Mental illness is the second leading cause of disease burden in the United States.1 The Centers for Disease Control and Prevention (CDC) has estimated that 25% of adults in the United States will suffer from mental illness this year and nearly 50% will develop at least one mental illness in their lifetimes.2 Studies have demonstrated that a substantial number of people use hospital emergency departments (EDs) for mental health problems.3 A recent study demonstrated that adverse drug events from adult therapeutic use of psychiatric medications led to almost 90,000 ED visits in the US annually from 2009 through 2011, with almost half involving adults age 19 to 44 years and with 1 in 5 visits resulting in hospitalization.4 Between 1992 and 2000, psychiatric-related ED visits increased 15% despite overall rates of ED visits remaining the same.3 During this time, there were 53 million mental health-related ED visits in the United States.3 More recent data5 have shown that this alarming trend is accelerating. For example, the CDC reported that between 2010 and 2011, approximately 468,000 ED visits were made by patients with bipolar disorder.5 In 2002, the estimated economic burden of all mental illness in the US was more than $300 billion.6 By 2010, this had risen to $210.5 billion for major depressive disorder alone.6 By contrast, health expenditures per capita for the prevention, stabilization, and treatment of mental illness continue to decline, ranging from $0.20 in low-income countries to $44.84 in high-income countries.2
The dearth of funds available for mental health has led to a marked decline in the number of beds in inpatient psychiatric facilities, causing desperate patients with psychiatric emergencies to turn to local EDs as a last resort. Psychiatric problems account for approximately 6% to 7% of all ED visits.4 Among the estimated 53 million mental health-related ED visits from 1992 to 2001,2 the most common diagnoses were substance-related disorders (30%), mood disorders (23%), and anxiety disorders (21%). These three, along with psychosis (10%) and suicide attempts (7%), accounted for 79% of all psychiatric ED visits.7 The remaining visits encompassed all other Diagnostic and Statistical Manual of Mental Disorders, fourth edition8 diagnostic codes. Decreased stigmatization and increased public and clinical recognition has led to significant increases in the point prevalence and incidence of mental illness globally.7 This, combined with a sharp reduction in psychiatric inpatient beds, significant gaps in crisis care, and lack of easily accessible and affordable mental healthcare, has led to a huge increase in the number of patients with acute mental illness presenting to EDs. This represents a significant challenge both to mental health and ED providers as well as policy planners. EDs cannot be expected to continue providing mental health services to an increasing number of acutely ill psychiatric patients. Passage of the Emergency Medical Treatment and Active Labor Act, mental health insurance restrictions, and exclusions and changes in mental health delivery systems mean that EDs have become the default option for many acutely ill psychiatric patients including those with active psychosis and those who are acutely suicidal.7 Urgent action is required at local, state, and federal levels to remedy this catastrophic situation.
Substance Use Disorders in Emergency Departments
The prevalence of alcohol and substance use problems in patients presenting to EDs is 50% to 100% higher than US averages.9 These patients also use EDs repeatedly and are more likely to be admitted to the hospital. Alcohol and tobacco are the most prevalent substances used by ED patients, with cocaine and marijuana being the most common illicit drugs9 (Table 1). Men and younger adults are more likely to test positive for illicit drugs, although women who are heavy drinkers are more likely to visit EDs.9 Substance abuse can mimic the clinical presentation of many major psychiatric illnesses, including schizophrenia and bipolar disorder. Substance abuse in patients with comorbid psychiatric illness is frequently underestimated,10 even though rates of substance abuse in psychiatric patients are higher compared to the general population. For instance, patients with first episode psychosis are twice as likely to abuse substances compared to the general population, with a lifetime prevalence rate of 74%.10 Up to 20% of adults with mental illness (any diagnosis) were diagnosed with a substance abuse problem in 2010 compared to 5% of adults without a psychiatric diagnosis.10 ED physicians and psychiatrists not only have to be on the lookout for conventional drugs of abuse (cocaine, heroin, cannabis and methamphetamine) but also prescription medication and new “designer” drugs that may not show up on routine drug screens. Traditional approaches to diagnosing substance abuse in the ED (ie, standardized questionnaires, patient self-reports, and urine/blood screening) may not be adequate in detecting substance abuse in all patients presenting to the ED.10 Misdiagnosing substance abuse as a major psychiatric illness can have far-reaching consequences for patients and society at large.
Common Substances of Abuse in Patients Who Present to the Emergency Department
In addition to the well-documented medical consequences of drug abuse (increased incidence of HIV, hepatitis, and other infectious diseases; cardiovascular and neurological damage; increased incidence of certain types of cancer; renal disease), there are a number of other adverse health outcomes that have been linked to drug abuse including unintentional injuries, motor vehicle accidents, interpersonal violence, high-risk behaviors, and overdoses.11 In addition, alcohol is associated with almost 70% of homicides, 40% of suicides, 50% of car accidents, 60% of fatal burns and drowning, and 40% of fatal falls.12 Substance users who seek care at EDs have the following common characteristics: they are sicker and use more health services, they have higher rates of mental illness, they are economically disadvantaged, and they visit primary care practitioners and mental health facilities less often.13
Basic Principles of ED Management of Patients with Substance Use Disorders
A thorough psychiatric assessment is crucial and should include the following:
- Detailed current and past history of substance abuse and its effects on the cognitive, psychological, and physiological functioning of the patient
- General and psychiatric medical history as well as a detailed physical examination
- A detailed history of previous psychiatric treatment
- Family and social history
- Substance abuse screening (breath, blood, and urine)
- Complementary laboratory tests as indicated
- Collateral history from family or significant others (with the patient's permission)
ED physicians need to be aware that EDs are often the first treatment facilities sought out by those with substance use disorders, so initial detoxification will often need to be carried out in the ED. The American Psychiatric Association has provided guidelines for the acute management of substance intoxication.14 The general objectives and considerations are listed in Table 2 and Table 3.
American Psychiatric Association Guidelines for the Acute Management of Substance Intoxication
Considerations That Are Helpful When Deciding Ongoing Treatment After Acute Detoxification
ED Management of Common Substances of Abuse
Alcohol. Clinical presentations of alcohol intoxication vary depending on blood alcohol content and tolerance. Impaired muscle coordination and mood and behavioral changes (at levels between 20 mg/dL and 80 mg/dL) will progress to neurological manifestations including ataxia and slurred speech followed by impaired levels of consciousness and hypothermia (at levels beyond 300 mg/dL) and eventually coma. Patients with blood alcohol levels above 150 mg/dL require monitoring in a safe, quiet environment as well as airway protection, and respiratory and cardiovascular support. Additional medications should generally be avoided except in cases of extreme agitation.
Symptoms of alcohol withdrawal syndrome generally begin within 4 to 12 hours after cessation of use, peak at 2 to 3 days, and subside by day 5. They include gastrointestinal discomfort, tremors, anxiety, elevated blood pressure, tachycardia, and autonomic instability. Seizures, hallucinations, and delirium are less common but can be life threatening. Recommendations for care include administration of thiamine, maintenance of fluid-electrolyte balance, the use of benzodiazepines, and in some patients the use of anticonvulsants or antipsychotics. Wernicke's encephalopathy should be considered in all patients with chronic alcohol use and treated accordingly. After acute detoxification, the decision for continuing hospitalization versus outpatient treatment is based on the severity and complexity of withdrawal.
Cocaine and other stimulants. Stimulants are generally used in bingeing episodes and their physiological effects include increased sympathetic activity (pupillary dilatation, increased heart rate and blood pressure, alertness, and increased motor activity).15 Stimulant intoxication is generally self-limited and requires only supportive treatment.14 Hypertension, seizures, tachycardia, or psychosis may require more specific measures. Rare cases of “excited delirium” require intensive care treatment in the hospital. Benzodiazepines in judicious combination with neuroleptics provide the best outcomes.14 Chest pain with associated signs or laboratory evidence of cardiac involvement needs to be treated as acute coronary syndrome. A recent overdose of amphetamines may require gastric lavage with activated carbon.
The “cocaine crash” following sudden cessation of use can include acute craving, irritability, agitation, anhedonia, hypersomnolence, depression, and exhaustion. Residual symptoms can last several months and pharmacological interventions are usually not helpful.
Benzodiazepines and opioids. Benzodiazepines are central nervous system depressants and their acute intoxication effects are similar to alcohol. Respiratory depression can be more pronounced and may need ventilatory support. Flumazenil, a specific benzodiazepine antagonist, can be used in severe cases. Mild to moderate cases of opioid intoxication do not require specific treatment. In cases of severe intoxication, the presence of miosis, bradycardia, respiratory depression, stupor, or coma indicate acute hospitalization followed by support ventilations. Oral or intravenous naloxone can be helpful but can precipitate severe withdrawal.
Withdrawal from benzodiazepines can cause insomnia, anxiety, agitation, nausea/vomiting, tremor, and orthostasis. A structured withdrawal protocol with long-acting benzodiazepines (diazepam, chlordiazepoxide, or in some cases lorazepam) followed by a gradual taper is recommended. Opioid withdrawal can be managed either with long-acting agents such as methadone (in a structured setting) or second-line agents such as clonidine.14
Marijuana. Marijuana is the most widely used illicit substance worldwide.16 It can cause acute anxiety episodes in beginning users (more common with high doses) or psychosis. Intoxication can cause paranoia and aggression.16 Treatment principles are the same as for stimulant users. Withdrawal from marijuana in chronic and heavy users can cause irritability, appetite changes, weight loss, and physical discomfort. No specific pharmacological treatments have been recommended.
Newer Drugs of Abuse
In addition to the commonly abused “traditional” substances (as outlined above), a whole host of new “designer” drugs routinely evade drug legislation, are readily available on the Internet and in local stores, and can be relatively low in cost. The US Drug Enforcement Agency continues its efforts to curb use through federal legislation, but manufacturers routinely evade legal consequences by modifying the chemical compounds to avoid Schedule I designation, which is defined by the US Food and Drug Administration as having no currently accepted medical use and a high potential for abuse. Drug developers further circumvent federal legislation by placing “not for human consumption” on the label. Marketing often promotes the “legal” aspect of these designer drugs, and users are also enticed by the difficulty of detection of these drugs by routine drug screening. Because most designer drugs cannot be detected by routine urine or serum drug screenings, diagnosis is mostly based on history and clinical presentation. Treatment is supportive and symptomatic in most cases. After a safety assessment, rapid-onset benzodiazepines are often initiated to calm an agitated patient suspected of intoxication. Some of these newer drugs that an ED physician or a psychiatrist working in the ED can expect to encounter are profiled below.
Synthetic cannabinoids. Synthetic cannabinoids (SCs) were initially developed for research purposes and production methods are readily available to the public through scientific literature. Misuse became evident in the United States by 2008 when they became popular as “all natural” herbal blends. The Internet, convenience stores, and “head shops” allowed easy access to SCs, which were sold under a variety of names, including “spice,” “K2,” ‘black mamba,” “Scooby snax,” and “kush.” More recently, solutions designed for e-cigarettes have been developed such as “Buddha-blue,” “C-liquid,” or “herbal liquid.”16 Effects of SCs are often more intense than those observed with cannabis smoking, partly due to full agonist activity and higher affinity for cannabinoid receptors.17 Common neuropsychiatric presentations of SC misuse include agitation, delusions, cognitive impairment, anxiety, auditory and visual hallucinations, paranoia, and catatonia.17,18
N-methoxybenzyl. N-methoxybenzyl (NBOMe) belongs to a new group of phenethylamine derivatives of the 2C class of hallucinogens. Street names include “n-bomb,” “smiles,” and “legal acid.” Although routes of administration can vary, sublingual and buccal ingestion using blotter paper makes NBOMe compounds familiar to people who use lysergic acid diethylamide (LSD), who often use blotters. NBOMe effects include euphoria, increased awareness and stimulation, agitation, paranoia, and panic.19
Cathinones. Cathinones, commonly referred to as “bath salts” in the United States, continue to remain popular due to their cocaine-like effects at low doses and amphetamine-like effects at higher doses. The most common methods for consumption include snorting, inhalation, and oral ingestion. A frequent behavioral effect is agitation, which often requires repeated doses of benzodiazepines to treat. Other psychiatric presentations include anxiety, paranoia, delusions, depression, and suicidal ideation.18
Piperazine. Piperazine abuse dates back to the late 1990s when they were popular as “party pills” or “legal ecstasy.” Unlike many designer drugs, piperazines are completely synthetic. Due to the numerous potential chemical substitutions, piperazines are particularly challenging to legislate, so most piperazine derivatives are legal to possess and use. Piperazines have stimulant effects at lower doses and produce hallucinations at higher doses. Common ED complaints include anxiety, paranoia, auditory hallucinations, and agitation.18
Non–Substance Use-Related Psychiatric Emergencies in the Emergency Department
In the absence of any substance use, psychiatric emergencies can still occur and pose grave risk of harm to self or others. Compared to medical emergencies, which usually only affect the health of the individual patient, psychiatric emergencies are unique in that they pose a risk to families or to an entire community. They may be classified as major and minor. Major psychiatric emergencies are those that are life-threatening for the patients themselves or those around them whereas minor psychiatric emergencies pose no threat to life but can result in incapacitation.20 The following text summarizes psychiatric emergencies that are frequently encountered in the ED.
Suicide is the 10th leading cause of death in the United States. Per CDC records, a total of 44,193 deaths occurred in 2015 as a result of suicide (77% men, 23% women). The most common methods of suicide include firearms (50%), suffocation (27%), and poisoning (15%).21 The frequency of suicide attempt-related visits to the ED peaks between ages 15 and 19 years and plateaus between ages 35 and 45 years, with a mean age at presentation of 33.2 years;22 seasonal variation was also noted with a late spring peak. Approximately 83% of the patients had a preexisting mental disorder; mood disorders were most prevalent in these patients, followed by substance use disorders and anxiety disorder.22
In comparison to the general population, people with preexisting (and comorbid) mental illness and substance use disorders have a higher risk of all-cause mortality as well as suicide. The risk of suicide is highest in patients with borderline personality disorder (BPD), depression, bipolar disorder, and schizophrenia.23 Self-mutilation (cutting oneself, wall punching, head banging) and rates of attempted suicide are high in both adolescents and adults with BPD. Adolescents have a higher incidence of self-mutilation, whereas adults have higher rates of attempted suicide. Overdoses account for more than one-half of the cases of attempted suicides in patients with BPD.24
Depression is strongly associated with suicidal ideation. In a recent study, genetic factors were found to influence suicidal ideation in addition to other non-shared environmental factors. Similarly, more than 25% of patients with bipolar disorder have a history of suicide attempts, and up to one-third of these patients have a history of more than one attempt.25 Patients with poor access to follow-up care after discharge from psychiatric hospitals appear to be at higher risk for repeat suicide attempts.26
ED physicians play a critical role in the initial management of cases of attempted suicide and in ensuring the safety of the patient. All such patients should be screened for depressive symptoms and, if they screen positive, comprehensive psychiatric assessment and management should be initiated before making further management decisions.27
Altered Mental Status
Altered mental status is a diverse term that encompasses minor agitation, unresponsiveness, delirium, and coma. Flaherty et al.28 have proposed that mental status evaluation should be recognized as the sixth vital sign (in addition to respiratory rate, temperature, pulse rate, blood pressure, and pain).
Medical conditions that predispose to altered mental status include electrolyte and pH abnormalities, dehydration, infections, liver and renal diseases, medication use (anticholinergics, sedatives, hypnotics), stroke, and surgeries.29 Such patients can be angry, irritable, or potentially violent. Physician and medical staff safety as well as safety of the patient and other patients in the ED is paramount. A quiet, separate examination room is preferred. Careful selection of words and nonthreatening body language can help calm the patient. Trained ED staff need to be present in case the patient needs to be physically restrained and/or medicated. Restraints are used as a last resort if all other measures fail.30
Delusional disorder, schizophreniform disorder, schizophrenia, and mania can all present with psychotic symptoms such as delusions, hallucinations, and disorganized thought process/motor activities (in addition to negative symptoms). Many of these symptoms overlap but there are some distinguishing features. For example, patients who are manic have more thoughts of grandiosity, are socially interactive, and can be more delusional (with florid, grandiose delusions), whereas patients with schizophrenia tend to be more disorganized in their thoughts and social encounters. Depressed patients with psychotic features might demonstrate mood-congruent hallucinations or delusions along with depressed mood.31
Psychosis can be the result of an underlying medical condition. Neurological neoplasms, Huntington's disease, epilepsy, central nervous system infections, hypothyroidism, hyperthyroidism, electrolyte imbalances, systemic lupus erythematosus, and many other conditions including hepato-renal diseases can present as psychosis and, unless there is a longstanding history of mental illness, must be appropriately investigated and ruled out.32
Panic attacks are sudden, acute episodes of both physical (palpitations, trembling, sweating, chest discomfort, dizziness, paresthesias) and psychological (overwhelming fear of death and re-occurrence of the attack) symptoms. The prevalence of panic disorder is 2% to 3% in the general population, with slightly higher incidence in women.32
Because panic symptoms overlap with a number of medical symptoms (cardiac, pulmonary, and other illnesses), they need to be thoroughly investigated medically (if not done so already). Panic symptoms can be accompanied by behavioral symptoms (agitation, restlessness, irritability) that may need emergent treatment.