Acute Care: The
Mentally Ill
Dr. Jerry Morris, Medical Psychologist
Introduction
• As if your acute care job isn’t complex &
demanding enough, let me do the
psychologist’s destiny & bring the complex
reality into focus! First, 24% of the
population has an active mental disorder in
any 24 month period (1 in 4 people you
pass on the street, and treat in your
hospital), as do 57% of the population
(more than 1 of every 2) when lifetime
prevalence is the time horizon (Morris, J. A., Practicing
Psychology in Rural Settings: Hospital Privileges & Collaborative Care, APA Books,
Washington, DC, 1997).
Med/Surg Hospitals Have
Always Treated the
Mentally ILL
• The point is this: “You are treating patients with
mental disorders, and the only question is
whether you and the acute care hospital staff
identify them, accurately diagnose them,
adequately apply scientifically validated
treatments and care plans for them, have skills
and opportunities to grow in these skills specific
to this large subpopulation of acute care
patients, and whether you adequately prepare
these patients for linkage with appropriate
aftercare services and treatment.
Med/Surg Hospitals Have
Always Treated the
Mentally ILL
• Tips & Pearls in Identifying Patients Needing
a Psychological Consultation: 1. Review of
medications-ARE THERE PSYCH MEDS ON
BOARD AT ADMISSION OR IN THE RECENT
HX; 2. In your assessment, does the patient
have a psychiatrist, psychologist, or mid-level
mental health professional actively treating them
on an outpatient basis; 3. Is there a family hx of
MI or Substance Abuse; 4. Have there been
frequent ED or Hospital admissions in the last
year.
Caring for the Angry Patient
• General Principles of Management
• The safety of patient, clinician , staff ,other patients
and potential intended victims is of most importance
while looking after aggressive patients
• The doors should be open outwards and not be
lockable from inside or capable of being blocked from
inside.
• while working with impulsively aggressive or violent
patients in any setting one must take care to reduce
accessibility to patients of movable objects as well as
jewelry and other attire that might add to the risk of
injury during an assault, including neckties,
necklaces, earrings, eyeglasses, lamps and pens.
Caring for the Angry Patient
Principles of Management: Continued
• Adequate caregiver training and the availability of
appropriate supervision are critical safeguards in the
treatment of potentially dangerous patients.
• The caregiver may choose to present a few key
observations in a calm and firm but respectful
manner, putting space between self and patient;
avoiding physical or verbal threats, false promises
and build rapport with client.
• For caregivers treating patients with a high risk for
violence behavior, training in basic self defense
techniques and physical restraint techniques are
useful.
Pharmaceutical Treatment
• Drug Treatment in Aggressive and Violent
Behaviors
Medications are used primarily for 2 purposes• To use sedating medication in an acute
situation to calm the client so that client will not
harm self or others.
• To use medication to treat chronic aggressive
behavior.
• Factors influencing choice of drug –availability
of an IM injection, speed of onset and previous
history of response.
Video Example & Training
Click Here to see video
Video Discussion
• Call for help!
• Ensure you have backup and the team
understands the situation (weapons,
room dangers, lead up)!
• Logistics: entry and exit, safe distance,
body language, respect!
• Non-threatening, honest identification of
effect of the behavior on staff,
engagement of pt. in problem solving
and solutions.
Pharmaceutical Treatment
•
Drug Treatment in Aggressive and Violent Behaviors
• Acute agitation and aggression
• Antipsychotic –often it is the sedating property of
antipsychotic that produce the calming effect for the client.
Atypical antipsychotic are also commonly used. But only
Ziprasidone is available in intramuscular form.
• Haloperidol-1 mg or 0.5 mg IM
Risperidone o.5mg-1mg- In dementia and schizophrenia.
Trazodone – 50-100mg . In older clients with sun downing
syndrome and aggression.
• Benzodiazepines- used due to the sedative effect and rapid
action. Most commonly lorazepam, oral or injection. Other
sedating agents used include Valproate, chloral hydrate and
diphenhydramine.
Psychopharmacology Tenets
Options for Control
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Lorazepam (Ativan)
Midazolam (Versed)
Diazepam (Valium)
Haloperidol (Haldol)
Droperidol (Inapsine)
Diphenhydramine
(Benadryl)
Benztropine (Cogentin)
Ziprasidone* (Geodon)
Olanzapine* (Zyprexa,
Zydis)
Risperidone (Risperdal)
Aripiprazole* (Abilify)
Quetiapine (Seroquel)
ACEP Clinical Policy
Level B/C Recommendations
•
Benzo OR a conventional
antipsychotic
• If rapid sedation is required,
consider droperidol* instead
of haloperidol.
• Oral benzodiazepine + oral
antipsychotic if cooperative
patients.
• HAC may be faster than
monotherapy
Lukens et al. Clinical Policy: Critical Issues in the Diagnosis and
Management of the Adult Psychiatric Patient in the Emergency
Department. Annals of Emergency Medicine. Vol 47, No 1,
January 2006.
Benzodiazepines
Expert Consensus Guideline
2005
• “BNZs are
recommended when no
data are available, when
there is specific
treatment (e.g.,
personality disorder), or
when they may have
specific benefits (e.g.,
intoxication).”
Allen et al. The Expert Consensus Guideline Series:
Treatment of Behavioral Emergencies 2005. Journal
of Psychiatric Practice. Vol 11, Suppl 1
• Why BZNs are Preferred
for Undifferentiated
Agitation
• Safe. No EPS. No Sz. No
QT problems
• Easy to titrate
Preferred for intoxications
• Preferred for seizure, etoh
w/d.
• Works some for psychosis
• Preferred by patients
ETOH and Amphetamines
Just really drunk?
• Benzos vs
antipsychotics?
• Project BETA
recommends Haldol
• Some stick with
Ativan and avoid
midazolam
Wilson MP, Pepper D, Currier GW, Holloman
GH, Feifel D. The Psychopharmacology of
Agitation: Consensus statement of the
American Association for Emergency
Psychiatry Project BETA sychopharmacology
Workgroup. West JEM. In press
Psychotic from meth?
• Ativan still good
• Second Gen
Antipsychotics
effective against meth
psychosis.
Shoptaw SJ, Kao U, Ling W.
Treatment for amphetamine
psychosis. Cochrane
Database Syst Rev. 2009; 1:
CD003026.
Expert Consensus
“Within the limits of expert
opinion and with the
expectation that future
research data will take
precedence, these
guidelines suggest that :
• SGAs are now preferred
for agitation in the setting
of primary psychiatric
illnesses
• But, BNZs are preferred in
other situations.”
Allen et al. The Expert Consensus
Guideline Series: Treatment of
Behavioral
Emergencies 2005. Journal of Psychiatric
Practice. Vol 11, Suppl 1
Project BETA Recommendations
• SGAs recommended over
Haldol
• Risperidone or olanzapine
if will take oral.
• Ziprasidone or olanzapine
if IM
Wilson MP, Pepper D, Currier GW, Holloman GH,
Feifel D. The
Psychopharmacology of Agitation: Consensus
statement of the American
Association for Emergency Psychiatry Project
BETA Psychopharmacology
Workgroup. West JEM. In press.
Second Line Approaches
What if that didn’t work?
• Change class?
• Add more benzo?
• Benzo after IM Zyprexa?
Chronic, Rather than
Acute Aggression
based on underlying diagnoses
• Antipsychotic
• Anxiolytics- Buspirone
• Carbamazepine and valproate to treat bipolar
associated aggressive behaviour.
• Antidepressants –trazodone in aggression
associated with organic mental disorder.
• Antihypersensitive medication – Propanolol to
treat aggression related to organic brain
syndrome.
Responses to Lower
Aggression
Use de-escalation techniques and
crisis communication to avert
aggressive behavior.
Tips and Pearls:
A. “I understand…..”
B. “I accept……….”
C. “But, …………”
Managing a psychiatric crisis
If your patient experiences a psychiatric crisis, use the following
techniques to help de-escalate the situation.
• Maintain a calm demeanor.
• Speak in a soft, clear voice.
• Convey empathy. For instance, ask, “How can I help you?”
• Allow the patient to vent.
• Listen to the patient; then reflect back what she has said so she
knows you’ve been listening. This may make her more likely to be
Receptive to you.
• Use appropriate problem-solving techniques.
• Offer reassurance and support. Let the patient know you’re trying
to ensure her safety.
• Avoid a power struggle.
• Don’t argue with the patient.
• Keep your options open by avoiding definitive statements.