Mental Health Emergencies PDF

Mental health emergencies Nicholas Procter, Monika Ferguson, Graham Munro, Michael A. Roche Essentials Incorporate the needs of individuals and their family/carers into clinically informed responses. People experiencing mental health concerns have be er outcomes when clinical judgement is combined with the ‘voice’ of the individual and their family/carers. Seek help from specialist mental health/drug and alcohol workers to intervene early to prevent an escalation of crisis or recurrence of mental illness. Provide a positive, supportive response without further increasing the risk of stigmatising mental illness or enforcing excessive surveillance and scrutiny, which may increase distress and further alienate the individual. Provide a comprehensive mental state examination with all individuals experiencing mental health problems/mental illness. Active engagement with the individual, carers and other emergency personnel will help ensure that a comprehensive assessment is possible. Continue to conduct regular observations and communicate with the individual, ensuring that their concerns are listened to. Use an accredited interpreter whenever assessing a person who does not speak English. Non-accredited interpreters (such as family members and friends) should only be used in cases of extreme emergency. Be alert to the dangers of self-interest when working with a person who is acutely mentally unwell. Seek help and assistance and make decisions as a team. This is not the time to be a hero. Introduction This chapter guides the practitioner through the considerable challenges of working with people experiencing mental health concerns outside of hospital and on arrival at an emergency department (ED). It encapsulates the best of current practice in mental healthcare relevant to a range of emergency se ings and across the life span. Comprehensive discussion of mental health emergencies is beyond the scope of this chapter; therefore, the material presented here focuses on those conditions seen frequently within the paramedic and ED scope of practice. It is a compilation of practice thinking and innovation in the care of individuals who have symptoms of anxiety, panic, depression, mania, schizophrenia, eating conditions, Munchausen's syndrome, serotonin syndrome and neuroleptic malignant syndrome. A focus is also placed on dual diagnosis, and suicide and selfharm, as well as legal considerations, supportively managing violence and aggression, seclusion and restraint, and cultural considerations. This chapter concludes by highlighting the importance of interprofessional collaboration and the prevention of communication breakdown and clinical pathway deadlock between individual practitioners and organisations. Background Mental health is a growing national concern across Australia and New Zealand. Results from the most recent Australian National Health Survey (2016) indicate that 4 million Australians (18%) reported having a mental or behavioural condition in 2014–15, largely including anxiety-related conditions and mood (aﬀective) disorders (e.g. depression).1 More detailed results can be gleaned from the 2007 National Survey of Mental Health and Wellbeing,2 the most comprehensive understanding of the prevalence of mental illness in Australia. The Survey indicates that one in ﬁve people aged between 16 and 85 years experience at least one of the highly prevalent forms of mental illness (anxiety, aﬀective conditions and substance-use conditions) in any one year. Prevalence rates vary depending upon age and are highest during the early adult years. It is estimated that almost 64,000 Australians (aged 18–64 years) have a psychotic illness and are in contact with public specialised mental health services each year, with prevalence rates being highest for males aged 25–34 years.3 Suicide is also a concern across Australia.4 With the median age at death being 43.3 years for suicide (compared to 81.9 years for all deaths), suicide is the leading cause of death for people aged 15–44 years, and the second leading cause for those aged 45–54 years.4 Hickie and colleagues5 identify the following trends in mental health in Australia: More than half of all health-related disability costs in 15- to 34-year-olds are a ributable to mental health problems. 27% of all years lived with disability in Australia are a ributable to mental conditions. Less than 40% of individuals with mental conditions receive any mental health care in a 12-month period compared with almost 80% for other common physical health problems. 75% of mental health care is provided in the primary care sector, with limited access to specialist support. Almost 50% of individuals with mental conditions are not recognised by their general practitioner as having a psychological problem. Over 50% of psychotic conditions commence before age 25, often with a delay of 2–8 years before ﬁrst presentation for treatment. Up to 60% of cases of alcohol/other substance use could be prevented by earlier treatment of common mental health problems. Although current rates of mental illness among Aboriginal and Torres Strait Islander people are undetermined, data from the 2015 Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples Survey6 outline that Aboriginal Australians are nearly three times as likely as non-Aboriginal Australians to report either high or very high levels of psychological distress. There are also indications for the future of mental health care in Australia. There is an increasing incidence of mental conditions in young people, increased numbers of presentations for care, and more disturbed behaviour, often in association with alcohol or other substance misuse problems. Most likely, the incidence of mental illness across Australia will continue to increase, particularly among younger people, partly because of the adverse eﬀects of current social and environmental factors (including increased family breakdown, decreasing participation in and sense of belonging to community-based structures, such as churches, sporting and recreational associations and social clubs, and increased exposure to substances such as cannabis and illicit stimulants), as well as ineﬀectiveness of current treatment modalities.7 The prevalence of mental conditions among older adults will also continue to rise as the ageing of Australians is accompanied by an increased incidence of vascular, degenerative and other brain conditions.5 There are similar concerns in New Zealand. The most recent statistics from the Ministry of Health8 indicate that the prevalence of high or very high levels of psychological distress among those aged 15 and over was 6.8% in 2015–16. Of note, this rate was higher for females (9%), Māori and Paciﬁc adults (11%), and those living in the most socioeconomically deprived neighbourhoods (11.5%). Further, rates of distress decreased with age, from 8% among those aged 15– 44 years, to 5% for those aged 65 years and over. While a high or very high level of psychological distress can indicate a high probability of a person having a diagnosis of anxiety or depression, this data does not tell us about mental health diagnoses speciﬁcally. Although becoming dated now, further information can be gleaned from the Te Rau Hinengaro or New Zealand Mental Health Survey, which was undertaken between 2003 and 2004, as a nationwide faceto-face household survey of residents aged 16 years and over. It aimed to estimate the prevalence and severity of anxiety, mood, substance and eating conditions in New Zealand, and associated disability and treatment. There were 12,992 participants (including 2595 Māori and 2236 Paciﬁc Island people). Compared with other World Mental Health survey sites, New Zealand has relatively high prevalence, although almost always a li le lower than for the United States.9 Key ﬁndings of the survey were as follows:10 46.6% of the population were predicted to meet criteria for a condition at some time in their lives, with 39.5% having already done so and 20.7% having had a condition in the past 12 months.11 Younger people had a higher prevalence of mental illness in the past 12 months and were more likely to report having ever had a mental illness. Females had a higher prevalence of anxiety conditions, major depression and eating conditions than males, whereas males had substantially higher prevalence of substanceabuse conditions. Prevalence was higher for people who were disadvantaged, whether measured by educational qualiﬁcation, equivalised household income or living in moredeprived areas.12 Prevalence was higher for Māori and Paciﬁc Islanders than for the other composite ethnic group. The 12-month prevalence was 29.5% and 24.4% respectively for Māori and Paciﬁc Islanders (compared to 20.7% for the total New Zealand population). This appears to largely be a ributed to the youthfulness of these populations and their relative socioeconomic disadvantage.13 People with more serious mental condition in the past 12 months were more likely to have visited the healthcare sector for mental health reasons, including for problems relating to their use of alcohol/other drugs. However, the proportion making a visit is low—only 58.0% of those with serious mental illness, 36.5% of those with moderate mental illness and 18.5% of those with mild mental illness.13 Co-morbidity of mental illness (the experience of more than one condition/disease by an individual) is common, with 37.0% of those experiencing 12-month mental illness having two or more conditions (most frequently mood and anxiety conditions). Co-morbidity is associated with suicidal behaviour and increased service use. There is also co-morbidity between mental and physical conditions. People with mental illness have a higher prevalence of several chronic physical conditions compared to people without mental illness of the same age. People with chronic physical conditions are also more likely to experience mental illness compared with those without physical conditions. In the New Zealand mental health survey, 15.7% reported having thought seriously about suicide (suicidal ideation), 5.5% had made a suicide plan and 4.5% had made an a empt. The risk of suicidal ideation in the past 12 months was higher in females, younger people, people with lower educational qualiﬁcations and people with low household income, and among people living in moredeprived areas.14 In terms of suicide deaths, 508 New Zealanders died by suicide in 2013, with the highest rates being for males, Māori, youth (15–24 years) and people living in the most deprived areas.8 Various Australian mental health policies15,16 acknowledge that many of the determinants of good mental health, and of mental illness, are inﬂuenced by factors beyond the health system. The Fifth National Mental Health and Suicide Prevention Plan16 stresses a commitment for governments across Australia to work together towards integrated planning and delivery of services, and ensuring that consumers and carers play a central role in the service planning, delivery and evaluation. It also emphasises the critical need to address social and emotional wellbeing across the nation, and to address the physical health needs of those experiencing mental illness. This is particularly important to paramedical and other health personnel working in the context of signiﬁcant eﬀorts being made to combine mental health services within the general health system and a community-based system of assessment, treatment and support. A whole-of-government, cross-sectorial approach is based upon principles of human rights and equity, and the belief that integrated mental health and community services could and should provide holistic care to individuals in a manner that contributes to the prevention of illness and the reduction of stigma.17 Practice tip People who live with mental illness are also more at risk of physical health problems (e.g. cancer, cardiovascular illness or diabetes) and average life expectancy is shorter. Be equally alert to physical and mental health. Apply this knowledge to the person's assessment and treatment. Prevalence of mental health admissions in EDs As indicated by the prevalence of mental illness in Australia and New Zealand, mental health in emergency situations is also a growing concern, with increasing numbers of distressed people presenting in mainstream hospital and community se ings.17 Certain mental health presentations are more common in EDs than others. In Australia, it was estimated that there were over 273,000 ED visits with a mental-health related principal diagnosis during 2015– 16, although this number is believed to be an underrepresentation due to diﬃculties with deﬁning mental and behavioural disorders, and in capturing self-harm presentations in these statistics.18 The most common principal diagnoses were either: mental and behavioural conditions due to psychoactive substance use (29%); neurotic, stress-related and somatoform conditions (26%); or aﬀective conditions (12%). Schizophrenia, schizotypal and delusional conditions accounted for a further 11% of visits. Individuals aged 15–54 accounted for a higher proportion of mentalhealth-related visits (79%) compared to all ED visits (49%), and males (52%) had a slightly higher proportion of presentations compared to females (48%). Thirty-six per cent of these presentations resulted in a hospital admission. The National Disability Insurance Scheme (NDIS) was introduced in 2016 in Australia. The NDIS is a national approach to individualised, self-directed care for people with physical, intellectual or psychosocial disability. There are suggestions that this scheme has not accounted for suﬃcient numbers of mental health consumers, with a signiﬁcant reduction in services to more than 100,000 people.19 Similarly, the episodic nature of many mental illnesses will make it diﬃcult to establish the permanent impairment necessary to access the scheme, again reducing the numbers of those in receipt of services.20 There are also potential impacts on people with co-morbid intellectual and mental illnesses, a high proportion of whom already have signiﬁcant contact with ED and other acute y g It therefore appears likely that emergency services will have increased contact with people diagnosed with mental illness, consequent to the introduction of the NDIS. For further discussion on the NDIS see Chapter 37 People with disabilities. services.21 Supporting individuals in the out-ofhospital environment As with all aspects of the assessment and management of patients, it is important to be able to review, synthesise and analyse the most recent literature and the various approaches to patient care in the out-of-hospital environment. A selection of ambulance service clinical practice guidelines from Australia, New Zealand, Canada, Ireland and the United States have been examined and summarised here with respect to their approaches to the management of a person experiencing a mental health emergency.22–35 Mental health response teams Guidelines for the management of an individual experiencing a mental health crisis in the out-of-hospital environment vary slightly from state to state in Australia and New Zealand and in other jurisdictions around the world. In some areas of Australia and New Zealand, special teams exist, comprising a mental health professional, a police oﬃcer, or a paramedic, that respond to requests for the management of a person experiencing a mental health crisis. The focus of these teams is to provide a person-centred approach to assessment and intervention. They can manage the person at the scene and, if required, facilitate transport to alternative destinations, such as a medical clinic or other type of mental health facility. The teams provide alternatives to management and transport by ambulance service paramedics, which reduces the burden on the ambulance services and hospital EDs.36–41 Intervention by paramedics Prevalent across clinical practice guidelines is the importance of ensuring the personal safety of the paramedics, the patient and all others at the scene. If, upon initial contact, paramedics determine there is a potential for harm to themselves or others, then quickly exiting the scene to a place of safety is recommended. In addition, contact with police services is strongly advised to assist with management of the situation. In most cases, an a empt to establish a rapport with the patient is recommended, along with the use of de-escalation techniques as an initial intervention. The primary focus of de-escalation is to enable the person to rapidly regain control of their own behaviour.42 Supporting a person to shift from an agitated state to a calm state using a de-escalation technique should take between 5 and 10 minutes.43 There is no universally accepted model of de-escalation technique,20 but there are some commonly shared aspects of intervening with an aggressive or agitated person: 1. Respect personal space 2. Do not be provocative 3. Establish verbal contact 4. Be concise 5. Identify wants and feelings 6. Listen closely to what the person is saying 7. Agree or agree to disagree 8. Set clear limits 9. Oﬀer choice and optimism.40 The normal rules of safety within a structure or outside area apply. These include: Ensure that you have clear access to an exit —never let the person or others get between you and that exit. Don't insist on performing clinical procedures like taking a BP or starting an IV. Focus on the issues at hand. Avoid verbal confrontations. Reassure the person that you are there to help. If you need to medicate the person, obtain their consent, whenever possible, and assure them that it will help them to calm down.44 Pathways to the ED People experiencing signiﬁcant distress associated with their mental health can come to the a ention of emergency mental health services in a number of ways. They may present to an ED via their own mode of transport, or that of a family member/carer. They may also be transported by a community mental health team, or by police oﬃcers. Alternatively, paramedics may transport the individual via ambulance. Whatever the pathway, the safety of the person in distress, the a ending professionals, family members and bystanders are major priorities. Guidelines for the transport of an individual to hospital via ambulance vary from state to state. The details here use current Victorian protocol45 as an example (it is recommended that readers use this as a guide only, in conjunction with speciﬁc legislation and protocols within their state/territory). The Victorian protocol recognises the need to provide a person-focused approach, in which the individual, their family/carer and other health/mental health professionals are involved in the transport decision. Where a decision has been made that a person requires admission to an approved mental health service, a decision about the most appropriate form of transport should include assessing: the individual's physical and mental state the individual's immediate treatment needs the risk of harm the individual poses to themselves and others the likely eﬀect on the individual of the proposed mode of transport expressed wishes of the individual and/or their carer(s), where practicable availability of the various modes of transport, including non-emergency patient transport vehicles the distance to be travelled the individual's need for support and supervision during the period of travel. In certain circumstances, consideration should ﬁrst be given to non-ambulance transport (other options include private vehicle, mental health professional agency vehicle, non-emergency patient transport vehicle). Transport via police vehicle should be regarded as a last resort (used only when absolutely necessary, such as when an individual is in police custody), due to the potential to give the impression that the person is suspected of having commi ed a crime, which could cause unnecessary distress and anxiety, and perpetuate stigma. Where an individual is detained under the relevant Mental Health Act (see Chapter 4), the police must maintain their custody and therefore will remain until the conclusion of the person's mental health assessment, even if the person is transported by ambulance to the ED. If it is decided that an ambulance is the preferred mode of transport, the ambulance responses are categorised into the following three codes: emergency, urgent and routine (see Table 36.1). Generally, people experiencing a mental illness who may require transport to hospital need to be assessed by a health/mental health professional ﬁrst, to determine whether hospitalisation is required, as well as what form of transport is needed. Sometimes, such as in cases of an overdose, an individual/family member/carer will need to contact ambulance services directly. In these instances, a judgement will be made by the ambulance service to categorise the request in accordance with Table 36.1. If, upon ambulance arrival, the person appears to have a mental illness but does not require hospitalisation, then the local mental health service triage must be contacted to arrange appropriate management. If the person requires hospital treatment but refuses ambulance transport, the paramedics must contact the local area mental health service triage to organise a more urgent response. TABLE 36.1 Categories of ambulance response45 AMBULANCE CATEGORY RESPONSE AND ACUITY Code 1— Emergency response using lights and emergency sirens, with person being transported to nearest appropriate ED for treatment/stabilisation. Code 2— A response (no lights and sirens) where urgent the person is transported to the nearest ED or nearest appropriate mental health service. Code 3— routine DESCRIPTION There is an actual or potential risk that the person's life is immediately threatened (e.g. suicide a empt or overdose of harmful substance) The person: exhibits evidence of acute mental illness, accompanied by agitation, distress, impulsivity, unpredictability and/or propensity to destructive acts has a empted/threatened suicide but their life is not immediately threatened is unable to be contained safely in a care or support situation in the community and has been sedated to enable safe transport requires approved mechanical restraint for safe transport, or is in crisis and has been apprehended by police under the Mental Health Act. In some circumstances (e.g. in rural Adequate care is currently being areas), a person will need to be provided, but the person requires transported to the nearest transport to an approved mental appropriate approved mental health health service (e.g. inter-hospital service for admission (rather than transfers). Other forms of transport the catchment area service the have been considered and deemed person should normally be unsuitable by the mental health admi ed to). This may occur where professional. either: the person's wellbeing may be adversely aﬀected by a long-distance transfer, or a long-distance transfer at that time might adversely aﬀect the provision of acute ambulance care in the rural community from which the ambulance would need to be dispatched. Out-of-hospital assessment and management Responding to people experiencing mental health emergencies can be common for paramedics and therefore paramedics play a crucial role in out-of-hospital assessment, treatment and care, particularly in instances when assistance from mental health services is not present (for example, when an ambulance has been requested by a member of the community, rather than by a community mental health team). Assessing the current status of the person's mental health can be accomplished by using one of several available assessment procedures.25,46 A key component of this assessment is the requirement to eliminate all possible organic/medical causes for the person's behaviour, before initiating any interventions based on an assessment of mental illness. Such causes can include hypoglycaemia, hypoxia, sepsis, head injury, dementia and substance abuse.28 Paramedics are also well placed to undertake a screening mental state examination (mental health assessment) to determine if the person is at risk of self-harm or harm to others, is becoming aggressive and whether action is required to reduce this risk. A screening mental state examination involves enquiring about the individual's current circumstances and any recent changes in their life, as well as understanding their present thought processes and content, actions, emotions and feelings.47 Consultation with any family and friends present can further assist with understanding the individual's current behaviour and experiences. Conducting screening risk and mental state assessments at ﬁrst contact can also help build a clinical picture over time, documenting any signiﬁcant change in behaviour, suicidal ideation or clinical presentation. An example of a mental state examination is provided in Table 36.2. TABLE 36.2 Mental status examination48 PROCEDURE Assess the patient appropriately to ascertain the cause of the presenting signs and symptoms Exclude and/or manage causes of abnormal behaviour where possible Using the guide to mental status examination, observe, question and note relevant information. This must be conducted in a highly respectful and empathetic manner. Judgemental a itudes, interrogatory questioning styles or other disrespectful stances will usually only serve to exacerbate a patient's condition. Be mindful that diﬀerent cultures hold diﬀerent beliefs about mental illness. For some cultures, mental health is determined by physical and/or spiritual inﬂuences. For others, mental illness is a taboo subject and is not discussed openly. MENTAL HEALTH ASSESSMENT GUIDE Appearance grooming Thought amount posture form rate build derailment clothing ﬂight of ideas cleanliness Behaviour eye contact Thought disturbances mannerisms content delusions gait suicidal activity obsessions level Speech rate Perception illusions volume thought pitch insertion tone broadcasting ﬂow hallucinations pressure Mood Emotion Insight cognition as and illness described: judgement anxious understandin depressed g cheerful cause and eﬀect Aﬀect Emotion as observed: restrictive blunted labile CC BY-NC-ND 4.0 Once the assessment of the person's mental state has been completed, the paramedic must then decide which course of action is required. If a mental health assessment team is present, they can take responsibility for the person and determine if a referral is appropriate or if more deﬁnitive intervention is required.40 If the team is not present, they can be requested to a end if the situation is deemed safe to do so. If a team is not available, then the paramedic must decide what course of action is in the best interest of the person. Prior to transfer to the most appropriate place of care (and if time permits), paramedics are well placed to enquire about and document the immediate home or living environment and all collateral contacts, including any eﬀorts to obtain collateral information from them. Other documentation to be completed by paramedics includes the use of mechanical devices or pharmacological agents for restraint and any adverse events that compromise safety to paramedics, the person being transported, family members or bystanders. In many instances there will be no mental health professional present or available to assess or assist with the person. In severe cases, paramedics may be required to administer pharmacological interventions such as lorazepam (1–2.5 mg orally) or midazolam (5– 10 mg intramuscularly) and provide physical restraints—sometimes without the need to consult a mental health practitioner. Practice tip Responding to a person experiencing mental health emergencies in the out-of-hospital environment requires an assessment of the person's current mental state, including an assessment of the person's presenting signs and symptoms, to eliminate alternative causes for their current presentation. A mental health assessment includes exploration of the person's appearance, behaviour, speech, mood, aﬀect, thoughts, perception and judgement. ED triage assessment Upon arrival at the ED, the ﬁrst step in the care process is triage assessment. In mental health emergencies, the screening and classifying of distressed persons to determine priority needs and actions calls for sharp assessment skills and eﬃcient use of human resources, equipment and other resources. If appropriate resources are not available for urgent cases, then steps should be taken to bring these to the individual as soon as possible. Table 36.3 has been adapted from best-practice principles currently used in New South Wales49 (again, it is important to ensure that readers also access protocols from their own state/territory, as these may vary). It outlines some key markers for determining mental health triage categories and the typical presentations observed or reported by secondary (non-consumer) sources. While these categories diﬀer in their degree of risk, complexity and cross-cultural applicability, they do oﬀer a consistent approach to decision-making following initial screening of all incoming referrals and admissions to the ED. It is worth noting that, similar to all ED presentations, 78% of mental health-related presentations in 2015–16 were classiﬁed as semiurgent or urgent (individual to be seen within 60 minutes and 30 minutes respectively), less than 15% were classiﬁed as emergencies, and approximately 2% required resuscitation.18 For further information on triage practice see Chapter 11. TABLE 36.3 Mental health triage assessment in the emergency department49 TRIAGE CATEGORY AND TREATMENT ACUITY 1 Immediate 2 Emergency Within 10 minutes DESCRIPTION Deﬁnite danger to self or others Probable risk of danger to self or others AND/OR Client is physically restrained in ED AND/OR Severe behavioural disturbance Australasian Triage Scale states: Violent or aggressive: Immediate threat to self or others Requires or has required restraint Severe agitation or aggression TYPICAL PRESENTATION OBSERVED AND/OR REPORTED Observed: Violent behaviour Possession of a weapon Self-harm in ED Displays extreme agitation/restlessness Bizarre/disoriented behaviour Reported: Verbal commands to do harm to self or others that the person is unable to resist (command hallucinations) Recent violent behaviour Observed: Extreme agitation/restlessness Physically/verbally aggressive Confused/unable to cooperate Hallucinations/delusions/paranoia Requires restraint/containment High risk of absconding and not wanting treatment Reported: A empt/threat of self-harm Threat of harm to others Unable to wait safely TRIAGE CATEGORY AND TREATMENT ACUITY 3 Urgent Within 30 minutes DESCRIPTION Possible danger to self or others Moderate behavioural disturbance Severe distress Australasian Triage Scale states: Very distressed, risk of self-harm Acutely psychotic or thought-disordered Situational crisis, deliberate self-harm Agitated/withdrawn 4 Semi-urgent Within 60 minutes Moderate distress Moderate distress Australasian Triage Scale states: Semi-urgent mental health problem Under observation and/or no immediate risk to self or others 5 Non-urgent Within 120 minutes No danger to self or others No acute distress No behavioural disturbance Australasian Triage Scale states: Known patient with chronic symptoms Social crisis, clinically well patient TYPICAL PRESENTATION OBSERVED AND/OR REPORTED Observed: Agitated/restless Intrusive behaviour Confused Ambivalence about treatment Not likely to wait for treatment Reported: Suicidal ideation Situational crisis Presence of psychotic symptoms: Hallucinations Delusions Paranoid ideas Thought disordered Bizarre/agitated behaviour Presence of mood disturbance: Severe symptoms of depression Withdrawn/uncommunicative And/or anxiety Elevated or irritable mood Observed: No agitation/restlessness Irritable without aggression Cooperative Gives coherent history Reported: Pre-existing mental health disorder Symptoms of anxiety or depression without suicidal ideation Willing to wait Observed: Cooperative Communicative and able to engage in developing management plan Able to discuss concerns Compliant with instructions Reported: Known patient with chronic psychotic symptoms Pre-existing non-acute mental health disorder Known patient with chronic unexplained somatic symptoms Request for medication Minor adverse eﬀect of medication Financial/social, accommodation or relationship problems For each presentation the assessor should answer the following questions: Can I safely interview this person on my own, or do I need backup? Is the person going to be safe where they are? Can the person be left alone and/or with others safely? What degree of observation does the person need and can it be provided in the ED? Where is the most appropriate place to interview the person given their level of arousal and agitation? Answering these questions will help make the fullest and safest triage assessment possible, to beneﬁt the person, their family/carers and the treatment team. The assessment must be recorded clearly and, if decisions are made, reasons given. In many instances the assessment will involve formulation of a diﬀerential diagnosis— most commonly for episodic referrals. It will be teamwork and interdisciplinary consultation, collaboration on the need for further investigations and active involvement of sub-specialties in clinical cases that will help determine an appropriate clinical pathway. The names of other colleagues who are consulted or involved in the decision must also appear in the clinical record. After triage Once the triage assessment has been made, a brief mental state assessment will be conducted, usually by a general nurse and/or medical oﬃcer. As previously discussed, the purpose of the mental health assessment is to obtain information about speciﬁc aspects of the individual's mental health experiences and behaviour at the time of interview (see Table 36.2). If necessary, the individual will then be referred to the mental health team for a further interview, with an assessment conducted by a mental health liaison nurse consultant. Following this assessment, the mental health nurse, in consultation with the mental health team and the referring medical oﬃcer, will make a decision about the next course of action. In instances where immediate care is needed, the individual will then be admi ed to hospital. Alternatively, if it is deemed safe and in the best interests of the individual to go home, the mental health nurse will provide them with information regarding support services in the community. These services should be as speciﬁc to the concerns experienced by the individual as possible. In instances where it is clear that additional community support is needed, the nurse will make a referral to a community mental health team. Refer to Chapter 11 for further discussion on triage. Referral and care continuity Crucial to the practice of eﬀective mental health interventions is the way that an assessment is communicated, the way in which symptoms are described and the language used by both practitioners and the individual in this process. The formulation of a succinct summary of a person's history, current circumstances and main problems will help set the diagnosis in context.51 It is particularly useful in conveying essential information upon discharge, when making a referral to a specialist mental health service or when referring for other specialist intervention. The time taken to communicate assessment ﬁndings will go a long way to help ensure continuity of information and, if more than one provider is involved, continuity of the therapeutic relationship and timely referral for additional assessment or care (Box 36.1). Box 36.1 Important items for referral to additional services 5 0 Description of the presenting complaint, its intensity and duration. Relevant current and past medical history and medication. A note of mental state examination results with key or contradictory ﬁndings highlighted. An estimate of degree of urgency in terms of risk to the consumer and others. Indication of referrer's expectations (assessment, advice, admission). The most urgent requests should be reinforced by telephone or email. The role of ED mental health liaison nurse consultants In some Australian states and territories, general hospitals have employed mental health liaison nurse consultants to assist with clinical assessment and treatment of people experiencing mental health problems/mental illness. The role is developed and deﬁned by the needs of the hospital/health service. The main workload is assessment and support for individuals with new or pre-existing mental illness, management of emotional complications of physical illness or trauma, management of the behavioural disturbance, assessment of abnormal social behaviour, management of behavioural and emotional consequences of intoxication and drug use and clinical assessment following a empted suicide and selfharm. High consumer satisfaction with the role has been found, particularly in terms of the service provided, information oﬀered and improvements to consumer health outcomes.52 Similarly, recent evidence indicates that this role can play an important part in EDbased outpatient services, particularly regarding improved consumer access to specialised mental health care.53 Psychiatric Emergency Care Centres Extending the role of liaison nurse consultants, many hospitals now have Psychiatric Emergency Care Centres (PECCs), which have been co-located alongside EDs. These centres serve to provide timely, specialist mental health assessment on-site in the ED.54 Generally, these services oﬀer 24-hour mental health staﬀ presence. PECCs also provide high-level observation/immediate care for people requiring short-term mental health care (usually up to 48 hours). While the nature of work undertaken within a PECC may vary across jurisdictions, there is usually a protocol for fast-tracking mental health assessments of ED presentations. The PECC environment should be one that is constantly monitored, with the provision of providing appropriate use of sedation and restraint only when necessary and in line with local policies and clinical protocols. Mental health conditions This section outlines various mental health conditions that may be seen in emergency situations. The symptoms and diagnostic characteristics described are based on the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders.55 The WHO International Classiﬁcation of Diseases56 can also be used for diagnosis. It is critical to note that while these descriptions are important, each individual will experience mental health conditions diﬀerently, and so presentations of the same diagnosis might diﬀer from person to person. Additionally, many individuals will experience co-morbidity—that is, a diagnosis of more than one condition. At all times, care should be tailored to the individual as much as possible. By their very nature, mental health conditions must be assessed holistically, taking account of psychosocial, cognitive, biological and interpersonal domains. Assessment therefore requires the practitioner to have an understanding and recognition of the symptoms of mental health conditions, and to be able to distinguish these from physical health diagnoses. Assessment is primarily made through talking to the individual and, where possible, their family/carers/friends and any other professionals involved in their care. Various assessment tools can be used for the diﬀerent conditions, and typically these will be in a questionnaire-type format, addressing the experience of various symptoms. However, a richer and deeper understanding will come from listening to the individual sharing their story, as well as from observations of the individual's behaviour. Anxiety conditions Anxiety is the most commonly experienced mental health condition, aﬀecting approximately 11% to 15% of Australians and New Zealanders aged between 16 and 85 years, with a higher prevalence in women than men.1,10 Some of the anxiety conditions include generalised anxiety, obsessive compulsive conditions, social phobia, panic condition, agoraphobia, speciﬁc phobia and post-traumatic stress. Common to all of these is excessive fear and anxiety, as well as related physical/behavioural symptoms; often this experience is so overwhelming that it can interfere with a person's day-to-day functioning. While the causes of anxiety are not fully understood, it is likely that a particular anxiety condition is a result of several interacting factors and is aﬀected by stressful life events and personality traits such as:57 excessive or unrealistic worries (generalised anxiety condition) compulsions and obsessions which the individual cannot control (obsessive compulsive condition) intense excessive worry about social situations (social anxiety condition) panic a acks (panic condition) an intense, irrational fear of everyday objects and situations (phobia). Generalised anxiety condition Generalised anxiety is one of the more commonly experienced anxiety conditions. Many individuals diagnosed with this condition report having experienced feelings of anxiety and nervousness throughout their lives.54 Symptoms and diagnostic criteria The symptoms of generalised anxiety involve excessive anxiety or worry about particular life domains, which is perceived to be diﬃcult to control by the individual. Symptoms are both psychological and physical (see Box 36.2 for diagnostic criteria). Box 36.2 Criteria for diagnosing generalised anxiety 5 5 People diagnosed with generalised anxiety describe excessive anxiety or worry for the majority of the week for at least 6 months. The person may be preoccupied about work and work relationships, performing well at school or at some other activity. Despite their best eﬀorts, the person struggles to control or block out their worries and preoccupations. At the same time they may experience motor restlessness, irritability, diﬃculty in concentration, feeling highly strung and unable to process everyday information. The physical eﬀects of generalised anxiety include tense and sore muscles and disturbed sleep. Where sleep is possible, it may be only for short periods and unsatisfying. The change in the person's behaviour is not a ributable to the physiological eﬀects of a substance or to another medical condition. Management Treatment can help people manage, reduce or even eliminate anxiety symptoms. Diagnosis is generally made by a psychiatrist. Clinical psychologists, social workers or counsellors often manage ongoing treatment. Eﬀective treatments include medication, cognitive behavioural therapy and community support and recovery programs. During cognitive behaviour therapy, a person learns new and eﬀective ways to cope with their symptoms. The skills of the nurse will include cognitive behavioural interventions, understanding the nature of the concern, oﬀering reassurance and focusing on the positive abilities of the person to take control of the situation, to overcome the limitations of their thinking. Panic Due to the associated physical symptoms of a panic a ack, people experiencing this condition might present to the ED. Panic condition has a high co-morbidity with other anxiety and depressive conditions.58 Symptoms and diagnostic criteria Panic condition is signiﬁed by recurrent, unexpected panic a acks. The acute panic a ack usually begins with a sudden onset. Key diagnostic criteria are described in Box 36.3. Box 36.3 Criteria for diagnosing a panic condition 5 5 People diagnosed with a panic condition experience an overwhelming and abrupt surge of intense fear and discomfort that reaches a peak usually within a short time-frame (usually minutes). The person is visibly distressed, often sweating, with a rapid and thumping heartbeat. They may also be trembling and describe a sense of impending doom. Additional feelings and sensations include shortness of breath and a feeling that the person is not breathing in adequate amounts of air. The person may also feel as if they are suﬀocating or choking. The strength of emotions and feelings of dizziness and/or light-headedness may be accompanied by a fear of losing control or ‘going crazy’, or perhaps a fear of dying. For the diagnostic criteria to be met, the panic a ack itself must have been followed by at least 30 days of at least one of the following: (a) persistent concern/worry about additional panic a acks or their consequences; or (b) a signiﬁcant maladaptive change in behaviour related to the panic a acks. The change in thought, feeling and behaviour is not a ributable to the physiological eﬀects of a substance or to another medical condition. Management The skills needed to manage panic are to be calm and reassuring and to reduce unnecessary or distressing stimulation. The practitioner should speak in a calm and controlled voice, asking the person to focus on their breathing, talking to them in such a way that they are helping to de-escalate the situation, le ing the person know that they are in a safe and protective environment and that they are likely to feel be er once they regain control of their situation. Actively helping the person to relax, and educating other practitioners to take a similar stance, will greatly enhance the person's ability to reduce the intensity of the panic. It may be necessary to have a relative, friend or carer sit with the person, working closely with the practitioner to reinforce that they are safe and that no one intends to make their situation worse or bring harm. Aspects of communication with a person in the acute phase of panic are discussed in Box 36.4. Box 36.4 Aspects of communication with a person in the acute phase of panic 5 9 Foster trust and conﬁdence—stay with the individual; ensure continuity of practitioners; reassure the individual that they are not dying, will not lose consciousness, that you are working with others to help resolve the situation and restore calm. This will help counter the feeling of being out of control, a fear of having a heart a ack or of losing one's mind. Model calmness and reassurance—have the individual follow you in the taking of long, deep breaths. Breathing with the individual will help encourage teamwork and joint problemsolving. Slow, deep breathing can help reduce panic to a manageable level of anxiety. Individuals experiencing a panic state may take their physiological symptoms as an indication that they are going to die. Self-monitor your own reactions to acute panic—do some deep breathing, use quiet pauses and seek out support from colleagues to maintain self-conﬁdence and clear thinking. Acute anxiety can be transmi able from one person to another and this can create a roller-coaster of emotions. Practice tip Be alert to the contagion eﬀects of anxiety and panic, and guard against them. Front-line workers working in high-stress environments must initiate self-care to reduce the impact of mental health presentations on their own health and wellbeing. Affective conditions Aﬀective conditions involve a change in aﬀect or disturbance in mood. Aﬀective conditions are experienced by women more than men (7.1% versus 5.3% in Australia; 9.5% versus 6.3% in New Zealand).2,10 Some aﬀective conditions include major depression, mania (as a feature of bipolar condition) and postnatal depression. Major depression Depression aﬀects the way someone feels, causing a persistent lowering of mood. In 2014–15 it was estimated that more than 2 million Australian adults experienced depression.1 Globally, depression is the third leading contributor to the disease burden.60 Symptoms and diagnostic criteria Depression is often accompanied by a range of physical and emotional symptoms that can impede the way a person is able to function at home, at work and in their everyday life. Key diagnostic criteria are outlined in Box 36.5. Box 36.5 Criteria for diagnosing a major depressive condition 5 5 People diagnosed with a major depressive condition often experience a feeling of depressed mood for most of the day, nearly every day for the week just past. There may be a markedly diminished interest or pleasure in most or a majority of activities for several days during the past 14-day period. The marked diminished interest in pleasure is often indicated by a subjective account or observation from others (for example, work colleagues or family members). At the same time there may be signiﬁcant weight loss (when the person is not actively dieting) or weight gain, or a decrease in appetite nearly every day. They may have diﬃculty sleeping (either ge ing to sleep or staying asleep) or hypersomnia reported nearly every day. The subjective impression of the person is that they are ‘not the same’, with noticeable psychomotor agitation/retardation nearly every day (observable by the person, and noticeable to others, and not merely subjective feelings of restlessness or being slowed down). An overwhelming feeling of fatigue and/or loss of energy nearly every day may leave the person in a distressed and unse led state of mind. There may also be impairment in family, social, employment or other important areas of daily functioning. The change in thought, mood and behaviour is not a ributable to the physiological eﬀects of a substance or to another medical condition. Management Management of depression can involve medication, individual therapy or community and social support programs—or a combination of all three. Medications assist the brain to restore its usual chemical balance, helping to control the symptoms of depression. Individual therapy involving a doctor, psychologist or other healthcare professional talking with the person about their symptoms, and discussing alternative ways of thinking about and coping with them, can be eﬀective, particularly in building conﬁdence and self-esteem. Similarly, community support programs are most helpful when they include information about the condition, accommodation support and options and help with ﬁnding suitable employment, training and education, psychosocial rehabilitation and mutual support groups. Understanding and acceptance by the community—including the therapeutic community in the ED—is also very important. Postnatal depression Postnatal depression is a signiﬁcant clinical condition experienced by approximately 14% of women who give birth in Australia and New Zealand.61,62 The risk factors for postnatal depression include a personal or family history of depression, severe ‘baby blues’, ambivalence towards or unwanted pregnancy and poor social and/or partner support. Postnatal depression is much less common than the postnatal blues but if left untreated may become a chronic condition. Symptoms The clinical features of postnatal depression are similar to those of major depression, although during a mental state assessment there may be thought content that includes worries about going outside the home, and worries and concerns about the baby's health or the ability to cope adequately with the baby. Management Management of postnatal depression is largely supportive, educative and interactive between practitioner and consumer. Providing an explanation of the condition and education about treatment can provide a certain amount of relief. This can help women and their partners give meaning to their experience and prevent unhelpful worry that they are ‘going crazy’ or that their situation is one of personal failure because they are unﬁt to be a mother. Explaining what postnatal depression is, how it is not related to personal shortcomings and giving ample opportunity for the mother to talk openly and freely about such things as her relationship with her own mother, her partner, her disappointments, frustrations or stressors can generate trust and informed awareness of the situation. The emergency nurse can assist with organising help with childcare or respite, placing the woman in touch with support organisations and peer support workers, helping the woman recruit ongoing help and support from her GP, family and friends and referring the woman to professional mental health care. Depression in later life Consistent with global ageing estimates,63 it has been predicted that the number of people aged over 65 years will be within 1.28–1.37 million by around 2040 in New Zealand, and by the 2050s it is predicted that approximately 25% of those aged 65+ will be 85+.64 Similarly, in Australia, the proportion of the population aged 65–84 years is predicted to be 18% by 2055 (or 7 million people), and nearly 5% of the population will be aged 85 and over at this time.65 While many people can age well, growing older also presents certain challenges, including increased isolation and loneliness, deaths of partners and/or friends, as well as the development of medical conditions and cognitive decline,66 all of which can contribute to feelings of alienation, hopelessness and lowered self-esteem.67 Not surprisingly, depression is one of the most common mental health concerns in later life and can have severe eﬀects on physical health and social relationships. Management Treating depression in older people requires ﬂexibility and sensitivity, such as working at a slower pace and being prepared for the potential need to repeat conversations when interacting with older adults.68 In addition, the use of pharmacological treatment needs to be considered with caution, as such treatments can place older people at increased risk of injury as a result of adverse eﬀects.69 The emergency nurse can support a person with depression in later life by promoting activities that improve nutrition, social interaction and social support and family relationships. While this might seem diﬃcult to do in a busy ED, the promotion of supportive activities in the presence of family, for example, can go a long way to support messages that are being given by others (GPs, community nurses) who will also have contact with the consumer in the community. Some consumers may have a negative view of themselves as people, of their contribution to family and society and of their future. Family members, social support networks and others important in the life of the consumer should be reminded that depression is not a weakness or a failure and that family education and social support and, in some instances, antidepressant medication can bring considerable beneﬁt. Manic episode A manic episode is a period of unusually elevated mood and irritability which aﬀects occupational and social functioning. Such an episode is typically experienced by individuals with a diagnosis of bipolar I condition. Symptoms and diagnostic criteria A manic episode is primarily marked by symptoms of elevated mood and a tendency to engage in behaviour that could have serious social or ﬁnancial consequences.70 Diagnostic criteria are listed in Box 36.6. Box 36.6 Criteria for diagnosing a manic episode 5 5 At the time of a manic episode people experience a distinct period of abnormally and persistently elevated, expansive or irritable mood and out-of-character and persistently increasing goal-directed activity or energy. These combined experiences last at least 7 days and are present most of the day, nearly every day. The symptoms at this time are such that immediate hospitalisation may be required. During the episode the person displays disturbed mood and increased energy or physical activity and there is a noticeable change from their usual behaviour, incorporating the following symptoms: a feeling of overstated self-esteem/grandiosity; a decreased need for rest or sleep; being extravagant and overly more talkative than usual, with a pressure to keep talking. There is a discernible rapid thinking—sometimes described as a ‘ﬂight of ideas’. The subjective experience at this time is that thoughts are racing and the person is easily distracted, giving rise to a ention being too easily drawn to insigniﬁcant or immaterial external stimuli. Disturbance in mood is so severe as to cause marked impairment in functioning in social, family and work-related activity. The change in behaviour is not a ributable to the physiological eﬀects of a substance or to another medical condition. Management The speciﬁc management of a manic episode will include administration of medication (usually a benzodiazepine or antipsychotic in acute behaviour disturbance), keeping the environmental stimuli to a minimum, allowing the person to move yet remain under constant observation and providing physical supports as continuous motor activity, sleeplessness and overactivity may lead the patient to physically stop without much warning. The combined elements of this approach are designed to decrease the prospect of behaviour escalating and becoming out of control, and help restore calm at a time when the consumer does not have adequate internal control. This will also help promote physical safety for the person, staﬀ and others present. Schizophrenia Schizophrenia aﬀects the regular functioning of the brain, interfering with a person's ability to think, feel and act. In Australia, schizophrenia is the most commonly experienced psychotic condition, with two-thirds of consumers experiencing their ﬁrst episode prior to the age of 25 years.3 Some individuals do recover completely from this illness, and, with time and appropriate medication, community support and acceptance, most ﬁnd that their symptoms improve. However, for many, schizophrenia is a prolonged illness which can involve years of distressing symptoms and disability. Family and social relationships may be fragmented or broken and, as a result of the episodic nature of the illness, stigma and other social factors, there may be an inability to maintain contact with individuals with this diagnosis over prolonged periods. This situation is made more challenging when the causes of schizophrenia are not fully understood by both the scientiﬁc community and wider society. Recently it has been accepted by a range of professionals that stress, for example, or use of drugs such as marijuana, LSD or speed can trigger the ﬁrst episode of the illness. Individuals aﬀected by schizophrenia have one ‘personality’, just like everyone else. It is a myth and totally untrue that those aﬀected have a so-called ‘split personality’. Symptoms and diagnostic criteria Schizophrenia is often characteristised by a range of cognitive, behavioural and emotional dysfunctions. Diagnostic criteria are shown in Box 36.7. Box 36.7 Criteria for diagnosing schizophrenia 5 5 People diagnosed with schizophrenia experience at least two of the following symptoms for a majority of days during a 30-day period: delusions (ﬁxed false beliefs that are not amenable to change in light of contradictory evidence); hallucinations (often in the form of hearing or visual perception-like experiences that occur without external stimulus); disorganised and often incoherent speech; grossly disorganised/catatonic behaviour (may be expressed in a range of ways, such as childlike silliness or unexpected agitation); negative symptoms (i.e. reduced emotional expression and avolition). For a signiﬁcant portion of the time since the onset of the condition, the level of functioning in one or more major areas, such as work, day-to-day interpersonal relations or self-care, is distinctively below the level achieved prior to the start of the condition. The changes in behaviour are not a ributable to the physiological eﬀects of a substance or other known physical condition. Management When a person experiencing schizophrenia requires emergency mental health care, they are likely to be encountering severe symptoms of psychosis. It is important to encourage the individual to feel safe, and to de-escalate their stress as much as possible. The management of such individuals involves the following key features:50 Clarity and congruence—ensure that communication is congruent between verbal and non-verbal messages. This is because some consumers may be very sensitive to non-verbal behaviour and whether the nonverbal supports the verbal message. Where possible use ‘I’ and ‘you’ rather than ‘we’ and ‘us’ to avoid confusing the consumer. Model desired behaviours—model expression of thought and feeling by interacting with other practitioners in the presence of the consumer with an inclusive fashion, then, where possible, openly discuss, repeat and reassure the core messages from the healthcare workers. Individuals with schizophrenia may take additional time to reach a level of trust where they can accept actions directed from healthcare professionals towards them. Foster trust and relationship-building—follow through on commitments made, inform the person when you will be talking to them, give careful explanations for treatments and medications and allow the consumer to control the amount of self-disclosure that takes place in the interaction. Such actions demonstrate trust by making the healthcare worker accessible to the person both physically and emotionally. Eating conditions An eating condition is characterised by persistent thoughts and disturbance regarding eating, eating-related behaviour and body weight. There is no single cause for eating conditions; a number of factors are involved to varying degrees in diﬀerent people, including genetic inheritance, personal and psychological factors related to adolescence or family issues, for example, and social factors such as media representation of body image. It is estimated that approximately 2 in every 100 people will develop some kind of eating condition at some time in their lives. More females than males tend to be aﬀected, particularly young women. Typically, there is a high prevalence of co-morbidity with other mental illnesses, particularly major depression.71 While eating conditions can include limited food intake (anorexia nervosa), food intake followed by purging (bulimia nervosa) or overeating (compulsive overeating),72 anorexia nervosa is likely to be the greatest concern in emergency situations, due to the physical eﬀects of extreme weight loss. Symptoms and diagnostic criteria of anorexia nervosa Anorexia nervosa is characterised by restricted food (energy) intake. This condition commonly begins in adolescence or early adulthood. Diagnostic criteria are described in Box 36.8. Box 36.8 Criteria for diagnosing anorexia nervosa 5 5 The overall clinical picture for people diagnosed with anorexia nervosa is marked by a restricted energy intake comparative to daily requirements, leading to a signiﬁcantly lower body weight (deﬁned as weight that is less than minimally normal/expected for age and gender, developmental stage and pre-existing physical condition). People experience an intense fear of gaining weight/becoming fat, or express dogged behaviour that interferes with pu ing on weight, even though they are at a notably low weight. There are conspicuous changes in the way in which they describe and experience their body weight and shape, and this may be expressed in words or drawings. There is also a steadfast lack of personal recognition of the risk and potential seriousness of the current low body weight. Management Due to the physical manifestations associated with anorexia nervosa, management requires a multi-disciplinary approach involving psychiatrists, dietitians, psychologists, nurses and others. In some instances, the associated medical implications will be severe, particularly when major organs are aﬀected by prolonged reduced energy intake.55 It is essential that these physical impairments are treated along with the psychological impacts. For example, initiating cardiovascular monitoring is important, considering the risk of profound bradycardia and electrolyte abnormalities associated with this condition (see Chapter 22 for cardiac monitoring techniques). Since many individuals will also experience depression, anxiety and/or bipolar condition, this co-morbidity needs to be considered in the individual's management. Once the immediate physical implications are managed, some individuals may require admission to specialist eating condition wards for treatment. Munchausen's syndrome Munchausen's is a complex condition that centres upon the intentional production or feigning of physical or psychological signs or symptoms, often to gain a ention or the ‘sick role’.73 An alternative presentation, Munchausen's syndrome by proxy, is a form of child abuse, usually by the mother, in which there is the deliberate production of physical or psychological signs or symptoms in a child, in the absence of an external incentive (see Chapter 39).74 Symptoms Symptoms of this condition vary and can include a range of physical or psychological complaints (from abdominal complaints through to pseudo-seizures). Other characteristics of individuals who exhibit this condition include: a dramatic style of presentation (that is, the individual presents in signiﬁcant distress and is demanding in their requests); a background that provides the individual with enhanced medical knowledge; and vaguely presented histories or reluctance to provide answers regarding medical history/prior hospitalisations.73 Management Munchausen's syndrome requires careful assessment and observations of symptoms, generalised illness behaviour and hospitalisations over the years. Skills required of the nurse and paramedic will include careful assessment and history-taking, good observational skills to be able to diﬀerentiate true illness behaviours and understanding of the family functioning dynamic. Serotonin syndrome Serotonin syndrome is a relatively rare yet dangerous condition associated with the introduction of or increase in a serotonin agent (commonly selective serotonin re-uptake inhibitors (SSRIs)). Symptoms Serotonin syndrome is characterised by altered mental state, racing thoughts and agitation, tremor, shivering, diarrhoea, hyperreﬂexia, myoclonus (spasm of a muscle or group of muscles), ataxia, hypertension and hyperthermia. It can occur as a result of overdose or drug combinations and, rarely, with therapeutic doses.75 The onset is usually rapid and most acute cases resolve with appropriate treatment within 24–36 hours. Management First actions include making sure that oﬀending agent(s) is/are ceased immediately. If the condition is due to over-dosage, activated charcoal should be considered (see Chapter 30). For the treatment of agitation, seizures and myoclonus, benzodiazepines may be considered. Treatment for respiratory distress and dehydration should be accompanied by close monitoring of the consumer. If there is concern for dangerous medical complications, the consumer should be provided with close nursing supervision. Neuroleptic malignant syndrome Neuroleptic malignant syndrome (NMS) is seen in individuals who have recently commenced neuroleptic medications, or for whom the dosage of a neuroleptic has increased, either intentionally or unintentionally. It may also be seen in individuals for whom a dopaminergic agent has been rapidly withdrawn. Risk factors are listed in Box 36.9. Box 36.9 Risk factors for NMS* 7 6 Consumer factors male sex (male:female = 2:1) dehydration agitation organic brain disease Drug-dosing factors high initial neuroleptic dose high-potency neuroleptic (e.g. haloperidol) rapid dosage increase depot neuroleptics. *Duration of drug exposure and toxic overdose are not related to risk of developing NMS. Symptoms NMS is characterised by fever, muscular rigidity, pallor, dyskinesia, altered mental status, unstable blood pressure and pulmonary congestion. Death is usually due to respiratory failure, cardiovascular collapse or myoglobinuric renal failure.74 There can be a latent period of several days and the condition can be diﬃcult to clinically distinguish from serotonin syndrome.76 Management Clinical management of NMS begins with stopping the agents thought to be causing it. In critical cases, supportive measures such as oxygen, steps to reduce temperature such as cooling blankets, antipyretics, cooled IV ﬂuids and ice packs should be considered. If the person has acute behavioural disturbance, oral benzodiazepines can be helpful. The condition may last 7–10 days if secondary to oral antipsychotics, and up to 21 days for depot antipsychotics. Substance misuse and dual diagnosis Substance misuse conditions (dependency or harmful use of alcohol or other drugs) are slightly less prevalent than other forms of mental illness, aﬀecting 5.1% and 3.5% of Australian2 and New Zealand adults10 respectively. These conditions are more frequently experienced by younger men (aged 16–24 years) and are commonly experienced by people with another mental health condition.2 Individuals experiencing a mental illness and a co-existing alcohol and other drug condition are referred to as having a dual diagnosis. There is considerable concern among paramedics and ED staﬀ that individuals with a dual diagnosis may receive less-than-optimal treatment, in part because: these individuals often present as a diagnostic challenge as each condition may complicate the other the separation of drug and alcohol and mental health services may allow some individuals to ‘fall between the gaps’. Lack of early identiﬁcation and treatment increases the cost for the individual, the family, healthcare systems and the community. As people with dual diagnosis are often seen in an emergency context, it is important to ensure coordination of services for these individuals. Access would have to be ensured to drug and alcohol agencies, either by the location of a dual-diagnosis practitioner in the service or by the availability of a designated worker within the integrated mental health service. The outcome indicators of good clinical management include: improved alliances between drug and alcohol services and the ED, bringing coordination of all ma ers pertaining to drug (including alcohol) issues, including prevention, treatment, health promotion, education and evaluation, into a coherent framework for action seriously mentally ill individuals are treated by the psychiatric services, with the drug and alcohol services using their allocated worker for those who do not meet the criteria for case management in the psychiatric service.77 The combined eﬀect of the above is improved connectedness with the person's preferences,78 stigma reduction and improved teamwork and collaboration across disciplines. For more detail regarding use of alcohol, tobacco and other drugs, and management of overdose, see Chapter 40. Suicide and self-harm Although suicide and self-harm are typically considered behaviours, not mental health conditions, those who are diagnosed with a mental health condition are more likely to experience suicide and/or self-harm ideation and behaviour.54 Encountering individuals who experience suicidal and self-harming behaviours is common for emergency clinicians. Often, these behaviours will be experienced by individuals who present with dual diagnosis (that is, drug/alcohol misuse and another mental health condition), and who have recently experienced a situational crisis, such as relationship breakdown. Suicide The WHO deﬁnes suicide as ‘the act of killing oneself … deliberately initiated and performed by the person concerned in the full knowledge, or expectation, of its fatal outcome’.79 Across the globe, over 800,000 people die by suicide each year, with suicide being the second leading cause of death for people aged 15–29 years.80 Rates of suicide are thought to be underreported, with 508 deaths by suicide recorded in New Zealand in 2013,81 and 28864 in Australia in 2016, typically with higher rates in males and those living in rural areas.4,81 The ED is central to any strategy for reducing the incidence and impact of suicide, particularly because a key predictor of death by suicide is a history of depression and a previous suicide a empt.14,82 It is hoped that opportune intervention in the ED may prevent some suicides. Training speciﬁcally aimed at recognising, assessing and supporting individuals experiencing suicidal ideation and behaviour is needed.16,83 Suicide and self-harming behaviour Many suicide a empts do not end in death and the incidence of suicidal behaviour and self-harm (‘deliberate damage to the body without suicidal intent’)84 is much higher than that of suicide, occurring more frequently in females than males.81 There were 7267 reported incidents of intentional self-harm hospitalisations in New Zealand in 201381,85 and an estimated 26,062 in Australia during 2010–11.86 Of those in Australia, 82% were accounted for by intentional self-poisoning and 13% by intentional self-harm by sharp object.86 Other examples of non-fatal and self-harming behaviours include: jumping from heights, a empted hanging, high-speed motor vehicle crashes that are deliberate and burning of ﬂesh. While some people will only engage in these behaviours once, or for a short duration of time, others will continue for many years. There is a connection between suicide and self-harm, with previous a empts and expressions of self-harming behaviour being common among those who have died by suicide.84,87,88 Immediate care following suicide and selfharming behaviour Paramedics and ED nurses are often some of the ﬁrst responders when a person has engaged in suicidal/self-harming behaviours, and therefore both play a crucial role in providing immediate care. Due to the nature of suicidal and self-harming behaviours, there is likely to be an immediate need to tend to the medical aspects of the behaviour89 (e.g. wound suturing). Ensuring the safety of the individual and others present is also essential. This involves checking whether the individual is in possession of any items that could be used to cause further harm (e.g. sharp objects). Once these needs have been met, speciﬁc psychological care can begin.90 Following consultation with people with lived experience of suicide and clinical staﬀ, as well as the international literature, the Black Dog Institute recently released a set of guidelines for providing care to people in EDs and other acute se ings.91 Readers are strongly encouraged to read this document, and consider it an adjunct to their state/territory and workplace recommendations. These guidelines suggest best-practice for working with a person experiencing suicidal crisis, and aim to support those working in acute se ings to provide the most supportive response to such individuals and their carers/family. At its core, the guidelines stress the importance of a person-centred and collaborative approach. Suicide assessment and management Central to supporting a person in suicide-related distress is gaining an understanding of their current experiences and recent life events. The best course of action when managing an individual experiencing a suicidal state is to directly raise the topic with the individual, with the view to understanding risk and protective factors for suicide. It is preferable to do so knowing something of the framework and/or system supports available to the practitioner if indeed suicide is a very real option for the individual. Warning signs are listed in Box 36.10. Box 36.10 Warning signs of suicidal intentions 9 1 The majority of people give warning signs about their suicidal intentions. Some of these warning signs are: expression of hopelessness or helplessness wri en or spoken notice of intention, saying goodbye dramatic change in personality or appearance irrational, bizarre behaviour overwhelming sense of guilt, shame or reﬂection changed eating or sleeping pa erns severe drop in school or work performance giving away possessions or pu ing aﬀairs in order lack of interest in the future self-harming actions, such as overdoses, which can be lethal to the person. While the approach taken must be non-threatening, open and conﬁdential, conﬁdentiality cannot always be unconditionally assured. A careful balance must be maintained between preserving conﬁdentiality as a fundamental aspect of clinical practice and the need to breach it on rare occasions in order to promote the person's optimal interests and care, and/or the safety of others.93 There will, however, be many professional situations that call for the sharing of information between practitioners. On occasions, individuals or relatives may be asked to provide a considerable amount of personal information, especially when consumers are ﬁrst assessed or admi ed. When this happens, it should be explained in a sensitive manner that other staﬀ will have access to some of the information. Employees therefore have a duty of care to ensure that they are aware of the implications of any legislation relevant to their particular role, and follow the statutory requirements of legislation and the requirements of their employer.93 Nevertheless, empathy and a genuine interest in the inner life of the person involved must be apparent during the clinical interview. In this way, it may be possible to motivate the person to come around to the idea that suicide is no longer a viable alternative. The following biopsychosocial approach, based on the International Association for Suicide Prevention guidelines,94 is essential to promote an individual approach. Although interactions can be constrained by time in the ED, this process highlights the importance of adopting a narrative approach—a process where the person is encouraged to share their story with the clinician, and where the person and clinician can work together to identify the needs of the individual.95,96 Practice tip Be alert to behaviours that indicate a possible increased risk of suicide, such as giving away possessions, talking about suicide or the withdrawal from family, friends and normal activities. Document and communicate this knowledge to others as part of the consumer's assessment. Early recognition and communication of risk can improve outcomes and safety. First contact: a positive, supportive response Initial contact with an individual experiencing a suicidal crisis is particularly important, but it often occurs in less than ideal circumstances, such as on the street, in a busy ED, in the person's home or on the telephone. Regardless of the speciﬁc course of action required, it is critical that the individual is responded to with empathy and compassion by staﬀ, as evidence indicates the quality of care a person receives in the ED can impact their future risk of suicide.91 Managing people experiencing suicidal thoughts and actions in crisis situations hinges upon ensuring safety for all concerned. This means scanning the environment for potential risks, speaking in a calm voice and favourably shifting risk as far as possible. Many people in suicidal crisis are at high imminent risk of suicide/selfharm, and require constant one-to-one monitoring and secure support. In the ED it is not always realistic or desirable for the primary support person to constantly be at the side of and interacting with someone while simultaneously recording observations. The important point here is for human contact with the distressed person, a ending to any immediate health concerns following assessment. This is an opportunity for the clinician to generate trust with the person, maintaining support and facilitating appropriate expressions of anger. Clinical engagement with people who are experiencing suicidal crises can evoke mixed feelings in everyone and paramedics/ED staﬀ are not immune to having thoughts and feelings which could be anti-therapeutic. It is important that the ﬁrst response is not primarily defensive. It is critical to realise that not everybody has to take on the responsibility of treating those with suicidal thoughts/actions, but at the very least those who are in the situation where such persons may present should have the basic skills to provide a compassionate response and make a general assessment of suicidal persons (even though they should not feel obliged to continue management). Indeed, those involved should be aware of their limitations, and be willing to seek the assistance of colleagues with appropriate referral. It is important to recognise that often people experiencing suicidal crises have recently perceived rejection, and a considerable degree of compassion and patience may be required in order to establish rapport. This can be achieved by communicating the wish to understand what is happening to that person and that time has been set aside to do so. Having established a reasonable environment in which to assess the person, that person should be enabled to present their history in as full a manner as possible. When a empting to elicit information from individuals it should be remembered that challenging or direct questions that could be interpreted as critical will rarely help. Rather, open-ended and non-judgemental comments, such as: ‘Things seem to be diﬃcult for you right now’ or ‘You must have been feeling pre y upset about that’, can encourage people to talk about their diﬃculties, and the open-ended question: ‘Can you tell me more about it?’ is often useful. Some individuals may remain resistant, but by stressing that it is important to try to understand what is happening and by the therapeutic use of silence, which further indicates a willingness and openness to listen, most will respond and rapport can be achieved. Assess the degree of suicidal intent Recent best practice evidence indicates that although asking about suicide intent is critical and is not associated with an increased risk for suicide, evidence is still mounting to determine the best ways to ask about suicide.97 Regardless, there is a general consensus that detailed questions should be asked in order to understand the extent of suicidal intent—including how, when, where and by what means the individual has considered ending their life, as well as the frequency, intensity and resistibility of these thoughts. It is also critical for paramedics and ED staﬀ to recognise that, for many people, suicidal states ﬂuctuate rapidly, indicating the need for ongoing and frequent assessment in order to best understand the individual's present experience.98 Assessment must recognise the basic human need for autonomy as well as safety, and this means creating strategies to enable disclosure and trust wherever possible. More direct questions may be necessary in order to elucidate the degree of suicidal intent. Suicidal thoughts and behaviour usually revolve around interpersonal phenomena, and the role of persons of signiﬁcance to the consumer should be sought. This may necessitate a systematic enquiry about the person's relationship with family members and friends. More speciﬁcally, suicidal intent can be determined on the basis of the degree of planning, knowledge of the lethality of the intended suicidal act, the degree of isolation of the person and also by asking open-ended questions, such as: ‘What are your feelings—right now—about living and dying?’ Such a question permits those with suicidal thoughts to express their feelings in a way that is not provided for by direct questions such as: ‘Do you really want to kill yourself?’, which may be too confronting and does not allow for the ambivalent feelings that are almost invariably present among people experiencing suicide-related distress. Practice tip Reassure people that no ma er how challenging their situation is right now, the way forward is best achieved by working together. Where possible use a conversational-style risk-assessment approach to create interactive dialogue and trust. Commence initial management The most important initial decision is based on assessment of the safety of the individual. It may be that the opportunity of ventilating thoughts and feelings to a concerned person has been suﬃcient for some people. In the absence of a mental condition, or if suicidal thoughts and actions have resulted in positive changes in personal relationships, further contact may be unnecessary, although the opportunity for further follow-up should be left open, particularly if there are inadequate social supports. Again, it is critical to remember that suicidal states ﬂuctuate and that the presence or absence of suicide-related symptoms at one point in time is not indicative of future suicidal states for the individual. For those who are profoundly suicidal with a severe mental illness, detention under the relevant Mental Health Act and hospitalisation may be necessary (see Chapter 4). Indeed, sometimes compulsory hospitalisation in order to reduce the likelihood of danger to the person or to others is required. If so, it must be emphasised to the individual and their relatives/carers/friends that it has been done in order to protect, not punish, the person. If this should happen, try to seek input from the relative, carer or friend in order to ensure that this is the best approach to the current situation. Current evidence suggests that working with the individual to cocreate a safety plan can be an important suicide prevention strategy.99 The safety planning intervention was initially developed in the United States for use in the ED, and involves working with the individual to develop a range of strategies to help keep them safe. A particular emphasis is placed on drawing on the person's internal resources and coping strategies, as well as involving supportive others and services. It should also include steps that the individual will take to remove/minimise lethal means from their environment. Each person's safety plan should be personalised to their experience, and should not be confused with a management plan. A safety plan can be commenced in the ED and then completed with external service providers. Various examples of safety planning templates exist, including the ‘BeyondNow’ application developed by beyondblue.100 Suicide and self-harm in Aboriginal and Māori communities Despite the strength and resilience of Aboriginal people, the subject area of suicide and self-harm among Aboriginal Australians is one of persistent and overwhelming tragedy, marked by ongoing expressions of intergenerational pain, disconnection and despair. Based on data from New South Wales, Queensland, Western Australia, South Australia and the Northern Territory during the period 2012–16, intentional self-harm was the leading cause of death for Aboriginal children and young people, as well as those aged 15– 34 years, and the second leading cause for 35–44-year-olds.4 Of note, the median age of death was signiﬁcantly lower for Aboriginal people at 29 years, compared to 45 years for non-Aboriginal Australians. Rates are typically higher for men in rural communities,87,101–103 and often the death results from violent means, particularly hanging or ﬁrearms.98 Self-harm is thought to be equally common among males and females.101 Several writers warn against a narrow focus on both suicidal and self-harming behaviour in the Aboriginal context.104 All selfharming behaviour, they argue, should be seen as a drastic response to certain stressful experiences (risk factors) and violence in the broader social and emotional context of cultural meaning, cultural identity, historical and current socioeconomic conditions.102 Additionally, threats towards death by hanging may have signiﬁcant historical messages of hurt, injustice, tyranny and domination for Aboriginal people.105 Rates of suicide and self-harm are also more prevalent among Māori peoples. In 2013, the suicide rate for Māori was 15.8 per 100,000 people, compared to 9.7 per 100,000 for non-Māori (a rate of 1.6 times higher). Rates were particularly high among males and youth.81 These elevated rates can be a ributed to higher rates of social deprivation and disadvantage, as well as acculturative stress, resulting from colonisation in the 1800s;10 much like those factors faced by Aboriginal Australians. It is critical for practitioners to be aware of the way that suicide is experienced in Aboriginal and Māori communities in order to ensure a culturally sensitive and competent approach to those experiencing suicide-related crises. Suicide and self-harm among people seeking refuge and people seeking asylum Suicide and self-harm are common issues experienced by people seeking refuge and people seeking asylum, with suicide thought to be the leading cause of premature death for individuals in immigration detention in Australia.106,107 A refugee is someone who, ‘owing to a well-founded fear of being persecuted on account of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of their nationality, and is unable to or, owing to such fear, is unwilling to avail him/herself of the protection of that country’.108 An asylum-seeker is someone who has left his or her country of origin in search of protection—whether or not their claim for refugee status has been determined. In what appears to be the only and most recent study exploring the use of ED by immigration detainees in Australia, it has been shown that the most common primary diagnosis of all a endances to a Darwin ED in 2011 was psychiatric problems (24% of 770 total a endances).109 Of these a endances, 138 were associated with selfharm, more commonly among men. Twenty of the total a endances were by children (9–17 years), of which 75% were related to selfharm. Suicidal and self-harming behaviour among these populations may be associated with the considerable uncertainty for the individual, which can contribute to anxiety, mental distress and uncertainty for the future. Such factors are thought to be linked to depression, post-traumatic stress and other mental health concerns among these individuals.110 Speciﬁcally, these behaviours might be associated with rejected visa applications and claims for permanent protection being refused, as well as being linked to past trauma and/or torture issues. Concerns are currently particularly high for those seeking asylum who have arrived in Australia by boat, with mental deterioration a ributed to periods of prolonged uncertainty.110 The acts of suicide and self-harm by people seeking asylum are widely regarded by practitioners as among the most common and stressful emergency issues encountered by health and human service professionals. Emergency clinicians may feel overwhelmed and be left feeling unsure what to do by the complexity and the unusual depth of personal feeling they confront. For this reason, there is a real need for emergency clinicians to work together with advocate, migration, refugee and trauma services, so that all concerned can be supported in managing their own feelings and reactions while making themselves available to the individual. As with any individual engaging in these behaviours, it is important to ensure the safety of the person and to encourage them to feel listened to and validated. Other considerations when providing emergency mental health care Legal considerations It is important to be reminded of the legal considerations when providing emergency mental health care. In particular, not all people come to the a ention of emergency health services voluntarily. In some instances, a person may be treated without their consent or against their will. This situation arises when a person requires urgent treatment to save their life or to prevent serious harm to their health, or when the individual is in need of urgent treatment but is incapable of giving consent. Involuntary treatment orders can take the form of speciﬁc ‘licence conditions’, Community Treatment Orders (CTOs) or a legal order for care by an authorised oﬃcer for immediate detention under relevant legislation. For more detail and the Mental Health Acts for each state and territory, see Chapter 4. In addition to involuntary detention, some Mental Health Acts also contain regulations for the administration of sedatives. For example, the New Zealand Mental Health Act contains a provision that enables a medical practitioner, in certain circumstances, to administer an appropriate sedative to a person (Section 110A). If a medical practitioner administers urgent sedation, they must do so in accordance with relevant guidelines and standards of care and treatment issued by the Director-General of Health under Section 130 of the Act. Occasionally, issues will arise when people with mental illnesses come into contact with the criminal justice system. There is much publicity of critical incidents involving ‘mentally disturbed’ people, which gives rise to the popular belief that a high proportion of people with mental illness commit crimes. This is generally not the case. Most people with a mental illness, including those with major illnesses, do not commit crimes; but people with mental illness nevertheless are over-represented in the criminal justice system— rates of mental illness are up to four times higher in prison populations than in the general Australian population.111 Australian paramedics achieved national health professional registration in 2019, with the Paramedicine Board of Australia adopting professional capabilities for registered paramedics. While role activities may be governed by legislation that varies across health jurisdictions, all paramedics will be required to meet Professional Competency Standards and Professional Capabilities for paramedics.112 Paramedics must have a comprehensive understanding of their legislative obligations to comply with the various mental health acts across the diﬀerent geographical jurisdictions. Early intervention in aggression and mitigation strategies to prevent unnecessary use of restraint and/or restrictive practices Not all people experiencing a mental health emergency display aggression and/or violence. Further, for many people displaying these behaviours, these are often unrelated to the individual's mental health. However, aggression and violence in healthcare is a growing concern among staﬀ, often leading staﬀ to feel unsafe.113,114 For example, a recent South Australian Ambulance Service report indicated a 74% increase in incidents of physical and verbal abuse directed at paramedics in the previous 2 years (from 57 incidents in 2012 to 99 incidents in 2013).115 In addition to their role in dealing with the aftermath of pre-hospital aggression and violence, EDs are also faced with occurrences of aggression and violence within the hospital se ing.116 ED nurses are frequently subjected to verbal abuse (e.g. swearing or obscenity, shouting and sarcasm) and physical abuse (e.g. pushing, hi ing, use of a weapon and punching).117 Risk factors thought to be associated with these incidences include a past history of violence, substance and alcohol misuse, medical diagnoses (including mental illness), long waiting times and time of day (with increased incidents in the evenings). Some researchers play down the linkages between violence and mental illness.118 While some have found that those individuals who experience comorbid schizophrenia/other psychoses and substance misuse are at a greater risk of violent behaviour,119 others have found that this risk is no greater than that for those individuals who have a substanceuse condition only.120 Robust and assertive practice of early identiﬁcation and early intervention of aggression and violence are the ﬁrst steps in any deescalation process. Where the prospect of violence is deemed to be real, staﬀ must act in a defensive and anticipatory manner, at all times ready for the level of violence to escalate.121 Early detection of the potential signs of aggression is the ﬁrst step towards prevention and de-escalation. Some signs of potential aggression and general pre-hospital and ED management guidelines are listed in Box 36.11 See also Chapter 11 for pre-hospital scene triage assessment and management. The primary concern in the management of people displaying violent or aggressive behaviour (and of the impact of their behaviour on those present) is positive engagement and safety leading to de-escalation of the individual's behaviour in the least restrictive environment. This is not a time to be a hero. Rather, it is a time to ensure personal safety and for all involved to work using exemplary communication, teamwork and strategic use of medication and physical interventions. Box 36.11 Detection and management of aggression 1 2 1 Early detection of the potential signs of aggression Being under the inﬂuence of alcohol or other drugs, particularly psychostimulants Having slurred speech, being sarcastic, abusive, threatening, using foul language Intruding personal space; deﬁant and uncooperative Hostile facial expression with prolonged eye contact and staring Bloodstained clothing, dishevelled appearance Possession of a weapon (actual or potential) Obvious motor restlessness, pacing, tapping feet (exclude akathisia), clenching of ﬁsts or jaws, twisting of neck. Pre-hospital and ED management guidelines for aggression Consider personal safety at all times Avoid an argumentative, confrontational response Show you are listening—paraphrase back a summary of what is being said to you and communicate that you are trying to solve the problem Calm the person as much as possible, encouraging them to slow down prior to solving the problem Show concern through verbal and non-verbal responses. Avoid patronising their concerns Adopt a non-threatening body posture, voice tone and disposition more broadly Consider the safety of other consumers and their visitors at all times Avoid an audience or crowd forming around the consumer Place the person in a quiet and secure area and let staﬀ know what is happening and why Never turn your back on the individual Don't walk ahead of the individual and ensure adequate personal space Avoid sudden movements or elevation of voice that may startle or be perceived as a threat, danger or a ack Provide continuous observation and record behaviour changes in consumer notes Wear a personal duress alarm at all times Let the person talk Never block oﬀ exits and ensure you have a safe escape route. Practice tip Be alert to warning signs of aggression to prevent patient and staﬀ harm. Aggression behaviours that indicate an increased risk of aggression include intense staring, yelling, intoxication, threatening gestures. Use de-escalation techniques and seek support. This is not the time to be a hero. Minimisation of seclusion and restraint As discussed earlier in the chapter, certain situations (i.e. when an individual is behaving in ways that put them at risk to themselves or others) will require paramedics to implement processes of physical and/or chemical restraint in order to safely provide care and/or transport of the individual. For these same reasons, restraint is sometimes required in the ED. Each state, territory and emergency care provider has diﬀerent legal regul

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