It’s one of yours: Psychiatry in the

emergency department

Dr. Simon HatcherUniversity of Auckland

“Medical clearance”

•What does it mean?

•Focuses on disposal of patient and timing of assessments rather than need

•“Focused medical assessment” - medical cause excluded and acute care complete (but doesn’t address cognitive status)

“Medical clearance”

•Evidence that a careful history may be more effective in identifying medical problems

•One study found history alone had a 94% sensitivity

•Low yield for most laboratory tests

“Clues to distinguish between medical and psychiatric disorder”

•New symptoms, especially in older adult

•Abrupt presentation

•Presence of positive history in review of systems

•Extensive PMH

•Polypharmacy

•History of medication change

“Clues to distinguish between medical and psychiatric disorder”

•History of poor medication adherence

•No personal or family history of psychiatric disorder

•Visual, tactile, olfactory hallucinations

• Altered/variable level of consciousness

•Presence of abnormal vital signs, lab data or physical examination

•Lack of expected response to treatment• Hillard and Zitek 2004

TREC studies•BMJ Sep 23 2003; Oct 27, 2007

•Midazolam (7.5-15mg) vs Haloperidol (5-10mg) and Promethazine (50mg)

•Olanzapine (10mg) vs Haloperidol and Promethazine (NNS 5-8)

•Haloperidol vs Haloperidol and Promethazine

Suicide deaths and rates2002 2003 2004

NumbersTotal 465 516 486Male 352 375 377Female 113 141 109RatesTotal 12.8 13.6 12.8Male 19.8 20.2 20.3Female 6.2 7.3 5.8

Suicide death rates, by sex, three-

year moving averages, 1984–2004

• Two thirds of people who commit suicide will have been in contact with an emergency department in the months before their death

• 12% of people attending for non psychiatric reasons have suicidal thoughts

• 2% have plans

• 25 of the 31 patients planning suicide were undetected during their index visit; 4 attempted suicide within 45 days of the visit. All survived.

Suicide