Depression: Emergency Department Evaluation and Management

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)

Case

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 attempt^1–3.

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 ideation^7-9. 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.

MDD Mimics

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 illness^11–14.

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 when^15,16:

• 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 conditions^15,16:

• 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 studies^19–23have 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 commonplace^24,25.

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.

Medical History

Review of Systems

Examination

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 assessment^30,31.

Laboratory Studies

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 patients^21,26. 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.

Imaging Studies

There is no evidence to support the use of radiologic studies for patients with symptoms of isolated depression^20,22,26,34. Neuroimaging is advised for patients exhibiting focal neurologic deficits and/or cognition changes and should be considered in the setting of recent head trauma^20,22,26,34.

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 bed^19,20.

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 rates^32,35. Efforts should be made to schedule outpatient appointments prior to ED discharge.

ED Boarding

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 nation^36,37. There is a positive association between psychiatric boarding, increased symptom exacerbation, and patient elopement⁴¹_.

Key Points

• 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:

References/Further Reading:

1. Chepenik LG, Mallory MNS. Behavioral Emergencies for the Emergency Physician edited by Leslie S. Zun. Cambridge Core.
2. Boudreaux ED, Clark S, Camargo CA. Mood disorder screening among adult emergency department patients: a multicenter study of prevalence, associations and interest in treatment. Gen Hosp Psychiatry. 2008;30(1):4-13.
3. 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.
4. Diane M. Birnbaumer MD. A Sad Performance by the SADPERSONS Scale. NEJM J Watch. 2013;2013.
5. NIMH » Ask Suicide-Screening Questions (ASQ) Toolkit. https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials/index.shtml. Accessed June 3, 2019.
6. 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.
7. 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.
8. Zaleski ME, Johnson ML, Valdez AM, et al. Clinical Practice Guideline: Suicide Risk Assessment. J Emerg Nurs. 2018;44(5):505.e1-505.e33.
9. Hoyer D, David E. Screening for Depression in Emergency Department Patients. J Emerg Med. 2012;43(5):786-789.
10. 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.
11. Hall RC, Gardner ER, Stickney SK, LeCann AF, Popkin MK. Physical illness manifesting as psychiatric disease. II. Analysis of a state hospital inpatient population. Arch Gen Psychiatry. 1980;37(9):989-995.
12. Carlson RJ, Nayar N, Suh M. Physical disorders among emergency psychiatric patients. Can J Psychiatry Rev Can Psychiatr. 1981;26(1):65-67.
13. Hall RC, Gardner ER, Popkin MK, Lecann AF, Stickney SK. Unrecognized physical illness prompting psychiatric admission: a prospective study. Am J Psychiatry. 1981;138(5):629-635.
14. Hoffman RS. Diagnostic errors in the evaluation of behavioral disorders. JAMA. 1982;248(8):964-967.
15. The Depressed Patient And Suicidal Patient In The Emergency Department: Evidence-Based Management And Treatment Strategies. https://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=275&inittopicdload=1. Accessed April 28, 2019.
16. Privitera MR, Lyness JM. EHD Paul R Katz and Michael LMalone. Depression. Practice of Geriatrics. Fourth Edition. Saunders Elsevier; 2007.
17. Anton Helman, A, , Steinhart, B, Dawe, I. Medical Clearance of the Psychiatric Patient | EM Cases. Emerg Med Cases. August 2016. https://emergencymedicinecases.com/medical-clearance-psychiatric-patient/. Accessed June 11, 2019.
18. Olshaker JS, Browne B, Jerrard DA, Prendergast H, Stair TO. Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med Off J Soc Acad Emerg Med. 1997;4(2):124-128.
19. 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
20. Wilson MP, Nordstrom K, Anderson EL, et al. American Association for Emergency Psychiatry Task Force on Medical Clearance of Adult Psychiatric Patients. Part II: Controversies over Medical Assessment, and Consensus Recommendations. West J Emerg Med. 2017;18(4):640-646.
21. Parmar P, Goolsby CA, Udompanyanan K, Matesick LD, Burgamy KP, Mower WR. Value of mandatory screening studies in emergency department patients cleared for psychiatric admission. West J Emerg Med. 2012;13(5):388-393.
22. 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.
23. Korn CS, Currier GW, Henderson SO. “Medical clearance” of psychiatric patients without medical complaints in the Emergency Department. J Emerg Med. 2000;18(2):173-176.
24. Maine Health Medical Clearance Protocol. https://mainehealth.org/-/media/mainehealth/pdfs/clinical-guidelines-and-resources/emergency-medicine/emergency-medicine-guidelines-and-protocols/mainehealth-psych-med-clearance.pdf?la=en. Accessed June 6, 2019.
25. Joint Task Force of the Massachusetts College of Emergency Physicians and the Massachusetts Psychiatric Society: The Medical Clearance Exam. https://www.acep.org/globalassets/uploads/uploaded-files/acep/advocacy/state-issues/psychiatric-hold-issues/ma-medical-clearance-guidelines-toxic-screen-ma.pdf. Accessed June 6, 2019.
26. Lukens TW, Wolf SJ, Edlow JA, et al. Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med. 2006;47(1):79-99.
27. Medical Assessment of the Patient With Mental Symptoms – Psychiatric Disorders. Merck Manuals Professional Edition. https://www.merckmanuals.com/professional/psychiatric-disorders/approach-to-the-patient-with-mental-symptoms/medical-assessment-of-the-patient-with-mental-symptoms. Accessed June 5, 2019.
28. Staff NP, Windebank AJ. Peripheral Neuropathy Due to Vitamin Deficiency, Toxins, and Medications. Contin Lifelong Learn Neurol. 2014;20(5 Peripheral Nervous System Disorders):1293-1306.
29. Clinical Manual of Emergency Psychiatry. https://www.appi.org/Clinical_Manual_of_Emergency_Psychiatry_Second_Edition. Accessed June 5, 2019.
30. Huff JS, Farace E, Brady WJ, Kheir J, Shawver G. The quick confusion scale in the ED: comparison with the mini-mental state examination. Am J Emerg Med. 2001;19(6):461-464.
31. Kaufman DM, Zun L. A quantifiable, Brief Mental Status Examination for emergency patients. J Emerg Med. 1995;13(4):449-456.
32. ACEP Emergency Medicine Practice Committee. Care of the Psychiatric Patient in the Emergency Department – A Review of the Literature. https://www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/resources/mental-health-and-substance-abuse/psychiatric-patient-care-in-the-ed-2014.pdf. Published October 2014. Accessed June 6, 2019.
33. Brown MD, Byyny R, Diercks DB, et al. Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. Ann Emerg Med. 2017;69(4):480-498.
34. 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.
35. Boudreaux ED, Niro K, Sullivan A, Rosenbaum CD, Allen M, Camargo CA. Current practices for mental health follow-up after psychiatric emergency department/psychiatric emergency service visits: a national survey of academic emergency departments. Gen Hosp Psychiatry. 2011;33(6):631-633.
36. American College of Emergency Physicians. Psychiatric and Substance Abuse Survey American College of Emergency Physicians, Accessed March 28, 2016.; 2008. http://www.acep.org/uploadedFiles/ ACEP/Advocacy/federal_issues/PsychiatricBoardingSummary.pdf.
37. Misek RK, DeBarba AE, Brill A. Predictors of Psychiatric Boarding in the Emergency Department. West J Emerg Med. 2015;16(1):71-75.