Mental health in the care of paramedics: part 2

Lithium toxicity

With lithium, it is important that the plasma level is maintained within the typical therapeutic range of 0.4–1.0 mmol/l. One of the significant, though uncommon, problems associated with lithium treatment is acute lithium toxicity (Table 2) and such patients may present to the paramedics or emergency health care services.

Any patients on lithium presenting with the above symptoms or otherwise unexplained symptoms should be brought to the medical attention immediately to have their lithium level and U+Es checked. A lithium level above 1.2 mmol/l is of immediate clinical concern and above 2 mmol/l is critical.

Anorexia nervosa

Anorexia nervosa is characterized by deliberate and sustained weight loss induced by restricted diet, self-induced vomiting, and/or excessive use of laxatives and diuretics, dread of fatness and amenorrhoea (WHO, 1992). Anorexia nervosa in women has a lifetime mortality of at least 10% due to acute complications (Table 3) (Crisp et al, 1992).

Any patient with a history suggestive of anorexia may present to emergency health care services. Such presentation commonly includes physical symptoms due to complications (Table 3) or co-morbid depressive symptoms (e.g. self harm or suicidality). Therefore a risk assessment is a must for any initial work-up. Any high risk cases presenting to paramedics should be immediately brought to the hospital for an assessment of their physical and mental health, depending on their presentation.

In general, anorexia nervosa should ideally be managed by specialist mental health teams, mostly in the community. High risk cases may need admission in a specialist eating disorders unit or acute medical ward. Assiduous monitoring of ECG, electrolytes, fluid and calorie intake is essential. The Mental Health Act (1983) can be used to compulsorily admit the anorexic patient for treatment and re-feeding, even to a general medical ward. However, this would be a final recourse only for critically ill patients. Anorexia nervosa should not be managed on a general psychiatric ward, although patients can be admitted to a general psychiatric unit for co-morbid depression or suicidal tendencies provided the physiological condition is fully stable.

Postnatal depression

Ten to fifteen percent of mothers become depressed following delivery (O’Hara and Swain, 1992). The features and management are generally similar to those for major depression. Sleep problems and anxiety about the infant or maternal capability are common. Most cases are managed in the community by the patient's general practitioner (GP) or mental health teams. However, any sign of severe depression, infant-neglect, suicidal or infanticidal thoughts or psychosis necessitates same-day psychiatric assessment. Severe cases should be admitted to a specialist mother and baby psychiatric unit (MBU), however, if this is not available immediately, they can be admitted to local general acute psychiatric unit and can be transferred to MBU later on.

Child protection may be an immediate concern in severe cases. Paramedics should follow local safeguarding children policy and can access social services (including out of hours) and named professional for safeguarding children for advice when they have such concerns (Department of Health (DH), 2010).

Postnatal psychosis

Postnatal, or puerperal, psychosis occurs in 1:1000 deliveries (Kendell et al. 1987). Onset is acute within hours or days following delivery and represents a psychiatric emergency. The mother may be vague or confused, without any clear psychotic features and at times appears normal. Features of postnatal psychosis include labile (changeable) mood, restlessness, delusions and hallucinations, perplexity and suspiciousness, obsessive concerns about the baby's health, anxiety, confusion interspersed with lucid intervals, infanticidal and suicidal thoughts (Sadock and Sadock, 2008).

Any mother who ‘goes strange’ in the days after delivery should be presumed to have puerperal psychosis until proved otherwise. All cases of postnatal psychosis should be admitted to psychiatric hospital, preferably a mother and baby unit (MBU). Sometimes, when mother is very disruptive or violent, it is more appropriate to admit them to a general acute psychiatric unit initially, to be transferred to MBU later on. Postnatal psychosis responds well to antipsychotics such as olanzapine (usual dose 10 mg per day).

Rarely, serious medical conditions such as cerebral thrombosis or sepsis can present as puerperal psychosis. All psychotic mothers should, therefore, have a thorough physical assessment before being disposed of to psychiatric services.

The single most common error in the evaluation of postnatal psychosis is failure to take account of the lucid interval. To the family, the mother may have been continually disturbed for several days but just at the point of presentation, she may enter a lucid phase of a few hours. The professional may then find the mental state to be normal and erroneously suppose that the family is giving undue emphasis to trivial symptoms. Thus, considerable weight should be given to the history of the presentation and collateral information.

Intoxication

Drunk or drug-intoxicated mothers may present to emergency medical services. It is a criminal offence to be in sole charge of a baby while in an intoxicated state and the police and CSF should be involved under such circumstances.

Assessment

When dealing with such cases, paramedics should urgently establish the likely physical risk in addition to the emotional state and a risk of re-attempt. Urgent treatment in an A&E may be needed if the risk is significant. NICE recommends that most people who have taken overdoses or self-poisoned should be urgently brought to an A&E because the amount and nature of ingested substance may not be clear, making accurate risk assessment difficult. (NICE, 2004).

If urgent treatment in an A&E is not required, paramedics should assess the context of the self-harm, risks involved, needs (including psychosocial factors), support network and emotional state. They should forward this information to the emergency department, the GP, secondary care mental health (including out–of–hours services such as crisis resolution teams) or any other services as appropriate.

It is useful to consider the dimensions of ‘lethality’ (medical seriousness of the self-harm or overdose) and strength of ‘intention’ to die. During assessment, the patient's account of the events may not be adequate or reliable and it is useful to obtain a collateral history. For example, a case of personality disorder may claim high intention but the circumstances may well suggest otherwise (e.g. overdose taken at home, early detection likely, summoned help). Conversely, an older person may deny suicide intent although the evidence is to the contrary (e.g. alone, doors locked, family away, last will and testament revised, ‘parting’ letters).

The chance of a patient actually dying by suicide in the week or two after a self-harm event is only 1 in 5000 (Harris et al. 2005; Cooper et al. 2007). Those patients who combine a mood disorder, substance abuse disorder, and personality disorder are at particularly high risk of committing suicide. The problem is that suicide remains, at any given point in time, a rare event. Identifying individuals who will commit suicide is not currently feasible. While assessing a person with self-harm, priority should be given to identify any risk factors amenable to therapeutic and/or social interventions e.g. long–term physical problems, relationship difficulties, bereavement or an underlying mental disorder. Approximately, 5% of such cases have schizophrenia or bipolar disorder (Haw et al, 2001).

This ‘treatment’ perspective suggests that taking a risk (e.g. deciding not to hospitalize a patient because community intervention seems to be the most effective intervention of that risk factor) can sometimes be the best decision. (Forster and Wu, 2002). Immediate safety of the patient needs to be weighed (and should be given priority in some cases) against the long-term outcome. The need for referral, treatment or admission should be based largely on the patient's needs, distress and disability, rather than perceived suicide risk.

Suicide risk-assessment scales cannot be relied upon (NICE, 2004) but they are an aid to asking the right questions. Options include: the Beck suicide intent scale; the Pierce suicide intent scale and SADPERSONS (Patterson et al, 1983; Beck et al. 1974; Pierce, 1977; Harris et al. 2005). Older adults (i.e. aged 60 years and over) who self-harm for the first time in their lives should be taken very seriously and be assumed, unless proved otherwise, to have severe depression requiring psychiatric admission.

Management

Paramedics have an increasingly important role in the assessment and early management of self-harm. They should be adequately trained in such skills, including consent and capacity and be made aware of the local protocols agreed between PCTs, acute and mental health trusts and the ambulance trust. NICE has published guidelines for the ambulance services for the assessment and initial management of self-harm, which includes physical interventions (e.g. activated charcoal) (NICE, 2004).

Initial management may include removing the medications or substances reducing the risk of a repeat attempt. If a person is assessed as being mentally incapable to consent to treatment for the self-harm, paramedics have a responsibility under the Mental Capacity Act (2005), to act in that person's best interests, which may include in some cases, taking the person to hospital and detaining them for an assessment and treatment. If a person meets the criteria for assessment and treatment under Mental Health Act (1983), the physical consequences of his/ her self harm also can be treated under the same Act, if required.

The management options (from a mental health point of view) for a person presenting with self-harm includes discharge with appropriate advice but no follow-up, follow-up by GP and a referral to secondary care mental health services. Referral to mental health services can be through community mental health teams or immediate referral through crisis resolution team and A&E, which may result in discharge with a follow-up plan or admission to a psychiatric unit (voluntary or under a section of Mental Health Act (1983).

How the options might be applied is exemplified in the cases in Table 4. These are just examples and the management advice is to be used as a guide, based on the author's experience, for paramedics to make an informed decision, rather than a standard for the management of such cases. Of course, paramedics are not expected to make all such decisions. However, awareness of these strategies would help them make an informed decision about the next most appropriate step while dealing with such patients. If in doubt, they must consult the person's GP, A&E or mental health services.

Security

A health professional cannot make good decisions if under threat and professional security must, therefore, come first. A brief inspection of the patient and the environment often has to suffice. One should take into account: the patient's arousal level, body language, possession of, or access to, weapons and their strength. The practitioners should also consider their escape routes should matters turn. The practitioner should not get involved in restraint unless they are well trained or experienced in such procedures.

Assessment

The assessment usually has to be quick and provisional but should identify a probable cause of the disturbance. In cases involving the police, it may not be clear whether the person is ‘behaving ill’ or ‘behaving bad’. Where there is doubt, the person may be taken to hospital, but with the police retaining responsibility for their prisoner until assessment reaches a definitive conclusion.

Talking

If the patient can be engaged in some, even minimally, reasonable level of conversation, this can be highly effective. For example a drunken person may mellow; a confused person might settle. ‘Talking down’ usually works quickly, or not at all.

Tranquilization

Paramedics are not expected to do this in most of the cases. When tranquilization is needed, options include haloperidol (5–10 mg O/IM), lorazepam (2–4 mg O/IM) or olanzapine (5–10 mg O/IM) (Battaglia et al, 2003). Lorazepam (a good choice for the non-specialist and for use in antipsychotics naive patients) will produce a satisfactory behavioural outcome in 60% of patients after 60 to 90 minutes and can be reversed by flumazenil if there is respiratory depression. Haloperidol is highly effective but causes acute dystonic reactions in 10% of cases (Wright et al, 2001), so an IV anticholinergic drug must be to hand (benzatropine, orphenadrine or procyclidine as per BNF 4.9.2) (Joint Formulary Committee, 2008). There is some recent evidence for using promethazine, in combination with haloperidol, which will help in tranquillization as well as prevent acute dystonic reactions due to haloperidol (Huf et al. 2009a; 2009b).

For the elderly, or acute confusional states, doses should be much lower, for example one quarter of the usual dose. Once tranquilized, the patient should be kept under continuous observation until in a safe place (e.g. admitted to hospital) and vital signs and arousal levels recorded regularly (e.g. half-hourly).

Intoxication

The features of common intoxicated states are summarized in Table 6 (see also www.erowid. org). It is important to note the fine difference between intoxication and overdose (could be accidental). For example, overdose of opiates or benzodiazepines is a potentially fatal condition.

Alcohol withdrawal

Alcohol withdrawal starts 12 to 24 hours after cessation or reduction of heavy alcohol use and may progress over 2 to 3 days to a potentially fatal condition. It can present with either medical or psychiatric features including autonomic hyperactivity (sweating, tachycardia, and unstable blood pressure), insomnia/nightmares, tremor, nausea and vomiting, visual hallucinations (e.g. insects/monsters), auditory hallucinations, agitation and anxiety. Metabolic features (dehydration, electrolyte disturbance, fever) confusion, delirium and seizures can be present in severe cases.

Chlordiazepoxide (a benzodiazepine) is commonly used to mitigate the withdrawal: (10–50 mg QDS daily depending on severity, gradually reducing over 7 to 14 days). Mild cases, presenting early, can be managed at home under GP care. IM nutritional supplements (e.g. Pabrinex BNF 9.6.2.) are recommended. Severe cases are a medical emergency and need full workup in a medical assessment unit.

Opiate withdrawal

Opiate withdrawal, although profoundly unpleasant and painful, is not dangerous. The onset is 6 to 12 hours after last dose of heroin and 1 to 2 days for longer acting drugs (e.g. methadone). Features include: craving, nausea/vomiting, myalgia, lacrimation, running nose, diarrhoea, sweating, yawning, insomnia and fever. Although dihydrocodeine (30 mg q.d.s.) can be used electively, one should never accede to pressure to prescribe or administer an opiate in the urgent situation. Symptomatic relief can be provided by ibuprofen, metoclopramide, loperamide and sedative antihistamines.

Other drug withdrawal

Amphetamine and cannabis have withdrawal syndromes but there is no specific treatment. Abrupt cessation of some antidepressants (e.g. paroxetine, venlafaxine, citalopram) can cause a withdrawal syndrome (Warner et al, 2006) and the treatment is to restart the drug plus a single dose of diazepam (5 mg). Short-acting benzodiazepines (e.g. lorazepam) can produce a withdrawal syndrome if stopped abruptly. However, in the emergency situation, only two days of replacement therapy should be prescribed.

Mental Health Act

The Mental Health Act, 1983 (amended in 2007) has five sections relevant to the acute assessment of psychiatric disturbance. The common indications for requesting a Mental Health Act Assessment (MHAA) include severe psychotic, schizophrenic or manic presentation, extreme depressive states and confusional states.

A person presenting with features suggestive of a mental disorder, who appears to be in need of hospital admission against his/her wishes needs a MHAA. A definitive diagnosis is not required before requesting a MHAA; reasonable suspicion will suffice. Dependence on alcohol or drugs is not in itself considered to be a mental disorder for the purposes of the act, however, conditions arising consequential to substance misuse are, for example, drug induced psychosis.

A MHAA is organized by contacting an approved mental health professional (AMHP, formerly known as approved social worker or ASW) who can apply for detention of the patient on recommendation by two doctors (only one medical recommendation is needed for section 4). It is usual that the AMHP will summon the doctors required to conduct the assessment from a local rota of psychiatrists or GPs authorized under Section 12 of the Mental Health Act. During-outof-hours, AMHP can be contacted by approaching emergency duty team of social services. Such patients should also be referred to crisis resolution team.

Commonly used sections of MHA (1983)

Those sections particularly relevant to paramedics are summarized below.

Mental Capacity Act

The Mental Capacity Act, 2005 protects vulnerable people who cannot make their own decisions (HMSO, 2005). There are five principles:

Mental capacity is time-specific and decision-specific. Judging capacity to consent to assessment and treatment can be difficult. In emergency psychiatric situations, the professional will usually be on the safe ground in providing whatever urgent care is considered necessary to preserve life and health and allowing a mental health professional to more fully assess the patient's capacity later on. The issue of capacity is particularly important while dealing with cases of self-harm.

The presence or absence of capacity to consent to treatment is not a relevant consideration when applying for sections 2, 3, 4, 135 or 136 of the Mental Health Act. For example, a patient with psychotic symptoms may well technically possess full capacity and can refuse the admission but a Mental Health Act section could nonetheless be applied to protect the patient, or other persons, from harm if needed. It is generally held that the Mental Health Act is super-ordinate to (i.e. ‘trumps’) the Mental Capacity Act.