Managing Psychiatric Emergencies

Scott Snyder, Sean Kivlehan and Kevin Collopy are featured speakers at EMS World Expo 2013, Sept. 8–12, Las Vegas Convention Center, Las Vegas, NV.

This CE activity is approved by EMS World Magazine, an organization accredited by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS) for 1 CEU. To take the CE test that accompanies this article, go to www.rapidce.com to take the test and immediately receive your CE credit. Questions? E-mail editor@EMSWorld.com.

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Objectives
• Discuss psychiatric emergencies commonly managed by prehospital providers
• Review assessment and management strategies
• Discuss signs of suicidal ideations

Psychiatric disorders are an epidemic problem across the United States and the world. In a comparison of two European EMS systems, psychiatric emergencies accounted for 12% of all EMS responses—equivalent to the number of responses for both traumatic and neurological emergencies.¹ These numbers are similar to those experienced in the U.S. For example, the Hennepin County Medical Center in Minneapolis, MN, treated over 102,000 emergency department patients in 2009 and 10,316 of these visits were for acute psychiatric services.²

Despite the high frequency of psychiatric emergencies, there has been a shift from inpatient to outpatient psychiatric care. The number of psychiatric inpatient beds has declined from 264 to 112 beds per 100,000 U.S. citizens, while the frequency of patients experiencing post-traumatic stress disorder, depression and other psychiatric emergencies continues to rise.3 Despite all of this, the EMS provider’s ability to understand, assess and manage these emergencies remains poor.

Major Depressive Disorder

Depression is a broad mental illness that affects nearly 18 million persons in the United States.⁴ The Diagnostic and Statistics Manual of Mental Disorders (DSM IV-TR)5 lists nine forms of depression, which are identified in Table 1.

Individuals are diagnosed with a major depressive episode when they present with a depressed mood or loss of interest/pleasure for at least 14 days; have impaired social/occupational area functioning; and have at least five of the following symptoms: depressed/sad mood most of the day, every day; diminished interest or pleasure in activities; significant weight loss (>5%) when not dieting; insomnia or hypersomnia; psychomotor agitation or retardation observed by others; fatigue or loss of energy; self-worthlessness or inappropriate guilt; diminished ability to concentrate (subjective or observed); and recurrent thoughts of death or suicidal ideations.⁵

To meet the clinical criteria for a major depressive episode, these symptoms cannot be caused by bereavement or drugs, and the patient cannot meet the criteria for a mixed episode. A mixed episode occurs when the patient has seven days of social function loss brought on by symptoms of a major depressive episode as well as a manic episode.

Manic episodes are characterized by at least a week of abnormal and persistent elevated/irritated mood. In addition to mood elevation, the patient must have impaired social interactions and also experienced at least three of the following: inflated self-esteem or grandiosity; decreased need for sleep; increased talkativeness; flight of ideas or racing thoughts; distractibility; psychomotor agitation; and excessive involvement in pleasure activities.

Major depressive episodes and manic episodes are the baseline diagnoses from which all other depression-related diagnoses are made. For example, a hypomanic episode is a 4–7-day period of a manic episode that does not cause marked functional impairment; major depressive disorder is the presence of a major depressive episode. Table 1 contains a sampling of the different types of depression, several of which are discussed in this article.

Table 1: Types of Depression

• Major depressive episode
• Hypomanic episode
• Manic episode
• Major depressive disorder
• Mixed episode
• Dysrhythmic disorder
• Bipolar I disorder
• Bipolar II disorder
• Cyclothymic disorder

Clinical Symptoms
EMS providers are not expected to diagnose patients with psychiatric emergencies. That said, even patients with diagnosed depression do not always complain directly about being depressed. Their symptoms may initially be vague, with complaints of weight loss, insomnia, fatigue or trouble focusing. If necessary, elicit the help of family and friends on hand to identify symptoms supporting depression as a differential diagnosis. The diagnostic criteria for major depressive order, discussed earlier, identify the symptoms consistent with depression. Depression is distinguished from feelings of being upset or sad by the duration of the symptoms and the absence of a single upsetting incident (e.g., a fight with a family member, a death, etc.).

There are some atypical depression symptoms worth noting. Catatonic depressive features require the patient to experience at least two of the following: motoric immobility (catalepsy or stupor); purposeless motor activity; extreme negativism; echolalia (the immediate and involuntary repetition of a word or phrase); or voluntary movement peculiarities, such as posturing, grimacing, mannerisms and stereotyping.

Postpartum depression is experienced by 10%–15% of women in the three months following childbirth. While up to 85% of women may experience mood swings following childbirth, these symptoms resolve within two weeks. When symptoms persist for more than two weeks—and are consistent with a major depressive episode—it is appropriate to consider postpartum depression in the differential diagnosis. The most common symptoms include extreme sadness, anxiety and despair.⁶

Who is At Risk?
By age 18, 14% of youth have experienced a major depressive episode, with another 11% admitting to experiencing minor depression symptoms.⁷ These numbers are significant, as up to 84% of these youth go on to experience major depressive episodes during adulthood.⁷ Making it through adolescence without depression doesn’t signal that it cannot occur. More than 20% of women and 12% of men experience a major depressive episode at least once in their lifetime.⁶ There is a bit of debate whether the risk for depression increases with advancing age. The incidence of psychiatric illness as a whole increases with advancing age and it can be difficult to distinguish atypical depression from other diseases, including dementia.

Risk for Associated Emergencies
Depression is linked to increased patient morbidity and mortality. Depression contributes to suicide, substance abuse, alcoholism and recurrent poor health. When depression complicates chronic medical conditions, such as diabetes and coronary artery disease, mortality increases. Elderly patients who develop depression double their risk for mild cognitive impairment and have an increased risk for dementia. Over half of all suicide attempts occur in patients previously diagnosed with depression. Nearly 20% of patients with untreated depression ultimately commit suicide.⁶

Patient Care Considerations
Long-term care for the patient with depression is provided by a psychologist and/or therapist, and sufferers may be prescribed one of the various prescription drugs available. The most commonly prescribed drugs are selective serotonin reuptake inhibitors (SSRIs), which include Celexa, Lexapro, Prozac, Paxil and Zoloft. SSRIs have gained popularity as they are easy to dose and have a wide therapeutic window, which reduces their toxicity in overdose. In contrast, tricyclic antidepressants have fallen out of favor as they commonly cause side effects, have a narrow therapeutic window and cause toxicity during overdoses.

EMS providers may interact with patients experiencing depression at their homes and during interfacility transports. When evaluating and managing these patients, management focuses on providing a compassionate, safe and empathetic environment. It is beyond the scope of our care to try to correct depression. Pay attention to your demeanor. Body language such as crossed arms, furrowed brow, clenched hands or standing rigidly suggests to the patient you are judging them or talking down. Instead, sit so your eyes are on the same level as the patient. Speak softly to the patient and ask open-ended questions that encourage the patient to share and speak freely. Be non-judgmental and seek to understand the patient’s situation. During emergent care of the depressed patient, it is essential to determine if the patient has suicidal ideations (discussed later). Patients with suicidal or homicidal ideations are an immediate risk and need transport for further psychiatric care.

Bipolar Affective Disorder

There are two forms of bipolar affective disorder, both of which are considered forms of depression. The DSM-IVTR characterizes bipolar I as the occurrence of one or more manic or mixed episodes (of depression). Bipolar II is characterized by at least one hypomanic episode and one or more major depressive episodes.

Etiology and Epidemiology
The mechanisms by which people develop bipolar disorder are not known. There does appear to be a genetic link, as individuals who have a first-degree relative with bipolar have a sevenfold greater likelihood of developing bipolar disorder.⁸ Further, recent research has identified a link between bipolar and two central nervous system genes. Dysfunction of one or both of these genes has been identified in patients with both bipolar and schizophrenia, and this dysfunction seems to move within families. When an identical twin is diagnosed with bipolar, the second twin is later found to also suffer from bipolar in nearly 90% of cases.⁸ The prevalence of bipolar I and II in the United States is about 1.6%, with the mean age at diagnosis being 21 years. Most cases are identified between ages 15–19.

Clinical Symptoms
Patients with bipolar experience profound swings in their mental health, with manic episodes followed by major depressive episodes. In between these mood swings a patient with bipolar may lead a normal, functioning life. The major depressive episodes of bipolar patients are identical to previously described major depressive episodes.

The characteristic feature of bipolar is mood elevation. Patients with bipolar I experience manic episodes. During manic episodes, patients experience excessively elevated moods and irritability. It is common for patients to go days without sleeping, experiencing pressured speech, increased sex drives, and reckless behaviors without regard for the safety of themselves or others. It is not uncommon for patients to experience delusions and have severe thought disturbances. Manic episodes last at least one week and have at least three of the symptoms within the DIG FAST mnemonic explained previously.

Bipolar II also causes mood elevation, but these elevations are considered hypomania episodes. Characterized by a lack of shyness, these patients are overly outgoing and talkative. They tend to jump to conclusions, their minds move quickly, and experience an elevated sense of well-being and confidence. The key difference between hypomania and mania is the absence of the reckless behaviors and functional impairment experienced by patients with the former. Hypomanic episodes last at least four days and also require three symptoms be present, though they are generally not as severe.

When evaluating a patient with depression or bipolar, consider the following: appearance, affect/mood, thought content, judgment and violence/suicide/aggression. During depressed episodes patients may appear to have poor hygiene and be unkempt; when experiencing manic or hypomanic episodes, their energy is up and they are often dressed in a manner that draws attention or appears hasty and disorganized.

It is common for patients to avoid making important decisions during depressive episodes. Their judgment is impaired with an inability to look at the future with a positive light and there is little to no insight into behavior. During a manic episode, a patient will have no problem making a decision—they just don’t evaluate what the good decision is! Feedback is ignored, suggestions are discarded and patients seem to do whatever they want without regard for what is right.

Suicide rates are high during major depressive episodes and the lifetime successful suicide risk for bipolar patients is 17%.⁸ As such, caregivers and prehospital providers should take any reference to suicidal ideations seriously. Patients may plot or plan their suicide during their major depressive episode and not carry it out until they begin to emerge from their depression. Do not let your guard down just because someone is beginning to feel better emotionally. Hypomanic and manic patients are at low risk for suicide but are at risk for being combative and aggressive toward others. It’s common for these patients to believe others must obey them (grandiose beliefs); homicidal actions may appear if the patient has delusions in which they believe others are threatening their well-being.

Care Considerations
Management of bipolar patients is driven by the phase the patient is experiencing. It is not uncommon for patients to require in-patient care during both manic and depressive episodes. As a general rule in-patient care is indicated, and involuntary transport may be necessary, when a patient is a danger to themselves or others; unable to function; uncontrollable or in need of close monitoring due to another medical condition.
The care of a patient with a bipolar-associated major depressive episode is identical to managing any other depressed patient. Patient care during manic episodes is safety driven. Avoid aggressive behaviors at all times! A manic episode is not the time to attempt to provide psychotherapy or bring the patient back to reality. Instead, speak calmly with the patient and try to build a bond without lying or participating in any delusions the patient may be experiencing. These patients require safe transport for medical management.

It may become necessary to provide pharmacological support to safely transport these patients. Sedation for psychiatric emergencies is a controversial issue and should only be performed in consultation with medical direction. Should sedation be required, the American Psychiatric Association recognizes the use of benzodiazepines as a useful adjunct until anti-manic medicines can be administered. Further, the National Association of EMS Physicians (NAEMSP) has taken the position that chemical restraint with a medication such as a benzodiazepine is safe and effective to protect a violent or combative patient.¹⁰

Many patients with bipolar disorder chronically take lithium for prophylaxis management of manic episodes. It is considered the first-line treatment for bipolar and patients receiving lithium to have their serum levels closely monitored to ensure they stay in a therapeutic range. Lithium is also suspected to be a neuroprotective drug that decreases the risk of suicide.8 Lithium levels are considered toxic when the serum level is elevated above 1.5 milliequivalents per liter (mEq/L). Prehospital providers may see patients with lithium toxicity complaining of shakiness and tremors; thirst; excessive urination; diarrhea and vomiting; muscle weakness; flattened T-waves on an EKG; and, in severe cases, seizures.

Conclusion

Depression and bipolar disorders are two psychological emergencies commonly seen by EMS providers and both are closely linked with suicide.
Major depressive episodes are rarely something patients experience only once; rather, it is an illness patients experience throughout their life.
Bipolar disorders combine major depressive episodes with manic mood swings alternating extreme lows and emotional highs in close succession. Patients can experience suicidal ideation with and without depression or bipolar disorder.

Suicidal ideation is a serious psychological problem that requires immediate attention and a thorough assessment. Treat all patients with dignity and respect and seek to understand their position.

By being compassionate and speaking in an honest, reassuring manner to your patients, you may discover valuable information that means the difference between life and death.

Standards for Emergency Detentions

Each state has its own requirements for forced hospitalizations. Depending on the state, these instances may be called “holds,” “pick-ups,” “detention,” “72-hour emergency admissions,” etc. Criteria for forced hospitalization include:

1. The patient must have a “mental illness,” or serious emotional disturbance.
2. The illness disables the patient or impairs logical thinking, resulting in the patient refusing examination after a full explanation; the patient is without care; or the patient poses a likely or real threat of harm, or appears in “immediate danger to self or others.”
3. If the above criteria are met, the individual may be detained by a law enforcement officer, physician, community mental health worker or qualified psychologist.

Check your own state’s standards for emergency hospitalization at www.treatmentadvocacycenter.org/storage/documents/Emergency_Hospitalization_for_Evaluation.pdf.

Legal Obligations

Never promise the patient anything regarding what may happen as a result of transport to an emergency department for evaluation. Do not promise that they will or will not be admitted to a hospital. Either promise can create significant problems for hospital staff. Offering false hope can create a legal risk of your own. Laws vary from state to state. Review the previous sidebar and link for more information on each state’s regulations.

As a general rule, a patient who has shown evidence of a danger to himself or others as a result of mental disorder can be taken to an emergency department against the individual’s wishes—with the authorization of a physician. Also, many states provide for the involuntary hold and transport of patients deemed to be “gravely disabled,” or unable to care for themselves and meet basic needs.

If through a thorough history taking you’ve identified information that places the patient or those around him or her in immediate danger, do not leave the patient alone! Ultimately, the preferred strategy is to have the patient agree to transport to an emergency department for psychological evaluation. Work with the police and online medical control to determine the best strategy if the patient will not agree to go. Each state has its own requirements regarding forced medical transports and forced hospitalizations. If it can’t be shown that the patient poses an immediate danger to themselves or others it is unlikely they can be forced to receive care.

If police use involuntary commitment paperwork, make sure the form is completed correctly before accepting it and transporting the patient. It is a best practice to have police ride with you to the hospital. Many EMS systems that work closely with their police departments will transport the patient and meet police in the emergency department for the appropriate paperwork. If your system uses this practice, ensure your EMS administration has a policy stating it is OK to meet the police at the hospital to complete paperwork. Otherwise, you may put yourself at risk for litigation should the paperwork not get completed for some reason.

When restraints are necessary to complete the transport safely, do so with extreme caution. NEVER restrain a patient with a longboard or in a prone position. Always maintain the patient’s dignity, even if they disrespect yours. Should an officer use handcuffs to restrain the patient, ensure that an officer with a key to the cuffs rides with you to the hospital. In the event of an accident or patient decompensation it is dangerous to have the patient locked to the stretcher without the ability to free them. Every system and state has their own regulations for restraints but they each follow the same principles:

• Soft restraints are preferred over hard restraints.
• Frequently check distal circulation.
• Obtain an online order for restraints.
• Consider sedation as an alternative.

Suicidal Ideations

Suicide is the 10th-leading cause of death in the United States. On average, 105 people kill themselves each day.10 It is believed that for every suicide death another 25 individuals attempt suicide; there are an estimated 790,000 annual suicide attempts. There is a direct link between suicide and mental illnesses, including drug and alcohol dependency.¹¹

The word suicide is derived from the Latin sui caedere, “to kill oneself.” A completed suicide means an individual has died; there is no clinical definition for a “successful” suicide. A suicide attempt is a serious act on one’s own life that potentially could have resulted in death. Finally, a suicidal ideation is any thought about, planning for or consideration for suicide. The Centers for Disease Control and Prevention considers suicidal ideations a serious problem but recognizes they are underreported and poorly tracked.

Prehospital providers need to understand their legal obligations as well as the warning signs surrounding suicidal ideations. Most people have warning sings prior to attempting suicide, including:⁶

• Diagnosis of major depression.
• Previous attempts.
• Burden of a major medical illness.
• Recent stressful life events.
• Lack of social support.
• Recently widowed or divorced.
• Presence of a gun in the home.
• Unexplained weight loss.
• High anxiety.
• Lack of a reason not to commit suicide.
• Presence of a practical plan.
• Rehearsal of the plan.

Reviewing a patient’s prescription medications can also help providers understand a patient’s suicide risk. Individuals taking antidepressants likely have a history of major depressive episodes. There is an increased risk of suicidal tendencies when patients are first prescribed SSRIs, although this risk disappears after being on the drug for 30 days. There is also some evidence that anticonvulsants (e.g., gabapentin), pain medications (e.g., tramadol and pain patches) and smoking cessation medications, such as varenicline, increase suicide risk as well.⁴

There is often a personal or familial history of psychological illnesses in patients who attempt suicide, and 30%–40% of individuals who successfully commit suicide have attempted suicide previously.¹¹

Patients with suicidal ideations who have a history of PTSD, depression or schizophrenia are at an increased risk of carrying out any plan they develop.

Assessing the Risk
While prehospital providers should NOT try to determine when a patient with suicidal ideations is serious or not, it is essential to assess the patient’s suicide risk to determine if there is enough data to seek help in obtaining an involuntary commitment/transport should the patient be unwilling to seek help.

When patients are reported to have suicidal ideations, inquire directly if they have a desire to hurt themselves or not. It is OK to ask the patient, “Are you currently thinking, or have you thought about, hurting yourself?” Patients are more likely to appreciate a provider who asks them directly than someone who is elusive in asking the question. It is essential to ask clear questions as the answers a patient provides can be used as a basis for an involuntary admission for mental healthcare. If the patient admits to considering suicide (they have ideations), determine in a non-threatening manner if they have a plan and what it is. While this seems invasive, you may find valuable information. By asking, “Have you thought about how you may do it?” you may discover the patient recently purchased a gun or drugs they were planning to use. These clues can be invaluable and can mean the difference in a patient being allowed to stay home or an involuntary commitment. Ask the following questions to any patient with reported or admitted suicidal ideations:¹¹

1. Have you ever considered suicide?
2. If you have, for how long?
3. If you haven’t made an attempt, have you been rehearsing an attempt?
4. Have you tried to commit suicide before?

Follow this up with the affirmation that you would like to help the patient, and state that you’d like to take them somewhere to be evaluated.

Suicidal Patient Care
Patients who are considering or who have attempted suicide are in psychological turmoil. Approach them with a degree of understanding of their turmoil and speak in a calm, supportive manner. Avoid judging and do not “blow off” the patient’s concerns or issues. Respect the patient and their wishes to the greatest degree possible. Display caring mannerisms. Do not establish blame or provide a moral stance.

References
1. Pajonk FG, et al. Psychiatric emergencies in prehospital emergency medical systems: a prospective comparison of two urban settings. General Hospital Psychiatry, 2008 July–Aug; 30(4): 360–66.
2. Hennepin County Medical Center. 2009 HCMC Emergency Services Statistics, www.hcmc.org/depts/em/emstats.htm.
3. Allen MH, et al. The Expert Consensus Guideline Series Treatment of Behavioral Emergencies. American Association for Emergency Psychiatry, emergencypsychiatry.org.
4. Andrew LB. Depression and Suicide. Medscape, emedicine.medscape.com/article/805459-overview.
5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR, 4th ed. American Psychiatric Pub, 2000.
6. Halverson JL. Depression. Medscape, emedicine.medscape.com/article/286759-overview.
7. Abela JRZ, Hankin BL. Handbook of Depression in Children and Adolescents. New York: Guilford Press, 2008.
8. Soreff S. Bipolar Affective Disorder. Medscape, emedicine.medscape.com/article/286342-overview.
9. Kupas DF, Wydro GC. Patient restraint in emergency medical services systems. PEC, 2002; (6)3: 340–45.
10. Centers for Disease Control and Prevention. Understanding Suicide Fact Sheet 2012, www.cdc.gov/violenceprevention/pdf/suicide_factsheet_2012-a.pdf.
11. Lipton L. Emergency responders management of patients who may have attempted suicide. The Internet Journal of Rescue and Disaster Medicine, 2006; 5(2). DOI: 10.5580/8f0

Kevin T. Collopy, BA, FP-C, CCEMT-P, NREMT-P, WEMT, is performance improvement coordinator for Vitalink/Airlink in Wilmington, NC, and a lead instructor for Wilderness Medical Associates.E-mail kcollopy@colgatealumni.org.

Sean M. Kivlehan, MD, MPH, NREMT-P, is an emergency medicine resident at the University of California, San Francisco. E-mail sean.kivlehan@gmail.com.

Scott R. Snyder, BS, NREMT-P, is a faculty member at the Public Safety Training Center in the Emergency Care Program at Santa Rosa Junior College, CA. E-mail scottrsnyder@me.com.