Mental Health in the ED – Induction

Author: Tessa Dick. Updated by Itunuayo Ayeni and Duncan Brooke/ Editor: Liz Herrieven / Codes: / Published: 08/12/2020

Here are some tips on the common mental health presentations to the emergency department. Mental health is a huge topic and affects a huge number of our patients and our colleagues. Do explore RCEMLearning for more content, especially our wellbeing content found here.

More so than most other specialties, MH facilities are usually detached from physical health facilities. The ability to manage a physical illness in a MH facility is often severely limited by equipment and staff confidence (try looking at a MH crash trolley).

Just as with other conditions the management of MH problems is often intermingled with concurrent physical health issues. It is therefore important that we work together with MH colleagues to achieve the best outcome for our patients (see side by side & London Trusted Assessment Framework).

Equally it is well recognised (outdated ACEP guidance a good start) that a few patients admitted to a MH facility will have an underlying medical cause despite “medical clearance”. There must be an acceptance on all sides that this area is difficult and that we don’t necessarily need to change entire policies on the basis of a few “mistakes”. 

Tess was inspired to put pen to paper by RCEM’s Mental Health Toolkit whose introduction states:

“The core principle of Mental Health in the Emergency Department: A patient presenting to ED with either a physical or mental health need should have access to ED staff that understand and can address their condition”.

As a doctor that has previously struggled with my Mental Health I hope to try and help promote a greater understanding amongst ED staff by sharing some of my experiences, and by talking through the recommendations in the Toolkit. 

Mental Health problems are a common presenting issue for patients attending the ED; one Consultant Psychiatrist even said that we see more mental health patients than the psychiatrists so it’s important we feel confident in how to manage them. It’s important to remember that mental health presentations aren’t just those who present with “overdose” – they’re the lonely 70 year old with chest pain, the anxious 30 year old with asthma, the somatising chronic pain patient. They’re all important and we are privileged enough to look after them all!

I think it’s most doctors’ worst nightmare to think a patient may abscond or be discharged and then harm themselves again after presenting to the ED. The Toolkit gives a set of recommendations for what to cover when assessing a patient presenting with a Mental Health problem; the recommendations reassure us that we have covered the important things and that our management decisions are justified:

• Physical needs should be met promptly.
• Mental Health history. This is something we document only 50% of the time, and it covers information that Mental Health teams are interested in knowing when we refer.
• Risk assessment e.g. Pierce suicidal intent score. This can help us decide if a patient is at high risk of harming themselves again, it helps justify discharge with a plan for the GP to follow-up, and it clarifies if we need the Mental Health team to assess a patient prior to them leaving. Find out which risk assessment tool your department uses.
• Mental Capacity assessment gives us information on whether a patient has the ability to make decisions against medical advice. This group of patients are more likely to want to leave before treatment is complete and we need to be able to document whether they can process the information we give in order to make a competent decision. If they are not able to make a competent decision we may need the help of security, or 1-to-1 nursing to keep the patient safe.

Although it is good to have a checklist of what to cover, it can take an enormous amount of time in order to get the information that the Toolkit recommends. When under time pressures it can feel like these recommendations are unrealistic. But then I remember the time I saw a patient return multiple times with Paracetamol overdoses who was hell-bent on committing suicide. She needed a lot of encouragement to agree to treatment for her overdose as she had capacity to refuse treatment. If I hadn’t taken the time to understand why she took the overdose, I wouldn’t have discovered that the relative who had sexually abused her as a child was due to be released from prison, which had made her suicidal. She had grown up in foster care so was institutionalised; she wanted to be in hospital when she died as she felt safe there so would present to hospital after she’d overdosed. Finding out this information meant we could provide her with support and inform the Mental Health team why she was continuing to need help.

I get that when working hard and seeing waiting times rise in the department we might question whether this is the right place to manage these patients, but ED staffing and skill mix usually mean we can provide higher doses of sedation to agitated patients than can be provided elsewhere, can manage both the physical and mental issues these patients present with, and we are open 24/7 unlike other services. Sadly, this frustration can compromise our ability to empathise.

As a doctor that has personal experience of Mental Health problems I agree wholeheartedly with the sentiment in which the Mental Health Toolkit is written, encouraging healthcare staff to be more open about Mental Health and to show empathy and understanding. My experience as a patient taught me that a balance between empathy and straight-talking helped me open up and engage with treatment. The repercussions of poor communication with patients who are already feeling emotionally unstable can be explosive. As an example I can remember a patient brought to my department under a section 136: he was a young guy who had been found on the railway track attempting suicide. He was agitated, violent towards staff and himself, and he was easily provoked. He had been seen at another department and had received input from both the Mental Health Team and the ED staff before discharge. The police still had concerns that the patient was a danger to himself and others, so they brought him to our department. He was angry because of his desperation; all he wanted to do was commit suicide and we were stopping him from doing what he wanted. Having been suicidal myself I can understand why he was so volatile; it is a thought that consumes you – you can get lost in plans of how to achieve it, and if it doesn’t work out it can feel that all your hopes of a solution to your problems have been taken away. After a time he calmed down enough for us to reason with him and he engaged with the Mental Health team. Ultimately he agreed to a voluntary admission.

Absconding Patients

Mental Health patients are at high risk of absconding or not waiting to be seen. This can risk missing an opportunity to manage a vulnerable person who may come to further harm. I really like the importance the RCEM Mental Health Toolkit places on taking every opportunity to offer patient support, recommending the supply of a leaflet “Feeling on the Edge” to every self-harm patient at triage and suggesting educating patients on the existence of community-based support networks like the Liverpool Light caf where they can seek support if they don’t feel they need help urgently. When I struggled with depression I often felt guilty telling people about my difficulties as I didn’t understand why I couldn’t manage my emotions myself. Taking every opportunity to show that it’s OK to find life hard, and that there is support out there, reassures, and the leaflet Feeling on the Edge is thought to reduce the number of patients who do not wait in the ED.

RCEM has clear advice about how to safely manage absconding patients, and how to prevent absconding. If one of your patients absconds, speak to a senior to work out a safe and proportionate welfare check. 

Suicide and Self Harm

Generally, I think we healthcare professionals are an understanding and open-minded bunch, but sometimes I think we forget ourselves. I was a teenager that self-harmed. I didn’t think about how it would affect people’s impression of me when I was older, but now I’m a doctor, I do feel a certain stigma attached to being someone that has previously self-harmed. In fact, as a medical student I was told by a fellow student that people who have had Mental Health problems in the past shouldn’t be doctors as they wouldn’t have the mental strength to work as a doctor. I can understand why people might think that as I did have an unhealthy coping strategy for stress at that point. The therapy I had helped me reflect on experiences and learn from them, which built up a resilience that I wouldn’t have had without it. Now, I’m not saying that I have some sort of superpower because I’ve had therapy and others haven’t. Resilience is something that people develop in different ways, but I do feel more in touch with my emotions and understand more about how my thought processes contribute to how I feel and act, which helps me work on how to cope in times of stress and sadness. I think that has made me a stronger person.

Address any physical needs in conjunction with the mental health needs, and treat the patient with compassion. Appropriate treatment should not be withheld because the harm was self inflicted – if a wound needs suturing, and the patient would like it suturing… suture it – with appropriate analgesia and local anaesthetic. 

Perform a relevant mental state examination and risk assessment as appropriate. Many departments require all patients presenting with suicidal ideation or self harm to see the mental health team, but a risk assessment will still help the team to prioritise their workload. 

If a patient wishes to leave the department against your advice, follow the relevant legal framework. We recommend using this table from the RCEM document. 

Agitation and Mania

It can be tempting to automatically sedate any patient who presents to the department agitated, whatever the cause of their agitation. Mental health patients, just like delirious elderly patients, may have a reversible cause for their agitation – anti-psychotic medications may precipitate urinary retention, they may want a cup of tea, or they might just want to know what is happening! 

Treat patients compassionately and address any reversible causes, utilising verbal de-escalation techniques as appropriate. If that fails to reduce the patient’s agitation, ask yourself whether they need chemical sedation for their safety, or the safety of others – or to make you feel better. It it’s the latter they probably don’t need anything! Your trust will have a rapid tranquilisation guideline – have a look at it and follow it. It probably suggests oral medication like lorazepam, followed by IM benzodiazepines if the patient won’t take oral medication. 

Eating Disorders

Eating disorders are poorly recognised, and poorly managed in the ED. Physical and mental health needs must both be met. The MARSIPAN score might help highlight physical health needs. For more information, start by reading this blog from MIND.

Medically Unexplained Symptoms

MUS are a tricky problem, as MUS might just mean that the Clinician hasn’t looked hard enough, or the problem hasn’t been identified yet. It’s easy to attribute dizziness or headache to MUS – but think about carbon monoxide poisoning, or brucellosis, for example.

We all function as an integrated mind-body system, so what affects the soma must also affect the psyche. It could be argued that all illness is a mixture of soma and psyche.

Sometimes in illness, the psyche has a strong influence on the soma, manifesting as disease. There are lots of names for this, and there are slight differences between them:

• psychosomatic
• functional disorder
• persistent physical pain
• somatisation, dissociative or conversion disorders
• medically unexplained symptoms
• bodily distress syndrome

However, people still think in terms of physical or mental and if a ‘physical’ cause cannot be elucidated then it is ‘all in the mind’ and therefore imaginary.

As a clinician, our first job must be to validate the patient’s experience. A pain is no less a pain because it has a psychological rather than a physical basis. We must rule out physical disease as much as is safe to do so, and help the patient to work out a solution.

Non-epileptic seizures

A common presentation of functional disorder to the ED  is non-epileptic seizures. There’s no easy way of knowing if seizures are non-epileptic or not but if you suspect a non-epileptic seizure, be kind. Treat the patient by keeping things calm and quiet, and reassuring them that they are safe. Don’t shout and suggest finding big ocular needles – it doesn’t help and makes things worse. 

Anxiety

Anxiety is present in many emergency department presentations, and is often easily reduced by explaining what is happening and why. Grounding exercises, relaxation and square or rectangular breathing may also be useful. 

Substance Misuse

Alcohol withdrawal is covered in a separate learning session – always consider withdrawal and delirium tremens. Find your trust’s protocol for opiate withdrawal and methadone provision. We’re starting to see more patients presenting with cannabis hyperemesis syndrome – maybe because the type of cannabis is changing. GHB withdrawal can be dramatic – liaise with your seniors for management advice. 

Section 136

The police have the powers to put someone on a section 136, a part of the mental health act, if the police believe they are suffering from a mental health crisis, and the patient is in a public place. If it is clear these patients have mental health needs only, they are transferred directly to a 136 suite, if there is one available. If there are physical needs, or it is unclear whether physical needs may also be present, the patient is brought to the emergency department for “medical clearance”. Depending on staffing and hospital protocol, the police may liase with senior hospital staff, and transfer care of the patient to the hospital, or they may stay. 

How to medically clear a patient is difficult – liase with your seniors to find out what happens in your department. Always assess the patient and formulate your own opinion – the patient may have a significant head injury causing their agitation, hypoglycaemia, thyrotoxicosis, sepsis etc., and interpretation of investigations may be difficult. 

Special Circumstances

Children and young people may present with MH problems. Their physical treatment will be similar to those in adults. They have extra safeguarding requirements, and a social services referral should be made. A body map should be completed if consent is given. Have a look at the ABC of treatment here. The law is tricky in young people (especially 16-17 year olds), so involve a senior early if the patient wants to leave or if you have any concerns. 

Postpartum ladies are very high risk and should always be referred to the mental health team, even if their presentation seems benign. 

Elderly patients are not immune from mental health presentations. New psychosis should prompt investigations for an organic cause. New depression can be complicated – take a careful social history, as social isolation may be a significant influencing factor.  

So I guess my take-home message from this blog is to encourage everyone to have a structure when they speak to patients with Mental Health problems so they know they have covered all the bases, whether that’s in the form of a proforma(which is what the Toolkit suggests) or in their head; to be mindful of how they communicate, especially with patients who are more emotionally vulnerable even if they are presenting in an aggressive way; and when talking about Mental Health, be aware that 1 in 4 people experience a Mental Health problem each year and an atmosphere of openness and understanding will help people come forward, talk about it and deal with it better.

References and Further Reading:

RCEM Toolkit
RCEM Mental Health in the ED
RCEM Absconding Patients
RCEM Consent in the ED
RCEM Section 136
RCEM MCA
RCEM Patients in police custody
RCEM Acute Behavioural Disturbance

RCEMLearning Capacity SAQ
RCEMLearning The MCA – a podcast
RCEMLearning Explored MCA Cases
RCEMLearning Podcast on mental health guidelines
RCEMLearning Somatisation in the ED blog
RCEMLearning Blog – consent, capacity, communication in adolescents
Psychiatric Emergencies – RCEM Member Benefit – Learning Module

RCEMLearning Wellbeing Resources 

NCEPOD Report
RCPsych – feeling on the edge leaflet
RCPsych – side by side