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Mood disorders are grouped into four broad categories: depressive disorders, bipolar disorders, mood disorder due to a general medical condition, and substance-induced mood disorders. This chapter provides some guidelines on the assessment and management of mood disorders in the emergency department (ED) setting. Cardiovascular diseases, such as coronary artery disease, myocardial infarction, and stroke, are also often associated with depression. The diagnosis of a mood disorder is based on history, collateral information, and observation of the patient's behavior. Mood disorders should be suspected in patients with multiple, vague, nonspecific complaints and in patients who are frequent users of medical care. The creation of a safe and stable environment for the patient should be a first priority in management. The patient with an acute manic episode may be disruptive, refuse medical evaluation, and make repeated attempts to leave the ED.
Emergency physicians, in all practice settings, care for patients with both undifferentiated psycho-behavioral presentations and established psychiatric illness. This reference-based text goes beyond diagnostics, providing practical input from physicians experienced with adult emergency psychiatric patients. Physicians will increase their understanding and gain confidence working with these patients, even when specialized psychiatric back-up is lacking. Behavioral Emergencies for the Emergency Physician is comprehensive, covering the pre-hospital setting and advising on evidence-based practice; from collaborating with psychiatric colleagues to establishing a psychiatric service in your ED. Sedation, restraint and seclusion are outlined. Potential dilemmas when treating pregnant, geriatric or homeless patients with mental illness are discussed in detail, along with the more challenging behavioral diagnoses such as malingering, factitious and personality disorders. This go-to, comprehensive volume is invaluable for trainee and experienced emergency physicians, as well as psychiatrists, psychologists, psychiatric and emergency department nurses and other mental health workers.
This chapter addresses three themes relevant to the coordination of care between the emergency medicine and psychiatry clinicians: who is involved in the coordination of care; creating a coordination team; and the benefits of nonclinical interdisciplinary collaboration. Coordinating care with mental health professionals suggests the challenge of understanding who's who, and who's likely to be doing what. Creating an effective team requires additional steps, including assessing the availability of willing resource-partners, recognizing the abilities and liabilities of those resource-partners, and designing a model for coordinating care. These themes were chosen to highlight differences in culture, training or approach and may provide providers with the clarity to decrease interdepartmental frustrations and improve patient outcomes. In addition to coordinating patient care, collaborations between psychiatry and emergency services can be helpful for growing departments in several ways including through education for capacity building, research initiatives, and improving well-being and morale.
The Emergency Medical Treatment and Active Labor Act (EMTALA) was enacted in 1986 as a component of the Consolidated Omnibus Budget Reconciliation Act of 1985. The emergency physician must ensure that a psychiatric presentation is not masking or coinciding with another illness, such as an occult head injury, metabolic disturbance, or toxic ingestion. It is commonplace for mental health screeners from the community to participate in the evaluation of patients with psychiatric emergencies and assist in locating inpatient availability when the emergency medical condition (EMC) is not stabilized and inpatient care is required. Failure to comply with EMTALA can lead to substantial consequences for hospitals and physicians. Emergency psychiatry involves a broad healthcare team and members vary in their level of responsibility and education. Understanding the requirements imposed by EMTALA is an essential compliance topic for each team member.
This chapter describes the magnitude of the problem of mental illness, both globally and in terms of specific mental health-related visits encountered in emergency department (ED) settings. The WHO's cross-national comparisons show a globally high prevalence of major Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) mental disorders (anxiety disorders, mood disorders, impulse control disorders, substance use disorders) with 25th-75th percentiles ranging from 18.1% to 36.1%. The chapter describes the magnitude of the problem of ED presentations for specific mental disorders. The most prevalent conditions are highlighted. After anxiety disorders, mood disorders are the second most common psychiatric disorder in the general population, occurring in 10% of the U.S. adult population each year. Schizophrenia spectrum diagnoses account for approximately two thirds of all psychotic disorders. Almost 1 in 10 of the adult U.S. population is estimated to have an Axis II personality disorder in any year.
This chapter introduces and describes the process of medical evaluation, also termed medical screening, of the psychiatric patient in the emergency department (ED). It discusses the diagnosis of medical mimics, along with the utility of both the patient history and physical exam and laboratory evaluations. The evaluation that an emergency physician conducts is an extremely important and, albeit, limited chance for the patient to be treated for a medical condition that may be causing their symptoms. The chapter also discusses the use of standard screening algorithms, which have been shown in several studies to decrease testing costs for ED patients undergoing medical screening. Local processes, such as coordination of care, trust between providers, wait times for subsequent psychiatric admission, facility overcrowding, and subgroup demographics may play a strong role in acceptance and accuracy of the emergency medicine evaluation process.
Children and adolescents who come to the emergency department (ED) with a psychiatric crisis are a concern for all ED professionals. The disposition plan for the suicidal child or teen should include mental healthcare referral. The substance use may represent an incidental finding in the ED, or the substance use can cause directly a youth's presentation in the ED due to symptoms of intoxication. Schizophrenia and bipolar disorder, two common and severe psychiatric disorders arising in young adulthood, can occur with an earlier onset if there is strong familial genetic loading for the condition. Post-traumatic stress may emerge in children and teens who are exposed to overwhelming experiences: accidental trauma; physical or sexual abuse; repeated or prolonged medical or surgical hospitalizations with difficult procedures to endure. Some ethnic and racial minority patients are at increased risk for traumatic experiences, including child abuse.
In a busy emergency department (ED), agitation requires immediate attention and intervention. This chapter addresses methods of verbal de-escalation for the patient who is agitated, but still in control, or who can regain control without the need for restraints or medication, but who, without some verbal intervention, could escalate into full-blown agitation and behavioral dyscontrol. Verbal de-escalation takes no more than five or ten minutes. The best treatment for agitation is to prevent it, or prevent it from escalating. This chapter addresses techniques of verbal de-escalation that the emergency physician can quickly learn and implement as an alternative to seclusion and restraint. Ultimately, verbal de-escalation improves staff morale and patient adherence, because it uses a non-coercive, patient-centered approach. Verbal de-escalation takes no more than five to ten minutes and enhances the doctor-patient relationship, while seclusion and restraint require more staff and takes more time to implement.
Convergent evidence implicates white matter abnormalities in bipolar disorder. The cingulum is an important candidate structure for study in bipolar disorder as it provides substantial white matter connections within the corticolimbic neural system that subserves emotional regulation involved in the disorder.
To test the hypothesis that bipolar disorder is associated with abnormal white matter integrity in the cingulum.
Fractional anisotropy in the anterior and posterior cingulum was compared between 42 participants with bipolar disorder and 42 healthy participants using diffusion tensor imaging.
Fractional anisotropy was significantly decreased in the anterior cingulum in the bipolar disorder group compared with the healthy group (P=0.003); however, fractional anisotropy in the posterior cingulum did not differ significantly between groups.
Our findings demonstrate abnormalities in the structural integrity of the anterior cingulum in bipolar disorder. They extend evidence that supports involvement of the neural system comprising the anterior cingulate cortex and its corticolimbic gray matter connection sites in bipolar disorder to implicate abnormalities in the white matter connections within the system provided by the cingulum.
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