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Chapter 95 ACUTE PSYCHOSIS658

6. Why is it important to control psychotic behavior immediately?

Patients who present in a psychotic state have no impulse control. They cannot distinguish

internal from external stimuli and are unable to prioritize their reactions to them. Because

of this dysfunction, they should always be considered a signiﬁcant danger to themselves

or to others. The best way to deal with violent behavior is to prevent it. Emergency

physicians should recognize patients who are obviously confused, irrational, paranoid,

or excited. Emergency physicians must also develop an intuitive vigilance to detect the

possibility of violence in patients who present more rationally and less ﬂoridly psychotic.

Any history or comment that suggests violence should be taken seriously. The potential

for violence in general is particularly high in patients who are psychotic secondary to illicit

drug use.

7. Are there behavioral controls that can be used immediately for the psychotic

patient?

Yes. Recognizing the potential for violence and physical harm, deﬁnitive steps should be taken

to avoid confrontation:

Environmental: Keep the environment simple and stimuli-free, and minimize staff changes.

Interpersonal: Assume the role of patient advocate, and engage the patient in a calm and

self-assured voice. Recognize the patient’s right to privacy and dignity.

8. What options can be exercised if the patient becomes increasingly

disorganized, agitated, and violent?

See Chapter 97.

9. How do I obtain a history on a psychotic patient?

Because acutely psychotic patients may not be able to provide an adequate history, all

available sources for obtaining information must be explored. This may include speaking to

emergency medical services (EMS) personnel, family, friends, neighbors, and law enforcement

ofﬁcers, as well as reviewing old medical records. A telephone conversation with caregivers

and signiﬁcant others can also be helpful.

10. What historical information is important?

Onset. Did the behavior change suddenly or gradually?

Longitudinal course. What was the precipitating event? Is this the ﬁrst such event? What

was the behavior like on previous events?

Psychosocial setting. Obtain some information regarding the patient’s support system.

Previous psychiatric disease, organic brain disease, the use or misuse of medication,

history of illicit drug use.

What are the current medications and have they been taken as prescribed?

11. How should my physical examination be tailored for a psychotic patient?

In retrospective reviews performed by Reeves, Tintinalli, and Riba, a high percentage of missed

organic diagnosis in psychotic patients was due to the lack of a complete history and physical

examination. Thus a complete and thorough physical examination, including a mental status

examination, is imperative. Always note the vital signs and pulse oximetry readings. In most

cases, emergency physicians will have built sufﬁcient rapport with patients that they will

cooperate with the examination. Tell the patient exactly what you are doing and what you are

going to do during the examination. This helps to provide structure for the psychotic patient

and avoids confusion or misunderstanding.

12. What is the difference between organic and functional psychosis?

Organic psychosis refers to a reversible or nonreversible dysfunctional mental condition

that can be identiﬁed as a disturbance in the anatomy, physiology, or biochemistry of the

brain (i.e., dementia, withdrawal states and intoxications).

Chapter 95 ACUTE PSYCHOSIS 659

Functional psychosis refers to a dysfunctional mental condition identiﬁed as schizophrenia, a

major affective disorder, or other mental disorders with psychotic features (i.e., schizophrenia

and the affective disorders).

13. Summarize the key points to consider in the differentiation of organic from

functional psychosis.

See Table 95-1.

14. List the possible causes of alcohol-related organic psychosis.

Chronic alcoholism

Thiamine deﬁciency (i.e., diet, starvation, and emesis)

Alcohol-dependent withdrawal states

Comorbid substance abuse

Comorbid psychotic and mood disorder

Alcohol idiosyncratic intoxication (pathologic intoxication)

15. Is there a brief, self-limited, and nonorganic psychosis?

Yes. Some individuals may become acutely and brieﬂy psychotic after exposure to an

extremely traumatic experience. If such a psychosis lasts for less than 4 weeks, it is termed a

brief psychotic disorder. Precipitants of the psychosis include the death of a loved one, a life-

threatening situation, such as combat or a natural disaster, or other life stressors. Patients

with hysterical, borderline, and narcissistic personalities are prone to brief psychotic disorder,

Organic Functional

M 5 Memory deﬁcit Recent impaired Remote impaired

A 5 Activity Hyperactivity and hypoactivity

Tremor

Ataxia

Repetitive activity

Posturing

Rocking

D 5 Distortions Visual hallucinations Auditory hallucinations

F 5 Feelings Emotional lability Flat affect

O 5 Orientation Disoriented Oriented

C 5 Cognition Some lucid thoughts

Perceives occasionally

Attends occasionally

Focuses occasionally

No lucid thoughts

Unﬁltered perceptions

Unable to attend

Unable to focus

S 5 Some other ﬁndings Age . 40

Sudden onset

Physical examination often

abnormal

Vital signs may be abnormal

Social immodesty

Aphasia

Consciousness impaired

Confabulation

Age , 40

Gradual onset

Physical examination

normal

Vital signs usually normal

Social modesty

Intelligible speech

Alert, awake

Ambivalence

TABLE 95–1. MADFOCS MNEMONIC

Chapter 95 ACUTE PSYCHOSIS660

and some studies support a genetic vulnerability. Emotional turmoil, confusion, and extremely

bizarre behavior and speech are common symptoms on presentation.

16. Summarize the potentially reversible causes of psychosis.

DEMENTIA mnemonic:

D 5 Drug toxicity

E 5 Emotional disorders

M 5 Metabolic disorders

E 5 Endocrine disorders

N 5 Nutritional disorders

T 5 Tumors and trauma

I 5 Infection

A 5 Arteriosclerotic complications

17. Name the life-threatening causes of acute psychosis.

WHHHIMP mnemonic:

W 5 Wernicke’s encephalopathy

H 5 Hypoxia or hypoperfusion of the central nervous system

H 5 Hypoglycemia

H 5 Hypertensive encephalopathy

I 5 Intracerebral hemorrhage

M 5 Meningitis/encephalitis

P 5 Poisonings

18. List pharmacologic agents that can cause acute psychosis.

Digitalis

Corticosteroids

Isoniazid (INH)

Disulﬁram (Antabuse)

Tricyclics

Anticonvulsants

Cimetidine

Benzodiazepines

Amphetamines and related drugs

Antidysrhythmics

Narcotics

Barbiturates

Methyldopa

Nonsteroidal anti-inﬂammatory drugs

Anticancer agents

Recreational drugs: alcohol, cocaine, amphetamines

19. Is laboratory screening necessary in the work-up of an acute psychotic patient?

Patients, with established psychiatric diagnosis, presenting to the ED with psychiatric chief

complaints, benign histories, and normal physical examinations have a low likelihood of

clinically signiﬁcant laboratory ﬁndings. Therefore, routine laboratory tests are not

recommended. If a patient presents with their ﬁrst psychotic episode, then laboratory studies

are indicated to distinguish functional versus organic psychosis. The following tests are

recommended: complete blood count, electrolytes, toxicology screens, pregnancy test, thyroid

function tests and computed tomography (CT) scan of the brain.

20. Are there any other clinical rules of thumb in the work-up of the acute

psychotic patient?

Fever and psychosis 5 meningitis

Acute psychosis and alcoholism 5 Wernicke’s encephalopathy

Chapter 95 ACUTE PSYCHOSIS 661

Headache and psychosis 5 tumor or intracranial hemorrhage

Abdominal pain and psychosis 5 porphyria

Sweating and psychosis 5 hypoglycemia or delirium tremens

Autonomic signs and psychosis 5 toxic or metabolic encephalopathy

21. When should hospitalization be recommended?

If this is the patient’s ﬁrst psychotic episode

If the patient is a danger to self or others

If the patient is unable to care for self appropriately

If the patient has no social support system

If the functional psychotic patient is not sufﬁciently clear after initial ED tranquilization

If an acute organic psychosis does not clear while the patient is in the ED

22. How do I treat the acutely psychotic patient in the ED?

See Chapter 97.

KEY POINTS: ACUTE PSYCHOSIS

1. Deﬁnition: delusions or prominent hallucinations

2. Least restrictive restraint: isolation; restraints; psychotropic medication

3. Complete and thorough history and physical examination, including mental status examination,

is imperative

4. Organic versus functional disorder

BIBLIOGRAPHY

1. American College of Emergency Physicians: Clinical policy for the initial approach to patients presenting with

altered mental status. Ann Emerg Med 33:251–281, 1999.

2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, ed 4, Washington, DC,

2000, American Psychiatric Association.

3. Bresler RE, Klinger BI, Erickson BJ: Acute intoxication and substance abuse among patients presenting to a

psychiatric emergency service. Gen Hospital Psychiatry 18:183, 1996.

4. Broderick KB, Lerner EB, McCourt JD, et al: Emergency physician practices and requirements regarding the

medical screening examination of psychiatric patients. Acad Emerg Med 9:88–92, 2002.

5. Frame DS, Kercher EE: Acute psychosis: Functional vs. organic. Emerg Med Clin North Am 9:123–136, 1991.

6. Hillard JF: Emergency treatment of acute psychosis. J Clin Psychiatry 59:57, 1998.

Consensus guidelines on the medical clearance examination for the evaluation and management

of the psychiatric patient in the emergency department: www.macep.org/site/index.php?option5

com_content&task5view&id557&Itemid574

WEBSITE

ACKNOWLEDGMENT

The editors gratefully acknowledge the contributions of Eugene E. Kerchner, MD, author of this

chapter in the previous edition.

Chapter 95 ACUTE PSYCHOSIS662

7. Kercher EE: Acute psychosis. In Rund DA, Barkin RM, Rosen P, Sternbach GL, editors: Essentials of

emergency medicine, ed 2, St. Louis, 1996, Mosby, pp 647–655.

8. Reeves RR, Pendarvis EJ, Kimble R: Unrecognized medical emergencies admitted to the psychiatric units.

Am J Emerg Med 2000. 18:390–393.

9. Riba M, Hale M: Medical clearance: fact or ﬁction in the hospital emergency room. Psychosomatic 1990.

31:400–404.

10. Tintinalli JE, Peacock FW, Wright MA. Emergency medical evaluation of psychiatric patients. Ann Emerg Med

1994. 23:859–862.

11. Yildiz A, Sachs GS, Turgay A: Pharmacological management of agitation in emergency settings. Emerg Med J

20:339–346, 2003.

12. Zun LS, Leikin JB, Stotland NL, et al: A tool for the emergency medicine evaluation of psychiatric patients. Am

J Emerg Med 14:329–333, 1996.

663

CHAPTER 96

DEPRESSION AND SUICIDE

Douglas A. Rund, MD, and Radu V. Saveanu, MD

DEPRESSION

1. What are the symptoms of depression?

The cardinal symptoms of depression are a dysphoric or sad mood or a loss of interest

or enjoyment. To diagnose depression, one of these must be present nearly every day

over a 2-week period. There must also be at least four of the following symptoms during

this same period: sleep disturbance, feelings of guilt or worthlessness, lack of energy,

decreased concentration or ability to make decisions, appetite disturbance (usually

diminished), psychomotor changes (agitated or slowed), and suicidal thinking. The

mnemonic SIG E CAPS can be remembered by thinking of what you want to do for

depressed patients (ﬁguratively): prescribe energy capsules.

Five of the following are necessary for the diagnosis of depression, one of which must be

the I, loss of interests or depressed mood:

S 5 Sleep disturbance

I 5 Interests/mood

G 5 Guilt

E 5 Energy

C 5 Concentration

A 5 Appetite disturbance

P 5 Psychomotor changes

S 5 Suicidal thinking

2. Why is depression considered a mood disorder?

Mood refers to a person’s internal state, as subjectively experienced and reported by that

person. Affect is a person’s outward appearance, as objectively experienced by another. The

term mood disorder has essentially replaced affective disorder in much of the psychiatric

literature and communications. The main mood disorders are:

Major depression (or unipolar disorder), which is exclusively depression

Manic depression (or bipolar disorder), which is depression with a history of at least one

manic episode

3. What is the difference between primary and secondary depression?

Major depression is classiﬁed as primary if the symptom complex appears before or is

causally unrelated to any other signiﬁcant medical or psychiatric illness. It is considered

secondary when it follows and is causally related to another medical or psychiatric

illness.

4. List medical conditions that might cause secondary depression.

Endocrine disorders

Hypothyroidism

Diabetes mellitus

Cushing’s syndrome

Neurologic disorders

Cerebrovascular accidents

Subdural hematoma

Multiple sclerosis

Brain neoplasm

Parkinson’s disease

Seizure disorder

Dementia

Connective tissue diseases

Systemic lupus erythematosus

Neoplasms

Pancreatic cancer

Chapter 96 DEPRESSION AND SUICIDE664

5. List medications that might cause secondary depression.

Antihypertensives (b-blockers)

Hypnotics and sedatives (benzodiazepines and barbiturates)

Corticosteroids

Cimetidine

Ranitidine

6. Why should the clinician always inquire about alcohol use when evaluating

depression?

Alcohol use and abuse is an extremely common comorbid condition with depression and

should always be queried for several reasons. First, alcohol use can be disinhibiting with regard

to behavior, putting a depressed and suicidal person at increased risk of impulsively acting on

suicidal tendencies. Second, depression cannot be treated effectively if there is ongoing alcohol

abuse. Third, alcohol is a depressant and is a common cause for depression, a problem known

as alcohol-induced mood disorder. It may be that the patient’s depression is secondary to

alcohol use and is treated best by abstaining from alcohol, rather than by administering an

antidepressant. This situation is suggested when the onset of the mood disturbance occurs

during an extended period of regular (usually daily) alcohol use, rather than before it.

7. When should I suspect depression when a patient presents with what seems

to be a medical complaint?

Screen for depression when patients present with nonspeciﬁc complaints, such as “sick all

over,” “weak and dizzy,” or “just feeling bad.” Using the SIG E CAPS mnemonic (see Question 1)

aids in diagnosis. Often depression is expressed in physical rather than emotional terms.

Nonspeciﬁc physical complaints, such as fatigue, exhaustion, headache, gastrointestinal

complaints, muscle aches, and nonspeciﬁc pain, are common. Anxiety is seen commonly with

depression and can manifest as shortness of breath, nervousness, irritability, and difﬁculty

swallowing, among other symptoms. Panic attacks, a severe form of anxiety that often occurs in

the context of depression, are a common cause of ED presentations of atypical chest pain.

8. Are psychotic features ever a manifestation of depression?

Sometimes. If psychotic symptoms accompany depression, it signiﬁes a more severe and

dangerous form of depression. When this is the case, psychiatric consultation and often

psychiatric hospitalization are indicated. Common psychotic symptoms are hearing guilt-

provoking or self-critical voices, called auditory hallucinations, and ﬁxed, false beliefs that can

be persecutory or paranoid in nature, referred to as delusions. Patients with psychotic

depression are at higher risk for suicide, especially when they have auditory hallucinations

commanding them to harm themselves.

9. Name therapies available for treatment of depression.

Antidepressant medications, psychotherapy, and electroconvulsive therapy.

10. What antidepressant medications are used to treat depression?

Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) are the two oldest

classes of antidepressants, both of which have fallen into relative disuse because of their side

effects and dietary restrictions (in the case of MAOIs). Serotonin reuptake inhibitors are still the

most commonly prescribed class of antidepressants, mainly because of comparable efﬁcacy,

greater ease of use, and fewer adverse effects. These are ﬂuoxetine (Prozac), paroxetine (Paxil),

sertraline (Zoloft), citalopram (Celexa), ﬂuvoxamine (Luvox), and Escitalopram (Lexapro).

Newer and perhaps better medications that act on multiple neurotransmitter systems are now

available, and also have better side-effect proﬁles than the older TCAs or MAOIs. These include:

Venlafaxine (Effexor)

Bupropion (Wellbutrin)

Mirtazapine (Remeron)

Duloxetine (Cymbalta)

Lithium, psychostimulants, and thyroid hormone are common adjunctive treatments.

Chapter 96 DEPRESSION AND SUICIDE 665

11. What are some psychotropic-related emergencies or precautions?

MAOIs in combination with sympathomimetic agents can cause hyperadrenergic crisis, and

their combination with meperidine (Demerol) or dextromethorphan can cause

cardiovascular instability and central nervous system excitability.

Neuroleptics can cause dystonias, including laryngeal spasm and neuroleptic malignant

syndrome (delirium, rigidity, fever, and autonomic abnormalities), both medical emergencies.

Anticholinergic toxicity may occur because many psychotropics have anticholinergic

properties and often are used in combination; these include benztropine mesylate

(Cogentin); trihexyphenidyl (Artane); diphenhydramine (Benadryl); TCAs; and low-potency

and mid-potency neuroleptics.

Many other commonly used agents have dose-related toxic side effects, particularly the mood

stabilizers, which include lithium and the anticonvulsants valproic acid and carbamazepine.

12. When should the emergency physician prescribe antidepressant therapy?

Because antidepressants generally take weeks to begin working and often require monitoring of

side effects and dose titration, prescribing them in the ED should be avoided whenever

possible. Exceptions include a patient who is already on treatment and needs a reﬁll or a patient

who is initiating new treatment after an emergent consultative evaluation by a psychiatrist.

Ideally, in both of these cases, a 1- to 2-week supply of medication can be prescribed, and the

patient should follow up with outpatient psychiatric care.

13. What is the most serious complication of depression?

Suicide. Major depression accounts for an estimated 50% of all suicides.

14. Which patients should be hospitalized for depression?

Depressed patients who express suicidal intent or have a plan for suicide should be

hospitalized. Psychotically depressed patients should usually be admitted. Also, patients who

have just made a violent suicide attempt, have tried to avoid rescue, or are refusing help

should be admitted for further observation. Do not forget to institute suicidal precautions

while these patients are in the ED.

SUICIDE

15. What is the proper approach to a patient who has attempted suicide?

Medical management of any life-threatening condition precedes psychiatric evaluation. It is

important, however, that as the treatment proceeds, the ED team maintain a nonjudgmental

approach. Punishment or ridicule is neither therapeutic nor proper conduct for medical

professionals. Nearly all patients who attempt suicide are at least ambivalent about the wish to

live or die. Demeaning or harsh treatment of such patients, especially by health professionals

who are symbols of medical authority, worsens the already low self-esteem and may make

subsequent psychiatric care more difﬁcult.

16. Describe suicide precautions.

Because some patients have been known to repeat a suicide attempt while in the ED, suicide

precautions are necessary. Such precautions include searching the patient and recovering

weapons, pills, or other potential means of self-injury; keeping the patient under close

observation; recovering any potential dangerous items from the immediate care area (e.g.,

needles, scalpels, glass, razors); and not allowing the patient to go anywhere (e.g., bathroom)

unaccompanied. When constant staff observation is not possible, physical restraints may be

necessary to protect the severely suicidal patient from further self-harm.

17. Are accidents ever suicide attempts?

It is important to remember that victims of trauma may have actually attempted suicide.

Single-victim accidents, such as a car driven at high speed into a concrete structure, a

pedestrian hit by a high-speed vehicle, or a fall from a height, are classic examples of suicide

Chapter 96 DEPRESSION AND SUICIDE666

attempts presenting as trauma. Medical management should be followed by an assessment of

suicide intent, including a discussion with family members and perhaps psychiatric

consultation.

18. What psychiatric disorders are associated with attempted suicide?

Major depression, alcohol and drug dependence, schizophrenia and other thought disorders,

personality disorders, panic disorder, adjustment disorders, and organic brain syndromes.

19. How do I evaluate the risk of a subsequent suicide in someone who attempted

suicide?

The following elements are part of an emergency assessment of suicide risks: age, gender,

marital status, social supports, physical illness, previous attempts, family history of suicide,

risk of the attempt versus likelihood of rescue, secondary gain, nature of any psychiatric

illness, alcohol or drug abuse, attitude (hopelessness, impulsivity) affect, and future plans of

the suicide attempter. If, after reviewing these factors, the emergency physician is still unsure

of the patient’s risk, psychiatric consultation is often helpful.

20. How does age relate to suicide risk?

Older patients (especially . 65 years) are statistically more likely to complete suicide than

younger patients. Such patients may experience loss of spouse, loneliness, physical illness, or

economic hardship in addition to depression. A worrisome increase in suicide among younger

persons has emerged, however. Suicide is now the third leading cause of death in youth and

young adults (19–24 years of age).

21. What role does gender play?

The rates of completed suicide in men are higher than those for women, whereas the rates

of attempted suicide are higher for women than for men. This difference has to do with the

lethality of the means. Men attempt suicide more often by violent means, such as shooting,

stabbing, hanging, or jumping from a height, whereas women typically use less violent and

less lethal methods, such as drug overdose.

22. What is the relationship of marital status to risk of successful suicide?

Never having been married carries the highest risk, followed in decreasing magnitude of risk

by being widowed, separated, divorced, and married.

23. What about other social support?

Unemployment, loneliness, loss of home, and relative isolation increase the risks of suicide.

Church, family, or community support helps to mitigate suicide risk.

24. Is there a relationship between physical illness and suicide risk?

Yes. Patients with a medical illness, especially a painful, incurable one, may seek a “way out”

through suicide. The most common nonpsychiatric diagnoses associated with suicide are

chronic medical conditions, such as cancer, chronic obstructive pulmonary disease, and

chronic pain. Renal dialysis patients have a suicide rate 400 times higher than the general

population, and HIV patients also have a higher than average rate.

25. Does a history of prior suicide attempts signify increased risk?

Yes, especially if each subsequent attempt escalates in severity. The risk of completed suicide

is more than 100 times the average in the ﬁrst year after an attempt—200 times greater for

people older than 45 (National Mental Health Association: www.nmha.org). An exception may

exist if the previous attempts all have been minor and considered to be manipulative acts.

26. What is the relationship of family history to suicide risk?

Patients with a family history of suicide, alcoholism, or depression have a higher suicide risk

than patients without such a family history. A family history of suicide in ﬁrst-order relatives

(e.g., parent or sibling) should cause particular concern.

Chapter 96 DEPRESSION AND SUICIDE 667

27. How does the risk of the suicide attempt and the likelihood of rescue affect a

suicide evaluation?

In general, a more serious or risky attempt is considered a more likely predictor of subsequent

attempts than a minor attempt. An attempt carried out in such a way that rescue is probable is

associated with a lower risk of subsequent successful suicide. The patient’s belief about the

lethality of the attempt is at least as important as the physician’s assessment of the

seriousness of it.

1. Patients thought what they did in their attempt to commit suicide was likely to kill them.

2. They did it in such a way as to have a low chance of being rescued.

3. They are not talking much about how they are feeling now.

4. They have little social support and are unwilling to reach out to others or accept help from

available resources.

5. They still want to die.

KEY POINTS: SERIOUS SUICIDE ATTEMPTS

28. What is secondary gain as it applies to suicide attempt?

Sometimes a suicide attempt seems to have a goal other than death. This goal, which is

termed secondary gain, may be increased attention from parents, friends, or lovers. In

attempts with no expected gain other than death, the potential for subsequent successful

suicide is great. With the increase in successful suicides among the young, the physician

must be careful in ascribing suicide attempts to the desire for attention or secondary gain until

a reasonably thorough evaluation can be completed.

29. What is the value of assessing the suicidal patient’s attitude and affect?

The patient who appears exhausted, helpless, hopeless, or lonely represents high risk. The

patient who attempts suicide because of anger or in an effort to gain revenge has a much

better prognosis than one who appears quiet, sad, fatigued, or apathetic.

30. Why is it important to inquire about a speciﬁc plan?

Never hesitate to ask the patient about any plans regarding suicide. The patient who continues

to express suicidal ideation after one attempt is at risk for a subsequent attempt. The risk is

highest if the plan is detailed, violent, or feasible.

31. What is the SAD PERSONS Scale?

In 1983, Patterson et al. used known high-risk characteristics to develop the mnemonic SAD

PERSONS Scale. The scale was designed to be used by nonpsychiatrists to assess the need

for hospitalization in suicidal patients. Hockberger and Rothstein modiﬁed the scale to

facilitate use in the ED (see Table 96-1). A score of 5 or less indicates that a patient probably

can be discharged safely. Scores of 6 or more require psychiatric consultation, and a score of

9 or more indicates the probable need for psychiatric hospitalization.

32. In general, which suicidal patients should be hospitalized?

Absolute indications for hospitalization after suicide attempts (involuntarily, if necessary)

usually include the following: presence of psychosis; a violent, nearly lethal preplanned

attempt; and continued suicidal ideation with deﬁnite plans for a repeated attempt.

Relative indications include age older than 45; high risk-to-rescue ratio; serious mental

illness; alcoholism; drug addiction; living alone with poor social support; and hopelessness,

helplessness, or exhaustion.