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Chapter 35. Psychiatry

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All medical practitioners should be able to recognize stress-induced psychiatric illness and be prepared to do basic interventions. Psychiatric help is often not immediately available in austere situations.

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In austere medical situations, mental health professionals and psychiatric facilities will usually be inadequate or nonexistent. Psychiatric medications may be scarce or of limited variety. The first step for the nonpsychiatrist when working with patients with psychiatric disorders is to review Table 35-1. It describes the general approaches for common psychiatric presentations.

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Table 35-1 Common Psychiatric Presentations and Clinical Responses
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Table 35-1 Common Psychiatric Presentations and Clinical Responses
Patient PresentationClinical Response
Patient <40 years old with new-onset psychiatric symptoms and normal vital signs. (If ≥40 years old, do as complete a medical evaluation as possible.)Brief medical workup and, if available, admit to psychiatric facility. Begin atypical antipsychotics, if available. The presentation of new-onset psychiatric symptoms usually warrants inpatient care or the use of antipsychotics.
Any patient with an altered mental status whose condition appears to vary over time without an obvious cause.Look for causes of delirium, including alcohol or drug withdrawal. Sedate or medicate the patient only if absolutely necessary and with the smallest dose possible.
Cooperative patient with known psychotic illness but taking no medication.Try to find "last known good" regimen and restart, if possible. Otherwise, prescribe effective agent based on side-effect profile matched to patient factors.
Uncooperative manic bipolar patient with known organic disease.Ensure everyone's safety; use restraints, if necessary. If available, use disintegrating tabs of antipsychotics. Oral medications may work; use parenteral agents when necessary.
Agitated and dangerous patient with unknown pathology in need of sedation.Use antipsychotics, benzodiazepines, or both. Choose agents based on degree of sedation desired. Use enough medication.
Elderly patient with psychosis or dementia and possibly ill.Evaluate for delirium. Use low-dose antipsychotics. Atypicals are presumed safe for limited exposure. Avoid benzodiazepines.
Elderly patient with known psychiatric illness and psychotic symptoms.Evaluate for delirium or causes of psychosis. Antipsychotics are useful. Avoid benzodiazepines.
Agitated patient on alcohol.If available, use lorazepam or clonidine. If not, antipsychotics are safe for sedation; benzodiazepines are drug of choice for withdrawal.
Agitated patient on other psychoactive agents.Antipsychotics are drugs of choice. Use benzodiazepines if more sedation is needed.

Data from Angelino and Cordover.1

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The most critical patients are those with new presentations of psychiatric disorders, including delirium. These symptoms represent serious disease states, often from a systemic disease or drug effect, that often respond to rapid treatment.

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In any setting, use Table 35-2 to screen patients for mental health problems. It can be helpful with both mentally healthy people who are responding to abnormal situations and individuals with preexisting mental health problems who are in abnormal situations. Note that if the patient has more than a "moderate symptom" rating for any of the first six items or exhibits any symptom in items 7 to 18, the presence of a mental disorder (psychiatric or organic) must be investigated.

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