The Evaluation and Treatment of
the Emergency Psychiatric Patient
W. Scott Griffies, M.D.
LSUNO Department of Psychiatry
An ER Behavioral
Healthcare Infrastructure
• ER physician assessment includes mental status
exam.
• Crisis Assessment S.W., P.N.P., or P.R. include
complete psychosocial assessment.
• Psychiatric Consultant rounds bi-daily.
(possible telepsychiatry)
• Social Service (S.W.) Discharge
Plan/Resources.
CIU/BHETU
• Stabilization Units
• In Conjunction with ER
• 5-30% have medical illness
Disposition Evaluation
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Nature and duration of Illness
Relationship to baseline
Adequacy of self-care
Level of social supports
Risk of homicide/suicide
Differential Diagnosis
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Delirium
Psychotic Disorders
Mood Disorders
Developmentally Disabled – have above
diagnoses, but, since they are often
nonverbal, diagnoses will be primarily
based on behavioral observations and
descriptions.
Medical Delirium
• Acute Onset
• Fluctuating, Altered Sensorium
• Abnormal MMSE
Life-Threatening - WWHHIMP
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Drug withdrawal
Wernicke encephalopathy
Cerebral hypoxemia
Hypoglycemia
Hypertensive encephalopathy
Intracranial bleeding
Meningitis/encephalitis
Poisoning
An Option for Outpatient Psychosocial
Planning of Substance Dependence
• Call AA/NA and have sponsor visit patient
in ER
• Prescribe daily or bidaily NA/AA Group
meetings for first 2 weeks post discharge.
• Follow-up with addiction disorder clinic.
• Register for Rehab Program.
Psychotic Disorders
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Clear sensorium
Delusions
Hallucinations
Disorganized speech and behavior
Flat or inappropriate affect
Psychosis Differential
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Substance – induced
Due to medical condition
Schizophrenia
Mood Disorder (BMD/MDE)
Dementia with delusions
Psychosis Differential (cont.)
• Brief Psychotic Episode
• Schizophreniform
• Delusional Disorder
Mood Disorders – BMD and MDE +/Psychotic Features, Severe Agitation
• Mania - - Decreased need for sleep,
increased energy, agitation, irritability,
liability, projects, missions, hypertalkative,
pressured, racing.
• R/o organic etiology, especially if acute.
Treatment of Acute
Psychotic/Severe Agitation
• Haldol 5 mg, Benadryl 50 mg, Ativan 2 mg
IM. (B52)
• Repeat Haldol 5mg IM +/- Ativan 1-2 mg
q1-2h IM as needed until calm.
Other Guidelines
• Use 25-50% for elderly
• Monitor ECG when possible
• Most calm after 1-2 injections
Treatment of Acute Agitation
Other Options
• Zyprexa 10 mg q 2 h X 1, then q 4 h not to
exceed 30 mg/24 h. Do not give
concomitant Benzos.
• Geodon 10 mg q 2 h or 20 mg q 4 h, not to
exceed 40 mg/24 h.
• Use 25-50% for elderly/medically
compromised.
• Not indicated for dementia-related
psychosis.
Switching to Oral Antipsychotics for
Schizophrenia, BMD, MDE with Psychoses
While Awaiting Admission.
• Haldol 2-5 mg po q daily --BID
• Zydis (melts in mouth): 10-15 mg po q daily
initially.
• Seroquel 50 po BID. Increase by 100 mg/day
to 600 mg/day in divided doses - - more at
night.
Switching to Oral Antipsychotics for
Schizophrenia, BMD, MDE with Psychoses
While Awaiting Admission. (Cont.)
• Risperidol 1 mg po BID. 1st day, 2 mg BID
2nd day, 3 mg 3rd day.
• Geodon 40 mg po BID (usually 2nd line)
• Abilify 10-15mg
• Use 25-50% for elderly/medically
compromised.
Second Generation Antipsychotics:
Long term Side Effects
• Zyprexa, -- most weight gain, metabolic
syndrome (Relative cotraindication in D.M.
Obesity, Cholesterol)
• Risperidol, Seroquel – Second-most
metabolic syndrome issues.
• Geodon, Abilify – least weight gain and
metabolic syndrome.
Second Generation Antipsychotics:
Side Effects
• Risperidol – hyperprolactenemia
• Geodon – Relative QTC prolongation
Relative contraindication in patients with
CVS history. If CVS history, perform EKG.
• Seroquel – most antihistaminic, sedating
Anxiety
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Adjustment d/o with anxious mood
GAD
Panic
OCD
Social Phobia
ER Treatment of Anxiety
• Ativan 1-2 mg po q 4-6 h
• Klonipin 0.5 – 1 mg po BID – TID
• Use SSRI long term.
Borderline P.D.
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Impulsivity
Parasuicidal behavior
Abandonment anxiety
Labile affect
Agitation in Borderline P.D.
• Benzodiazepines may disinhibit
• Seroquel 50 po nightly/BID
Suicide
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Level of intent
Level of lethality
Prior attempts
Late life white divorced male
Living alone
Lack of sleep/agitation
Major Depressive Episode (MDE)
• Depressed mood or loss of interest/pleasure
x 2 weeks.
• Five/nine symptoms – depressed mood,
interest/pleasure,  or  weight,
insomnia/hypersomnia, psychomotor
agitation/retardation, fatigue/  energy, 
selfworth,  concentration, SI
Choice of Antidepressant –
General Issues
• Needs weekly f/u x 4 weeks with new
antidepressant
• Start low, go slow, especially in anxious,
somatisizing patients.
• Early side effects usually diminish in 10-14
days. If tolerable, hang in there.
Choice of Antidepressant –
General Issues
• Activating agent may need sleeping agent –
Trazodone (Priapism), Ambien, Lunesta
• Don’t give if mania hx
Antidepressant Choices–
Selective Variables
• Wellbutrin (150 mg) norepinephrine/dopamine – activating, 
energy,  concentration, no sexual SE’s.
• Effexor (75 mg) - combination serotonin,
norepinephine – monitor BP, especially at
higher dose – good for GAD also.
Antidepressant Choices–
Selective Variables
• Cymbalta (30 mg) – combination
norepinephrine/ serotonin – pain
syndromes, start 30 mg for 7-14 days to
mitigate nausea.
• Remeron (15 mg) – po q nightly –
combination serotonin, norephinephrine,
sedating
Antidepressant Choices –
Selective Variables
• Prozac (10-20 mg) – in some, more
activating, give in am, start 10 mg in
panic/anxiety.
• Paxil (10-20 mg) – in some more sedating,
more wt gain.
Antidepressant Choices –
Selective Variables
• Zoloft (25-50 mg) – activating or sedating,
can be nicely calming
• Celexa/Lexapro (10-20 mg) – most
serotonin - receptor selective.
ER Physician
• R/O underlying medical causes for
presenting delirium, psychosis, or mood
disorder.
• PEC if S/H or G.D.
Mental Status Exam: ARTT SMAJIC
• Appearance – well dressed/disheveled
• Rapport – good/eye contact
• Thought Process – linear, goal
directed, looseness of associations (LOA),
tangential, disorganized
• Thought Content – S/HI, A/VH
• Speech – N/R/R/V/T
Mental Status Exam: ARTT
SMAJIC (Cont.)
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Mood – upset, angry, sad
Affect – blunted, full range, depressed
Judgment – good, poor
Insight – good, poor
Cognition – see MMSE
“MINI-MENTAL STATE EXAM”
Maximum
Score
5
5
Score
Orientation
( ) What is the (year) (season) (date)
(day) (month)?
( ) Where are we? (state) (country)
(town) (hospital) (floor).
MMSE (Cont.)
Maximum
Score Score
Registration
3
( ) Name 3 objects: 1 second
to say each. Then ask the
patient all after you have
said them. Give 1 point for each
correct answer. Then repeat
them until he learns all 3.
Count trials and record.
Trials_________
MMSE (Cont.)
Maximum
Score Score Attention and Calculation
5
( ) Serial 7’s 1 point for each
correct. Stop after 5 answers.
Alternatively spell “world”
backwards.
Recall
3
( ) Ask for the 3 objects repeated
above. Give 1 point for each
correct.
MMSE (Cont.)
Maximum
Score Score
Language
9
( ) Name a pencil, and watch (2 pts)
Repeat the following “No ifs, ands
or buts.” (1 point)
Follow a 3-stage command:
“Take a paper in your right
hand, fold it in half, and put
it on the floor” (3 points)
Read and obey the following:
MMSE (Cont.)
Maximum
Score Score Close your eyes ( 1point)
5
( ) Write a sentence ( 1 point)
Copy design (1 point)
Total Score________________
FIG 6-1. From Folstein MF, Folstein SE, McHugh
PR: J. Psychiatr Res 1975, 12:189-198
Structured Diagnostic Interview
with Psychosocial Assessment
• S.W./Psychiatric Nurse
Practitioner/Psychiatric Resident
- HPI, DSM IV symptoms
- Past psychiatric history
- Family psychiatric history
- Past medical history
- Social history with current social
supports and resources.
- MSE
Psychiatrist Consultant
• Confirm diagnosis
• Medication recommendations
Disposition and Treatment
Recommendations
• Inpatient
• Outpatient
• ER medications
Withdrawal Delirium
(alcohol, benzodiazepine, barbiturates)
• Fixed with symptom triggered schedule.
Ativan 1-2 mg PO, IM or IV, Q 4-6 h;
Ativan 1-2 mg PO, IM, IV; Q 1-2 h prn
P>100, BP> 150/100; hold for sedation
• Or, give symptom – triggered alone, if more
appropriate.
Alcoholism
• Thiamine 100 mg po q daily
• Folate
1 mg po q daily
• MVI
1 taken po q daily
Opiate Withdrawal Evaluation
• Positive Opiate UDS
• Positive history
• Dilated pupils, piloerection, muscle cramps
Opiate Withdrawal Treatment
• Clonidine 1 mg po TID – QID
with 1 mg po q 2 h for BP > 150/100,
p > 100
• Bentyl 20 mg po QID prn abdominal
cramps.
• Pepto-Bismol, Imodium, Maalox, Mylanta
• Robaxin - muscle spasm.
Substance Dependence Disposition
• Medical admission for detoxification if
unstable.
• Psychiatric admission if suicidal.
• Outpatient addiction follow-up and rehab.
Outpatient Detoxification Option
• Patients w/o history of prior seizures or
withdrawal delirium.
• Valium 10 mg po TID-QID with 2-3 prn for
agitation/tremulousness
• Taper over 5-7 days
• MVI
Ativan Outpatient
Detoxification Option
• If patient has increased LFT’s
• Ativan 1-2 mg po q 4-6 h with 2-3 prn’s
• Taper over 10-14 days by dose, while
preferentially maintaining frequency.
MEDICAL DELIRIUM
TREATMENT ISSUES
• CBC, electrolytes, BUN, Cr, LFT’s, UDS,
possible CT scan.
• Admit for medical stabilization of
underlying causes.
Psychosis Due to Medical Condition
• Drugs and Toxins
• Intracranial masses (tumor, abscess,
subdural)
• Anoxia
• Normal Pressure Hydrocephalous
Psychosis Due to Medical
Condition (cont.)
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Neurodegenerative diseases
Infection
Nutritional (B12 , Folate)
Metabolic/Endocrine
Inflammatory/autoimmune
Mood Disorder Due to a
Medical Condition
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Carcinoid
Pancreatic Cancer
Collagen-vascular disease
Endocrinopatheses (Cushings, Addison’s
hypoglycemia, hyper/hypocalcaemia,
hyper/hypothyroid)
• Lymphoma
• Viral illness (mono, hepatitis, flu)
Depressed Mood Due to a
Pharmacologic Agent
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Clonidine
Propanolol
Corticosteroids
Ibuprofen
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Indomethacin
Ampicillin
Teracycline
Cimetidine
Mania Due to
Pharmacologic Agent
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Baclofen
Cimetidine
Corticosteroids
Disulfiram
Isonazid
Levodopa