Mental Health Act, Psychiatric Emergencies and ECT

Question 1

What are the criteria for a patient to be placed under an assessment order?

Answer 1

• The person appears to have a mental illness AND
• Appears to need immediate treatment to prevent serious deterioration in their physical or mental health AND
• Serious harm to themselves or others is a possibility

Question 2

If a patient is placed under an assessment order, what does this mean?

Answer 2

• An authorised psychiatrist must assess the patient within 24 hours (72 if inpatient order)
  
  • These orders can be extended up to two times
• Notification must be made to the authorised psychiatrist at the mental health service

Question 3

When can a temporary treatment order be given for a patient under the Mental Health Act? For what duration does it apply?

Answer 3

• Ifan authorised psychiatrist determines that the criteria necessary for an assessment order apply
• Temporary treatment order can be issued for a maximum duration of 28 days in an inpatient or outpatient setting

Question 4

How long can a treatment order (under the Mental Health Act) last for? Who can determine these?

Answer 4

• Made by a mental health tribunal
• 6 months (inpatient) or 12 months (outpatient)
  
  • 3 months (minor)

Question 5

Describe a framework for assessing a suicidal patient

Answer 5

• Establish rapport, be non-judgmental
  
  • Best approach often not to ask direct questions
• C - current plan/intent/suicidal thinking
  
  • Details (how, when and where), access to means (especially potentially lethal), any provisions for being saved/agreeing to help, any plans for future and how realistic (affairs in order?)
  • MSE
• P - past history
  
  • Psychiatric disorders or self-harm (actual or fantasised)
• R - resources
  
  • Internal (coping strategies, personality style) and external (supports, accommodation)
• Static and dynamic risk factors

Question 6

Describe some behavioural red flags for violence in a patient

Answer 6

• Loud speech, increased muscle tension, hyperactivity, violent actions

Question 7

Describe an approach to the management of a violent patient

Answer 7

• Interview techniques
  
  • Don’t interview in a cramped space
  • Patient and clinician to have access to door
  • Show concern, develop rapport.
  • Be self-aware - your subjective feelings can be an indication as to the severity of the situation, and also can worsen it
• Redirection > time out > restraint > seclusion/medication (debrief patient afterwards if this is ever necessary)

Question 8

What is the presentation of someone with neuroleptic malignant syndrome? What causes it? What will investigations show?

Answer 8

• Complication of treatment with antipsychotic drugs
• Rigidity, hyperthermia, sweating, hypertension, tachycardia, akinesia, mutism, altered LOC
• Elevated CK, leukocytosis

Question 9

How might you manage someone with neuroleptic malignant syndrome?

Answer 9

• Depending on severity
  
  • Supportive
  • Antipsychotic cessation
  • Dantrolene/bromocriptine
  • ICU admission and monitoring for renal failure

Question 10

What is the presentation of someone with serotonin syndrome? What drugs is this associated with?

Answer 10

• Cognitive
  
  • Headache, agitation, hypomania, mental confusion, hallucinations, coma
• Autonomic
  
  • Shivering, sweating, hyperthermia, vasoconstriction, tachycardia, nausea, diarrhea
• Somatic
  
  • Myoclonus (muscle twitching), hyperreflexia (manifested by clonus), tremor, nystagmus
• Drugs
  
  • SSRIs, SNRIs, MAOIs, lithium, opioids, antipsychotics

Question 11

How is serotonin syndrome managed?

Answer 11

• Hyperthermia? - ICU admission
• Cease serotonergic drugs
• 5-HT antagonist (cyproheptadine) or B-blockade

Question 12

What are the indications for ECT?

Answer 12

• Refractive major depressive disorder
  
  • Requires maintenance psychotropics
• Mania
• Bipolar and schizophrenia - conflicting benefits

Question 13

What are the absolute contraindications for ECT?

Answer 13

• Raised ICP (absolute)
• Hyperthyroidism, general medical morbidities
• Pregnancy and pacemakers are not contraindications. ICDs should be turned off

Question 14

When must a mental health tribunal be involved in the decision to administer ECT to a patient?

Answer 14

If they lack capacity or are under 18

Question 15

What are some side-effects of ECT?

Answer 15

• Antero/retrograde amnesia (especially episodic memory)
• Confusion
• Persistent memory disturbance
• Headache
• Muscle aches
• Nausea