Big Book of Emergency Department Psychiatry

A Guide to Patient Centered Operational Improvement

Yener Balan, Karen Murrell, Christopher Bryant Lentz

• Publisher: Productivity Press
• Year: 2017
• ISBN:
  9781351984188
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

This book focuses on the operational and clinical strategies needed to improve care of Emergency Psychiatric patients. Boarding of psychiatric patients in ED's is recognized as a national crisis. The American College of Emergency Physicians identified strategies to decrease boarding of psychiatric patients as one of their top strategic goals.

Currently, there are books on clinical care of psychiatric patients, but this is the first book that looks at both the clinical and operational aspects of caring for these patients in ED setting. This book discusses Lean methodology, the impact of long stay patients using queuing methodology, clinical guidelines and active treatment of psychiatric patients in the ED.

CLINICAL CARE

III

Chapter 10

Anxiety and Mood Disorders in an Emergency Context

Christopher Lentz

Contents

10.1Introduction: Background

10.2Anxiety Disorders

10.2.1Panic Disorder

10.2.2Post-Traumatic Stress Disorder

10.2.3Acute Stress Disorder

10.2.4Self-Medication of Anxiety Symptoms

10.3Mood Disorders

10.3.1Depression

10.3.1.1Symptoms

10.3.1.2Assessing Depression in an Emergency Setting

10.3.1.3Suicidal Ideation and Suicide

10.3.1.4Suicidality: The Middle Ground

10.3.1.5Non-Suicidal Self-Injurious Behavior

10.3.1.6Parasuicidal Gestures

10.3.2Bipolar Disorder

10.3.2.1Mania

10.4Medical Mimicry: Conditions Posing as and Associated with Anxiety or Mood Disorders

10.4.1Hypo- and Hyperthyroidism

10.5Treatment Options for Anxiety and Mood Disorders

10.5.1Medications

10.5.1.1Antidepressants

10.5.1.2Anxiolytics

10.5.1.3Mood Stabilizers

10.5.2Therapy

10.5.2.1Relaxation Skills Training: Quick Interventions for the Emergency Setting

10.5.2.2Cognitive Behavioral Therapy Interventions: Changing the Patient’ s Frame of Mind

10.5.2.3Encouraging Patient Self-Care: The Positive Outcome on Anxiety and Mood Disorders

10.5Conclusion

References

10.1 Introduction: Background

Nationally, emergency departments (EDs) are experiencing an influx of patients seeking treatment for a variety of mental health crises. Among these mental health crises, anxiety and mood disorders are common and presented in EDs at a rate of 24.2% in 2009 and 2010 (Centers for Disease Control and Prevention 2009– 2010). Between 2006 and 2013, there was an overall increase of 64.5% in male patients 45– 65 years old seen in EDs in the United States for depression, anxiety, or stress-related issues (Weiss et al. 2016). With the advent of federally funded national healthcare, all arenas of medical care have experienced an increase in patient census.

Disorders, with varying symptoms, ranging from panic attacks, post-traumatic stress disorder (PTSD), and generalized anxiety to major depression and mania will present in patients arriving to the ED for treatment when the symptoms they are experiencing have become acutely exacerbated and are negatively impacting the patient’ s ability to cope with the symptoms and participate in socially sanctioned activities of daily life. Typical anxiety disorders that we see in the ED include panic attacks, PTSD, and to a lesser degree, generalized anxiety disorder. Of the mood disorders, depression and bipolar are most often associated with self-injurious behaviors and suicidal thoughts. For example, a patient who is severely depressed may reach the point of contemplating or even making attempts to carry out suicide.

When patients present themselves for treatment, family members, friends, coworkers, or even community service agency representatives (e.g., law enforcement) may transport a patient suffering from an acute exacerbation of an anxiety or mood disturbance to the ED for help, especially when the symptoms the patient is exhibiting begin to negatively impact the people in their social network or if concern about the individual’ s ability to care for themselves or maintain their safety comes into question. For instance, a patient experiencing recurrent panic attacks may be unable to function at work or within their family structure.

Given the increased national presentation of anxiety and mood disorders in EDs, it is imperative that ED staff, including physicians, nurses, and psychiatric clinicians, are properly prepared to adequately treat and support patients presenting with these complaints. Anxiety and mood disorders can afflict any and all individuals. This can include your family members, friends, and even coworkers. It is important that any individual working in the ED setting understands how these disorders affect the patients that they may come across on a shift in the ED and how that patient should be treated. The treating clinician, whether it be a nurse or psychiatric social worker, needs to use insight and be aware of their own bias related to working with anxiety and mood disorders to prevent a potential damaging experience for a patient in need. For example, statements made to a patient like, “ Hey, you have nothing to feel depressed about” or “ Just calm yourself down, why are you allowing yourself to feel so anxious” do not help the patient feel supported and can have an iatrogenic effect.

What are the more common anxiety and mood disorders that the ED team needs to be prepared to treat? What are the common syndromes and symptoms that the ED staff should be aware of? How are these disorders treated and what methods of treatment are used in an ED setting? These are some of the pertinent questions that this chapter will answer.

10.2 Anxiety Disorders

Anxiety disorders are very prevalent in the general population with a lifetime rate of about 29% in adults (National Institute of Mental Health 2005a) and 25% in children (National Institute of Mental Health 2005b). Of all the anxiety disorders, specific phobias tend to have the highest prevalence rate (National Institute of Mental Health 2005c). In 2009 and 2010, EDs saw and treated 14.5% of all patients for anxiety-related issues out of all those treated for a primary mental disorder (Centers for Disease Control and Prevention 2009– 2010).

In the ED setting, of the primary anxiety disorders, panic disorders, and exacerbations of prior acute stress symptoms are common patient presentations. Acute stress disorder may also be commonly seen in the ED, especially, if a patient has experienced any type of life-threatening trauma. Many patients that experience a primary anxiety disorder may feel debilitated during an anxiety attack and a sense of shame after the episode has ceased. It is important that ED clinicians are aware of this and act to support the patient both during and after the anxiety episode. The patient needs to be reassured that the anxiety episode is temporary and can be managed by the patient, with proper treatment, in the future. This will help to instill a sense of hope and a positive internal locus of control for the patient. Many therapeutic options exist for treating the primary anxiety disorders. Medication interventions, talk therapy, relaxation skills training, and mindfulness skills have all been used as effective treatment modalities.

10.2.1 Panic Disorder

The experience of panic disorder symptoms can create a sense of terror and a feeling of being overwhelmed for the patient coping with the illness. Many patients describe the experience of the panic attack as akin to having a heart attack or simply state that they felt like they are going to die during the episode. When the patient presents to the ED with a panic attack, there may be multiple physical complaints that are described. Racing heartbeat, shortness of breath, chest pain, dizziness, nausea, numbness in the hands or feet, and a feeling of losing control, going crazy, or dying may be experienced by the patient who has gone through a panic attack (American Psychiatric Association 2013).

In these cases, more often than not, the chief complaint tends to be a medical one due to the highly physical nature of the panic symptoms (Härter et al. 2003). Many patients with panic disorder may complain of experiencing symptoms similar to those of a heart condition (Fleet et al. 1996; Lynch and Galbraith 2003). The assigned ED physician will perform a focused medical examination and routine laboratory tests to rule out any possible medical cause for the complaint. Once the medical examination and laboratory results show normal physical functioning, the ED psychiatry team may be consulted to meet with the patient to help diagnose panic disorder. Patients that experience panic symptoms tend to frequently use ED and emergency medical services for treatment of their symptoms (Marchesi et al. 2004; Zane et al. 2003).

Typically, anxiety disorders do not require inpatient psychiatric hospitalization to treat and can be managed well on an outpatient basis (Zeller 2010). Unfortunately, a small percentage of patients that experience panic disorder may need to be psychiatrically hospitalized to help stabilize their symptoms depending on how acute the symptoms are and how severe the patient’ s ability to care for themselves is affected by the disorder. Suicidal thoughts may also be present in patients with anxiety disorders, especially if they reach a point in which they are unable to continue to cope with and manage their symptoms (Sareen et al. 2005; Weissman et al. 1989). These patients may also require inpatient psychiatric treatment, if they are unable to maintain their personal safety without supervision.

The Diagnostic and Statistical Manual of Mental Disorders , fifth edition (DSM-5) (American Psychiatric Association 2013) has provided more flexibility in the diagnostic arena for clinicians working with patients that present with panic symptoms. A panic attack can be diagnosed in a patient, provided that they meet the diagnostic criteria for the attack, with any other type of primary mental illness. For example, a patient that has been coping with major depression for many years may start to experience panic attacks. The panic attacks, in this case, can be added to the patient’ s diagnostic picture. This can be useful for coding and billing purposes for the treating clinician.

10.2.2 Post-Traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is, per the DSM-5, a trauma and stress-related disorder due to the main diagnostic requirement that the patient must have experienced or witnessed a stressor that they believed was life-threatening in nature. Common examples of stressors that may elicit PTSD symptoms in a patient include rape, attempted murder, surviving a natural disaster, such as an earthquake or hurricane, or war-related incidents, such as gunfire or bombings.

PTSD was initially referred to as “ shell shock, bullet wind, soldier’s heart or battle fatigue” when it was first identified and diagnosed in soldiers in World War I that had been through live combat experience (Jones 2010). It has become a more well-known disorder in recent decades due to soldiers experiencing war trauma in the Gulf region wars.

As stated earlier, a patient may not present to the ED requesting to be treated for PTSD in and of itself, but rather will present with a primary complaint of exacerbation of one or more of the associated symptoms of the disorder. Symptoms such as flashbacks, recurrent nightmares leading to insomnia, a...

Table of contents

• Cover
• Half-Title
• Series
• Title
• Copyright
• Contents
• Preface
• Acknowledgments
• Editors
• Contributors
• SECTION I FRONT LINE PERSPECTIVES
• SECTION II STRUCTURAL APPROACHES TO PATIENT CENTE RED CARE
• SECTION III CLINICAL CARE
• SECTION IV SPECIALIZED POPULATION CARE
• SECTION V MET HODS FOR OPERATION AL IMPROVEMENT
• Index