1. Psychiatric emergencies Assoc.prof. B.Burba

2. Any disturbances in thought, feelings or actions for which immediate therapeutic intervention is necessary Any disturbances in thought, feelings or actions for which immediate therapeutic intervention is necessary Vide range of specialized problems are beyond the general psychiatry (substance abuse, violence, suicide, homicide, rape, homelessness, aging, unemployment, etc.) Vide range of specialized problems are beyond the general psychiatry (substance abuse, violence, suicide, homicide, rape, homelessness, aging, unemployment, etc.)

3. Most primary psychiatric evaluations are done by non-psychiatrists Most primary psychiatric evaluations are done by non-psychiatrists An adequate number of staff members is essential (psychiatrists, nurses, social workers, security, etc.) An adequate number of staff members is essential (psychiatrists, nurses, social workers, security, etc.) Access to medical room and diagnostic services is necessary (one third of medical conditions present with psychiatric manifestations) Access to medical room and diagnostic services is necessary (one third of medical conditions present with psychiatric manifestations)

4. Psychiatric emergencies: epidemiology Men : women = 1 : 1 Men : women = 1 : 1 ~ 20 % suicidal patients ~ 20 % suicidal patients ~ 10 % violent patients ~ 10 % violent patients Most common dgn: depression, mania, schizophrenia, substance abuse, other psychoses Most common dgn: depression, mania, schizophrenia, substance abuse, other psychoses ~ 40 % cases require hospitalization ~ 40 % cases require hospitalization No increase of cases during full moon or Christmas season No increase of cases during full moon or Christmas season

5. Psychiatric emergencies: general strategy Self-protection (get the maximum information about the patient, be alert to risk of impending violence, do not threat the patient, leave physical restraint procedures to trained persons) Self-protection (get the maximum information about the patient, be alert to risk of impending violence, do not threat the patient, leave physical restraint procedures to trained persons) Prevent harm (prevent self-injury and suicide, prevent violence toward others, the most violence is self- defensive!) Prevent harm (prevent self-injury and suicide, prevent violence toward others, the most violence is self- defensive!) Rule out organic causes Rule out organic causes Rule out impending psychoses Rule out impending psychoses

6. Psychiatric emergencies: patient safety The physical and emotional safety of the patient takes priority over all other considerations The physical and emotional safety of the patient takes priority over all other considerations If verbal interventions fail, the use of medication or restraints must be considered and ordered if necessary If verbal interventions fail, the use of medication or restraints must be considered and ordered if necessary The self-assessment should go on throughout the evaluation The self-assessment should go on throughout the evaluation

7. Psychiatric emergencies: evaluation The timely assessment of the patient in crisis The timely assessment of the patient in crisis Making the initial diagnosis Making the initial diagnosis Identification an immediate needs Identification an immediate needs Beginning the treatment (or referring the patient to the most appropriate diagnostic and treatment setting) Beginning the treatment (or referring the patient to the most appropriate diagnostic and treatment setting)

8. Psychiatric emergencies: specific situations Psychosis Psychosis Depression Depression Suicidal patient Suicidal patient Violent patient Violent patient Rape and sexual abuse Rape and sexual abuse Mania Mania Others (serotonin syndrome, tardive dyskinesia, bereavement, etc.) Others (serotonin syndrome, tardive dyskinesia, bereavement, etc.)

9. Psychiatric emergencies: specific situations Case (syndrome) Manifestation Treatment issues Psychosis Extreme psychotic symptoms, agitation, suicidal, homicidal risk, anxiety, threats Screen for medical illness, restraints, rapid tranquilization, hospitalization Depression Self-neglect, low mood, suicidal ideation and attempts, substance abuse Assessment of danger, evaluation of nonpsy- chiatric causes, hospi- talization if necessary

10. Psychiatric emergencies: specific situations Suicide Suicidal ideation, hopelessness Hospitalization, antidepressants Violence Agitation, homicidal ideation and gestures, substance abuse Restraints and rapid tranquilization if necessary, evaluation of causes Rape and sexual abuse Brief psychotic reaction, silent rape reaction, fear of infection or being pregnant Crisis-oriented therapy as rapidly as possible, legal counsel, medical examination, pregnan- cy prevention, etc.

11. Psychiatric emergencies: treatment Psychotherapy: Do psychotherapy as soon as possible Do psychotherapy as soon as possible All attempts are made to improve the patient’s self-esteem All attempts are made to improve the patient’s self-esteem No single approach is appropriate for all persons in similar situation No single approach is appropriate for all persons in similar situation “if you don’t know what to say – the best approach is to listen…” “if you don’t know what to say – the best approach is to listen…”

12. Psychiatric emergencies: treatment Pharmacotherapy: Indications – violent and assaultive behaviour, massive anxiety or panic, adverse effects of drugs, intoxication, paranoid psychoses, catatonic excitement, etc. Indications – violent and assaultive behaviour, massive anxiety or panic, adverse effects of drugs, intoxication, paranoid psychoses, catatonic excitement, etc. Antipsychotics, rapid tranquilization (benzodiazepines), mood stabilizers, etc. Antipsychotics, rapid tranquilization (benzodiazepines), mood stabilizers, etc. IV forms if necessary (with adequate nursing) IV forms if necessary (with adequate nursing) Vital signs monitoring, symptomatic treatment Vital signs monitoring, symptomatic treatment

13. Psychiatric emergencies: treatment Restraints: Restraints: Only when patients are dangerous for themselves or others and the situation cannot be controled in any other way Only when patients are dangerous for themselves or others and the situation cannot be controled in any other way May be temporarily to receive medication or for long periods May be temporarily to receive medication or for long periods Should be done by trained team (min 4 persons) Should be done by trained team (min 4 persons) Reasons should be explained to the patient Reasons should be explained to the patient Always thoroughly document the reason, the course and the patient response to restraints and treatment Always thoroughly document the reason, the course and the patient response to restraints and treatment

14. Psychiatric emergencies: treatment Disposition: Disposition: Allowing the patient additional time in a secure environment can result an improvement Allowing the patient additional time in a secure environment can result an improvement It can minimize the patient the trauma and stress of a psychiatric admission It can minimize the patient the trauma and stress of a psychiatric admission Disposition area should be quite, private and comfortable Disposition area should be quite, private and comfortable Nursing, hygiene, crisis intervention should be available Nursing, hygiene, crisis intervention should be available

15. Psychiatric emergencies: legal issues This is regulated by law (Law of the of mental health care): This is regulated by law (Law of the of mental health care): The law and order according peculiarities of mental health care setting. The law and order according peculiarities of mental health care setting. “Mentally ill person has all human rights - social, political, economical and cultural …” “Mentally ill person has all human rights - social, political, economical and cultural …”

16. Psychiatric emergencies: legal issues Involuntary admission: Only in case of real danger (life or health threat) for the patient or others Only in case of real danger (life or health threat) for the patient or others Only for 48 hours (temporary admission, until the court decision) Only for 48 hours (temporary admission, until the court decision) Right to refuse the treatment: Discharge the patient from the department* Discharge the patient from the department* Get the court permission to treat the patient* Get the court permission to treat the patient* * - 48 hours

17. Psychiatric service in Lithuania Primary mental health care level (munici- pality): pmhcc Primary mental health care level (munici- pality): pmhcc Secondary mental health care level (regio- nal): regional psyciatric hospitals, day-units, out-patient dept., psychiatric dept.in regional general hospitals Secondary mental health care level (regio- nal): regional psyciatric hospitals, day-units, out-patient dept., psychiatric dept.in regional general hospitals Third mental health care level (federal): Kaunas U-ty Hospital, Vilnius U-ty Hospital, Vilnius U-ty Child Development Center Third mental health care level (federal): Kaunas U-ty Hospital, Vilnius U-ty Hospital, Vilnius U-ty Child Development Center

18. Primary mental health care center Staff: psychiatrist, nurse, social worker, psychologist, child psychiatrist Staff: psychiatrist, nurse, social worker, psychologist, child psychiatrist Main goals: Main goals: Primary mental health care Primary mental health care Social support Social support

19. Psychiatric service in Lithuania: forensic psychiatry The setting of care: Out-patient dept. for forensic psychiatry (expertise) Out-patient dept. for forensic psychiatry (expertise) Inpatient dept. for forensic psychiatry (expertise) Inpatient dept. for forensic psychiatry (expertise) Mental hospital for forensic psychiatry (long term treatment of insanity cases) Mental hospital for forensic psychiatry (long term treatment of insanity cases)

20. Psychiatric service in Lithuania: forensic psychiatry Types of forensic expertise (evaluation): Forensic psychiatric exp. Forensic psychiatric exp. Forensic exp. for substance abuse Forensic exp. for substance abuse Forensic psychological exp. Forensic psychological exp.

21. Psychiatric service in Lithuania: forensic psychiatry Goals and types of decision of psychiatric expertise: Responsibility (guilty) Responsibility (guilty) Insanity Insanity Diminished responsibility Diminished responsibility Ability Ability