Mental Health Emergencies in Primary CareDr. L. Rozewicz, Clinical Director, Crisis & EmergencyDr G. Isaacs, Consultant Psychiatrist (Haringey)Dr H. Scurlock Consultant Psychiatrist (Enfield)

Overview

Description of common problemsWhat to doHow to manage in primary careHow 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

PhysicaloAcute infection (UTI, chest)oHypoglycaemiaoHypoxiaoHead injury – subduraloPost-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 AnxietyAgitated Depression Impulsive violence secondary to poor anger

controlAcute 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 Test10 QuestionsTakes 5 minutes92% sensitivity with 8 cut off95% specifity

Treatment Options - Alcohol

Refer to local alcohol serviceGP detox (chlordiazepoxide)Consider acamprosate post detoxDTs – refer to medicsDependence 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 practice8.5/100000 per yearNo single assessment tool

Risk Factors for Suicide:Socio-Demographic

Females more likely to attempt than males

Males more likely to dieYoung and OldPoverty, unemploymentPrisoners

Risk Factors for Suicide:Family and Childhood

Parental depression, substance misuse, suicide

Parental divorceBullying

Risk Factors for Suicide:Mental Health Problems

Impulsive, aggressive or socially withdrawn

Poor problems solving abilityMood disorders; bipolar, psychotic

depressionSubstance/alcohol misuseSchizophreniaRecent discharge from psychiatric hospital

Risk Factors for Suicide:Suicidal Behaviour

Access to means (guns, drugs, tablets)History of suicide attemptsSpecific 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 planRecord discussion with patient about

problem/management planRecord patient views