ACEP clinical policy - Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department

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1. In the alert adult patient presenting to the ED with acute psychiatric symptoms, should routine laboratory tests be used to identify contributory medical conditions (non psychiatric disorders)?

  • Level C recommendations - Do not routinely order laboratory testing on patients with acute psychiatric symptoms. Use medical history, previous psychiatric diagnoses, and physician examination to guide testing.

  • Changes from 2006 policy:

    • The previous policy had more emphatic Level B recommendations against routine labs.

    • The level of recommendation downgrading is because the current committee felt that the articles supporting the 2006 recommendation, and two new studies reviewed, lacked high quality evidence (Class X or Class III).

  • Evidence:

    • Two new studies were reviewed, both from 2012. They were of questionable methodology but basically showed routine labs changed management in only 1 of 502 patients in one study [1], and 1 of 191 patients in the second[2].  The 1 of 191 was a high acetaminophen level requiring NAC.

    • Both studies looked at patients admitted to inpatient psych, so these numbers exclude those who were discharged and those who were deemed to need a medical workup by ED staff.

 

  • Takeaways:
    • Don’t get “screening” labs for psych patients; based on the available (low quality) evidence it is exceedingly rare that this will change your ED management.  Thankfully we are rarely asked to do this by our psychiatric colleagues (breathalyzer notwithstanding).
    • Do think critically about whether your “crisis eval” needs a medical workup, and don’t forego labs on all of them.  These studies generally exclude patients who have, at the discretion of the physician (i.e. us), undergone a medical workup and found to have underlying medical issues.  Specific high risk populations include elderly, immunosuppressed, new-onset psychosis, substance abuse.

 

2. In the adult patient with new-onset psychosis without focal neurologic deficit, should brain imaging be obtained acutely? 

  • Level C recommendations -  Use individual assessment of risk factors to guide brain imaging in the emergency department for patients with new-onset psychosis without focal neurologic deficit. (Consensus recommendation)
  • Evidence:
    • The committee found a grand total of zero studies that they felt were either high enough quality or applicable to the ED population, so this recommendation is expert opinion.
    • The studies they looked at were flawed for reasons including lack of a definition of psychosis, no documented neurologic exam, no definition of clinically relevant imaging findings, or no standard imaging modality.
  • Takeaways:
    • New onset psychosis is one of those groups of psych patients we need to think harder about.
    • If something makes you suspicious you won’t be faulted for imaging, but there’s no evidence that this is standard of care.

3. In the adult patient presenting to the ED with suicidal ideation, can risk-assessment tools in the ED identify those who are safe for discharge? 

  • Level C recommendations - In patients presenting to the ED with suicidal ideation, physicians should not use currently available risk-assessment tools in isolation to identify low-risk patients who are safe for discharge. The best approach to determine risk is an appropriate psychiatric assessment and good clinical judgment, taking patient, family, and community factors into account.
  • Evidence:
    • Four studies were included for the recommendation, all published from 2011-2014 [3-6].
    • The study worth noting is Posner et al that looked at the Columbia-Suicide Severity Rating Scale (C-SSRS), which seems to be the tool with the best evidence behind it and is what our crisis team uses in the ED.  ACEP does not endorse it as a good screening tool in the ED because it is best at predicting lifetime suicide attempts, not imminent risk of suicide (i.e. doesn’t help with immediate disposition).  The paper reports 100% sensitivity AND specificity for identifying lifetime risk of suicide attempts and did include one cohort of ED patients.  I find any data that bats a thousand with sensitivity and specificity to be somewhat suspect, and despite considerable digging I couldn’t figure out exactly how they used the C-SSRS score to determine these numbers.  I couldn’t even find published data from the ED cohort (not to say it doesn’t exist).
    • The other 3 studies either had dismal sensitivity and specificity, or didn’t directly address risk or suicide [4-6].

 

  • Takeaways:
    • At least from ACEP’s perspective we can’t put a lot of stock in published risk-assessment tools, even the C-SSRS.
    • Even if the data is a little hard to interpret, C-SSRS at least has an encouraging body of evidence behind it, and provides a useful framework for evaluation.
    • I’ll consider using the C-SSRS when I’m working without a crisis team in the department to bolster my argument for discharging a patient I feel is truly low risk without involving psychiatry.

 4. In the adult patient presenting to the ED with acute agitation, can ketamine be used safely and effectively?

  • Level C recommendations - Ketamine is one option for immediate sedation of the severely agitated patient who may be violent or aggressive. (Consensus recommendation) 
  • Evidence:
    • The committee found zero articles that they felt met Class I-III data, so this is an expert opinion recommendation.  They did not include anything published after 2016, and we know there is some new data out there.
    • Multiple “Class X” studies are discussed, which are case series that show adequate sedation and low rates of adverse events but used variable doses, often combined with other drugs, and did not have comparison groups. 
  • Takeaways:
    • I think most of us have been glad to have ketamine as an adjunct when the typical antipsychotic/benzo cocktail isn’t cutting it.  Anecdotally, our experience seems to reflect the committee’s discussion that adverse events are uncommon.
    • This is an active area of research and this guideline is missing some recent data (Riddell 2017).
    • Some guidance on monitoring would be helpful since dosing for agitation and procedural sedation are equivalent.

 

Written by Brooks Motley, MD

Edited and Posted by Jeffrey A. Holmes, MD

REFERENCES

1.  Janiak BD, Atteberry S. Medical clearance of the psychiatric patient in the emergency department. J Emerg Med. 2012;43:866-870.

2.  Parmar P, Goolsby CA, Udompanyanan K, et al. Value of mandatory screening studies in emergency department patients cleared for psychiatric admission. West J Emerg Med. 2012;13:388-393.

3.  Posner K, Brown GK, Stanley B, et al. The Columbia–Suicide Security Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011;168:1266-1277.

4.  Tran T, Luo W, Phung D, et al. Risk stratification using data from electronic medical records better predicts suicide risk than clinician assessments. BMC Psychiatry. 2014;14:76.

5.  Bilen K, Ottosson C, Castren M, et al. Deliberate self-harm patients in the emergency department: factors associated with repeated selfharm among 1,524 patients. Emerg Med J. 2011;28:1019-1025.

6.  Randall JR, Rowe BH, Colman I. Emergency department assessment of self-harm risk using psychometric questionnaires. Can J Psychiatry. 2012;57:21-28.

7.  Riddel J et al.  Ketamine as a first-line treatment for severely agitated emergency department patients.Am J Emerg Med. 2017 Feb 13. pii: S0735-6757(17)30114-6. doi: 10.1016/j.ajem.2017.02.026.