Mental health in the care of paramedics: part 2


Mental disorders are common and frequently present in emergency and prehospital settings. Conditions presenting to emergency care services include new onset psychiatric disorder, relapse or exacerbation of a pre-existing psychiatric condition, acute reactions to social adversities or problems associated with substance misuse. Although the advanced management of such conditions requires considerable therapeutic sophistication, paramedical services can contribute greatly to the initial management of such patients. In the second of a two article series on mental disorders, this article will provide guidance on the early assessment and management of bipolar disorder, psychiatric conditions in women, parasuicidal behaviours, acutely disturbed patients and substance misuse disorders. Some relevant legal issues in mental health are also discussed.

Paramedics are often called for psychiatric presentations in various settings; some of these presentations are true psychiatric emergencies. While paramedics would not usually start treatment for these presentations, it is valuable to have insight into how to identify, assess and differentiate the psychiatric disorders. It is equally important to understand the principles of commonly used initial management strategies and relevant legislation. The previous article in this series focused on an overview of mental health services, personality disorders, anxiety disorders, depression and psychotic disorders. This article will consider bipolar disorder, women and mental disorders, self-harm and suicidal behaviour, acute behaviour disturbance, substance misuse and some legal aspects of psychiatric practice.

Bipolar disorder

The lifetime course of bipolar disorder is characterized by interspersed episodes of mania and depression. It has a lifetime prevalence of approximately 1–2% (Bebbington and Ramana, 1995) and usually starts in adolescence or young adulthood. Onset after the age of 40 years is uncommon. Bipolar disorder is strongly heritable.

The features of the manic episode are summarized in Table 1. Depressive episodes have the same features as unipolar major depression (as discussed in first paper of this series) but are usually more acute and severe. Most of the depressive episodes in bipolar disorder can be managed in the community by general practitioner, out-patient psychiatrists or by community mental health teams; but if the patient is psychotic, suicidal or not eating or drinking, admission to the hospital is usually necessary. Any patient presenting with manic episode should immediately be brought for an assessment by mental health professionals. Admission to psychiatric hospital is usually required in such cases.

Table 1.

Common features of mania

Elated or irritable mood Reduced need for sleep
Over-talkative and/or pressure of speech Grandiose ideas
Racing of thoughts, flight of ideas Impaired judgement
Increased psychomotor activity Impaired insight
Disinhibited and risk taking behaviour or (e.g. overspending, sexual indiscretions) Delusions and/ hallucinations in severe cases.

From: American Psychiatric Association (2000)

Manic episodes are usually treated with antipsychotics (e.g. olanzapine, aripiprazole, quetiapine etc). Depressed episodes are treated with antidepressants. Only rare cases are so exceptionally ill as to require electroconvulsive therapy (ECT). Long-term preventative pharmacotherapy with mood stabilizers is the cornerstone of the management of bipolar disorder. Commonly used mood stabilizers are valproic acid (usually up to 1500 mg/day) or lithium (dosed according to plasma levels, using plasma range 0.4 to 1.0 mmol/l). It is also common to use antipsychotics, mood stabilizers and antidepressants in combination, in preventative treatment. Lithium and valproate are usually avoided during pregnancy as they can cause foetal heart and neural tube defects, respectively.

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.

Table 2.

Lithium toxicity

Common causes
Inadequate monitoring of lithium levels Dehydration
Impaired renal function Deliberate overdose
Co-prescription of diuretics or NSAIDS  
Common features
Confusion Diuresis
Tremor Ataxia
Nausea and/or vomiting Renal failure in extreme cases.

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.

Women and mental disorders

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).

Table 3.

Emergency presentations of anorexia nervosa

Electrolyte abnormalities Hypoglycaemia
Cardiac conduction disorders Encephalopathy
Heart failure Hypothermia
Gastric rupture, oesophageal tears Acute starvation – BMI 13kg/ m2 or less

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.

Self-harm and suicidal behaviour

NICE (2004) defines the term self-harm as ‘self- poisoning or injury, irrespective of the apparent purpose of the act’. It is an expression of personal distress, not an illness, and there are many varied reasons for a person to harm him or herself (NICE, 2004). Self harm or suicidal behaviour is present in at least one-third of patients seen in the psychiatric emergency service (Dhossche, 2000), and in some ways, the assessment and management of suicidal patients is the prototype of emergency mental health care.

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.

Table 4.

Case examples of self harm

Example 1 Following a row with her boyfriend, Susie, aged 18yrs, scratched her forearm superficially with an intention to have her boyfriend back. There are no major concerns in the assessment. Management: ‘Discharge with an appropriate advice’ is likely to be the best action as lethality appears minimal and there was no intention to die. Too much attention may reinforce this behavior
Example 2 Archie, a 21-year-old student is falling behind on assignments and was dumped by his girlfriend. He ‘lost it’ while drunk and overdosed on a dozen antihistamine tablets. PHQ score is 13. Management: Archie needs to be brought to A&E and assessed when in a clear state of mind. He would benefit from a follow-up by his GP next day and may need some counseling, an academic review and possibly antidepressants
Example 3 Peter, aged 45 yrs, is on treatment for depression. He has increasing financial difficulties, marked anxiety, agitation and insomnia. His wife found him sorting lengths of rope in the shed for dubious reasons. Management: The picture is worrying. He should be referred to a psychiatric professional immediately (community mental health team or crisis resolution team). He may need admission or input from crisis team
Example 4 Florence, aged 72 yrs and widowed, is found dizzy and weak. Her antihypertensive medication (10 days dosage) is missing. She denies depression but admits to tiredness, insomnia and anorexia for several weeks. She says that she just ‘got muddled’ about the medication Management: The surface features do not appear grave, but it is likely that this was a serious overdose. A diagnosis of depression is likely. She must be brought to A&E immediately for a physical health review, following which admission to a psychiatric unit should be considered
Example 5 Keith, aged 25yrs, a patient with schizophrenia for three years, has carved religious symbols in his arms with a knife. He denies that he needs any help but gives no account for his actions. Management: Keith is not trying to kill himself but he is probably relapsing. He needs an immediate attention from mental health services. An immediate Mental Health Act Assessment is needed as he denies any help.

The acutely disturbed patient

Acutely disturbed patients can present as agitated, confused, aggressive or violent. Common causes of acute disturbance are summarized in Table 5. Paramedics should bring these patients to the nearest hospital, in most instances, for a thorough assessment. However, in order to achieve this, they should be aware of common causative factors and principles of initial assessment and management to make the person amenable for further examination and to ensure safety of patient as well as others. A general principle of management is S.A.T.T. (security, assessment, talking and tranquilization).

Table 5.

Common causes of acutely disturbed behaviour

Underlying condition Explanation for acutely disturbed behaviour
Acute schizophrenia Paranoia, hallucinations or disorganised thinking
Acute mania Excitement, euphoria, grandiosity
Severe alcohol intoxication Disinhibition (loss of restraint over angry and violent impulses). It settles as alcohol wears off
Drug intoxication It can produce any mental state. Crack cocaine can produce a homicidal state. Amphetamine can precipitate a paranoid state
Severe alcohol withdrawal Confusion (‘delirium tremens’). Medical admission is usually indicated
Acute confusion Related to general medical disorders, especially in the elderly. Metabolic/ electrolyte disturbances and infections are common
DementiaDisturbance attributable to personality disorder Behaviour disturbance is usually progressive over weeks or months. Troublesome rather than dangerouse.g. anger and rage in borderline and antisocial personality disorders
Learning disability Rare outside specialist residential units
Instrumental violence Violence with a purpose (e.g. beating up a love-rival). It is often fuelled by drugs and alcohol.

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).

Substance misuse

Conditions associated with substance misuse, which can present to paramedics, include intoxication and withdrawals. Some of these cases may present as medical emergency and paramedics should be able to make a quick assessment of severity, urgency and risks to physical health, to decide the next most appropriate step. The first step in all cases must be to ensure safety of the patient.

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.

Table 6.

Effects of commonly abused substances

Substance Features
Alcohol Dysarthria, uncoordination, ataxia, nystagmus, diplopia, impaired memory and drowsiness/ stupor/coma. Loss of judgment can lead to violence
Amphetamines, cocaine and derivatives Euphoria, excitement, arousal, agitation, dilatation of pupils, tachycardia or bradycardia, hypertension or hypotension, repetitive motor movements (e.g. chewing, bruxism), paranoia, confusion, seizures and coma
Cannabis Initially euphoria, later drowsiness and apathy, increased appetite (‘munchies’), conjunctival injection, dry mouth, tachycardia and paranoia
Opiates Initially euphoria, later drowsiness and apathy, constricted pupils, slurred speech and general inattention
Ecstasy (MDMA) Similar to, but less potent than, amphetamine, feelings of belonging/closeness (‘loved-up’), dehydration, hyperthermia
Benzodiazepines Similar to alcohol but profound sedation, potently amnesic.

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 and the law

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.

Section 2

This is a psychiatric admission order (for up to 28 days) for assessment followed by treatment if needed. It may be used if a patient is probably suffering from a mental illness and needs assessment. The grounds for applying a Section 2 are that there is at least one of:

  • Significant risk to patient's own health

  • Significant risk to patient's own safety, or:

  • Significant risk to the safety of other persons.

There is no legal definition of a ‘significant risk’ and thus the interpretation is a matter of professional judgment.

Section 3

This is similar to Section 2 except that it is a psychiatric treatment order to detain a patient for up to six months and used when it is certain that treatment is required.

Section 4

Mental health practitioners seek to avoid the use of Section 4, but where the patient's condition is of critical and urgent concern, it can legitimately be used to admit patients for up to 72 hours. As only one medical opinion is required for a Section 4, it can be undertaken more quickly than a Section 2 or 3.

Section 136

This is not an admission section, but holds a person, who a police officer suspects to be mentally ill, at a ‘place of safety’ for up to 72 hours. A ‘place of safety’ is usually a police station, an A&E department or a special reception facility within a psychiatric unit. The police powers of removal are ‘from a place to which the public have access’. This means almost anywhere other than the patient's own home, for which a Section 135 would be needed.

Section 135

This section allows a police officer to enter premises to search for someone with suspected mental health problems and take them to a place of safety. It needs a warrant which is obtained on the application of an AMHP to a local magistrate, a process usually taking one to two days. However, in high risk circumstances (such as a patient at home attempting suicide by hanging), the police will be prepared to enter a person's home without a warrant on the grounds of necessity.

Mental Capacity Act

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

  • Every adult has the right to make his/her own decisions and capacity to do so is presumed unless it is proved otherwise.

  • People must be given all appropriate help before anyone concludes that they cannot make their own decisions

  • Individuals retain the right to make eccentric or unwise decisions

  • Anything done for people without capacity must be in their best interests

  • Anything done for people without capacity should be the least restrictive option.

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.

Conclusion

This article concludes a series on mental health. It offers a short guide for paramedics to understand principles of initial assessment and management of mental health conditions which are commonly encountered in emergency settings—prehospital (in the community) as well as in the A&E department.

The goals of initial assessment should include identification of a psychiatric disorder, underlying cause or precipitating factor, assessment of severity, urgency, risks and assessment of the needs of the patient. The goals of the initial management should include making the patient safe, immediate relief of distress, and referral to appropriate services for further definitive management.

It is also useful to have an understanding of local non-NHS services (e.g. social services including children, school and families; options for emergency respite or shelter; non-statutory agencies; self-help groups; police and probation services etc) as many of these presentations would need attention from these agencies with or without medical care.

Some of the psychiatric patients may be assessed and treated against their will, under an appropriate section of MHA, 1983, when applicable. If MHA does not apply and patient is found to lack capacity to decide about the treatment, the practitioner could invoke the Mental Capacity Act, 2005. However, in practice, it is better to provide whatever urgent care is considered necessary to preserve life and health and allowing a mental healthcare professional to assess the patient's capacity later on.

Although this text has outlined the initial management of some common psychiatric emergencies, there are no formulae that can be universally applied. Experience and expert judgment will always be required to respond flexibly to the features of each case, taking in account the setting, context, urgency, severity, risks involved and available time and resources.

Key points

  • The goals of initial assessment should include identification of a psychiatric disorder (if any), underlying cause or precipitating factor and an assessment of severity, urgency, risks and needs of the patient.

  • The goals of the initial management should include making the patient safe, immediate relief of distress, and referral to appropriate services for further definitive management. Consult mental health professionals, as and when required.

  • Manic episodes, anorexia nervosa and post-partum mental disorders are high risk psychiatric presentations which need an urgent medical attention.

  • Self-harm/suicidal behaviour is very common and people presenting with these must receive a psycho-social assessment (not necessarily from a mental health professional).

Appendix. Summary of some common psychiatric emergencies

Bipolar disorder Manic episode usually needs hospitalization. Mood stabilizers are the cornerstone of long-term treatment. Treatment with lithium needs close monitoring of plasma levels (0.4–1 mmol/l) and so low threshold of suspicion is recommended for lithium toxicity
Anorexia nervosa This carries a high risk of mortality and physical complications. It should preferably be managed in a specialist eating disorders unit or acute medical ward if hospitalization is indicated
Post-partum mental illness Includes depressive episodes and psychosis. Risk to both mother and the infant should be considered. Psychotic mothers should be hospitalized, preferably in a mother and baby psychiatric unit
Self-harm/suicidal behaviour This itself does not imply mental illness and should always be assessed on its lethality and strength of intention. Suicide is a rare event and so management should depend on the patient's needs, distress and disability, rather than perceived risk of suicide. Management options range from discharge with no follow-up to detention in the hospital
Substance misuse Alcohol withdrawal starts 12 to 24 hours after cessation or reduction in heavy alcohol use and may progress over 2 to 3 days to a potentially fatal condition. Management includes detoxification regime with chlordiazepoxide over many days and pabrinex supplementation. Opiate withdrawal starts 6 to 12 hours after last dose of heroin and most of the cases can be managed symptomatically
Acutely disturbed patients These patients can present as confused or aggressive. Ensuring safety is of paramount importance. Definitive management depends on the underlying cause, though ‘talking down’ often works. Rapid tranquilization can be used in an emergency
Mental health legislation This includes S136 (police powers of removal of a person from a public place to a place of safety), S2 (assessment order for up to 28 days) and S3 (treatment order for up to 6 months) of the MHA, 1983. The MCA, 2005 protects vulnerable people who cannot make their own decisions.

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