRIC FACILITY
Not all patients who present with psychiatric symptoms have mental illness. Intoxication, withdrawal syndromes, medical illness, metabolic abnormalities, organic brain, seizure, and dementia often present with symptoms that mimic mental illness. The psychiatric patient is often unwilling or unable to fully cooperate, creating substantial difficulty in obtaining a comprehensive medical history.
Behavioral disturbances also present unique challenges to diagnostic assessment. Patients are often unwilling or unable to fully cooperate, making it difficult to obtain a comprehensive medical history.
Emergency medicine physicians are often asked to “medically clear” patients for transfer to psychiatric units or psychiatric facilities. These evaluations are challenging because there are no universal standards. In fact, the very term is misleading and can lead to the omission of important details of the patient’s medical history.
The purpose of “medical clearance” requested by evaluating psychiatrist is to:
determine if the patient has a serious medical condition that would make admission to a psychiatric hospital unsafe;
assess and treat any acute medical issue necessitating urgent or emergent intervention; and
help differentiate between an organic illness, a xenobiotic-induced disorder, and a primary mental illness as the cause of psychiatric symptoms.
The presence of either of the first 2 could well obviate the need for psychiatric admission and compromise or invalidate the accuracy of psychiatric assessment.46 The evaluation should include a history and a thorough physical examination, including neurologic and mental status examination.
Some signs that suggest a medical cause of psychiatric symptoms include new onset of symptoms in a patient older than 40, abnormal vital signs, recent memory loss, or clouded sensorum.25 Signs and symptoms that require further evaluation include abnormal vital signs, delirium, altered cognition, or an abnormal physical examination. Certain demographics are identified as high risk for medical instability: the elderly or very young, patients with substance abuse, abnormal movements, abrupt onset of symptoms, and patients with no prior psychiatric history. Patients with physical trauma and those with preexisting medical disorders or current medical complaints warrant special attention as well.33
Although the psychiatrist often requests routine laboratory testing for medical clearance, a number of studies demonstrate that selective testing based on history and physical examination is the correct and most cost-effective strategy. There is a strong consensus among physicians that routine laboratory testing is unnecessary, and without any clinical suspicion, the probability of false positive laboratory results begins to outweigh true positives.10,24 The American College of Emergency Physicians provides a level B recommendation that diagnostic evaluation be directed by the history and physical examination, and that routine laboratory testing is low yield and not necessary as part of the emergency department assessment.46
The American Psychiatry Association and American Diabetes Association practice guidelines for starting patients on long-term second-generation antipsychotics include obtaining baseline fasting plasma glucose and fasting lipid as these medications are known to cause the metabolic syndrome and/or diabetes. Although these guidelines are not applicable to the emergency department setting, it is helpful to be aware of them.
The American College of Emergency Physicians also provides a level C recommendation against routine urine toxicology testing and blood alcohol concentrations in alert, awake and cooperative patients, and specifies that transfer to psychiatric care should not be delayed to await collection of samples for toxicologic analysis.46 However, from the psychiatrist’s perspective, this testing is time-sensitive and can change psychiatric management and disposition considerably. If the emergency physician knows the patient will be transferred for psychiatric care and suspects substance abuse, it is helpful to obtain toxicologic results as early as possible.
Another important and common issue is acute intoxication with ethanol. At what point is it acceptable and appropriate to “medically clear” the patient for psychiatric evaluation? There are no evidence-based data to support that patients regain decision-making capacity at a particular blood alcohol concentration. Depending upon tolerance, cognition varies widely, and patients often develop ethanol withdrawal while significantly elevated blood alcohol concentrations persist.22 Therefore, The American College of Emergency Physicians provides a level C recommendation that the patient’s cognitive abilities be the basis on which the psychiatric assessment is initiated. A period of observation can be used to see if psychiatric symptoms resolve with resolution of intoxication, at which point the need for a psychiatric assessment can be revisited.46
Psychiatric facilities have varying degrees of capacity to care for medical conditions. Some facilities have onsite internal medicine providers and the ability to care for chronic or non-acute medical conditions. However, many do not. A shortcoming of psychiatric facilities is that few have the ability to care for either complicated acute or chronic medical illnesses. They often do not have adequate nursing capabilities or available equipment to care for patients with enhanced nursing need such as tracheostomies, tube feeding, intravenous fluids or medications, or supplemental oxygen. Therefore, emergency physicians are asked to identify a patient’s disabilities. Knowing the limitations of these facilities can enhance the relationship between emergency physicians and psychiatrists, and ultimately help to facilitate transfers. In addition, EMTALA (Emergency Medical Treatment and Labor Act) requires that psychiatric patients with medical problems be transferred to a psychiatric facility that is equipped to handle the patient’s medical problems.
The term suicide refers to self-inflicted death with either explicit or implicit evidence that the person intended to die. Suicide has been the tenth leading cause of death each year in the United States since 2008, and accounted for 44,193 deaths in 2015.17 It was the second leading cause of death among 10 to 34 year-olds in 2015, and accounts for 15.1% of deaths in this age group annually. Suicide accomplished in a variety of settings and by a variety of means, is associated with psychiatric-disorders and/or substance abuse, especially ethanol, and is frequently accomplished using psychoactive xenobiotics alone or in combination. Self-poisoning accounts for more than 70% of all serious suicide attempts.50
Suicidal thoughts and behaviors are common. The lifetime prevalence of adults having “seriously considered” suicide is 9.2%, whereas 3.1% report having formulated a plan, and 2.7% make a suicide attempt.32,52 Given less than a third of individuals who have seriously considered suicide in their lifetime ultimately make a suicide attempt, studies have searched for unique risk factors that contribute to the transition from suicidal ideations to attempting suicide.32,49,54 Given that the act of suicide is a statistically rare event in the overall population, it is difficult to definitively predict who will complete suicide. There are no proven formalized risk assessment tools. However, there are risk factors that are associated with an increase in the likelihood that an individual will attempt suicide, and there are some that are modifiable (Tables 26–2 and 26–3). The identification of modifiable risk factors provides opportunities for interventions. Additionally, there are protective factors that mitigate the risk for suicide, and it is important to assess for the presence or absence of these factors in determining the overall risk for suicide in a patient.
| Psychiatric Risk Factors | Neurological and Medical Factors | Sociodemographic Factors | Genetic and Familial Factors |
|---|---|---|---|
Major depressive disorder Bipolar disorder Schizophrenia Alcohol use disorder Other substance use disorders Alcohol intoxication Personality disorders Bulimia or anorexia nervosa Post-traumatic stress disorder Helplessness Hopelessness Impulsivity Aggression, including violence against others Agitation Factors related to current or past suicidal behavior: Prior suicide attempts Suicidal ideation Suicidal plans Suicidal intent and lethality | Multiple sclerosis Huntington disease Brain and spinal cord injury Seizure disorders Malignant neoplasms HIV/AIDS Chronic pain syndromes Functional impairment Low concentration of serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) in cerebrospinal fluid—(Research) | Access to firearms Caucasian race Male sex (suicide completion) Female sex (suicide attempts) Widowed, divorced, or single marital status, particularly among elderly men Elderly age group Adolescent and young adult age groups Gay, lesbian, or bisexual orientation Recent lack of social support (including living alone) Unemployment Decrease in socioeconomic status Domestic partner violence Recent stressful life event Childhood sexual abuse Childhood physical abuse | Family history of suicide (particularly in first-degree relatives) Family history of mental illness, including substance use disorders |
| Children in the home |
| Effective clinical care for mental, physical, and substance use disorders |
| Family and community support (connectedness) |
| Positive social support |
| Pregnancy |
| Religious beliefs and cultural practices |
| Skills in problem solving and conflict resolution |
It is worth noting here that not all self-inflicted injuries are suicide attempts. Many of these are suicidal gestures or self-injurious behaviors. It is worth noting the explicit terminology here.
Self-injurious behavior refers to the self-infliction of painful, destructive, or injurious acts without the intent to die. An example is the superficial cutting that occurs in a patient with a borderline personality disorder, which is actually a coping mechanism that provides psychological relief; one hypothesis is that relief is mediated by the endogenous release of opioids.62
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