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How to Tell Whether a Psychiatric Emergency is Due to Disease or Psychological Illness

By Anton Helman, MD, CCFP(EM), FCFP | on September 18, 2017 | 0 Comment
EM Cases
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How to Tell Whether a Psychatric Emergency is Due to Disease or Psychological Illness

Literature suggests a very low rate of clinically significant imaging findings in psychiatric patients without risk factors for organic illness. The yield of a clinically significant finding on a CT of the head in uncomplicated schizophrenia patients with normal vital signs and an otherwise normal physical exam (even if it is a first-time presentation) was published in a Canadian Journal of Emergency Medicine study.10 From three Ontario hospitals, the yield was one in 300. Another review of five studies from 2009 showed the diagnostic yield to be only 1.3 percent for CTs and 1.1 percent for MRIs in 384 CTs and 184 MRIs of first episode psychosis patients. CT is clinically indicated in psychiatric patients with altered mental status, trauma, immunodeficiency, or focal neurological findings.

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ACEP Now: Vol 36 – No 09 – September 2017

Three Main Take-Home Points in Medical Clearance

  1. Approach to psychiatric patients should be the same as your approach to any medical patient. An adequate history and physical are essential.
  2. Know which patients are at high risk for an organic cause of their behavioral presentation so that you have a heightened awareness for organic pathology in these patients.
  3. There is no evidence for benefit of routine diagnostic screening; tests should be ordered just as you would for medical patients, guided by the presenting complaint and findings on a thorough history and physical examination.

Thanks to Howard Ovens, Ian Dawe, and Brian Steinhart for their expert contributions to the EM Cases podcast that inspired this article.


Dr. Helman is an emergency physician at North York General Hospital in Toronto. He is an assistant professor at the University of Toronto, Division of Emergency Medicine, and the education innovation lead at the Schwartz/Reisman Emergency Medicine Institute. He is the founder and host of Emergency Medicine Cases podcast and website.

References

  1. Zhu JM, Singhal A, Hsia RY. Emergency department length-of-stay for psychiatric visits was significantly longer than for nonpsychiatric visits, 2002-11. Health Aff (Millwood). 2016;35(9):1698-706.
  2. Weiss AP, Chang G, Rauch SL, et al. Patient- and practice-related determinants of emergency department length of stay for patients with psychiatric illness. Ann Emerg Med. 2012;60(2):162-71.e5.
  3. Santillanes G, Donofrio JJ, Lam CN, et al. Is medical clearance necessary for pediatric psychiatric patients? J Emerg Med. 2014;46(6):800-807.
  4. Olshaker JS, Browne B, Jerrard DA, et al. Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med. 1997;4(2):124-128.
  5. Janiak BD, Atteberry S. Medical clearance of the psychiatric patient in the emergency department. J Emerg Med. 2012;43(5):866-870.
  6. Huff JS, Farace E, Brady WJ, et al. The quick confusion scale in the ED: comparison with the mini-mental state examination. Am J Emerg Med. 2001;19(6):461-464.
  7. Donofrio JJ, Santillanes G, McCammack BD, et al. Clinical utility of screening laboratory tests in pediatric psychiatric patients presenting to the emergency department for medical clearance. Ann Emerg Med. 2014;63(6):666-675.e3.
  8. Amin M, Wang J. Routine laboratory testing to evaluate for medical illness in psychiatric patients in the emergency department is largely unrevealing. West J Emerg Med. 2009;10(2):97-100.
  9. Shihabuddin BS, Hack CM, Sivitz AB. Role of urine drug screening in the medical clearance of pediatric psychiatric patients: is there one? Pediatr Emerg Care. 2013;29(8):903-906.
  10. Ng P, McGowan M, Steinhart B. CT head scans yield no relevant findings in patients presenting to the emergency department with bizarre behavior. CJEM. 2016;18 Suppl 1:S50.

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Topics: BoardingCriteriaDiagnosisdiseaseED Critical CareEmergency DepartmentEmergency MedicineEmergency PhysicianIllnessMedical ClearanceMental HealthPatient CarePhysical ExamPsychiatricPsychology and Behavioral DisordersuicideTreatment

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