A basic approach to a patient with a psychiatric problem

Image credit:  F.RdeC – La version originale anglaise du DSM-5 ainsi que la version française du DSM-IV-TR

A basic approach to a patient with a psychiatric problem

Oct 18, 2015 0
General medicine,onthepods,psychiatry
Summary writer:  Linda Wu
Editor:  James Edwards

James talks to Dr Julian Nasti about a basic approach to a patient presenting with a psychiatric problem and covers certain key considerations for safe medical practice.

Interviewee: Julian Nasti

About Dr Julian Nasti

Julian Nasti is an Advanced Trainee in Consultation-Liaison Psychiatry currently based at Canterbury Hospital where the main focus of his clinical work is perinatal mental health.

A basic approach to a patient with a psychiatric problem

With Dr Julian Nasti, Psychiatry Advanced Trainee, Canterbury Hospital.

Introduction

Patients commonly present with psychiatric problems and they can be confronting for junior doctors to manage. Developing an approach to a patient with a psychiatric presentation that covers certain key considerations is important for safe medical practice.

Case 1

You are a junior doctor working in a Mental Health Unit. A 35-year-old male is brought in by police from the Magistrate’s Court where he has been reviewed and deemed unfit for his court hearing. He is thought to be agitated and thought disordered.

  • Have a broad differential diagnosis: personality disorders, affective disorders, psychosis, organic problems, anxiety disorders, drug and alcohol issues, other
  • Life threatening medical conditions to exclude
  • Consider sources of information available
  • Take steps to ensure your safety
  • Consider disposition: inpatient vs outpatient, voluntary vs involuntary, community outreach
  • Assess your own blind spots to remind yourself of what else you need to ask, but sometimes forget to
  • Gather information from possible sources including:
    • Electronic medical record
    • Police
    • Charge sheets
    • Mental Health Assessment
    • Case managers, Non GovernmentOrganisation (NGO) officers
    • Family and friends
  • History:
    • Risk assessment: keep in mind that it may not be possible or safe to take a comprehensive history, in which case a collateral is sufficient in the acute setting
    • Ensureyour safety prior to approaching the patient:
      • Familiarise yourself with the physical environment of the assessment unit
      • Make sure nursing staff have searched the patient
      • Carry a duress alarm
      • Consider the need for a duress team, security staff – consult with nursing staff if unsure
      • Consider medications that may be useful and discuss this in advance with nursing staff
      • Consider what basics can be provided to reduce agitation e.g. food, drink, Nicotine Replacement Therapy, phone call. Remember that smoking is not allowed in the Mental Health Setting – so don’t make any promises
    • Circumstances leading to presentation
    • Current legal status
    • Past psychiatric history
    • Medication history
    • Allergies and adverse reactions
    • Drug and alcohol issues
    • Social circumstances: accommodation, finances, social support, case manager/Non GovernmentOrganisations, current or previous contact with mental health services, treatment plan
    • Clarify if patient is at baseline
    • Assess dangerousness – and what was used to manage this effectively in the past
  • Examination:
    • Conduct a full mental state exam. In particular look for:
      • Verbal threats
      • Threatening gestures
      • Increased psychomotor activity
      • Increased muscular tension e.g. clenched fists, gritted teeth, invasion of personal space
      • Signs of intoxication or withdrawal
      • Signs of delirium e.g. disorientation, inattention
      • Command hallucinations, persecutory delusions, homicidal ideation
    • Make a risk assessment – in this situation it involves assessing the likelihood of acute aggression based on:
      • Current mental state
      • Past history of aggression and the circumstances in which they occurred – psychotic or instrumental aggression
      • Recent use of drug and alcohol
      • Personality features (mainly from past history)
    • Physical exam
      • Firstly consider: is the patient presenting for the first time?Is this their baseline? Have they relapsed in their characteristic way?
      • Consider physical exam if not at baseline or atypical presentation, or features of delirium (drowsiness, poor concentration), or substance withdrawal/intoxication are present
      • If the above do not apply, then physical exam may be deferred if necessary until acute agitation has improved
      • Physical examination can help establish rapport
      • Can be importantin uncoveringoccult physical symptoms e.g. acute trauma
        • Psychiatric patients may have high pain thresholds, or interpret their physical symptoms in a bizarre way
  • Not all patients require investigations
  • Screening bloods for the next day: FBC, EUC, CMP, LFT, TFT
  • Urine drug screen
  • Beta HCG in women
  • ECG – look for prolonged QT interval
  • If first presentation, neuroimaging may be considered
  • Consider how to ensure safety
  • Determine disposition and legal status of patient
  • Pharmacological management
    • PRN and/or regular
    • Sometimes medication can help facilitate assessment by reducing agitation in the short terme.g. low dose quetiapine 25-50mg, low dose benzodiazepine (diazepam 5-10mg), wafer forms of olanzapine and risperidonecan be useful if concerned about diversion or non-compliance
    • If already medicated, decision to continue depends on the specific medication and compliance status, and should be discussed with senior staff. For example,clozapine may need to be retitrated if stopped for 72hrs, and should always be discussed with senior staff. Medications like quetiapine can lead to development of tolerance, and thus a lower dose may be required when restarting after a period of non-compliance
  • Ensure important comorbidities are addressed e.g. drug and alcohol use
  • Escalation to senior staff if:
    • Any ambiguity regarding legal status – voluntary/involuntary status
    • Considering starting a new antipsychotic
  • Don’t make assumptions! People often make assumptions about underlying diagnoses, patient motivations.
  • Establish rapport
  • Take patient preferences into account e.g. medication choices
  • Listen to the patient and their concerns
  • Risk assessment – majority of psychiatry patients are vulnerable rather than predatory, for instance to financial exploitation, physical illness.
  • Consider a career in psychiatry
  • Andrews, G, Erskine, A & Gee, H. Management of mental disorders: Treatment protocol project. 2004. NSW World Health Organization, Collaborating Centre for Evidence in Mental Health Policy.

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Tags: #anxiety,#health and wellbeing,#mental health,#mental health unit,#mental illness,#personality disorders,#psychiatric problems,#psychiatric review,#psychiatry,#psychosis,#safety

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