C.  Is The Patient Medically Or Psychiatrically Unstable?

 

OBJECTIVE

 

Identify the patient who needs to be stabilized before continuing in the algorithm.

 

ANNOTATION

 

Patients with problems that require emergency care or urgent action should not be further managed in this algorithm.  Emergency or urgent actions include unstable medical problems (e.g., acute trauma, myocardial infarction, and stroke) or unstable psychiatric problems (e.g., delirium and imminent risk of harm to self and/or others).

 

Delirium (APA, 1994)

Delirium can be identified through the following:

1.               Disturbance of consciousness (e.g., reduced clarity of awareness of the environment with reduced ability to focus, sustain, or shift attention).

2.               A change in cognition (such as memory deficit, disorientation, or language disturbance) or the development of a perceptual disturbance that is not accounted for by a preexisting, established, or evolving dementia.

3.               The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.

4.               There is evidence from the history, physical examination, or laboratory findings that:

·            Illness is characterized by an atypical course.

·            Disturbances are caused by the direct physiological consequences of a general medical condition.

·            Symptoms developed during substance intoxication or medication use are etiologically related to the disturbance.

·            Symptoms are developed during or following a withdrawal syndrome.

·            Delirium has more than one etiology (e.g., a general medical condition plus intoxication or a medication side effect).

 

Risk of harm to self or others

1.               If suicidal ideation is present, the imminent risk increases with one or more of the following risk factors:

·              Prior suicide attempt and lethality of prior acts

·              Level of intent and formulation of plan

·              Greater preoccupation (e.g., frequency, intensity, and duration of thoughts)

·              Availability of lethal means for suicide (e.g., firearms or pills)

·              Family history of completed suicide

·              Presence of active mental illness (e.g., severe depression or psychosis)

·              Presence of substance abuse

·              Current negative life events (e.g., loss in personal relationship)

·              Feelings of hopelessness or helplessness

2.               Consider the patient’s history of violent acts as an increased risk for violence toward self or others.

3.               Offer mental health counseling to patients with evidence of suicidal, assaultive, or homicidal ideation.

4.              Arrange voluntary or involuntary emergency psychiatric treatment and possibly hospitalization for patients with definite intent to harm self or others, particularly those with a plan and the available means.

 

Serious psychiatric instability

Obtain immediate mental health consultation if other psychiatric symptoms (e.g., acute psychosis) significantly interfere with further assessment and require immediate psychiatric treatment before continuing assessment.

 

EVIDENCE TABLE

 

	Recommendations	Sources of Evidence	QE		R
1	Assess imminent risk for suicide.	U. S. PSTF, 1996	II-2		A
2	Note increased risk for violence.	Hasting & Hamberger, 1997 Thienhaus & Piasecki, 1998	III		A
3	Offer counseling to patients at risk.	Hirschfield & Russell, 1997 U. S. PSTF, 1996	III		A
4	Arrange emergency treatment or possible hospitalization.	APA, 1993 CSAT, 1995 U. S. DHHS, 1993 & 1995 U. S. PSTF, 1996 VA Task Force, n/d.	III		A

QE = Quality of Evidence; R = Recommendation (See Introduction)