Presentation is loading. Please wait.

Presentation is loading. Please wait.

Mental Health Emergencies in Primary Care Dr. L. Rozewicz, Clinical Director, Crisis & Emergency Dr G. Isaacs, Consultant Psychiatrist (Haringey) Dr H.

Similar presentations

Presentation on theme: "Mental Health Emergencies in Primary Care Dr. L. Rozewicz, Clinical Director, Crisis & Emergency Dr G. Isaacs, Consultant Psychiatrist (Haringey) Dr H."— Presentation transcript:

1 Mental Health Emergencies in Primary Care Dr. L. Rozewicz, Clinical Director, Crisis & Emergency Dr G. Isaacs, Consultant Psychiatrist (Haringey) Dr H. Scurlock Consultant Psychiatrist (Enfield)

2 Overview  Description of common problems  What to do  How to manage in primary care  How to refer to specialist services

3 Overview  Emergencies relate to acutely disturbed behaviour  They can occur in surgeries, patients homes or public places  The most important initial decision is to exclude physical causes and or the effects of prescribed or not prescribed drugs  Obtain a history from the patient and or carer or relative

4 Acute confusional state  Most often elderly and patients with dementia  Fluctuating level of consciousness  Visual and/or tactile hallucinations  Disorientation in time/place  Overaroused or underaroused

5 Acute confusional state  Physical o Acute infection (UTI, chest) o Hypoglycaemia o Hypoxia o Head injury – subdural o Post-ictal

6 Acute confusional state  Drug and Substance Misuse Acute alcohol intoxication or withdrawal Steroid psychosis Amphetamine psychosis  Acute mental health problems Acute schizophrenia or psychotic depression Hypomanic episodes of bipolar disorder Personality disorder Severe anxiety disorder, panic disorder

7 Acute confusional state management  Admit to a medical ward – not managed in psychiatric units  Treat primary cause  Manage the environment – avoid sensory deprivation e.g. windowless room, avoid sensory overload e.g. noise  Think of patient safety, falls, infection, DVT, constipation  Major tranquillisers at low doses

8 Behavioural and Psychological Symptoms in Dementia  BPSD – non cognitive symptoms in dementia (psychosis, agitation, mood disorder)  FGAs traditionally used – haloperidol  SGAs better as no EPS  Risperidone licensed in UK for up to six weeks  SGAs now controversial (small effect size, sedation, increase in CVAs and all cause mortality, cognitive decline)

9 Behavioural and Psychological Symptoms in Dementia  Use risperidone (0.5-1mg), refer within seven days to specialist  Olanzapine is second line (5mg)  Stop after 2-3 weeks unless there is a specific indication

10 Acute mental health problems – general approach  Acute Anxiety  Agitated Depression  Impulsive violence secondary to poor anger control  Acute psychosis

11 Acute mental health problems – general approach  If violence is involved (or if there is a history of violence ask for police support)  Gather information from records, family, carers – think about drugs and alcohol  Tell receptionist your are visiting, call back within fixed time to confirm that you are OK, get receptionist to call police if they do not hear from you  Visit with someone else if possible  Do not try to restrain patient  Have an exit route

12 Anxiety Disorders  Very common chronic disorders in 10% of patients  Common overlap with depression  Commonly present with physical symptoms  CBT 7-14 hrs from IAPT (CBT is better than medication)  Avoid Benzos  Use SSRIs (Sertraline 50mg and then increase) or Pregabalin (75mg bd)  Pregabalin ‐binds to α2δ subunit of the voltage dependent calcium channel ‐works as quickly as benzos ‐75bd to 300bd (increase gradually)

13 ICD-10 Criteria for Alcohol Dependence  A strong desire or a sense of compulsion to drink alcohol  Difficulty in controlling drinking in terms of its onset, termination or level of use  A physiological withdrawal state  Evidence of tolerance  Progressive neglect of alternative pleasures  Persisting with alcohol use despite awareness of harmful consequences

14 AUDIT  Alcohol Use Disorders Identification Test  10 Questions  Takes 5 minutes  92% sensitivity with 8 cut off  95% specifity

15 Treatment Options - Alcohol  Refer to local alcohol service  GP detox (chlordiazepoxide)  Consider acamprosate post detox  DTs – refer to medics  Dependence and active suicidal refer to HTT

16 Suicide  Typical GP will see one suicide every five years on their list  One a year in a 10 000 group practice  8.5/100000 per year  No single assessment tool

17 Risk Factors for Suicide: Socio-Demographic  Females more likely to attempt than males  Males more likely to die  Young and Old  Poverty, unemployment  Prisoners

18 Risk Factors for Suicide: Family and Childhood  Parental depression, substance misuse, suicide  Parental divorce  Bullying

19 Risk Factors for Suicide: Mental Health Problems  Impulsive, aggressive or socially withdrawn  Poor problems solving ability  Mood disorders; bipolar, psychotic depression  Substance/alcohol misuse  Schizophrenia  Recent discharge from psychiatric hospital

20 Risk Factors for Suicide: Suicidal Behaviour  Access to means (guns, drugs, tablets)  History of suicide attempts  Specific plans

21 Suicide Questions  How does the future look to you? What are your hopes?  Do you wish you could jut not wake up in the morning?  Have you considered doing anything to harm yourself, or to take your own life?  Have you made actual plans to kill yourself? What are they?  What has stopped you from doing anything so far?

22 Care Plan  Document problem and provisional diagnosis in the notes  Document risk assessment  Management plan  Record discussion with patient about problem/management plan  Record patient views

Download ppt "Mental Health Emergencies in Primary Care Dr. L. Rozewicz, Clinical Director, Crisis & Emergency Dr G. Isaacs, Consultant Psychiatrist (Haringey) Dr H."

Similar presentations

Ads by Google