Chapter 286: Mental Health Disorders: ED Evaluation and Disposition

Over the last two decades, the rate of ED mental health–related visits increased 38%, from 17.1 to 23.6 per 1000 U.S. population.¹ Mental health and/or substance abuse accounts for about one of every eight ED visits in the United States, and covert mental health problems may be present in over 40% of all ED patients.² ED visit increases are especially noTable for older persons and those living in urban areas, and with visits related to mood and anxiety disorders, suicide attempts, and substance abuse. Behavioral disorders in children account for at least 1.6% of ED pediatric visits, of which nearly 20% are admitted. ED visits in children are often related to substance use, anxiety and attention deficit disorders, disruptive behavior, and psychosis.³

Because there are about 4000 general hospital EDs in the United States but <200 psychiatric EDs, the vast majority of acute behavioral problems are assessed and treated in general hospital EDs.^4,5 Patients with behavioral health problems often provide vague and nonspecific symptoms, and obtaining collateral information as part of the assessment is difficult and time-consuming.

ED disposition decisions can be especially challenging for homeless patients and for those with repeated ED visits. Given the complexities of assessment, diagnosis, and disposition, it is important to maintain a positive and nonjudgmental attitude toward patients with mental health disorders.

A decision strategy for emergency assessment of patients with mental health disorders should follow the sequence of actions in Table 286-1.

This chapter presents an overview of the care of adult patients with mental health disorders from ED entry to departure—triage, patient and staff safety, medical and psychiatric evaluation, admission and disposition decisions, and the care of patients with prolonged ED stays. Diagnostic criteria of the psychiatric disorders are summarized. Behavioral and psychiatric disorders in children are discussed in chapter 147, "Behavioral Disorders in Children."

Paramedics or police often provide advance notice to the ED, especially of the severely agitated patient, so preparations can be made for patient arrival. The best preparation includes assembly of an ED "psychiatric code" team, designation of an appropriate room, and having medications on hand. Team members may consist of an ED physician and nurse, hospital nurse manager, psychiatric clinical nurse, and security staff who can respond to threats of harm to others, patients with altered mental status, and patients trying to leave against medical advice.⁶

In most Western countries, psychiatric patients are triaged in the same manner as medical patients using the Emergency Severity Index, Canadian Triage Acuity Scale, Manchester Triage System, or Australasian Triage Scale/National Triage Scale. These triage tools were originally designed for medical patients. For psychiatric patients, behavior descriptors determine acuity. The most acute behaviors are actively dangerous (e.g., violent, possession of a weapon), with decreasing acuity as the likelihood of dangerousness to self or others declines.

THE PRECAUTIONARY PRINCIPLE

Agitated or distressed patients, those expressing suicidal or homicidal ideation, or patients who raise concern about harm to self or others should not be allowed to leave the ED before medical or psychiatric evaluation is completed, even if departure is formalized as "against medical advice."⁷ Many institutions have a formal process to make sure staff are aware that the patient cannot leave. Processes include the writing of an order (e.g., "sitter with patient," "precautionary hold," "suicide precautions"), but while the process varies by institution, the goal is to ensure patient and staff safety during the time-consuming process of evaluation. The foundation of such action is called the "Precautionary Principle," which is the need to prevent or minimize harm before it occurs.⁸

Fragmented mental health care and mass deinstitutionalization of the severely mentally ill have ensured that many psychotic, violent, and chronically mentally unwell patients now visit the ED on a regular basis. Mental health emergencies include situations in which patients are highly distressed, suicidal, and/or homicidal. Patients with suicidal or homicidal ideation, suicide or violence plans, or suicide or homicide attempts require measures to minimize the possibility of harm to themselves or others. Mental health disorders coexisting with substance abuse are also a recipe for violence.⁹ In one study of psychiatric patients in a veteran's hospital, about one third of patients who committed violence during hospitalization did so in the ED. Violent incidents have been associated with dementia, court-ordered admission, and mood disorder.¹⁰ Violent and aggressive behavior frequently demands immediate chemical or physical restraint to protect the patient, other patients, staff, and visitors.¹¹

Although hospital security forces and police are often available to subdue violent patients and reduce risks of staff or patient injury, ED staff must be educated and equipped with a range of skills to protect themselves. These skills include enhanced awareness of risk factors and warning signs of violent behavior, verbal de-escalation techniques, quick access to rapidly tranquilizing or neuroleptic medications, and emergency strategies for getting help quickly in explosive circumstances.

Approach patients with potentially dangerous behavior cautiously and with a nonthreatening attitude, with adequate security nearby. If necessary, isolate and restrain threatening patients before they are disrobed, gowned, and searched for weapons. Medical and nursing staff should stay distant from the patient; avoid excessive eye contact; maintain a calm, controlled posture and tone of voice; and stand in a location that neither threatens the patient nor blocks the exit of the healthcare worker from the room.

A number of techniques can help de-escalate aggressive patient behaviors. Allow patients to verbally ventilate feelings. Provide an environment that decreases stimulation. Place the patient alone in a room designed for patient safety, but with close monitoring by staff. Offer food or drink. Set limits on accepTable behavior and respond with neutral comments. Adequate force nearby should be visible to the patient, and tell the patient that uncontrolled behavior will result in restraint.

EXAMINATION ROOMS AND SECLUSION

Waiting rooms and examination rooms need to be designed to ensure safety. Steps that promote safety include security staff, metal detectors, rooms with doors that permit rapid and easy exit, panic buttons, and the removal of any objects that could be used in violent attacks or suicide attempts (including neckties of both staff and patient, large earrings, patient belts or belt buckles, shoes, shoelaces, stethoscopes, blood pressure cuffs, and cutting instruments).

Seclusion rooms may be used to protect patients and staff. Remove or carefully secure any objects that could be used for self-injury or against staff. Austere seclusion rooms may be useful for some agitated patients by providing relief from external stimuli. Search patients before entry, and remove potentially dangerous objects, clothing, or weapons. Make sure staff are aware of the location of exits and of panic buttons. Initially, leave the door open, but if the patient remains agitated, lock the door. Keep the patient advised of each action and the expected duration, and explain the consequences of violent behavior. Monitor the patient in a seclusion room with a personal guard or nurse-monitor, by closed–circuit television, or by individual checks about every 10 minutes. Give the patient opportunities to comply with staff demands for accepTable behavior that can lead to release from seclusion. If violent behavior persists, physical restraint is justified. Document all steps in the use of seclusion and medical and physical restraints.

CHEMICAL RESTRAINT

Pharmacologic/chemical restraint of violent or agitated patients is discussed in detail in chapter 287, "Acute Agitation." The Sedation Assessment Tool score (SATS) is one method of grading behavior and assessing medication options.¹² Treatment options can be selected based on behavior (Table 286-2).

Ketamine has been used for acute agitation or depression, but concerns about hypoxia or oversedation, and lack of large clinical ED studies, limit its use in the ED at the present time.^13,14,15

PHYSICAL RESTRAINTS

In many cases, there is no substitute for the application of physical limb restraints. Restraints should be applied rapidly and safely by individuals trained and skilled in their use. A team of five staff members is recommended: one team leader and one person for each limb. Sometimes, the show of force and the presence of many staff may in itself be sufficient to subdue the patient without recourse to restraints. The team leader oversees and orchestrates the procedure. The patient and any family members present should be provided with clear, ongoing explanations of all procedures. Place the patient on a bed or stretcher, and secure all four limbs with leather restraints. Be careful to avoid injury. Elevate the patient's head, if possible, to minimize risk of aspiration. Once the patient is restrained, offer medications, and if refused, administer medications involuntarily.¹¹

Hospital policies dictate the frequency and type of observation (e.g., vital signs, pulses, range of motion, skin integrity, toileting) with written orders that limit the time in restraint and require renewal as needed. Once the patient is calm and compliant, restraints can be removed one at a time, while staff carefully monitor the patient to ensure the safety of all concerned.

The initial steps include simultaneous medical and psychiatric evaluation while maintaining patient and staff safety.¹⁶ Obtain vital signs including pulse oximetry, and perform point-of-care blood glucose determination. Simultaneously assess the patient's potential for dangerous behavior, such as harming self or others or leaving the ED without medical advice; stabilize the behavior; and evaluate the chief complaint. Then, obtain a focused history; perform physical examination and mental status/-neurologic testing to identify comorbid or primary medical issues; and assess the need for hospitalization. Formulating a specific diagnosis is not as important as determining whether the patient is harmful to self or others or is unable to take care of self and needs hospitalization. Determining that an individual is suicidal and in need of protection and hospitalization, for instance, is more important than deciding whether that person has schizophrenia or psychotic depression.

The medical evaluation of patients with apparent psychiatric symptoms should be the same as for those with medical conditions¹⁷ (Table 286-3). The findings of the history and physical examination should guide laboratory testing and diagnostic inquiry. The combined findings from history, physical examination, laboratory testing, and diagnostic inquiry form the basis of the medical description of the patient.

The evaluation of the patient with psychiatric symptoms in the ED is commonly termed "medical clearance." This term is a misnomer because many patients have medical problems and the term does not really mean that the patient's medical problems have been "cleared." Rather, this process identifies medical problems and their relationship to the patient's presentation. One alternative to the term "medically clear" is a discharge note that includes key features of the history, physical examination, and mental status and neurologic examination; laboratory results; discharge instructions; and follow-up plans.¹⁸ Alternatively, the term "medically stable" could be used if a specific term is required.

The medical evaluation is used to determine whether the patient has a medical condition that causes or exacerbates the psychiatric illness. The medical evaluation process is also used to identify medical illnesses or injuries that are coincident to the psychiatric illness and that need to be identified and treated prior to a psychiatric admission. The determination of a medical versus psychiatric cause for psychiatric illness or behavioral change is difficult because many psychiatric patients have medical comorbidities and some with medical illness have undiagnosed psychiatric disorders. The most frequent medical comorbidities include diabetes, cardiovascular disease, and pulmonary disease.¹⁷ If the patient with medical comorbidities needs hospitalization, be sure the psychiatric facility can provide care for concurrent medical illnesses.

MEDICAL AND BEHAVIORAL HISTORY

Medical comorbidities may produce changes in behavior. Ask specifically about fever, head trauma, immunocompetence (including malignancies and risk factors for human immunodeficiency virus infection), diabetes, pulmonary diseases, and toxic ingestions or overdose.

Obtain information about recent changes in behavior from the patient, as well as from caregivers and family members. Obtain the history of previous psychiatric illness and treatment to identify patterns of relapse. Family and social history may identify stressors in the patient's environment that are a direct cause of changes in behavior or that accentuate any responses to underlying disease. Whenever possible, corroborate all history provided by the patient, with information from family members, care providers, or law enforcement. Compare direct observations of the patient's behavior with reports from the patient's family and caregivers. This is especially important for institutionalized or group home patients whose baseline mental capacity is often unclear to ED staff.

MEDICATION/DRUG HISTORY

Mental health disorders and substance abuse disorders frequently coexist.¹⁹ The syndromes associated with alcohol and substance abuse that can result in altered behavior include intoxication, withdrawal, delirium, hallucinosis, paranoid behavior, and dementia. Identify any initiation of substance abuse, changes in the patterns of abuse, and medication compliance.

Behavioral changes may be due to prescription or over-the-counter drugs, especially sedatives-hypnotics, stimulants, psychotropic agents, anticonvulsants, anticholinergic agents, angiotensin-converting enzyme inhibitors, β-blockers, corticosteroids, fluoroquinolone antibiotics, histamine-2 receptor blockers, opioids, salicylates, selective serotonin reuptake inhibitors, thiazide diuretics, and antiparkinsonian agents.²⁰ The increasing use of serotonergic agents makes it important to check drug interactions (e.g., linezolid, tramadol) to identify serotonin syndrome as a cause of behavioral change.²¹ Over-the-counter analgesics or herbals and alternative medications containing salicylates, anticholinergics, antihistamines, or bromides may produce delirium or toxic psychosis.²⁰ Alcohol and street drugs, such as phencyclidine, lysergic acid diethylamide, mescaline, amphetamines, and cocaine, can produce a toxic psychosis. Hypnosedatives, such as barbiturates and benzodiazepines, may produce a confusional state or delirium in both intoxication and withdrawal. Ask about alcohol and substance use in psychiatric presentations, even when the odor of ethanol or evidence of substance use is absent.

Psychoactive drugs are associated with a variety of hematologic and metabolic abnormalities. Clozapine, olanzapine, phenothiazines, and carbamazepine can cause neutropenia/agranulocytosis.²² Hyponatremia (sodium level <136 mmol/L) can occur with typical and atypical antipsychotics.²³ Hepatotoxicity, manifested as transaminitis, obstruction, or hepatic failure, has been reported with norepinephrine-selective reuptake inhibitors more than with selective serotonin reuptake inhibitors, and also with tricyclics/tetracyclics, monoamine oxidase inhibitors, and typical and atypical antipsychotics.²⁴ Of the herbal medications, kava-kava can cause serious hepatotoxicity, while St. John's wort has been indirectly associated with hepatotoxicity due to its effects on the P450 system of other medications.²⁵

PHYSICAL EXAMINATION

Perform a physical examination on every patient.^25,26,27 Measure vital signs, including temperature, and oxygen saturation by pulse oximetry. Investigate abnormal vital sign values, and do not dismiss them as due to anxiety or stress. Fever is especially important, because both local and systemic infections can cause altered mental status, as can meningitis, encephalitis, and brain abscess. Neuroleptic malignant syndrome and serotonin syndrome are causes of psychoactive drug-related fever.²⁸

Patients with abnormal vital sign values, abnormal mental status examination results, psychosis, mental retardation, or advanced age usually require a complete head-to-toe physical examination, with street clothing removed and dressed in a hospital gown. Look for signs of trauma to the head, face, and neck, and reconstruct any mechanisms of injury. In the homeless, or in those with exposure, assess for hypothermia and check the extremities for frostbite. Examine for skin rash, extremity trauma, and needle tracks. Neurologic examination typically includes an assessment of most cranial nerves, gait, mental status, and general motor function and strength. For more focused neurologic examinations, test for apraxias, agnosias, right-left disorientation, aphasias, visual field cuts, and inability to follow complex spoken and written commands. Such signs may or may not occur in association with other localizing neurologic signs, such as asymmetric reflexes, paralysis, or hemiparesis.

Table 286-4 lists signs and symptoms associated with medical causes of behavioral abnormalities. Sudden onset of major changes in behavior, mood, or thought in a previously normal patient, or definite deterioration in a patient with a chronic behavioral disorder should stimulate evaluation for an underlying medical or neurologic disorder. A sudden change in behavior, especially in a patient >45 years old, is an important indicator of a possible medical disease process. Evaluate neurologic symptoms such as fainting, dizziness, disorientation, impairment of speech, confusion, loss of consciousness, headaches, difficulty performing routine tasks, new cognitive deficits, and focal weakness.

MENTAL STATUS EXAMINATION

The mental status examination is conducted to understand the patient's mental state and, when combined with the history and physical examination, aids the formulation of a diagnosis and disposition. A mental status examination can help identify delirium, medical disorders, and psychiatric disorders; identify patients who are dangerous to themselves or others; and help assess patient disposition (Tables 286-5 and 286-6). A great deal of the information obtained in mental status examinations becomes evident through observing the patient's appearance, behavior, language, comprehension, and affect during the initial patient interview. However, cognitive assessment and determination of suicidal or homicidal ideation or hallucinations and delusions generally require additional questioning.

Important components of the mental status examination include ability to provide historical information, attention, speech patterns, language comprehension, affect and mood, hallucinations and delusions, level of cognitive functioning, degree of insight and capacity for introspection, and ability to establish a therapeutic relationship. Abnormal findings in any of the above components may suggest a medical basis for abnormal thought or behavior. Liability of affect, the need for simple questions to be repeated, irritability, disorientation, and lack of cooperation are some additional signs of medical dysfunction.

During the examination, the patient's affect or outward display of emotion should be evaluated for sadness, euphoria, and anxiety, and whether such emotions are appropriate to the current situation. This may help distinguish between cognitive disturbance induced by depressive disorders and dementia due to cerebral pathology. An examiner can draw some conclusions regarding a patient's thought processes during the patient's telling of his or her personal history. Disordered thought processes include paranoid or grandiose delusions, fixed false beliefs, and delusional denial of illness. Such beliefs should be compared with reports from family and friends. Visual hallucinations can occur in psychiatric illnesses (schizophrenia or affective disorder) but most often result from medical disease; assume medical pathology until proven otherwise. Judgment can be gained by asking the patient to describe how he or she would deal with day-to-day problems, such as finding the way home from the hospital. Judgment may be impaired in medical disease, so ask about historical evidence of faulty judgment.

COGNITIVE ASSESSMENT

Assess cognitive impairment to identify the presence of dementia or delirium. Cognitive impairment often is not detected in ED patients, despite estimates suggesting that from 26% to 40% of older ED patients are cognitively impaired.²⁹ There are many tests of cognitive function, from simple to complex, but few have been investigated in the ED.

The Quick Confusion Scale consists of seven items and takes about 3 minutes to administer (Table 286-7; see also Table 168-3). A cut-off of ≤11 points has a sensitivity of 64% and specificity of 85% for identifying cognitive impairment.³⁰

Another self-administered screening test for cognitive function is the clock test. Give the patient a piece of paper with a circle drawn on it, and ask the patient to "place the numbers on it to make it look like a clock." After completing this task, then ask the patient to place the hands of the clock to read a time such as "10 past 11." Although there are various methods for scoring the clock drawing test, the easiest for ED use is the simplest: correct or not correct. Using a more complex 10-point scoring system, the sensitivity for dementia detection was reported as 76% and specificity was 81%. Clock test results do not appear to be affected by depression.³¹

The Mini-Mental State Examination is a widely used tool for assessing cognitive impairment and to follow changes in cognition over time³² but is not practical for general ED use.

LABORATORY EVALUATION

Obtain laboratory testing based on abnormalities in the history and the physical examination. There is no unanimity between specialties about the need for extensive laboratory testing for all ED psychiatric patients.^33,34 The psychiatric literature reports that 46% to 80% of psychiatric patients have undiagnosed medical illness,^35,36 whereas the emergency medicine literature supports a selective approach to laboratory testing in the ED.^37,38 Often, routine testing is a requirement of the psychiatric consultant or is part of the admission process of the psychiatric hospital.^39,40 The best approach is to collaboratively establish standards for testing on a local level.

For adults with new psychiatric complaints, obtain a through laboratory evaluation including a CBC, electrolytes, liver and renal function studies, urinalysis, and possibly chest radiograph, neuroimaging, or drug and alcohol testing depending on the patient and the circumstances.

Many institutions require drug and alcohol testing for all patients with psychiatric complaints whether the patient admits to substance abuse or not. However, specific drug and alcohol testing is not clinically necessary if the patient admits to using alcohol and drugs when asked and is awake and cooperative.⁴¹ Urine drug testing and blood alcohol concentrations do not correlate with the degree of intoxication. The patient's cognitive abilities, rather than a specific blood alcohol level, should be the basis for assessment. On the other hand, patients with altered mental status without known cause need a complete evaluation including alcohol and drug testing.

One guide for the discretionary use of testing is provided in Table 286-8.^41,42 Documenting items in Table 286-8 can also be used as a communication tool to psychiatrists about the ED evaluation process.

Advanced testing such as radiographs, electrocardiograms, and electroencephalograms should be based on the patient's clinical condition and suspicion for medical illness. CT and related brain imaging should be considered for a clear change in behavior or if an intracranial cause is suspected. The type of diagnostic imaging depends on findings from the history, mental status examination, physical examination, and differential diagnosis.

Provisional psychiatric diagnoses can be made in the ED to facilitate treatment and disposition. Recognition of specific behavioral syndromes can assist in evaluating the presenting complaint, pursuing associated symptoms, and determining treatment and disposition. Emergency physicians should be sufficiently familiar with commonly seen psychiatric illnesses to describe their predominant clinical features.

The current official diagnostic nomenclature, most recently published in 2000 by the American Psychiatric Association, is the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (text revision), commonly known as DSM-IV-TR.⁴³ A copy of DSM-IV-TR should be available for reference in the ED, because it contains a list of criteria for each disorder and additional material on demographics, associated symptoms and syndromes, and differential diagnoses. As of this writing, the fifth edition of the DSM is in preparation, and publication is anticipated later in 2013.

The DSM-IV-TR diagnoses are structured on a multiaxial system in which each axis refers to a different domain of information (Table 286-9).⁴³ This system aids in making a comprehensive assessment, organizing complex clinical information, and communicating with other professionals. More details concerning selected psychiatric diagnoses are found at the end of this chapter, in the Overview of Axis I to V Disorders section.

A useful strategy for making a DSM-IV-TR diagnosis is to classify the primary feature into a major category, consider possible nonpsychiatric causes for the complaint, and then use the decision trees in the appendix of DSM-IV-TR to identify the appropriate diagnosis. The decision trees guide the clinician who is unfamiliar with the intricacies of the criteria within a category to identify the features that distinguish closely related conditions. An example of the decision tree for evaluating acute psychosis to determine the diagnosis is shown in Figure 286-1. There are five other decision trees that aid in the differential diagnosis and demonstrate the hierarchical nature of the DSM-IV-TR: mental disorders due to a general medical condition, substance-induced disorders, mood disorders, anxiety disorders, and somatoform disorders.

The determination to admit a patient with psychiatric illness from the ED is based on an assessment of danger to self or others and the ability to care for oneself. Some authorities also use additional criteria, such as desire and ability to cooperate with treatment and available support systems.

Many patients may benefit from outpatient or community resources instead of admission.^44,45 Knowledge of the specific options available in one's community helps determine disposition. The web site of the Substance Abuse and Mental Health Services Administration (www.samhsa.gov) is an excellent reference for local and community services. Once at the Substance Abuse and Mental Health Services Administration home page, select the "Topics" tab and query the Substance Abuse Treatment Services Locator or the Mental Health Treatment Services Locator. Resources can be identified by state, city, county, or zip code location and insurance status.

Psychiatric services available to the ED can reduce voluntary hospitalizations and increase patient compliance with outpatient visits.⁴⁶

The determination for psychiatric admission is based on the ED psychiatric assessment, sometimes with limited information and most often within a short time frame for assessment. A study involving psychiatrists in four urban psychiatric emergency services identified five variables, in declining order of importance, that predicted admission: level of danger to self, severity of psychosis, ability for self-care, impulse control, and severity of depression.⁴⁷

There are no currently validated tools that help determine the need for admission from the ED. The Crisis Triage Rating Scale (Table 286-10)⁴⁸ was developed by a community hospital's crisis intervention service but has not been validated for ED use. The scale ranks elements from three categories: dangerousness, support system, and ability to cooperate. A clinical scale/score cannot predict future behavior by a patient, but the scale items help in assessment of various factors to determine disposition.

Psychiatric consultation, by psychiatrists or psychiatric social workers, can be very helpful in determining patient disposition, especially when assessing danger to self or need for hospitalization.⁴⁹ Telepsychiatry can provide psychiatric consultations to facilities that do not have psychiatric resources. It is useful for rural, remote, and isolated populations and for a wide variety of diagnoses, ages, and mental health complaints. This resource can provide consultations, diagnostic assessment, medication management, and family and patient psychotherapy. It can aid in the determination of admission and care for psychiatric boarders.⁵⁰

In the absence of medical indications for admission, refer to a psychiatrist or a psychiatric facility. Provide results of the ED medical and psychiatric evaluation to the consultant. For patients who can safely leave the ED, provide clear discharge instructions, and schedule specific follow-up.

ASSESSMENT OF HARM TO SELF OR OTHERS

The most difficult determination and highest risk is the assessment of self-harm. Assessment of suicide risk requires attention to diagnosis and treatment and to immediate and long-term safety. The interests of other people must be considered, because homicide may be a risk, especially when partner or family conflict exists. A full history is needed, a diagnosis must be reached, and a plan of management must be instituted, all with the patient's involvement insofar as that is possible. Establishing rapport and a therapeutic alliance is critical. The key points in initial assessment and management are summarized in Table 286-11.

Arrange privacy for an assessment and show respect and courtesy. Carefully elicit any symptoms of psychological and physical illness. Assess especially for evidence of depression, psychosis, or substance abuse. Identify predisposing and triggering risk factors. Avoid challenging or critical questions. Empathic comments like "You must have been pretty upset" encourage patients to share their difficulties. An open-ended question like "Can you tell me more about it?" is particularly useful. Some patients may resist. When the interviewer stresses the need to understand the story and displays willingness to listen actively, most patients respond and rapport increases. Direct questions may be necessary to elucidate events leading to suicidal ideation and behavior. A systematic inquiry into stressful life events, relationships with family and other relevant people, and available social supports is always required.

After these are mapped out, decisions about future risk and treatment can be made. In general, risk of further suicidal behavior increases exponentially with increased number of health, mental health, and psychosocial risk factors.

SUICIDE RISK

A useful aid to assessing suicide risk is provided by the acronym SAD PERSONS, which is based on the first letters of 10 literature-identified suicide risk factors (Table 286-12).⁵¹ Clinical rating scales cannot predict suicide in the individual. Strict cut-off scores should not be used to dictate admission to the hospital. There are at least 31 tests of risk of suicidal intent, but few were designed or validated for ED use. None of these tools have sufficient sensitivity and specificity to predict discharge from the ED. Rather, these tools are components in the determination of suicidal risk and can serve as guides to document the reasons for admission or discharge.

Suicidal intent can be determined based on the degree of planning, the lethality of the method considered, and the existence (and content) of any suicide notes. If patients are asked open-ended questions such as "What were your feelings about living and dying?" or "I guess you had mixed feelings about living and dying" instead of "Did you really want to live or die?" they are better able to verbalize their motivations, including ambivalence. When appropriate tact is used, the question, "What has stopped you from killing yourself so far?" may reveal protective factors and also remind patients of reasons to continue living.

Patients who are single, divorced, separated, widowed, or recently unemployed are at higher risk than those who are married and employed. Recently widowed older white males with access to lethal means (e.g., a firearm) form the population at highest risk for completing suicide in the United States and thus should elicit a very careful evaluation. A psychotic patient who attempts suicide requires careful observation, with whatever restraint is necessary, and evaluation by a psychiatrist. A psychotic patient may respond unpredictably to distorted perceptions in a fearful or driven manner.

An important opportunity to assess future suicide risk is provided by asking patients their thoughts and feelings during the interview immediately after the suicide attempt.^52,53 For some patients, self-injury or suicide attempts appear to serve as a form of catharsis or emotional release, similar to weeping, talking to a friend, or becoming inebriated. Such patients did not undertake the attempt to die and do not identify the event as an attempt to do so. Often such patients may describe the attempts as being made when they were feeling angry, hurt, humiliated, ashamed, or vengeful and wanted to hurt others or extract a reaction from others. Patients who indicate remorse, shame, or embarrassment at having made a suicide attempt generally appear to have a lower risk of further suicidal behavior than those who do not show these responses. A patient who sits quietly; engages poorly with the physician; voices regret at surviving; expresses feelings of hopelessness, helplessness, or exhaustion; and refuses to provide additional information should be considered at high risk.

Secondary Gain Secondary gain is a term that indicates that although the primary motive for a suicide attempt appears to be death, the attempt may meet another need, such as a desire to gain attention or receive emotional help. When such needs are met by the attempt, a secondary gain is achieved, and the risk of subsequent suicide attempt is lessened momentarily. It is dangerous, however, to assume that secondary gain is the cause of a suicide attempt during an initial evaluation in an ED. All suicide behaviors should be taken seriously.

SUICIDE RISK AND DISPOSITION

Patient disposition can be assessed by estimating the lethality of the attempt and the likelihood of rescue, with the patient's perceptions and understanding of these taken into account. When there is a high likelihood of rescue and low lethality, there may be a lower risk of further suicidal behavior than if the possibility of rescue was remote and the patient believed the lethality of the agent or method was high. A patient who attempted suicide by hanging in an isolated area of the woods is at greater risk than a person who swallowed a few tablets of a substance of relatively low toxicity in front of witnesses.

Patients who have made previous suicide attempts are at greater risk for further suicide attempts and for suicide. Prior attempts are a particularly significant warning if the intensity and apparent lethality of the suicide attempts escalate with each subsequent attempt. Table 286-13 provides details of assessment.

Table 286-13 also provides high-risk and low-risk suicide profiles. High-risk patients with strong, pervasive suicidal intent require psychiatric hospitalization. Moderate-risk patients are those who present in a serious suicidal crisis but who, because of a positive response to initial intervention and favorable social support, may not be in immediate danger. Hospitalization can often be avoided for such patients, provided outpatient treatment can be established immediately and the patient engages with treatment. Such disposition decisions are most often made in concert with a psychiatric consultant. Before discharge, develop a safety plan with the patient and the patient's family, remove available means of suicide (such as firearms or drug supplies), prescribe conservative amounts of psychotropic medication (usually no more than a 2-week supply), and provide help-seeking advice and problem-solving strategies. It is important to have a family member take responsibility for managing a patient's medications.

Low-risk patients frequently present with suicidal ideation, threats, plans, or minor attempts that occur in the context of a clearly definable external crisis. Family and social support is usually readily available, caring, and sympathetic. Low-risk patients with the following stipulations may be discharged from the emergency department: medical treatment not needed, no prior suicidal attempt, not actively suicidal, adult in house with good relationship, adult agrees to monitor, adult will remove guns and medications, contact for deterioration available, follow-up arranged, and patient and support group agreement to plan and recommendations.⁵⁴

Before discharge, ensure that good social support is available to the patient. Social support includes a place to live and family or friends who will support the patient emotionally. Obtain agreement that a supportive individual can spend the next 24 hours with the patient.

However, because many attempts that appear trivial on first glance are found to have more serious implications on closer examination, carefully assess all patients coming to the ED after a suicide attempt. If there are any concerns about the safety of discharging a suicidal patient and psychiatric consultation is not immediately available, hospitalize the patient involuntarily.

No-Harm Contracts

"No-harm contracts" or "suicide prevention contracts" have sometimes been used as a method to lower suicidal risk. Typically, the no-harm contract is a verbal or written agreement initiated by the physician or psychiatrist in which the suicidal patient agrees not to harm or kill himself or herself and to adopt agreed-upon help-seeking behaviors if a crisis arises. Although proponents argue that the no-harm contract can be therapeutic by helping to reveal the intent of the patient and reduce it, and diagnostic by eliciting the nature and severity of a patient's suicidality, there is little evidence that such contracts prevent further suicidal behavior.⁵⁴ Currently, the use of no-harm contracts is not supported. Rather, the preparation of a joint safety plan with the patient and the patient's family or a commitment by the patient to treatment is more likely to be of therapeutic benefit.

Self-Injury Behaviors

Young adult and adolescent patients may present to the ED because of self-harm behaviors that are not dangerously suicidal but nonetheless require both medical and mental health care.²⁹ Typically, such patients cut or scratch their arms to "relieve tension" or burn themselves in an effort to feel a certain way. Females tend to more often cut themselves, while young men tend more often to burn themselves. Such acts are usually heralded by a state of mounting tension with depersonalization, followed by relief after the self-mutilating behavior. Self-injury is usually not suicidal behavior but rather a poorly learned coping mechanism that is used to reduce tension, self-soothe, and communicate feelings. For most young patients, self-injurious behavior appears to be time-limited and linked to problems with parents and is not associated with severe clinical symptoms or suicidality. However, some self-injuring patients do have clinical symptoms including high anxiety and active suicidality. In addition to tetanus prophylaxis and wound care, assess patients for suicidal ideation and further plans for self-harm. Nonsuicidal self-harm or self-mutilatory behaviors are seen in patients who may insert foreign bodies into their bladder, rectum, nose, or other orifices and may require GI or surgical intervention. Outpatient psychiatric follow-up and evaluation are usually appropriate for this type of behavior.

VIOLENCE TOWARD OTHERS

Potential victims who are clearly identified may need to be warned.⁵⁵ This can be done through the psychiatric consultant or hospital or local police. Clues that suggest potential violence include hostile behavior; homicidal ideas, fantasies, or preoccupations; verbal aggressiveness; statements about violent intent; weapons skill and access; motives for violence; and preattack planning and preparation.⁵⁵ Patients need immediate hospitalization.

Treatment of acute agitation is discussed in detail in chapter 287, "Acute Agitation."

Psychiatric patients who are noncompliant to their psychotropic medications need to be restarted on their medications. Mental health patients with a new psychiatric diagnosis also need to start treatment. For schizophrenic patients, haloperidol 2 to 5 milligrams IM and lorazepam 1 to 2 milligrams IM have the quickest effect. Oral risperidone (Risperdal^®) 3 to 6 milligrams per day or olanzapine (Zyprexa^®) 15 milligrams daily also may be useful. Do not given benzodiazepines with olanzapine, because the two drugs coadministered can result in hypotension an hour later. Historically, it takes weeks to months for antidepressant medications to have a clinical effect, and so medications are not typically started in the ED unless in close consultation with the follow-up psychiatric provider.

Ketamine is proposed as a quick treatment for depression and suicidal ideation. Ketamine results in improvement within 2 hours and has an effect after 24 hours.⁵⁶ In a small trial of suicidal patients, 15 suicidal patients received a subanesthetic IV dose of ketamine. Thirteen of 14 patients were completely free of suicidal ideation at 10-day follow-up.⁵⁷

Some advocate for treatment of suicidal patients in the ED. Techniques include a brief intervention, enhanced follow-up, video patient education, and family therapy, with a rapid ED response team consisting of a psychiatrist and psychiatric nurse or social worker. Such programs depend on sufficient ED resources and the ability to arrange solid follow-up.^58,59,60

PSYCHIATRIC BOARDERS IN THE ED

Unfortunately, a nationwide scarcity of inpatient psychiatric beds has led to the phenomenon of "psychiatric boarders," patients staying for days in the ED before psychiatric admission. Psychiatric boarders have also increased because some patients are sent to the ED for conflict resolution or respite from family, group home, or nursing home. The ED becomes the arbitrator in social issues that are better handled by police, counselors, or social workers. Boarding psychiatric patients is thought to result in premature ED discharge,⁶¹ increased complications while in the ED, escalated medical and psychiatric problems, and reduced ED efficiency. Psychiatric boarders in the ED stay longer in the ED than other patients.⁶²

Protocols for appropriate use of the ED for these patients and alternative care sites need to be explored, such as mobile crisis teams, expanded use of social workers, and police training in crisis intervention.⁶³ Community treatment consisting of supportive services, case management, emergency care, medications, and assistance of daily living can reduce ED use. Mobile crisis units can provide crisis stabilization in patient homes.

PSYCHIATRIC OBSERVATION UNITS

The best option for reducing psychiatric admissions is the acute psychiatric stabilization unit, which is similar to medical observation units. Acute psychiatric stabilization units are usually managed by psychiatric services, whereas medical observation units are often managed by the emergency service. Psychiatric stabilization units provide psychiatric assessment, crisis stabilization and drug treatment, and linkage with community resources before discharge. Acute stabilization of psychiatric patients allows time for diagnostic clarity, development of alternatives to admission, and a respite for the patient and family.⁶⁴

Axis I disorders include the clinical syndromes of mental disorders (Figure 286-2). For more than one axis I diagnosis, list the most important diagnosis first. Axis II includes personality disorders and developmental disorders, including mental retardation (Figure 286-3). The presence of axis II disorders complicates management of all other axis disorders. Axis III encompasses general medical conditions that are or could be relevant to the understanding or management of the patient's psychiatric illness. Axis IV consists of psychosocial and environmental stressors or problems. Axis IV conditions relate to primary support group, social environment, and educational, occupational, housing, economic, healthcare access, and legal issues. Axis V relates to the patient's current overall functioning using the global level of functioning scale. This scale ranges from 0 to 100, with 0 representing persistent danger to self or others and 100 indicating superior functioning in a wide range of activities. The axis I disorders most clinically relevant to ED practice are summarized below.

SCHIZOPHRENIA

Schizophrenia is the most prevalent psychosis. The essential features of schizophrenia are a deterioration in functioning, characteristic positive symptoms (hallucinations, delusions, disorganized speech, disorganized behavior, and catatonic behavior), negative symptoms (blunted affect, emotional withdrawal, lack of spontaneity, anhedonia, and attentional impairment), cognitive impairment manifested by loose associations or incoherence for at least 1 month, and the relative absence of a mood disorder. Schizophrenia is most likely a group of disorders with different causes that share a final common pathway. There is no evidence that psychosocial stressors or poor parenting is responsible for causing the illness, although these may have a profound effect on the patient's adaptation to this usually chronic disorder.

Symptoms of schizophrenia usually begin in late adolescence or early adulthood, although the onset can occur at any age. The childhood history of schizophrenics often is marked by shyness, odd or eccentric behavior, school difficulties, or paranoid behaviors, but such features are not always present. A prodromal phase, in which a gradual deterioration of function is noted, usually precedes the development of active delusions or hallucinations. Such deterioration usually includes the worsening of social withdrawal or the new onset of social withdrawal, odd behavior or speech, and difficulty in functioning at school or work. Patients or their families rarely seek care until the onset of the active phase of psychosis. Schizophrenic individuals seldom seek care at all because they lack insight; they do not realize that their perceptions, thoughts, and behavior are abnormal.

Disorganization of thinking and behavior characterizes schizophrenia. Disheveled appearance and poor grooming, bizarre behavior, poor judgment, and loosening of associations indicate such disorganization.

SCHIZOAFFECTIVE DISORDER

Schizoaffective disorder is diagnosed when the patient has depression, mania, or mixed episode together with classic schizophrenic symptoms such as delusions, hallucination, disorganized speech, disorganized or catatonic behavior, and affect flattening. Delusions or hallucinations need to occur for at least 2 weeks after the mood symptoms have ceased. The mood symptoms should be present for a substantial portion of time and not be due to drug use or medical conditions.

BRIEF PSYCHOTIC DISORDER

Some individuals may become acutely psychotic after exposure to an extremely traumatic life experience. If such a psychosis lasts for <4 weeks, it is termed a brief psychotic disorder. Precipitants include the death of a loved one or a life-threatening situation such as combat or a natural disaster. Emotional turmoil, confusion, and extremely bizarre behavior and speech are common in this disorder.

Substance-related disorders are due to ingestion of a drug of abuse or alcohol, side effects of a prescribed or over-the-counter medication, toxic exposure, or substance withdrawal.⁴³ The specific features of intoxication syndromes commonly seen in the ED are described in chapters on specific agents in the Toxicology section (Chapters 176 to 207) and Chapter 292, Substance Use Disorders.

The diagnosis of withdrawal is made by identifying the withdrawal toxidrome and evidence of recent use of the substance in a pattern sufficient to produce withdrawal when the amount ingested is decreased or stopped. Specific withdrawal patterns depend on the agent.

Malingering is the intentional invention or exaggeration of physical or psychological symptoms for external gain. The external gain may be maladaptive to avoid work or obtain drugs, or adaptive in response to being an enemy combatant in wartime. Malingering is distinguished from factitious disorders by the presentation of symptoms for a known secondary gain.

The mood disorders are the most prevalent of the major psychiatric disorders. The lifetime prevalence of mood disorders in the age group of 17 to 39 years was reported as 11.5% in the National Health and Nutrition Examination Survey III.⁶⁵

Mood, or affective, disorders differ from the normal extremes of sadness and happiness in that characteristic clusters of psychological and vegetative symptoms (depressive or manic syndrome) are present, and functioning is impaired. Depressive disorders are the major cause of completed suicide. Mood disorders tend to be episodic, with periods of remission and normal function. Any of the features of schizophrenia such as delusions, hallucinations, or disorganization may be present, but if a full depressive or manic syndrome exists, the diagnosis is likely psychotic mood disorder. The more common mood disorders are briefly discussed in the following sections.

MAJOR DEPRESSION

The essential features of major depression are a persistent sad or depressed (dysphoric) mood or pervasive loss of interest in usual activities lasting for at least 2 weeks. Associated psychological symptoms include guilt over past deeds, self-reproach, feelings of worthlessness or hopelessness, inability to experience pleasure, and recurrent thought of death or suicide. Vegetative symptoms involve physiologic functioning and include weight loss or gain, sleep disturbance, fatigue, inability to concentrate, and psychomotor agitation or retardation. Depression may begin gradually or rapidly but is usually present for several weeks before the patient seeks help.

Major depression is often superimposed on other mental disorders, such as substance abuse, personality disorders, and anxiety disorders, and such conditions are frequently comorbid conditions. Major depression is often recurrent, so certain patients must be maintained on long-term treatment to prevent relapse.

DYSTHYMIC DISORDER

Dysthymic disorder is a more chronic and less severe form of depressive illness and was previously termed depressive neurosis. Depressed mood must have been present most of the day, more days than not, for at least 2 years. Psychotic features are not seen, and patients with this disorder often have a lifelong gloomy, pessimistic outlook. Women are affected more often than men, and the onset is typically in childhood, adolescence, or early adulthood.

BIPOLAR DISORDER

Bipolar disorder, previously termed manic-depressive illness, is characterized by periods of mania cycling with periods of depression. A full manic syndrome is one of the most striking and distinctive conditions in clinical practice. The essential disturbance in mood is one of elation or irritability. Manic patients feel "on top of the world," expansive, and energetic. The state is precarious, however, and patients may quickly become argumentative, hostile, irritable, and sarcastic, especially when their plans are thwarted. Bipolar disorders are classified into types I and II based on the presence of mania, which is found in bipolar I disorder and not found in bipolar II.

The disorder is equally common in men and women, and the onset is usually in the third and fourth decades. Complications include suicide, substance abuse (excessive alcohol use is common during the manic phase), and marital and occupational disruptions. The course of bipolar disorder is episodic, with the duration, frequency, and regularity of the episodes varying greatly. Depressive episodes are more frequent than manic episodes.

The anxiety disorders are mental disorders in which apprehension, fears, and excessive worry dominate the psychological life of the individual. Pathologic degrees of anxiety are accompanied by different degrees of autonomic activity (sweating, tachycardia, or dizziness) out of proportion to any real danger or threat. Because anxiety is a ubiquitous condition and frequently associated with medical illness, depression, neurologic syndromes, and psychoses, a diagnosis of a primary anxiety disorder is made after exclusion of other causes.

PANIC DISORDER

Patients who experience recurrent attacks of severe anxiety are said to suffer from panic disorder. A panic attack consists of a sudden extreme surge of anxiety and dread accompanied by autonomic signs, including palpitations, tachycardia, shortness of breath, chest tightness, dizziness, sweating, and tremulousness. The symptoms develop over a few minutes at most and may be unprovoked or stimulus related.

GENERALIZED ANXIETY DISORDER

When anxiety attacks are absent but the patient complains of persistent worry, tension, or free-floating anxiety, a diagnosis of generalized anxiety disorder should be considered. This condition lasts at least 6 months and is characterized by apprehensive worrying, muscle tension, insomnia, irritability, restlessness, jumpiness, or distractibility. Associated autonomic symptoms include the cardiopulmonary, GI, and neurologic symptoms that are seen in panic attacks.

POSTTRAUMATIC STRESS DISORDER

Posttraumatic stress disorder is an anxiety reaction to a severe psychosocial stressor, such as military combat, fire, rape, a terrorist event, or natural disaster. Symptoms involve repetitive and intrusive memories of the event, nightmares, emotional numbing, survivor guilt, and different degrees of depression and anxiety. Substance abuse is a frequent complication.

OBSESSIVE-COMPULSIVE DISORDER

Obsessive-compulsive disorder is a mental disorder in which the patient experiences intrusive thoughts or images that cannot be eliminated from the mind. Typical thoughts involve images of graphic violence to self or others, contamination, or perverse sexual behavior that the patient would not carry out but nevertheless obsessively fantasizes about. To control the obsessive thoughts, the individual may engage in compulsive behavior or rituals, such as excessive washing, repetitive checking, or counting. When the obsessions and compulsions occupy a great deal of time, the patient may become significantly disabled and seek psychiatric attention.

Sleep disorders include hypersomnia, insomnia, and narcolepsy. Hypersomnia and insomnia can occur in association with other mental disorders. Narcolepsy is a neurologic sleep disorder, not caused by a mental disorder.

The eating disorders anorexia nervosa and bulimia nervosa are discussed in chapter 291, "Eating Disorders."

Factitious disorders are characterized by physical or psychological symptoms that are exhibited in order to assume a sick role. Patients may fabricate complaints, falsify vital sign values, self-inflict an illness, or exaggerate a preexisting medical condition. A factitious disorder demonstrates a psychological need to be in the sick role without external incentives. Munchausen syndrome is an extreme form of this disorder. Munchausen by proxy, or factitious disorder by proxy, is inducing or fabricating disease in a child to get medical attention.

Many patients have particular complaints or symptoms for which no medical explanation can be identified. These symptoms must cause the patient significant distress or impairment in social, occupational, or other areas of functioning. When a physical cause has been clearly eliminated and the complaint is not delusional or occurring in the context of a depression or anxiety disorder, somatoform disorders may be considered in the differential diagnosis. When the complaint involves a loss of function, usually in the neurologic system (e.g., paralysis, blindness, or numbness) and psychological factors are deemed etiologic, a conversion disorder may be present. Conversion disorders are much more common in culturally and psychologically unsophisticated persons. This diagnosis should be made with extreme caution, if at all, in the ED, because studies indicate that many patients (up to 50%) diagnosed with conversion disorder eventually develop signs of a physical disorder that explains the symptom.

Some patients have a wide variety of complaints and long, complicated histories of medical problems that have no apparent medical cause. Such individuals may have somatization disorder, a disorder beginning in the teens and twenties, usually in women, and leading to considerable unnecessary diagnostic and surgical intervention. The prototypical patient is a middle-aged woman who describes a "positive review of systems" in a dramatic and confusing way. As with conversion disorder, a diagnosis of somatization disorder should not be made on the basis of an ED visit, but the identification of somatizing behavior is useful for future reference, because patients frequently make repeated contacts with medical providers.

The dissociative disorders comprise a group of uncommon and poorly understood conditions in which the central feature is a sudden alteration in the normal integration of identity and consciousness. The dissociation often occurs under severe stress and may or may not be recurrent, although it is rarely permanent. The forms of dissociative state relevant to emergency practice are dissociative amnesia, a temporary loss of memory for important personal details related to a traumatic or stressful situation that is not due to a medical cause, and dissociative fugue, in which a similar loss of memory and assumption of a new identity are accompanied by travel away from home. Dissociative disorders are difficult to distinguish from malingering, in which an individual in pursuit of a clear goal, such as avoiding incarceration or military duty, may consciously feign amnesia. As always, medical illnesses and drug intoxication that may cause loss of memory, such as that resulting from transient global amnesia, must be ruled out.

This group of syndromes includes dementia, delirium, amnestic disorders, and other cognitive disorders characterized by a clinically significant deficit in cognitive or memory function due to a general medical condition. Dementia and delirium are also discussed in chapter 288, "Mental Health Disorders of the Elderly." Refer to Tables 286-6 for features of delirium and dementia.

DEMENTIA

Dementia is a pervasive disturbance of cognitive functioning in several areas, including memory, abstract thinking, judgment, personality, and other higher cortical functions such as language. If clouding of consciousness is present, then the patient does not have solely a dementing illness but has delirium, intoxication, or withdrawal. The presence of global cognitive impairment may be detected through the use of a bedside cognitive examination (see Table 286-7 and the clock test). Early in the course of dementia, anxiety, depression, or psychosis may dominate the clinical picture and obscure cognitive dysfunction. Maintain a high degree of clinical suspicion for dementia when evaluating an elderly patient with no prior psychiatric history who develops new psychiatric problems. Dementia is discussed in more detail in chapter 288, "Mental Health Disorders of the Elderly."

DELIRIUM

Delirium is characterized by global impairment in cognitive function but is distinguished from dementia in two major ways. In delirium, the patient has clouding of consciousness, a reduction in the awareness of the external environment (manifest as difficulty sustaining attention), varying degrees of alertness ranging from drowsiness to stupor, and sensory misperception. In most patients, an underlying general medical condition, substance intoxication, or withdrawal or medication use is the cause of the delirium. Delirium must be distinguished from psychiatric illnesses such as psychotic, mood, anxiety, and stress disorders. There is a long list of causes of delirium, including intoxicants, withdrawal syndromes, infections, trauma, seizures, endocrinopathies, inflammatory processes, shock, organ failure, and neoplasia.

The primary distinguishing feature of delirium is a typical acute course, with rapid deterioration in hours or days, rather than in months as with dementia. Also, the severity of delirium fluctuates over the course of hours; the patient may appear normal at one time and wildly agitated a few hours later. Hallucinations, often visual, are common. Delirium is discussed in more detail in chapter 288.

AMNESTIC DISORDERS

Amnestic patients typically are unable to learn new information or to recall information that is already learned. Amnestic disorders cause a problem in carrying out social and occupational functions and are not part of delirium or dementia. Causes of amnestic disorder include brain trauma, stroke, carbon monoxide poisoning, substance abuse, and chronic nutritional deficiency. Acute onset of amnesia needs to be carefully investigated.

MENTAL DISORDERS DUE TO A GENERAL MEDICAL CONDITION

When there is evidence that a psychiatric disturbance is a direct physiologic consequence of a general medical condition or substance, the mental disorder is specified as "due to" the medical problem, for example, "major depression due to hypothyroidism." The mental condition cannot be caused by another mental disorder, and it cannot be part of the course of delirium.

The diagnostic features of mental disorders due to a general medical condition rely on evidence from patient history, physical examination, and laboratory results indicative of a causative medical condition. Sometimes the cause cannot be determined in the ED, and the patient may need admission for further evaluation. General medical conditions may cause amnestic, psychotic, mood, and anxiety disorders.