by Veronica Tucci
Many medical conditions can present as psychiatric complaints. The case below will demonstrate the importance of the medical evaluation of these patients, as well as the need to keep a broad differential diagnosis. There are also medical problems which may exacerbate psychiatric symptoms or need to be addressed in order for a patient to be able to be transferred and safely managed at a psychiatric center. In addition to these scenarios, the patient’s underlying psychiatric disorder may lead to an emergent medical condition, such as an overdose or a self-inflicted trauma.
Psychiatric complaints are common presentations for our ED (emergency department) patients and are ever increasing. Mental health-related visits increase from 1992 – 2001, most significantly in the areas of substance-related disorders, mood disorders, and anxiety. Pediatric mental health visits are also increasing. Interestingly, one study which showed this increasing trend found that this did not hold true in the two areas that are mandatorily evaluated in the ED – suicidal ideation and acute psychosis. This suggested that the increase in visits was related to non-emergent psychiatric complaints that might be better managed by outpatient mental health professionals.
ED physicians are often tasked with evaluating these patients for medical problems prior to clearing them for possible psychiatric evaluation and admission. They must control the acute symptoms, attempt to determine the etiology of complaints (particularly functional vs. organic), provide appropriate initial treatment, and determine disposition. Of the utmost importance is identifying and treating immediate life-threatening problems. Historical data, mental status examination, physical examination, and appropriate ancillary testing are indicated.
This process has previously been termed “medical clearance.” While the importance of this process cannot be stressed enough, is fraught with both intrinsic and extrinsic difficulties. Nevertheless, a thorough medical assessment is imperative to taking excellent care of this high-risk patient population.
One challenge is with the term “medical clearance” itself, which can be misleading. It means different things to different providers, and its overuse can result in poor patient care. No standard criteria exist for what medical clearance consists of, or even what the status of a medically cleared patient truly is. Complicating this further, different specialties have their own approaches to this evaluation. In addition, receiving psychiatric facilities often have their own requirements, irrespective of what the treating ED physician and psychiatrists believe to be medically indicated. Some have suggested modifying the term or replacing it instead with a thorough discharge summary. Another suggestion is to provide a summary of the evaluation and treatment or using the term medically stable. There has also been shown to be wide variation in the comprehensiveness of medical clearance examinations.
A 35-year-old female presents to the ED after the family called the paramedics for “bizarre behavior.” She notes that her family persuaded her to seek evaluation; however, they are not with her currently. She seems somewhat paranoid and tangential and is difficult to obtain a history from. On review of systems does endorse some mild abdominal pain and diarrhea. Her vital signs on arrival as recorded in triage are as follows: heart rate 135, blood pressure 110/90, respiratory rate 24, oxygen saturation of 96% on room air, temperature 100.7. When you speak with the family, they state that she has been agitated and paranoid. They are also concerned that she made suicidal threats while with friends.
On physical examination, you see an anxious appearing woman. She is tachycardic with an irregular pulse. Her extremities are dry with 1+ lower extremity edema. Her abdominal is soft and non-tender. She has no meningeal signs. She is tachypneic and has crackles in the lung bases. Her neurologic examination is non-focal. She reports suicidal ideation without a plan.
General Approach and Critical Bedside Actions
The most important first step in the assessment of this patient is to assess for abnormalities in the airway, breathing or circulation which may require immediate stabilization. A rapid blood glucose level should be obtained early on. The patient should be placed on a cardiac monitor and continuous pulse oximetry, and IV access should be established with tubes collected for blood work. Place the patient on oxygen by nasal cannula, and consider IV fluid.
With regards to the family’s concern about suicidal ideation, some precautions should be taken. This may include removing items and clothing from the room that could be used for self-harm. The patient should not be left alone and should have a staff member or a reliable family member with them at all times. Importantly, she should not be allowed to leave the ED until the evaluation is complete.
History Taking and Physical Examination Hints
For this patient, you will want to obtain further history including prior episodes, past medical history, associated complaints (cough, fever, heat intolerance, headache, neck pain/stiffness, changes in hair or skin, etc.), prior medications, drug and alcohol use, prior hospitalizations. It is important to obtain collateral for this patient who may be unable or unwilling to provide a full and accurate history for you.
A thorough history and physical are the starting point of any patient evaluation. Several studies looking at missed medical diagnoses in patients with psychiatric complaints have shown that these should have been identified if a proper history and physical were performed. Unfortunately, studies looking at the thoroughness medical evaluations of these patients have often found them to be incomplete. An incomplete medical evaluation can lead to missed medical diagnosis, which can be dangerous for patients. One study found that “medically clear” had been documented in 80% of patients where a medical diagnosis should have been identified. One retrospective chart review found that complete vital signs were only documented 52% of the time.
All patients require a complete history, physical and mental status examination. This should be approached in an organized fashion in order to determine the etiology of their complaints as functional or organic. The medical evaluation of these patients should be no different than of those presenting with medical complaints. The history and physical should guide laboratory and other diagnostic testing and imaging. The information gathered from this will form the clinical picture.
History should be obtained from the patient in addition to those close to them like family and caregivers, and an effort should be made to confirm the information obtained from outside sources whenever possible. Sudden onset in changes in behavior, mood, or thought in a previously normal patient, or a deterioration in a patient with a chronic disorder should be suspicious for an underlying medical etiology.
Assessing for substance abuse, use, and changes are important. Also, inquire about adherence to their current medication regimen. Family and social stressor should be assessed. It is important to find out about medical comorbidities, or physical symptoms and complaints as these might also indicate a medical etiology (trauma, fever, etc.). Be aware that many medications can lead to changes in behavior, especially in at-risk groups. Physical complaints, abnormal exam findings, and abnormal vitals must be evaluated and addressed.
The mental status examination (MSE) plays a crucial role in the evaluation of these patients. The MSE needs to be focused and brief, and evaluate seven major areas (affect, attention, language, orientation, memory, visual-spatial ability, and conceptualization). Again, this should be structured and evaluate changes in alertness, cognition, behavior. Remember delirium, dementia, and psychiatric illness have significant differences in management and outcomes, and thus need to be identified. Delirium in the ED is associated with decreased survival. There are also alternatives to the traditional mental status examination. The quick confusion scale is a scoring system that was published and is quickly obtained, easily calculated, readily interpreted score.
In the above patient, the following is a list of possible etiologies for her symptom: sepsis, diabetic ketoacidosis, pneumonia, pulmonary embolism, meningitis, encephalitis, hyperthyroidism/thyroid storm, schizophrenia, bipolar disorder, psychosis, salicylate ingestion, acute intoxication, alcohol withdrawal/delirium tremens. There are several abnormalities in history and physical examination which suggest that the patient’s symptoms are not primarily psychiatric in origin.
Alterations in mental status may incorrectly be attributed to psychiatric diagnoses. A review looked at 64 cases of patients admitted to the psychiatric ward, whom were later found to actually have a medical diagnoses that explained their symptoms. The etiologies identified included intoxication, withdrawal syndromes, overdose. In this, they noted that none had an appropriate medical screening examination performed. In another study looking at factors which may have contributed to a patients symptoms being attributed to a psychiatric problems instead of a medical one, found that these patients had a lower rate of complete history, physical examination, cognitive assessment, indicated ancillary testing and treatment of abnormal vital signs in comparison to patients admitted to medical units.
Some special groups are at increased risk of having a medical etiology of their complaints, and care should be taken when evaluating these patients. Several prior studies have identified these as the elderly, those with substance abuse, those without a prior psychiatric history, and those with pre-existing or new medical complaints. Intoxicated patients represent a particular challenge. In addition to often providing a limited history, they may express certain complaints (like thoughts of self-harm), only while intoxicated. A study looked at 100 consecutive alert patients with new psychiatric complaints. They excluded those obviously intoxicated, prior diagnosis of abnormal behavior, those with medical complaints and overdose or suicide patients. For all patients, they then performed a history, physical, panel of laboratory tests, CT scan of the head and lumbar puncture if febrile. They concluded that 63/100 patients had an organic etiology of their symptoms. A study looking at 658 psychiatric outpatients receiving medical and biochemical evaluation found the incidence of medical disorders producing psychiatric symptoms at 9.1%. The etiologies included infectious, pulmonary, thyroid, diabetic, hematopoietic, hepatic and CNS. Another study of 100 psychiatric patients who had been previously medically screened found that 46% had a medical illness that caused or exacerbated their symptoms and 80% of these required treatment. They concluded that a battery of laboratory and ancillary testing would have identified the majority of these.
Emergency Diagnostic Tests and Interpretation
The following diagnostic testing should be considered in the above case.Table 1. Medical Clearance - Suicidal Thought/Ideation Diagnostic Tests
Medical Clearance - Suicidal Thought/Ideation Diagnostic Tests
|Complete blood count||Anemia, hematologic abnormality|
|Complete metabolic panel||Metabolic abnormality, uremia, liver failure, renal failure|
|Electrocardiogram||Arrhythmia, evaluation of tachycardia and irregular pulse|
|Chest X-ray||Pneumonia, heart failure, other etiology of tachypnea|
|Urinalysis/Urine culture||Source of sepsis|
|Blood cultures||Sepsis evaluation|
|Troponin and BNP||Heart failure|
|Thyroid function studies||Hyperthyroidism / thyroid storm|
|CT scan of the brain||Abscess, meningitis, mass|
|Alcohol level/urine drug screen||Intoxication, may be required at psychiatric facility|
|Acetaminophen and salicylate levels||Commonly ingested in suicide attempts|
While everyone can agree that these patients deserve a complete history and physical, the role of laboratory and ancillary testing is less well delineated and is often viewed differently among ED and psychiatric physicians. What studies are required for medical clearance of the psychiatric patient, and whether this process should be standardized, or be performed on a case by case basis, is the source of much controversy.
The American College of Emergency Physicians published a clinical guideline on the subject. They suggest that diagnostic evaluation should be directed by the history and physical and routine laboratory testing of all patients is of very low yield. Routine urine toxicology screens in awake, alert, cooperative patients do not affect ED management, and using this screening in the ED because of the requirement of receiving psychiatric facilities or service should not delay evaluation or transfer. They also say that patients’ cognitive abilities rather than a specific blood alcohol level should be the basis of beginning the psychiatric assessment and recommend considering a period of observation to determine if symptoms resolve as intoxication resolves. A study looked at patients with isolated psychiatric complaints and past medical history of psychiatric disorder. None of these had positive screening laboratory or radiograph results. The remaining patients had a presenting medical complaint as well, and these complaints directly correlated with the need for labs and radiography. They concluded that patients with a psychiatric complaint with a documented past psychiatric history, negative physical findings and normal vital signs, who deny current medical problems did not require further labs or testing in the ED.
Another systematic review of the literature indicated that history, physical examination, review of systems, and tests for orientation had relatively high yield for detecting active medical problems. Routine laboratory testing was relatively low yield. However, four groups were at serious risk for medical problems, and these included the elderly, substance users, patients with no psychiatric history, and patients with pre-existing medical disorders and/or concurrent medical complaints. A retrospective chart review of pediatric patients presenting to an academic pediatric emergency department for medical clearance for an acute psychiatric emergency found that screening laboratory tests resulted in few management or disposition changes in patients if they had a noncontributory history and physical, but did result in an increased length of stay. The costs of routine testing given the low yield also should be considered.
Emergency Treatment Options
The patient presenting above has several abnormal findings on history and physical which make a medical etiology more likely. While safety precautions for self-harm and levels of commonly ingested medications should be obtained, the more pressing concern is stabilizing this patient from a medical standpoint.
During her stay, she becomes more tachypneic and supplemental oxygen is placed. Her EKG reveals atrial fibrillation with a rapid ventricular response. Her troponin and BNP are mildly elevated. Her CXR reveals signs of heart failure and pulmonary edema. Her TSH < 0.01 and her T4 level is > 100. Overall, this is suggestive of hyperthyroidism/thyroid storm as the etiology of her psychiatric complaints.
Propanolol is promptly administered in a dose of 1 mg IV over 10 minutes. Propylthiouracil (PTU) is then administered in a dose of 200 mg and iodine is administered 1 hour later. Steroids are given to prevent the conversion of T3 to T4. She is admitted to the intensive care unit for thyroid storm. She has a prolonged and complicated hospital course and is discharged several weeks later. Her psychiatric symptoms resolved with her medical treatment.
In this case, the appropriate disposition of the patient is the intensive care unit. In general, In patients presenting with psychiatric complaints, the medical screening exam should identify medical problems which require admission, or concurrent medical issues which may inhibit their ability to go to a psychiatric facility. However, if after the evaluation none of these medical issues are identified, or they are adequately treated in the ED, the patient needs to be evaluated for the need for psychiatric admission. In a patient with suicidal ideation, there are several components to be considered.
Figure 1, Original by author
Severe anxiety, panic attacks, a depressed mood, a diagnosis of major affective disorder, recent loss of interpersonal relationship, recent alcohol or drug abuse coupled with feelings of hopelessness, helplessness, worthlessness, global or partial insomnia, anhedonia, inability to maintain a job and recent onset of impulsive behavior are predictors of suicidal behavior.
There are several clinical rating scales in suicide risk assessment. An example of one is the SAD PERSONS scale. It stands for: Sex, Age, Depression, Previous attempt, ethanol abuse, rational thinking loss, social support lacking, organized plan, no spouse, sickness. One point is given for each.
Assessing the risk of suicide is complicated, and complete psychiatric evaluation is ultimately needed. A study looking at several risk assessment scales found that in general, they overestimated suicide risk. They did note that they might help highlight important concepts and risk factors. This may be particularly useful for non-psychiatric medical personnel or junior residents. They may help identify high-risk patients in the ED early in assessment, and those that may need psychiatric referral.
The role of the ED provider in psychiatric care is increasing, and external resources are often inadequate. A study of California EDs showed that there are limited mental health resources for suicidal patients. It suggested the need for more regional solutions including improved access to mental health personnel and follow of suicidal patients and community mental health resources for patient referrals. The same is true in the pediatric patient. The ED physician plays an important role in the pediatric ED in the stabilization and management of a mental health crisis, the discovery of mental health issues in ED patients, and approaches to advocating for improved recognition and treatment in mental illness in children. The ED evaluation of pediatric mental health is crucial to the child’s long-term care and treatment.
It is important to note the overall significance of medical problems in the population of patients with psychiatric disorders, and the challenges that they face interfacing with and accessing the medical community. A study of this population out of Nova Scotia showed increased mortality from cancer, which may be attributed to delays in detection or initial presentation and difficulties in communication and access to healthcare contribute to this finding. Another study looked at compulsory community treatment in this patient population. They saw a reduction in all-cause mortality in their intervention, group which they stated that might be partially explained by increased contact with health services in the community. Looking at 200 patients receiving psychiatric care in the outpatient setting for schizophrenia and affective disorder diagnosis, both groups had greater odds of having comorbid medical conditions than those in the general population.
In addition to the challenges of assessment, these patients present logistical difficulties in the ED setting. Patents with psychiatric related complaints have long lengths of stays in the ED. Older individuals, the need for hospitalization, restraint use and diagnostic testing prolonged the length of stay. Drug and alcohol screening also led to delays. They also tend to have high rates of readmission. Predictors of 12-month readmission and ED revisits for patients with substance abuse, and mental health-related complaints were highest in those with dementia, psychotic disorders, autism, impulse control disorders and personality disorders.
The care of patients with psychiatric complaints is complicated and challenging. The ED physician is tasked with the initial assessment both of psychiatric risk and medical clearance. Care should be taken to stabilize any life-threatening condition and then to try to differentiate a functional versus organic cause of the patient’s symptoms. They must also assess for any underlying medical problems that may exacerbate the patient’s symptoms or need to be managed at a psychiatric facility. The psychiatric disorder itself may also lead to a life-threatening medical condition that needs to be threatened or treated. This is a very important part of the care of this challenging patient population.
References and Further Reading
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- Simon AE, Schoendorf KC. Emergency department visits for mental health conditions among US children, 2001-2011. Clinical Pediatrics. 2014; 53(14): 1359-1366.3
- Hakenewerth AM, Tintinalli JE, Waller AE, et al. Emergency department visits by patients with mental health disorders – North Carolina, 2008-2010. www.cdc.gov/mmwr/preview/mmwrhtml/mm6223a4.htm4
- Sills MR, Bland SD. Summary statistics for pediatric psychiatric visits to US emergency departments, 1993-1999. Pediatrics. 2002; 110 (4) e40.5
- Frame DS, Kercher EE. Acute psychosis. Functional versus organic. Emergency Medicine Clinics of North America. 1991; 9(1): 123-136.6
- Weissberg MP. Emergency room medical clearance: an educational problem. American Journal of Psychiatry. 1979; 136(6): 787-790.7
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- Smith MW, Stocks C, Santora PB. Hospital readmission rates and emergency department visits for mental health and substance abuse conditions. Community Mental Health Journal. 2015; 51(2): 190-197.37