mental health emergencies in primary care dr. l. rozewicz, clinical director, crisis & emergency...
TRANSCRIPT
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