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PSYCHIATRY CLERKSHIP

SURVIVAL MANUAL
UNIVERSITY OF BRITISH COLUMBIA

DR. ARUN JAGDEO

ORIGINALLY DRAFTED
2013

LAST UPDATED
AUGUST 2014

ORIGINAL AUTHORS
DR. ARUN JAGDEO
(PSYCHIATRY RESIDENT)

DR. DEBRA YEW


(PSYCHIATRY RESIDENT)

Dr. Arun Jagdeo 2013!

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TABLE OF CONTENTS
SECTION 1: SAFETY, DUTIES, CONFIDENTIALITY, AND CERTIFICATION!

SAFETY WHILST INTERVIEWING!

DUTIES AND CONFIDENTIALITY!

CERTIFICATION !

THE PSYCHIATRIC INTERVIEW (1): DATA, COMPONENTS!

THE PSYCHIATRIC INTERVIEW (2): HELPFUL MNEMONICS FOR COMMON ER


PRESENTATIONS !

MENTAL STATUS EXAM !

ADMISSION ORDERS!

COMMON ON-CALL SCENARIOS!

WHAT IS UNIQUE FROM ABOUT AN EMERGENCY PSYCHIATRIC ASSESSMENT?!

COMMON PSYCHIATRIC EMERGENCIES!

STEPS TO TAKE BEFORE SEEING PATIENT!

SUICIDAL IDEATION OR SUICIDE ATTEMPT!

THE PATIENT WITH PSYCHOSIS!

10

THE PATIENT IN ACUTE MANIA!

11

THE PATIENT AT RISK OF ALCOHOL WITHDRAWAL!

12

COMMON PSYCHIATRIC DRUGS !

13

ANTIPSYCHOTICS!

13

ANTIDEPRESSANTS!

14

MOOD STABILIZERS!

15

ANXIOLYTICS!

16

Dr. Arun Jagdeo 2013!

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SECTION 1: SAFETY, DUTIES, CONFIDENTIALITY, AND CERTIFICATION


SAFETY WHILST INTERVIEWING
In the ER environment patients are undifferentiated. Predictability of patients behaviour is only as good as experience of
the interviewer. Exercise of overt safety precautions is paramount. Here are some elements to be mindful of:
1.
2.
3.
4.
5.
6.
7.
8.
9.

Learn what you can about the patient before the interview; talk to nursing staff, review chart.
Be mindful of unpredictability in patient behaviour. Some factors to consider are intoxication, withdrawal,
persecutory delusions and previous assaultive behaviours.
Maintain physical distance in interview.
Interview in a room with a window so that youre at least semi-visible. Some rooms use television rather
than windows; in these rooms maintain visibility in the camera field of view.
Be aware of personal or desk alarms in case of emergency in interview.
Be aware of code white procedures.
Maintain close proximity to the door.
Consider nurse as safety chaperone.
Dont wear things that can be turned into a weapon, i.e. scarf, neck tie.

DUTIES AND CONFIDENTIALITY


DUTY TO WARN
DUTY TO PROTECT
1) CONTACT SOCIAL SERVICES IF
A) ABUSE / SAFETY AT RISK OF A MINOR (< 18Y) OR
B) ELDERLY INDIVIDUAL
2) CONTACT POLICE AND INFORM AFFECTED PARTIES IF
PATIENT HAS UTTERED THREATS AGAINST SAID PARTIES
3) CONTACT ICBC IF MEDICAL/PSYCHIATRIC CONDITION
IMPAIRING PATIENTS ABILITY TO DRIVE.

YOU

Dr. Arun Jagdeo 2013!

INFORMATION EXCHANGE

PATIENT
CERTIFIED

PATIENT
UNCERTIFIED

Consent not required for


collateral, but obtain if you
can anyway.

Consent required to obtain


collateral, but consent may
be waived in ER setting.

OTHER
PARTIES

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CERTIFICATION

WHAT

1) INVOLUNTARY HOSPITALIZATION

1) ANY FULLY LICENSED PHYSICIAN IN BRITISH COLUMBIA


CAN CERTIFY
2) RESIDENTS AND MEDICAL STUDENTS CANNOT CERTIFY
BUT SHOULD INFORM SUPERVISOR OF NEED FOR
CERTIFICATION IF PATIENT DEEMED TO NEED
CERTIFICATION.

WHO

1) HAS A MENTAL DISORDER


2) THAT DISORDER SERIOUSLY IMPAIRS ABILITY TO REACT
APPROPRIATELY TO ENVIRONMENT OR ASSOCIATE WITH
OTHERS.
3) SUPERVISION REQUIRED TO
i. PROTECT PATIENT

WHY

ii.PROTECT OTHERS
4) PREVENT DETERIORATION OF PATIENTS MENTAL
ILLNESS
5) UNSUITABLE AS VOLUNTARY PATIENT

FORM 4

HOW

Dr. Arun Jagdeo 2013!

MEDICAL CERTIFICATE THAT PROVIDES LEGAL AUTHORITY


FOR INVOLUNTARY ADMISSION

ONE COMPLETED FORM ALLOWS HOLD IN DESIGNATED


FACILITY FOR 48 HOURS

TWO COMPLETED FORM 4S ALLOW HOLD IN DESIGNATED


FACILITY FOR 1 MONTH

THE SECOND FORM 4 MUST BE COMPLETED:

BY A DIFFERENT PHYSICIAN WITHIN 48 HOURS OF


COMPLETION OF THE FIRST FORM

CANNOT BE COMPLETED BY A RESIDENT

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THE PSYCHIATRIC INTERVIEW (1): DATA, COMPONENTS


IDENTIFYING DATA

age
living situation
relationship status
financial status

CHIEF COMPLAINT / REASON FOR REFERRAL


HISTORY OF PRESENTING ILLNESS

current episode
financial
onset, duration, course
impact on function
baseline function
stressors
why presenting to ER now
screen
mood symptoms
anxiety symptoms
psychosis
substance use
current treatments
medications
psychotherapy
current involvement with mental health workers
past episodes
previous diagnoses

PAST PSYCHIATRIC HISTORY

diagnoses
hospitalization history, Voluntary Status versus
Involuntary Status
previous
medication trials, efficacy, side effects
ECT
current substance abuse
history of substance abuse
suicide attempts

MEDICAL HISTORY / SURGICAL HISTORY

traumatic brain injury


thyroid disorder
diabetes mellitus
chronic illness

MEDICATIONS

current psychiatric medications, compliance, side effects


OTC, herbal, naturopathic

ALLERGIES

food, drug, OTC

FAMILY PSYCHIATRIC HISTORY

Bipolar Affective Disorder


depression
psychosis
suicide
substance abuse

PERSONAL HISTORY

may defer some elements in ER setting


early childhood experiences
history of trauma or abuse
education
current employment, previous levels
relationship status and history
legal involvement
sexual history

HOW

explain to patient
how long the interview will be
what you will ask about
who youll review your case with
conduct interview and review with staff
communication with nursing and allied health is
important

Dr. Arun Jagdeo 2013!

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THE PSYCHIATRIC INTERVIEW (2): HELPFUL MNEMONICS FOR COMMON ER


PRESENTATIONS
DEPRESSION

MANIA

SIGECAPS

DIG FAST

Suicidal thoughts
Interests decreased
Guilt
Energy decreased
Concentration decreased
Appetite disturbance
Psychomotor changes
Sleep disturbance

ALCOHOL ABUSE
CAGE

Every felt you should cut down


your drinking?
Are you annoyed when people
criticize your drinking?
Ever feel guilty about your
drinking?
Have you ever used a drink as an
eye opener?

WORRY WARTS

Wound up
Worn-out
Absentminded
Restless
Touchy
Sleepless

BORDERLINE PERSONALITY
DISORDER

ANTISOCIAL PERSONALITY
DISORDER

IMPULSIVE

CORRUPT

Dr. Arun Jagdeo 2013!

Distractibility
Indiscretion
Grandiosity
Flight of ideas
Activity increased
Sleep deficient
Talkativeness

GENERALIZED ANXIETY
DISORDER

Impulsive
Moody
Paranoid
Unstable self-image
Labile intense relationships
Suicidal gestures
Inappropriate anger
Vulnerability to abandonment
Empty feeling

Cannot conform to the law


Obligations ignored
Reckless disregard for safety
Remorseless
Underhanded (deceitful)
Planning insufficient (impulsive)
Temper (irritable, aggressive)

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MENTAL STATUS EXAM


APPEARANCE / BEHAVIOUR

well-groomed versus unkempt


tattoos
cuts, bruises, slashes
eye contact
agitation
psychomotor retardation
unusual mannerisms
accessibility
reliability
rapport

SPEECH

how the patient speaks, rather than content


quantity
fluency
response latency

THOUGHT FORM

PERCEPTIONS

mood - how the patient tell you he/she feels


affect - what you observe

delusions
ideas of reference
obsessions
magical thinking
paranoia
realistic concerns / worries
suicidal ideation
homicidal ideation

Dr. Arun Jagdeo 2013!

need to know educational level


orientation, memory, attention, concentration,
calculations
MMSE
MOCA

INSIGHT

THOUGHT CONTENT

hallucinations
derealization
depersonalization

COGNITION

EMOTIONAL STATE

goal directed
coherent versus disorganized
tangential
circumstantial
flight of ideas
loosening of associations

awareness of illness
absent
poor
partial
impaired
complete

JUDGMENT

your confidence in patients decision making

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ADMISSION ORDERS
SAMPLE TEMPLATE

EXAMPLE

1.
2.
3.
4.
5.
6.
7.
8.

1.
2.
3.
4.
5.
6.
7.
8.

Admit to Psychiatry under Dr. _______


Diagnosis: _______
Involuntary Admission (Form 4 x _______ completed)
Diet as Tolerated
Activity: Level of Observation, Passes allowed?
Vital signs every _______
Investigations
Medications (patient is previously on any changes
made following your interview)
In case of agitation

9.
10.
11.
12.
13.
14. Withdrawal protocols
15. e.g. CIWA, Nicotine Replacement Therapy (patch,
etc.)
16. Order charts from other hospitals, if necessary

9.
10.
11.
12.
13.
14.
15.
16.

Admit to psychiatry, under Dr._______


Dx: Mania (Bipolar Disorder)
Involuntary Admission (2 Form 4s )
Diet as tolerated
No passes
Level 1 observation
VS twice per day x 2 days
CBC with Differential, E7, BUN/Cr, TSH, Urine Drug
Screen, Serum Drug Screen, Beta-HCG, EKG
Lithium 300mg PO three times per day
Risperidone 1mg PO HS
Loxapine 10mg PO/IM q1h PRN (max 60mg/24h)
Lorazepam 1 to 2 mg PO/IM q1h PRN (max 6mg/24h)
Benztropine 1 to 2 mg PO/IM q1h PRN (max 2mg in
any 24 HR period) for EPS
Bowel Protocol
Seclusion PRN for severe agitation / aggressive
behaviour
Order all old patient charts

COMMON ON-CALL SCENARIOS


WHAT IS UNIQUE FROM ABOUT AN EMERGENCY PSYCHIATRIC ASSESSMENT?

shorter
may be during off-hours
focus on history of presenting illness
4Ss
Stressors
Suicide
Substance use
pSychosis

COMMON PSYCHIATRIC EMERGENCIES

psychosis
suicide
drug-induced psychosis
mania
severe depression
depression with psychotic features
dementia
personality disorder

STEPS TO TAKE BEFORE SEEING PATIENT

review chart
review vital signs
review blood work drawn
talk to Registered Nurse, especially query safety risks in seeing patient by yourself
SAFETY FIRST

Dr. Arun Jagdeo 2013!

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SUICIDAL IDEATION OR SUICIDE ATTEMPT

Assessment
can use CASE (Chronological Assessment of Suicide Events) to evaluate risk 24 hours leading up to thought or event
? suicide note
? tell anyone
? purchase instrument of death
now ask about last month
Document
intent
lethality and access
review risk factors SAD PERSONS
Sex (male > female)
Age (risk with age)
Depression
Previous attempt ** (best indicator of suicide risk)
Alcohol abuse
Rational thinking loss (impulsive)
Social supports lacking
Organized plan
No spouse
Sickness
protective factors
children
social supports
religious
good health
pregnant
sense of responsibility
consider the following in your decision to discharge
diagnosis
severity of suicidal ideation
coping skills
living situation
social supports
risk factors
access to follow-up
References
SAD PERSONS mnemonic adapted from: Patterson WM, Dohn HH, et al: Evaluation of suicidal patients, THE SAD
PERSONS Scale, Psychosomatics, 1983.
Some content adapted from Emergency Psychiatry lectures by Dr. Levy and Dr. Sadrahasemi.

Dr. Arun Jagdeo 2013!

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THE PATIENT WITH PSYCHOSIS

Assessment
previous psychotic episodes
patient medically cleared?
is it safe to see the patient?
presence of delusions; note the themes
presence of hallucinations
ask specifically about COMMAND HALLUCINATIONS, as this is a significant risk factor for completed suicide
thought form disordered?
suicidal ideation or homicidal ideation
substance abuse?
conduct and document a thorough mental status examination
get collateral: (current psychiatrist, mental health team, G.P. family, friends regarding recent mental state and functioning,
to establish a patients baseline)
Investigations
CBC with Differential
Electrolytes
BUN/Cr
TSH
Liver Function Tests (AST, ALT, ALK, GGT, Total Bilirubin, Direct Bilirubin)
Urine Drug Screen
Serum Drug Screen
Consider, where warranted
Extended electrolytes (Ca, Mg, PO4)
Vitamin vitamin B12
VDRL
Lipids
Fasting Glucose
Head-CT
EEG
EKG
Beta-HCG if female, where appropriate
Management
Often restart antipsychotic medications
Consider
seclusion PRN and restraints PRN where warranted
PRN orders for agitation, withdrawal from substances
Factors pointing to possible organic cause of psychosis
Elderly patient, first episode
Current medical illness
Recent drugs (prescription or street)
Acute onset (within minutes to hours)
Non auditory hallucinations
Neurological signs
headache
neurological deficits (e.g speech, movement)
vision changes
gait changes
Fluctuating attention and concentration

Dr. Arun Jagdeo 2013!

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THE PATIENT IN ACUTE MANIA

Assessment
previous psychiatric diagnoses
previous hospitalization
previous hypomanic episodes
on mood stabilizers or antidepressants
adherence to medications
does the patient meet criteria for mania?
recent stressors, precipitating events
screen for
psychotic features
substance abuse
other comorbid conditions
presence of suicidal ideation/homicidal ideation
insight and Judgement intact?
obtain collateral
MSE (mental status examination)
elaborate fashion
pressured speech
psychomotor agitation
euphoric mood or irritable
labile affect
flight of ideas
grandiose thoughts
insight/judgement generally poor
is the patient medically cleared?
review most recent vital signs
review blood work
review investigations already ordered by ER
rule out organic causes
ensure that it is safe to see the patient (review safety guidelines)
Investigations
if on Lithium
CBC with Differential
electrolytes
BUN/Cr
TSH
Beta-HCG
EKG
Lithium level
if on Valproic Acid
same as above + liver panel
consider extended electrolytes
Acute Management
certify and admit the patient
consider potential for aggression or violence and order seclusion orders accordingly
restart mood stabilizer
may need low dose antipsychotic agent

Dr. Arun Jagdeo 2013!

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THE PATIENT AT RISK OF ALCOHOL WITHDRAWAL

Whos at risk?
Patients abruptly stoping or reducing alcohol intake after heavy or prolonged alcohol use.
Investigations
CBC with Differential
electrolytes
BUN/Cr
Ca, Mg, PO4
Liver Function Tests (AST, ALT, ALK, GGT, Total Bilirubin, Direct Bilirubin, Albumin, INR, PTT)
Beta-HCG where appropriate
consider EKG
STI testing
Signs Or Symptoms
ANS instability (fever, tachycardia, sweating, hypertension)
tremor
nausea/vomiting
auditory hallucinations / visual hallucinations
agitation
anxiety
seizures (generalized, tonic-clonic)
Complications
seizures
alcohol hallucinosis
delirium tremens
Management
benzodiazepines
monitor using CIWA (Clinical Institute Withdrawal Assessment) protocol
Thiamine 100mg PO once daily x 5 days
1 multivitamin PO daily
Magnesium sulphate 2g IV x 1 if tremulous
replenish extended electrolytes as needed
rule out UTI, pneumonia
consult addictions

Dr. Arun Jagdeo 2013!

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COMMON PSYCHIATRIC DRUGS


ANTIPSYCHOTICS
TYPICAL

ATYPICAL

HIGH POTENCY

Haldol 0.5 - 10mg

Risperidone 0.25 - 6mg


Paliperidone 3 - 9mg

MEDIUM POTENCY

Loxapine 10 to 250mg

Olanzapine 5 to 30mg
Ziprasidone 40 to 80mg PO twice per day
Aripiprazole 10 to 30mg

LOW POTENCY

Chlorpromazine 200 to 1000mg; start at 50mg

Quetiapine 300 to 900mg


Clozapine 100 to 800mg, start at 25mg

SIDE EFFECTS

more extrapyramidal symptoms (EPS) than


atypical antipsychotics
rare NMS (neuroleptic malignant syndrome)

EPS

acute dystonia (within 2 to 4h)


akathisia (within 2 to 4 days)
akinesia (within 2 to 4 days)
tardive dyskinesia (after 6 months, usually
years)

TREATMENT OF EPS

Dr. Arun Jagdeo 2013!

acute dystonia: Cogentin 1 to 2mg IM STAT


akathisia: Clonazepam / Propranolol
tardive dyskinesia: lower dose, switch to
atypical, can be permanent; Clozapine can
decrease TD

anticholinergic
dry mouth
confusion
dry eyes
urinary stasis
antihistaminic
sedation
weight gain
antiadrenergic
orthostatic hypotension
erectile dysfunction
metabolic side effects
type II diabetes
weight gain
cardiac
prolonged QT
rare NMS (neuroleptic malignant syndrome)

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ANTIDEPRESSANTS
SSRI (SELECTIVE SEROTONIN REUPTAKE
INHIBITOR)

Escitalopram | Cipralex 10 to 20mg


Sertraline | Zoloft 25 to 200mg
Citalopram | Celexa 10 to 60mg
Fluoxetine | Prozac 10 to 60mg
Paroxetine | Paxil 10 to 60mg
Fluvoxamine | Luvox 50 to 300mg

SNRI (SEROTONIN AND NOREPINEPHRINE


REUPTAKE INHIBITOR)

Venlafaxine | Effexor 37.5 to 225mg


Desvenlafaxine Succinate | Pristiq 50 to 100mg
Duloxetine | Cymbalta 60 to 120mg

NASAA

Mirtazapine | Remeron 15 to 45mg PO HS


benefits
fewer sexual side effects than SSRIs or SNRIs

NDRI (NORADRENALINE AND DOPAMINE


RECEPTOR INHIBITOR)

SIDE EFFECTS

same as SSRIs PLUS


blood pressure (~ 5mmHg)

SIDE EFFECTS

weight gain
sedation

SIDE EFFECTS

lowers seizure threshold

Wellbutrin | Bupropion 150 to 300mg


benefits
less sexual side effects than SSRIs or SNRIs
more activating than SSRIs
can use as nicotine replacement

TCAS, MAOIS, OTHERS

Dr. Arun Jagdeo 2013!

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MOOD STABILIZERS
VALPROIC ACID

Valproic Acid 750mg/day


loading dose = 20mg/kg/day, twice per day dosing
serum level 350 to 700mmol/L
mechanism: inhibits GABA transaminase

LITHIUM

Lithium carbonate 300 to 1200mg total daily dose


target serum level
0.8 to 1.2 in adults
0.5 to 0.7 in elderly
Lithium citrate 5mg = Lithium carbonate 300mg

SIDE EFFECTS

SIDE EFFECTS

SECOND GENERATION ANTIPSYCHOTICS

Olanzapine | Zyprexa
Quetiapine Fumarate | Seroquel
Risperidone | Risperdal

elevated liver enzymes


skin rash (rare Steven Johnson syndrome)
teratogenic (neural tube defects)

leukocytosis
weight gain
hypothyroidism
tremor
teratogenic
nephrogenic diabetes mellitus
nausea/vomiting
cardiac side effects
acne
psoriasis
toxicity: ataxia, dysarthria, myoclonus, mental status
changes, seizures, coma; dialyze if serum level > 2

SIDE EFFECTS

click to scroll up

OTHERS

Dr. Arun Jagdeo 2013!

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ANXIOLYTICS
FIRST LINE
SSRI (SELECTIVE SEROTONIN REUPTAKE
INHIBITOR)

may need higher dose of SSRIs to treat anxiety disorders


than mood disorders
Escitalopram | Cipralex 10 to 20mg
Sertraline | Zoloft 25 to 200mg
Citalopram | Celexa 10 to 60mg
Fluoxetine | Prozac 10 to 60mg
Paroxetine | Paxil 10 to 60mg
Fluvoxamine | Luvox 50 to 300mg

OTHERS - BUSPIRONE | BUSPAR

GAD only
5-HT1A agonist

SIDE EFFECTS

SIDE EFFECTS

OTHERS - BENZODIAZEPINES

potentiate GABA binding


many different agents available
e.g. Ativan 1 to 2mg
e.g. Clonazepam 0.25 to 1mg
indications
agitation
anxiety
insomnia
seizure
alcohol withdrawal
akathisia

Dr. Arun Jagdeo 2013!

nausea
diarrhea
weight fluctuations
sexual dysfunction
headache
dizziness
sleep disturbance
SIADH in the elderly

nausea
headache
dizziness
EPS

ADVERSE EFFECTS

tolerance
dependence
can worsen delirium

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