Depression: Emergency Department Evaluation and Management
- Aug 26th, 2019
- Saran S. Pillai
Authors: Saran S. Pillai, MBBS (@sspillai01, Medical Officer and Research Associate, Critical Care Medicine, KIMS hospital Trivandrum, Kerala, India) and Sameer Desai, MD, FACEP (@sameerdesai00, EM Attending Physician, University of Kentucky, Department of Emergency Medicine)// Edited by: Erica Simon, MD, MPH, MHA (@E_M_Simon); Alex Koyfman, MD (@EMHighAK); Brit Long, MD (@long_brit)
A 21-year-old female with a previous medical history of hypothyroidism presents with her parents for suicidal ideation. The patient’s mother discovered an internet search for “methods of suicide” on the family computer, prompting the emergency department (ED) visit. The patient has been living with her parents for two months, following significant work-related stress. Review of systems is remarkable for abdominal pain of two weeks duration, decreased appetite, decreased sleep, and lack of interest in daily activities. During the interview, the patient displays a flat affect; she fails to engage and will not reply to questions regarding substance abuse, previous psychiatric history, or compliance with current medications. The patient’s father denies a history of familial substance abuse or behavioral health diagnoses.
What are the next steps in your evaluation and treatment?
Behavioral Care and the ED
According to the National Institutes of Health, an estimated 47 million Americans are living with a mental illness1. The Emergency Medical Treatment and Active Labor Act (EMTALA), and exclusions in insurance-related mental health benefits have made the ED the choice for urgent and acute care for many of these individuals2. Today one in eight seek mental health treatment in the ED for suicidal ideation or substance abuse1, and nearly 6% of injury-related ED visits occur secondary to a suicide attempt1–3.
Depressed patients utilize the ED five times more frequently than the general population5. Chief complaints commonly include backaches, headaches, fatigue, restlessness, weakness, lethargy, and insomnia5. Upon interview, nearly 12% disclose ‘occult’ suicidal ideation6. Today the majority of EDs screen for depression during the triage process, as evidence suggests that enquiring regarding suicidal thoughts may reduce suicidal ideation7-9. Despite its ease of use, the SADPERSONS (sex, age, depression, previous attempt, ethanol, and drug abuse, rational thinking loss, organized plan, no spouse, sickness) tool for identifying patients at high risk for committing suicide is no longer recommended given its low sensitivity4. Moderate evidence supports the use of targeted screening assessments including the Ask-Suicide-Screening Questions (ASQ)5, Manchester Self Harm Rule (MSHR)6, and Risk of Suicide Questionnaire (RSQ)7, each demonstrating negative predictive values of 99.7%, 97%, and 97%, respectively8.
Major Depressive Disorder (MDD)
The annual incidence of MDD in the U.S. is estimated at 6.7 %, with one-third of cases described as severe in nature (significant degree of functional disability and distress)3-6. The average age of depression onset is 32 years, occurring more frequently in women than men (7:1 ratio)6. The common mnemonic, “In SAD CAGES”, details DSM-V criteria for the diagnosis of MDD12(Figure 1):
To screen positive for a MDD episode, the patient must have at least 5 of the above 9 criteria daily for at least 2 weeks including either loss of interest in activities or depressed mood9. A depressive episode may be classified into subtypes (melancholic and psychotic are most frequently encountered in the ED)13:
- Anxious – include anxiety symptoms and panic attacks.
- Atypical – mood reactivity, increased appetite and sleep, prolonged rejection sensitivity.
- Catatonic – includes psychomotor disturbances, especially inability to move normally.
- Melancholic –prominent MDD features with the absence of mood reactivity, diurnal variation with improvement in the evening hours, and prominent neurocognitive dysfunction.
- Mixed features – includes at least three of manic or hypomanic symptoms. (e.g. DIGFAST10: Distractibility, Irresponsibility or Irritability, Grandiosity, Flight of ideas, increased Activity, decreased Sleep, and excessive Talkativeness).
- Peripartum – MDD episode that begins during pregnancy or within 4 weeks of childbirth.
- Psychotic – includes psychotic features such as delusions or hallucinations.
- Seasonal – MDD episode that begins during a particular season and remits during another.
Nearly 34% to 50% of patients who present to the ED with psychiatric complaints have a coexisting medical problem playing a causative or aggravating role in their psychiatric illness11–14.
According to the DSM-V, conditions that mimic a major depressive episode may be broadly classified as:
- Mood/Axis 1 disorders that present with depressive symptoms (Figure 2)15.
- Depressive symptoms secondary to identifiable medical causes16.
Depressive symptoms secondary to identifiable medical causes can be either medication/substance-induced (Figure 3) or secondary to an organic pathology (Figure 4)16.
A substance-induced depressive disorder should be suspected when15,16:
- the depressive symptoms did not precede the onset of substance exposure/ intoxication/ withdrawal.
- the disturbance does not persist for a long period of time after cessation of drug use.
- there is no prior history of recurrent depressive episodes.
A depressive episode secondary to an organic pathology should be suspected under the following conditions15,16:
- Severe new-onset depression with psychotic features.
- New-onset depression in an older adult.
- Younger adult with significant medical conditions.
- Recurrent depression that is not readily understood in the context of the patient’s psycho-social stressors.
- Treatment-resistant depression.
Evaluation of the Depressed Patient
A focused assessment, popularly called a ‘medical clearance,’is required to identify medical etiologies of depression requiring emergent treatment and/or outpatient referral. The term does not suggest an absence of medical issues but rather describes the need to evaluate and diagnose conditions which could be contributing to a patient’s acute psychiatric presentation. Hence better terms such as ‘Evaluation for medical stability’ or ‘focused medical assessment of the altered patient’ have been suggested17.
A study by Olshaker18demonstrated patient history, physical examination, vital signs, and laboratory testing as having sensitivities of 94%, 51%, 17%, and 20%, respectively, for identifying comorbid medical conditions in psychiatry patients presenting to the ED. Patient self-reporting also had a 92% sensitivity for identifying those with a positive drug screen, and a 96% sensitivity for identifying those with a positive ethanol level18. Though these findings are dated (1997), a multitude of similar studies19–23have also shown that universal laboratory and toxicological screening of patients with psychiatric complaints is of low yield in medical clearance, and that the majority of patients with medical or substance abuse problems can be identified in the ED with a medical history, review of systems, physical examination including vital signs, and tests of orientation.
In recent years, the implementation of standardized medical clearance protocols to prevent overutilization, overtreatment, and increased ED lengths of stay have become commonplace24,25.
The medical clearance of a psychiatric patient should include:
- Complete medical history (Figure 5)
- Review of systems (Figure 6)
- Vital signs assessment
- Physical examination (Figure 7)
- Mental status assessment
In an intoxicated patient, it is sensible to wait for the patient to achieve a certain level of sobriety before completing the evaluation15.
Review of Systems
Mental Status Assessment
The key components of a mental status assessment include cognitive status, appearance, speech, affect/mood, thought content and process, perceptual disturbances, and suicidal or homicidal thoughts15. Time constraints in the ED setting make it difficult to elicit a full cognitive status evaluation with a mini-mental status examination (MMSE). EM physicians should assess orientation (place, person and time), memory (immediate and delayed recall) and judgment. Standardized tools are also available for this purpose (Quick Confusion Scale1, and Brief Mental Status Exam1) that correlate significantly with MMSE scores and physician assessment30,31.
Based on current literature, in evaluating and treating the psychiatric patient, ACEP guidelines do not advocate for routine or ancillary laboratory testing32. Studies should be ordered as indicated by findings in the history and physical examination of the patient, specifically if a thorough assessment is limited by the patient’s mental status33. Figure 8 provides scenarios where further investigation may be needed, and Figure lab and imaging assessments.
While the ordering of laboratory studies is specific to organizational policy, ACEP advocates for cooperation between the ED physician and mental health provider to develop suitable, cost-effective, evaluation plans for admitting psychiatric patients21,26. For patients with alcohol intoxication, the psychiatric assessment should be based upon the patient’s cognitive abilities, rather than a specific blood alcohol level. ACEP suggests clinicians consider using a period of observation to determine if psychiatric symptoms resolve as the episode of intoxication resolves32.
There is no evidence to support the use of radiologic studies for patients with symptoms of isolated depression20,22,26,34. Neuroimaging is advised for patients exhibiting focal neurologic deficits and/or cognition changes and should be considered in the setting of recent head trauma20,22,26,34.
Patient Management & Disposition
While evaluating a depressed patient, the ED physician should prioritize the creation of a safe and stable environment for the patient, with the least restrictive level of care possible to avoid coercion, and to form a therapeutic alliance1. Examples of such measures include administration of oral medications willingly by means of informed consent, verbal de-escalation, and minimal infringement of patient rights when possible1. Figure 10 demonstrates management considerations.
If the patient reports suicidal ideation, the room should be sanitized of all materials with which the patient may harm him/herself. Close monitoring by visual check, or 1:1 observation with a trained sitter is required19. This is particularly important during patient boarding, pending a formal psychiatric evaluation or an inpatient psychiatry bed19,20.
A typical regimen for rapid sedation of an acutely agitated undifferentiated patient includes an initial dose of 5 mg of haloperidol and 2 mg of lorazepam intramuscular (IM), followed by reassessment in 30-45 minutes. An additional 5 mg of haloperidol may be given if necessary1. Benztropine (Cogentin), 1 to 2 mg oral (PO) or IM, is frequently used to prevent extrapyramidal symptoms1. As compared to typical antipsychotic agents, atypicals, such as Ziprasidone, are gaining favor given their rapidly dissolving formulations, and less severe side effect profiles1.
For a depressed patient with an unremarkable medical evaluation, initiation of anti-depressants from the ED is not routinely performed given the lack of follow-up and delayed clinical effects of the most commonly prescribed medications (selective serotonin reuptake inhibitors)1. The anxious/depressed patient may be given a short course of an anxiolytic as a bridging therapy while awaiting formal evaluation by a psychiatric provider15.
Coordination of aftercare prior to ED discharge is paramount as care plans diminish hospitalization and repeat ED visit rates32,35. Efforts should be made to schedule outpatient appointments prior to ED discharge.
Boarding of psychiatric patients is defined by ACEP as a length of stay in the ED for ‘four or more additional hours’ after a decision has been made to admit36. It is a common problem affecting EDs across the U.S., where boarding durations range from 7 to 11 hours across the nation36,37. There is a positive association between psychiatric boarding, increased symptom exacerbation, and patient elopement41.
- 34% to 50% of patients who present to the ED with psychiatric complaints have a coexisting medical illness.
- Situations that favor a substance-induced depressive disorder include: absence of depression history, absence of symptoms prior to substance exposure/intoxication /withdrawal, absence of persistent symptoms following substance use or abuse.
- Seek out an underlying etiology for depression in patients presenting with: new-onset depression with psychotic features, recurrent depression not readily explained by the psycho-social stressors, or treatment-resistant depression.
- Laboratory studies and imaging should be obtained if indicated by history and physical examination.
- Antipsychotics or benzodiazepinesmay be administered to the distressed patient with psychotic features during the ED course.Initiation of outpatient anti-depressant therapy from the ED is not advised.
From Dr. Katy Hanson at Hanson’s Anatomy:
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- Boudreaux ED, Cagande C, Kilgannon JH, Clark S, Camargo CA. Bipolar Disorder Screening Among Adult Patients in an Urban Emergency Department Setting. Prim Care Companion J Clin Psychiatry. 2006;8(6):348-351.
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- Cooper J, Kapur N, Dunning J, Guthrie E, Appleby L, Mackway-Jones K. A Clinical Tool for Assessing Risk After Self-Harm.Ann Emerg Med. 2006;48(4):459-466.
- Horowitz LM, Wang PS, Koocher GP, et al. Detecting suicide risk in a pediatric emergency department: development of a brief screening tool. Pediatrics. 2001;107(5):1133-1137.
- Zaleski ME, Johnson ML, Valdez AM, et al. Clinical Practice Guideline: Suicide Risk Assessment. J Emerg Nurs. 2018;44(5):505.e1-505.e33.
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- Dailey MW, Saadabadi A. Mania. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2019. http://www.ncbi.nlm.nih.gov/books/NBK493168/.Accessed June 3, 2019.
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- Gregory RJ, Nihalani ND, Rodriguez E. Medical screening in the emergency department for psychiatric admissions: a procedural analysis. Gen Hosp Psychiatry. 2004;26(5):405-410. doi:10.1016/j.genhosppsych.2004.04.006
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