Monday, February 08, 2010

What's A Psychiatric Emergency?


People have been writing in to respond to my Emergency! post and asking what constitutes an emergency in psychiatry. Some people are worried that I'll be taken advantage of if I'm too easy to schedule emergent appointments.

So what's a psychiatric emergency?

First, let me say that by design, I keep my life a little loose. I don't like scheduling far in advance, I don't have a secretary, I try to be accommodating and mostly this works for me. Once in a great while I feel like people are playing musical appointments and I vaguely wish it weren't so, but you can't have your cake and eat it to (unless you buy two cakes, and that might well be an option). So people who miss a lot of appointments, I tell them to call when they want to come in. You want to return in 3 months? You think I know my schedule 3 months in advance? 4-6 weeks, that's it, so call when you want to come in. I may call you and shift things. I'll be nice when you call me to shift things. So when someone calls and wants to come, it's usually fine--it's how I work my life, and it's how I make my living. No one ever calls and says "It's an emergency." What they say is "can I come in today, I'm really upset" and if I have the time, I wouldn't refuse it to make some point --hmmm what would that point be?. My post was more about the person who calls with a request for an urgent appointment who then doesn't accept the time offered. People call me because life is distressing them, and that's fine. I don't typically tell patients to go to the ER, but I don't call "I'm upset" an emergency. How often does this happen? Rarely. And I suppose I believe that part of the trade off for a no-insurance, pay-up-front doc is that I'm available, and offer a degree of availability and reachability beyond what is offered in a 9-5 clinic or from a doc with a caseload of hundreds.

So what's an "emergency?" Some things in psychiatry are clearly an emergency:

  • Suicidal thoughts or homicidal thoughts that might be acted on. Chronic suicidal ideation in someone who is certain they will not take action on is not an emergency.
  • Command hallucinations telling the patient to hurt themselves or others where the patient does not clearly identify this as something chronic and ongoing that he certain he wouldn't listen to.
  • The acute onset of psychosis, especially if it leads to bizarre behavior. When someone is doing really usual things, it indicates that they are not differentiating reality from perceptual problems and they lose judgment and become completely unpredictable.
  • Anyone walking around naked in public, for similar reasons.

  • The acute onset of mania, because behavior can be unpredictable, dangerous, and expensive.

  • Any life-threatening behavior, directed at oneself or others.

  • Really uncomfortable side effects to medications, and sometimes this is best dealt with in an ER where medications to counter the side effects can be administered by injection.

  • High fevers when a patient is on certain medications-- they can be indicative of a drop in white blood count for a patient on Clozaril or Tegretol, or of neuroleptic malignant syndrome for someone on neuroleptics.

  • Severe anxiety or panic are not 'emergencies' but it would be hard to tell that to someone experiencing their first episode, it's terribly uncomfortable, and it can be confused with a heart attack-- this is one for the ER if there are cardiac symptoms and any doubt. Unless there's a negative cardiac work-up and a known history of panic attacks, calling a psychiatrist with chest pain, shortness of breath, and other cardiac symptoms makes no sense (call 911). Most patients with known panic disorder do not identify their episodes as emergencies.
  • Really disorganized behavior-- it can be indicative of a psychosis, a delirium, or a drug intoxication.
  • An overdose of any medication because it might lead to bad things shortly. Like death.
I may have missed some things, so do chime in.

Being upset about something bad that has happened is not a psychiatric "emergency", but if you can get hold of someone who can listen and say something comforting--- including a psychiatrist -- well, it's nice when that happens.

Mostly, I leave it to my patients to define when something is an emergency. I can't imagine it's every comforting to have someone say "now that's NOT an emergency."