Mental Health Emergencies
in Primary Care
Dr. L. Rozewicz, Clinical Director, Crisis & Emergency
Dr G. Isaacs, Consultant Psychiatrist (Haringey)
Dr H. Scurlock Consultant Psychiatrist (Enfield)
Overview
 Description of common problems
 What to do
 How to manage in primary care
 How to refer to specialist services
Overview
 Emergencies relate to acutely disturbed
behaviour
 They can occur in surgeries, patients homes or
public places
 The most important initial decision is to exclude
physical causes and or the effects of prescribed
or not prescribed drugs
 Obtain a history from the patient and or carer or
relative
Acute confusional state
 Most often elderly and patients with dementia
 Fluctuating level of consciousness
 Visual and/or tactile hallucinations
 Disorientation in time/place
 Overaroused or underaroused
Acute confusional state
 Physical
oAcute infection (UTI, chest)
oHypoglycaemia
oHypoxia
oHead injury – subdural
oPost-ictal
Acute confusional state
 Drug and Substance Misuse
• Acute alcohol intoxication or withdrawal
• Steroid psychosis
• Amphetamine psychosis
 Acute mental health problems
• Acute schizophrenia or psychotic depression
• Hypomanic episodes of bipolar disorder
• Personality disorder
• Severe anxiety disorder, panic disorder
Acute confusional state
management
 Admit to a medical ward – not managed in
psychiatric units
 Treat primary cause
 Manage the environment – avoid sensory
deprivation e.g. windowless room, avoid sensory
overload e.g. noise
 Think of patient safety, falls, infection, DVT,
constipation
 Major tranquillisers at low doses
Behavioural and Psychological
Symptoms in Dementia
 BPSD – non cognitive symptoms in dementia
(psychosis, agitation, mood disorder)
 FGAs traditionally used – haloperidol
 SGAs better as no EPS
 Risperidone licensed in UK for up to six weeks
 SGAs now controversial (small effect size,
sedation, increase in CVAs and all cause
mortality, cognitive decline)
Behavioural and Psychological
Symptoms in Dementia
 Use risperidone (0.5-1mg), refer within
seven days to specialist
 Olanzapine is second line (5mg)
 Stop after 2-3 weeks unless there is a
specific indication
Acute mental health problems –
general approach
 Acute Anxiety
 Agitated Depression
 Impulsive violence secondary to poor anger
control
 Acute psychosis
Acute mental health problems –
general approach
 If violence is involved (or if there is a history of
violence ask for police support)
 Gather information from records, family, carers –
think about drugs and alcohol
 Tell receptionist your are visiting, call back within
fixed time to confirm that you are OK, get
receptionist to call police if they do not hear
from you
 Visit with someone else if possible
 Do not try to restrain patient
 Have an exit route
Anxiety Disorders
 Very common chronic disorders in 10% of patients
 Common overlap with depression
 Commonly present with physical symptoms
 CBT 7-14 hrs from IAPT (CBT is better than
medication)
 Avoid Benzos
 Use SSRIs (Sertraline 50mg and then increase) or
Pregabalin (75mg bd)
 Pregabalin
‐ binds to α2δ subunit of the voltage dependent calcium channel
‐ works as quickly as benzos
‐ 75bd to 300bd (increase gradually)
ICD-10 Criteria for Alcohol Dependence
 A strong desire or a sense of compulsion to drink
alcohol
 Difficulty in controlling drinking in terms of its
onset, termination or level of use
 A physiological withdrawal state
 Evidence of tolerance
 Progressive neglect of alternative pleasures
 Persisting with alcohol use despite awareness of
harmful consequences
AUDIT
 Alcohol Use Disorders Identification Test
 10 Questions
 Takes 5 minutes
 92% sensitivity with 8 cut off
 95% specifity
Treatment Options - Alcohol
 Refer to local alcohol service
 GP detox (chlordiazepoxide)
 Consider acamprosate post detox
 DTs – refer to medics
 Dependence and active suicidal refer to
HTT
Suicide
 Typical GP will see one suicide every five
years on their list
 One a year in a 10 000 group practice
 8.5/100000 per year
 No single assessment tool
Risk Factors for Suicide:
Socio-Demographic
Females more likely to attempt than
males
Males more likely to die
Young and Old
Poverty, unemployment
Prisoners
Risk Factors for Suicide:
Family and Childhood
 Parental depression, substance misuse,
suicide
 Parental divorce
 Bullying
Risk Factors for Suicide:
Mental Health Problems
 Impulsive, aggressive or socially
withdrawn
 Poor problems solving ability
 Mood disorders; bipolar, psychotic
depression
 Substance/alcohol misuse
 Schizophrenia
 Recent discharge from psychiatric hospital
Risk Factors for Suicide:
Suicidal Behaviour
 Access to means (guns, drugs, tablets)
 History of suicide attempts
 Specific plans
Suicide Questions
 How does the future look to you? What are your
hopes?
 Do you wish you could jut not wake up in the
morning?
 Have you considered doing anything to harm
yourself, or to take your own life?
 Have you made actual plans to kill yourself?
What are they?
 What has stopped you from doing anything so
far?
Care Plan
 Document problem and provisional
diagnosis in the notes
 Document risk assessment
 Management plan
 Record discussion with patient about
problem/management plan
 Record patient views