Emergency Psychiatry Flashcards
1
Q
Goals of Emergency Psychiatry
A
Triage Assessment Diagnosis Short term management Discharge planning
2
Q
Describe triage
A
Collection first line information
Prioritise as per need
Communicate/escalate appropriately to arrange further care
3
Q
Describe assessment
A
Appropriate assessment to seek further diagnostic information pertinent to manage presenting problem.
Rapid understanding of aetiology is a key skill required.
4
Q
Describe short term management
A
Options such as medications, hospitalisation, seclusion/restraint and crisis social interventions and psychoeducation.
5
Q
Describe discharge planning
A
Longer term interventions should be planned including preventative strategies aimed at averting crises and rational follow-up strategies.
6
Q
What sx would make one suspect of withdrawal or intoxication of substances?
A
Disorientation Impaired consciousness Ataxia Autonomic dysfunction Hallucinations
7
Q
What sx would make one suspect agitated depression?
A
Subdued mood
Anxiety
Catastrophic/guilt delusions
8
Q
What would make one suspect of organic cause of catatonia?
A
No psychiatric hx
Worsens with benzos
9
Q
What makes one suspect depressive stupor?
A
Low mood
Hx of depression
Hopelessness
10
Q
What makes one suspect psychotropic induced catatonia such as NMS?
A
Rapid onset
Marked rigidity
Autonomic instability without posturing
11
Q
Causes of catatonia
A
Organic Depressive stupor Schizophrenia Manic excitement Psychotropic induced - NMS Autism/neurodevelopmental disorders
12
Q
What can cause starvation in the psychiatric patient?
A
ED Psychotic depression Schizophrenia Manic neglect Psychotropic induced - NMS OCD - food obsessions
13
Q
How can schizophrenia lead to starvation?
A
Suspicions around poisoning, disorganised behaviour
14
Q
How can OCD lead to starvation?
A
Recurrent irrational worries about safety, ritualistic behaviour
15
Q
Total global mortality from suicide
A
1-2%
16
Q
How high does suicide rank in developed countries?
A
Fifth most common cause
17
Q
How many deaths in England and Wales are from suicide?
A
1%
18
Q
Rate of suicide in England and Wales
A
8 per 100,000 per year
19
Q
In which group are suicide rates increasing?
A
Young men
20
Q
Most common suicide method in men
A
Hanging
21
Q
How many deaths by men are from hanging?
A
40%
22
Q
Second most common cause of death by men
A
OD
23
Q
How many deaths from OD are caused by men?
A
20%
24
Q
Third most common cause of death by men
A
Poisoning by car exhaust fumes
25
How many men die by poisoning from car exhaust fumes?
10%
26
Most common method of suicide by women
OD
27
Second most common method of suicide by women
Hanging
28
Third most common method of suicide by women
Drowning
29
How many women die by OD
46%
30
How many women die by hanging?
27%
31
How many women die by drowning?
7%
32
In most countries which age group has the highest rate of suicide?
>75
33
Predictors of suicide in the elderly
Depression
Social isolation
Impaired physical health
Personality traits - anxious, obsessive
34
Where is there an increase in suicide rates in kids?
Males aged 15-19
35
Principal methods of suicide in young males
Hanging
| Poisoning with car exhaust fumes
36
Traits amongst children who die by suicide
Antisocial behaviour
Suicide behaviour
Depressive disorders amongst parents and siblings
37
In which ethnic group is there a higher rate of suicide?
Asian women
38
Which occupational groups are at high risk of suicide?
Doctors - especially female
Anaesthetists, GPs and Psychiatrists
Farmers
39
Suicide due to depression
36-90%
40
Suicide due to alcohol abuse
43-54%
41
Suicide due to drug abuse
4-45%
42
Suicide due to schizophrenia
3-10%
43
Suicide due to organic mental disorder
2-7%
44
Suicide due to PD
5-44$
45
How many patients with a mood disorder will die by suicide?
6-10%
46
Which patients with depression are at highest risk?
Inpatients
Hx of impulsive and aggressive behaviour
Alcohol and drug misuse
Cluster B PD
47
How much does the risk of suicide increase if there is a history of a suicide attempt?
40x increase
48
Lifetime risk of suicide in alcohol dependence
7%
49
Suicide rate in heavy drinks
3.5x higher than general population
50
Suicide rate in alcohol use disorders
15x higher than general population
51
Suicide rate in drug dependence
15x higher than general population
52
Suicide rate in Anorexia
20-fold higher than general population
53
Lifetime suicide risk in schizophrenia
6%
| 10x higher than genera population
54
When do majority of schizophrenia patients commit suicide?
Active phase of disorder after suffering depressive sx
55
Characteristic traits of patients with PD who commit suicide
Comorbid depression or substance misuse
Impulsive and aggressive behaviour
Younger
56
Global annual suicide rate
1 in 6000/year
57
Male:female ratio of suicide
2-4:1
58
Most common age of suicide
15-24 females
| 25-34 males
59
In which age group is suicide rate decreasing?
>65
60
Most common psychiatric diagnosis in suicide
Depression 30-31%
| Alcohol dependence 17-24%
61
Mental disorders without much increase in suicide rate
Mental retardation
Dementia
OCD - if no depression
62
Suicides that have at least one recorded DSH attempt
40-60%
63
Number of people that will repeat DSH in one year
30%
64
Patients who were in contact with MH services at time of suicide
25%
65
Patients on psychiatry OP registers at time of suicide
25%
66
Patients who attempt suicide under alcohol influence
25%
| 50% of those who had alcohol within 6 hours
67
Patients who committed suicide who had seen a psychiatrist in the previous week
12.5%
68
Patients who commit suicide who had seen a health worker in last 3 weeks
33%
69
Patients who commit suicide who had seen their GP in last four weeks
66%
70
Patients who commit suicide who had seen their GP in the last week
40%
71
Most common method of IP suicide
Hanging - belt, curtain rail
72
How many IP suicides occur during first week of admission
25%
73
How many IP suicides occur when under routine (not constant or intermittent observations)
80%
74
How many patients who commit suicide were not compliant with meds?
20%
75
How many patients committed suicide within 3 months of d/c
25%
| 40% before first follow-up
76
How many patients committed suicide within 28 days of d/c
1 in 500-1000 patients
77
How many suicides were preventable according to MH teams in England?
22%
78
Strongest RF for suicide
DSH history
79
Risk of suicide within one year of DSH
0.7%
Males: 1.1%
Females: 0.5%
66x more than general population
80
How many patients who committed suicide were on the enhanced CPA
50%
81
How many elderly patients who committed suicide visited their GP
20% on same day
40% within 1 week
70% within one month
82
How many suicides do MH teams in England regard as identifiable factors which could have reduced risk?
67%
83
How many IP suicides occurred while on leave?
33%
84
How many patients who committed suicide missed a recent appointment in the community?
30%
85
How many Black Carribean patients in England and Wales who commit suicide have a diagnosis of Schizophrenia?
75%
86
What are suicides in ethnic minorities associated with?
Higher rates of recent onset treatment non-compliance
87
How many suicides in England are in the homeless community?
3%
88
Cross-national lifetime prevalence of suicidal ideation, plan and attempts?
9. 2%
3. 1%
2. 7%
89
How many transitions from suicidal ideation to plan to attempt occur within first year of onset?
60%
90
How many suicide attempts are recorded for every suicide?
25
91
How many suicide attempts are due to OD?
90%
92
Most common drug overdoses
Paracetamol
| Aspirin
93
Which antidepressants are commonly overdosed on?
TCAs
SSRI
(25%)
94
Age of those who complete suicide
Late middle age
95
Age of those who attempt suicide
Late teens/early 20s
96
Marital status of those who complete suicide
Widowed>Divorced>Single>Married
97
Marital status of those who attempt suicide
No pattern
98
Social class of those who complete suicide
Higher among unemployed and retired
99
Social class of those who attempt suicide
Lower and unemployed
100
Early childhood of those who complete suicide
Death of parent
101
Early childhood of those who attempt suicide
Broken home
102
Family history of those who complete suicide
Depression
Suicide
Alcoholism
103
FHx of those who attempt suicide
Similar episodes
104
Physical health of those who complete suicide
Handicapped
| Terminal illness
105
Personality traits of those who attempt suicide
Cluster B traits
106
Diagnosis of those who complete suicide
Major psychiatric disorders
| Substance use
107
Diagnosis of those who attempt suicide
Mental distress
| Reactive depression
108
Cognitive precipitants of those who complete suicide
Guilt
| Hopelessness
109
Cognitive precipitants of those who attempt suicide
Identity difficulties
| Emotional distress
110
Rate of DSH in UK
3 per 1000 per year
111
How many people who DSH will repeat the act in the next year
20%
112
How many people who DSH will die within the next year
1%
113
How many people who DSH will eventually complete suicide?
10%
114
How may people consume alcohol 6 hours before committing suicide?
33% males
| 25% females
115
Most common method of DSH
Laceration
116
How many people of DSH patients in hospital have a likely psych disorder?
90%
117
Most frequency diagnoses of those who DSH
Depression
Alcohol misuse and drugs (men) and anxiety (women)
PD
118
Factors associated with risk of repeating DSH
```
Age 25-54
Alcohol/substance use
PD
Hx of violence
Lower social class
Previous psychiatric treatment
Previous self harm
Single, divorced or separated
Unemployed
```
119
Clinical indicators of high suicidal intent
Act carried out in isolation and timed so intervention unlikely
Precautions taken to avoid discovery
Precaution made in anticipation of death (will, note)
Premeditated actions leading to final act (saving up tablets)
Communicating intent beforehand
Not altering potential helps after act
Admission of intent
Ongoing plans to repeat act
Continued access to means to reattempt
Diagnosable MI or PD
Physical illness - esp chronic conditions or those with pain/functional impairment
Recent contact with psych services
Recent d/c from psych IP
120
Demographic indicators of high suicidal intent
Male
Low socio-economic status
Unmarried, separated, widowed
Unemployed and living alone
121
Background history suggestive of high suicidal intent
```
DSH (with high suicidal intent)
Childhood adversity
FHx of suicide
FHx of MI
Clinical Hx
```
122
Psychosocial factors suggestive of high suicidal intent
```
Hopelessness
Impulsiveness
Low self-esteem
Recent stressful life event
Relationship instability
Lack of social support
```
123
Current content indicators of high suicidal intent
Suicidal ideation
Suicidal plans
Availability of means
124
Risk factors for completing suicide
```
Past DSH
Older age
Male
Social isolation
Psychiatric hx
Unemployment
Poor physical health
Access to means
```
125
What scales can be used to assess suicide risk?
SAD PERSONS
Beck Hopelessness
Beck Scale for Suicidal Ideation
126
What is the SAD PERSONS score?
10 major demographic risk factors used to assess immediate suicide risk in general hospital setting.
127
Outline the SAD PERSONS score
Sex - 1 if male, 0 if female
Age - 1 if <20 or >44
Depression - 1 if depression present
Previous attempt - 1
Ethanol abuse - 1
Rational thinking loss - 1
Social support lacking - 1
Organized plan - 1 if plan is made and lethal
No spouse - 1 if divorced, widowed, separated of single
Sickness - 1 if chronic, debilitating and severe
128
What is Beck Hopelessness Scale?
20 T/F statements focused on pessimism about the future.
129
Scores of Beck Hopelessness Scale
0-3 - minimal risk
4-8 - mild risk
9-14 - moderate risk
15-20 - severe risk
130
What is Beck Scale for Suicidal Ideation?
Self-reported 24-item scale (5 screening items) that assess patients thoughts, plans and intent to commit suicide.
131
Scoring of Beck Scale for Suicidal Ideation?
Scores range form 0-48.
Each item scored 0-2.
Higher score = greater suicide risk. No cut-offs.
132
What questions need to be asked when making a decision of someone who is at risk of suicide?
Is there evidence of MI?
Is there on-going suicidal intent?
Are there non-MH issues that can be addressed?
What is the level of social support?
133
Care of the potentially suicidal patient in the community
Full MH and social context assessment
Considering place of safety
Regular review of suicide risk and arrangements
Safe treatment using adequate dosage of less toxic drugs
Restricting prescriptions and other means of access
Involving relatives for safe keeping of tablest
Arrangement for crisis or urgent access for patient and cares
134
How many adolscents in the UK report suicidal ideation?
15%
Females: 22%
Males: 8.5%
135
Most common method of suicide in adolescence
Paracetamol OD
| Cutting
136
One year prevalence of self-harm amongst 5-10 year olds w/o MH issues
0.8%
137
One year prevalence of SH in 5-10 y/o with anxiety
6.2%
138
One year prevalence of SH among 5-10 year olds in children with conduct, hyperkinetic or less common MI
7.5%
139
One year prevalence of SH in 11-15 year olds without MI problems
1.2%
140
One year prevalence of SH among 11-15 year olds with anxiety
9.4%
141
One year prevalence of SH among 11-15 year olds with conduct, hyperkinetic or less common MI
8-13%
142
One year prevalence of SH among 11-15 year olds with depression
18.8%
143
Proportion of DSH in children that receives hospital attention
<13%
144
One year prevalence of SH in 15-16 year olds
6.9%
145
Proportion of under 16s who attend ED with self harm
5%
146
Proportion of adolescents that self harm at least once a week
41%
147
Factors associated with dangerousness
```
Younger age
Males
Past hx of criminality and violence
Childhood physical or sexual abuse
Childhood conduct disturbances
Psychiatric diagnosis
Conducive environment
Specific sx
Unemployment
```
148
Which specific sx are linked to dangerousness?
Command hallucinations
Agitation
Hostile suspiciousness
149
Initial steps to manage an agitated patient
Securing safety of patient and others
Verbal de-escalation
Defusing
150
Second line treatment of agitation
Lorazepam 1-2mg IM/PO
Haloperidol 5mg PO/IM
Olanzapine 5-10mg IM
Promethazine 25-50mg PO, repeated after 1-2 hours, max 100mg
151
Side effects of rapid tranq
Bradycardia or irregular pulse
Acute dystonia
Reduced breathing (<10) or falling sats
Drop in BP (orthostatic drop, <50 diastolic)
152
What to do if acute dystonia secondary to rapid tranq?
Procyclidine 5-10mg IM
| Benztropine 1-2mg
153
What to do if reduced RR/low sats secondary to rapid tranq?
Flumazenil if previous use of benzos
| Arrange ITU transfer for mechanical ventilation
154
What to do if drop in BP secondary to rapid tranq?
Lie flat
Raise legs
If no response, refer to physicians
155
What types of catatonia are there?
Withdrawn
| Agitated/excited
156
Risks in withdrawn catatonia?
Self-neglect leading to dehydration and starvation
157
Risks of untreated catatonia?
Physical complications - electrolyte complications, renal damage
158
Psychiatric associations with catatonia
Depression
NMS
Mania
Schizophrenia
159
Neurological associations with Catatonia
```
Postencephalitic states
Parkinsonism
Seizures
Basal Ganglia damage
Stroke
Tumours
```
160
Treatment of caatonia
Lorazepam 1-2mg IM/IV and treatment of underlying disorder
161
Treatment of NMS
```
Stop offending neuroleptic
Rehydration
Antipyretic
Dantrolene 2-3mg/kg or
Bromocriptine 2.5-10mg TDS
```
162
Most important intervention for the confused/delirious patient
Optimising patients environment by promoting presence of familiar people in vicinity
Well-lit nursing bay
Frequent reorientation to place and purpose
1:1 nursing
Encouraging fluid and food intake
Avoiding polypharmacy including routine sedatives and anticholinergics
163
Medication options for confused/delirious patients in distress who are elderly
Haloperidol 0.5mg, repeat after 2 hours.
164
Medication options for adults who are confused/delirious
Haloperidol PO 2mg
165
Factors associated with self neglect in the elderly
Advanced age
Lack of social contacts
Presence of medical morbidity
Diagnosis of dementia, depression or alcoholism
Poverty and illiteracy
Suspicious, mistrustful, avoidant or paranoid personality
Loss of a caregiver
Bereavement or other loss events
Decreased vision/hearing or other physical impairments
166
What must risk assessment of the elderly include?
```
ADLs
Environmental assessment
Cognitive assessment
Physical assessment
Capacity
```
167
Who can make an application for detention under s2?
Nearest Relative
| AMPH
168
Medical recommendation requirement for s2?
Two medical recommendations, one of which must be by an approved doctor
169
Duration of detention under s3
6 months
May be renewed for a further 6 months
Then can be renewed for 12 months
170
Who can be detained under s4?
Not yet admitted to hospital, including ED, OP and day hospitals
171
Who can use S5(2)?
Registered medical practitioner in charge of treatment
172
Where can S5(2) not be used?
ED/OP
173
What transfers cannot occur while a patient is under 5(2)?
Cannot be transferred to another ward as they are technically in a 'place of safety' unless the patients life is at risk and irreversible harm would be done.
174
How long does 5(4) last?
6 hours
175
Can treatment be given under 5(2)?
No
176
How were patients who lacked capacity treated prior to the MCA?
Under common law 'duty of care' (doctrine of necessity)
177
What are the five principles of the MCA?
Any person is assumed to have capacity unless it is established otherwise
An individual should not be regarded as unable to make a decision unless all practical steps to help him do so have been undertaken without success
An individual is not to be treated as unable to make a decision merely because he makes an unwise decision
Any action made under the Act or on behalf of someone who lacks capacity must be done in his best interests
Regard must be taken before an act is done as to whether there is a less restrictive option
178
What are the two stages of the assessment of capacity?
Is there impairment or disturbance in the functioning of the patients mind or brain?
If there is, does this make the person unable to make a particular decision?
Decision based on balance of probabilities
179
What is considered central to the assessment of capacity?
Understand info relevant to decision
Retain that info
Use or weigh up that info as prt of process of making the decision
Communicate decision
180
What is the person assessing capacity required to do?
Only has to have reasonable belief about what is in persons best interests
181
Focus of CRHTT
Reduce need for acute psychiatric hospital admission and occupancy of beds
182
Main reasons for focus on home treatment in CRHTTs
INterpersonal problems are major causes of psychiatric crises and best treated in settings where they arise. Coping skills are most effectively applied in context in which they are learned.
Patients prefer treatment at home than in hospital. Reduction in inequality of power at home.
Home treatment costs less
Hospital admission has harmful effects
183
What can CRHTTs do?
Avoid admission
| Facilitate early d/c with intensive home treatment and support
184
Key characteristics of a CRHTT
Multidisciplinary
Community based
Rapidly responsive (same day)
Partnership-working with other MH teams to ensure continuity of care
Focused on emergency situations where admission would otherwise be indicated
Maintain contact and facilitate early d/c when a patient is admitted
R/v patients daily (at least)
185
Responsivity of CRHTTs
Lower patient to staff ratio with capacity to visit a patient several times a day, 24 hour availability, response within 1 hour if needed.
May direct administration of medication up to QDS if needed.
186
Gate-keeping role of CRHTT?
No individuals are admitted to an acute psychiatric IP unit w/o CRHTT first assessing the patient and considering whether intensive home support and treatment would avoid admission
