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
Acute infection (UTI, chest)
Hypoglycaemia
Hypoxia
Head injury – subdural
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 group practice
8.5/ 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