Author: Joseph L D’Orazio, MD (EM Attending Physician/Director of Medical Toxicology, Albert Einstein Medical Center, @jldorazio) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Resident at SAUSHEC, USAF)

Basic Principles

In 2011, 0.7% of the 136.3 million U.S. Emergency Department (ED) visits resulted in a transfer to a psychiatric facility.1 Emergency physicians (EPs) are commonly called upon to evaluate these patients for “medical clearance” prior to a psychiatric admission. This article is a review of medical clearance for the psychiatric patient and the common pearls and pitfalls of the process.

“Medical clearance” is a term commonly used for the initial medical evaluation or focused medical assessment performed in the ED prior to transfer to a psychiatric facility. The term “medical clearance” can be problematic because there is no singular accepted standard definition or process among EPs or psychiatrists. Medical clearance is not a term to represent the absence of medical issues, but rather the absence of medical instability or a medical condition causing or contributing to the psychiatric presentation.

Determining medical causation for psychiatric disease is the most essential reason for the medical evaluation in the ED prior to psychiatric placement. There are numerous conditions that can cause psychiatric symptomatology including medication side effects, drug and alcohol abuse and withdrawal, infections, central nervous system disease, metabolic/endocrine conditions, and cardiopulmonary disease. If an underlying medical condition is found to be causing or exacerbating the psychiatric complaint, treatment in the ED or in a medical hospital is indicated.2

While discovering a medical cause for the psychiatric symptoms is the goal in screening, incidental findings of medical conditions with no causation are also commonly found (e.g. hypertension, diabetes, COPD, upper respiratory infections, etc). Collaboration with the psychiatrist to determine the practitioner and/or facility’s ability to care for concomitant medical conditions is essential in these scenarios.

Diagnostic Testing

Ancillary testing for psychiatric patients in the ED has been a highly debated topic in emergency medicine for a very long time. There are numerous articles published on this topic and various sub-topics. While some authors advocate for extensive testing including blood work and advanced testing (CT and EEG), authors on the other side of the debate argue for clinically indicated and cost-effective testing.

Routine laboratory screening of all patients that present to an ED for primary psychiatric complaints has been found unnecessary by many studies.3-7 The ACEP clinical policy on diagnosis and management of adult psychiatric patient recommends that routine laboratory testing is not necessary and should be tailored to history and physical findings in alert, cooperative patients with normal vital signs and a noncontributory history and physical exam (Level B).3

While some institutional protocols include routine diagnostics for all patients with primary psychiatric complaints prior to psychiatric admission, many studies have shown that this practice is unwarranted and wasteful.4-7 These studies suggest that a complete history and physical is an effective screening tool for identifying significant medical abnormalities.4-6

A 1997 study by Olshaker et al. of 345 patients presenting to an ED with psychiatric complaint, a complete history was most sensitive for identifying a common medical condition at 94%. Physical examination, abnormal vital signs, and laboratory studies had sensitivities of 51%, 17% and 20% respectively. The most shocking finding was that simply asking the patient if they had an underlying medical condition was almost as good as a history at 92% sensitivity.5 This refutes the commonly held belief that psychiatric patients are unable give an accurate history or convey their problems to medical staff. Only two laboratory abnormalities had no attributable cause on history and physical examination in this study. Both abnormalities were low potassium levels (2.9 and 3.1 mmol/L).5

Conversely, Henneman et al. recommend routine laboratory screening for adults patients with new psychiatric symptoms and no previously diagnosed psychiatric condition. Sixty-three of the 100 patients screened in this study were diagnosed with an organic etiology. This study is in contrast to most studies that look at patients with known psychiatric disease with primary psychiatric complaints. While stating that routine laboratory screening of all patients is not recommended, Henneman recommended routine laboratory screening in addition to history and physical examination in patients with new psychiatric symptoms with no underlying psychiatric history. The high rate of organic disease and low sensitivity of history and physical examination in this population is the basis behind the recommendation. Henneman et al. gives the caveat that a complete blood count (CBC) and prothrombin time (PT) could have been excluded from the diagnostic screening without sacrificing sensitivity of identifying medical conditions in this population.8

Routine laboratory testing in geriatric patients presenting with primary psychiatric complaints is often warranted secondary to the higher incidence of medical disease in this population.9 Elderly patients are highly susceptible to alterations in mental status from simple infections, electrolyte abnormalities, and medication side effects. Extra caution should be taken in elderly patients with psychiatric complaints.

Head CT: Computed tomography of the brain (CT) is clinically indicated in psychiatric patients with altered mental status, trauma, immunodeficiency, or focal neurological findings. As with laboratory testing, special caution should be taken when deciding whether to obtain a CT for elderly patients. The over-utilization of CT is a well-described phenomenon. A recent study showed that few patients benefit from CT when evaluated for dizziness or syncope unless they are older than 60 years, have a focal neurologic deficit, or have a history of recent head trauma.10 However, the decision to omit a CT in patients with psychiatric complaints is difficult and not well studied.11 As many would agree, routine CT in psychiatric patients is a low-yield study and is not recommended12 even in new-onset psychosis.13 On the contrary, Henneman et al. showed that 10% of patients with psychiatric complaints who had a CT performed had an abnormal finding of significance.8 While this study is not clear on actual CT findings and whether the diagnosis was also made on history and physical exam, it does speak to the importance of looking for organic brain disorders.

Urine drug screening: While useful for a psychiatrist in the disposition and treatment of psychiatric patients, routine urine drug screening is rarely helpful in the management of alert and cooperative patients in the ED with a noncontributory history, physical, and vital signs (Level C).3 Urine screening for drugs of abuse may identify unsuspected cases of drug abuse but does not always equate to the diagnosis of acute intoxication. For instance, a drug screen positive for methamphetamine does not mean the patient is presenting with acute intoxication with methamphetamine. EPs should look for signs of acute intoxication (i.e. vital signs and physical exam findings) rather then depend on a urine drug screen to identify intoxicated patients. Urine drug screens are unreliable with many false-positive and false-negative results and have very little impact on the care of patients in the ED.14,15 If urine drug screening is performed in the ED for use at a receiving psychiatric facility, it should not delay disposition.3

Routine blood alcohol testing: Acute alcohol intoxication is a common finding in the ED. While acute alcohol intoxication can cause central nervous system depression, not all intoxicated patients are medically unstable. In general, psychiatrists and psychiatric facilities will not accept acutely intoxicated patients who are impaired and unable to give a complete history for legitimate reasons. Although the legal limit for driving is often used as the threshold for an acceptable psychiatric evaluation, there is no data to support or refute this practice.3 The routine use of blood alcohol screening is not recommended in patients without obvious signs of intoxication and normal cognition.3 Conversely, alcohol screening may be useful in which a patient’s altered mental status is of unclear origin.

The diagnosis of alcohol and benzodiazepine withdrawal is even more important in the ED in making the diagnosis of intoxication. Patients with withdrawal from these substances may present with alcoholic hallucinosis and be misdiagnosed with a primary psychotic disorder. Looking for signs of withdrawal including tachycardia, hypertension, diaphoresis, tremor, agitation, and other sympathomimetic signs is integral in making the diagnosis. Assessing patients with excessive alcohol consumption for a history of withdrawal symptoms/seizures and use of “eye openers” is essential in determining probability of imminent withdrawal.

Thyroid Function Screening: Both hypothyroidism and hyperthyroidism mimic and/or complicate psychiatric diseases such as depression and bipolar disorder. Thyrotoxic patients can present with nonspecific psychiatric symptoms including anxiety, tremor, emotional lability, insomnia, agitation, and even psychosis or confusion. Looking for findings of hyperthyroidism on history and exam such as weight loss, tachycardia, exophthalmos, thyromegaly, and thyroid bruit are key in making the diagnosis in patients with new-onset psychiatric symptoms. Routine thyroid function test screening is unlikely to benefit patients in patients with no signs/symptoms of hyper-or hypothryoidism and may delay flow of patients in the ED.16-17

Asymptomatic hypertension: Elevated blood pressure is a common finding in the ED with approximately 30% or more of all adults in the U.S. being affected by hypertension. Patients with psychiatric disease are among a population particularly at risk for uncontrolled hypertension due to lack of adequate medical care and compliance with medications. A clinical policy article by ACEP in 2013 states that routine screening for end organ damage is unnecessary for asymptomatic patients in the ED. Furthermore, it is unnecessary for routine medical intervention in these patients as it did not improve immediate outcomes.18 Conversely, it is generally accepted that the rapid lowering of blood pressure can be harmful in patients.18 Patients should be provided outpatient follow-up for the management of hypertension, and in select patients with poor follow-up, initiation of long-term therapy is acceptable.18

Take Home Points

-Adult patients with no previously diagnosed psychiatric disorder presenting with a primary psychiatric complaint have a higher incidence of an underlying medical condition than those with a history of psychiatric disease.

-Have a high suspicion for underlying medical conditions in elderly patients presenting with psychiatric complaints. Infections, electrolyte abnormalities, and medication side effects are common causes of altered mental status that mimic psychiatric disease in the elderly.

– Look for signs of thyroid disease in patients with new-onset psychiatric symptoms.

– Patients with abnormal vital signs, delirium, altered cognition, or abnormal physical exam findings are likely to have an underlying medical condition causing a psychiatric complaint.

-Consider CT of the brain for patients with altered mental status, focal neurological deficits, trauma, advanced age, and immunodeficiency.

-A positive finding on urine drug screening does not indicate acute intoxication.

-Look for signs of alcohol and benzodiazepine withdrawal including tachycardia, hypertension, tremor and agitation.

–Rapid lowering of blood pressure can be harmful to patients.

References/Further Reading

Centers for Disease Control and Prevention. National Hospital Ambulatory Medical Care Survey: 2011 Emergency Department Summary Tables. Available at http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2011_ed_web_tables.pdf. Accessed 4/20/15 Zun LS. Evidence-based evaluation of psychiatric patients. J Emerg Med 2005;28(1):35-9. Lukens et al. Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. Ann Emerg Med. 2006;47(1):79-99. Korn CS, Currier GW, Henderson SO. “Medical clearance” of psychiatric patients without medical complaints in the emergency department. J Emerg Med. 2000;18(2):173-176. Olshaker JS, Browne B, Jerrard DA, Prendergast H, Stair TO. Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med 1997;4:124-8 Amin M, Wang J. Routine laboratory testing to evaluate for medical illness in psychiatric patients in the emergency department is largely unrevealing. West J Emerg Med. 2009;10(2):97-100. Parmar P, Goolsby CA, Udomoanyanan K, et al. Value of mandatory screening studies in emergency department patients cleared for psychiatric admission. West J Emerg Med. 2012;12(5):388-393 Henneman PL, Mendoza R, Lewis RJ. Prospective evaluation of emergency department medical clearance. Ann Emerg Med. 1994; 24:672-677. Kolman PB. The value of laboratory investigations of elderly psychiatric patients. J Clin Psychiatry. 1984;45:112-116. Mitsunaga MM1, Yoon HC. Journal Club: Head CT scans in the emergency department for syncope and dizziness. Am J Roentgenol. 2015;204(1):24-8. Wolfson A, et al. Harwood Nuss’ Clinical Practice of Emergency Medicine, 6th Edition, Philadelphia, Lippincott Williams & Wilkins, 2015 Agzarian MJ, Chryssidis S, Davies RP, Pozza CH. Use of routine computed tomography brain scanning of psychiatry patients. Australas Radiol. 2006;50(1):27-8. Goulet K, Deschamps B, Evoy F, Trudel JF. Use of brain imaging (computed tomography and magnetic resonance imaging) in first-episode psychosis: review and retrospective study. Can J Psychiatry. 2009;54(7):493-501. Tenenbein M. Do you really need that emergency drug screen? Clin Toxicol. 2009;47(4):286-91 Schiller MJ, Shumway M, Batki SL. Utility of routine drug screening in a psychiatric emergency setting. Psychiatr Serv. 2000;51(4):474-8. Ordas DM, Labbate LA. Routine screening of thyroid function in patients hospitalized for major depression or dysthymia? Ann Clin Psychiatry. 1995;7(4):161-5. Lachman A, Cloete KJ, Kidd M, Schoeman R. The clinical utility and cost effectiveness of routine thyroid screening in adult psychiatric patients presenting at Stikland Hospital, Cape Town, South Africa. Afr J Psychiatry (Johannesbg). 2012;15(1):36-41 Wolf S et al. Clinical policy: critical issues in the evaluation and management of adult patients in the emergency department with asymptomatic elevated blood pressure. Ann Emerg Med. 2013;62(1):59-68 http://www.ncbi.nlm.nih.gov/pubmed/24219903 http://www.ncbi.nlm.nih.gov/pubmed/24642041 http://www.ncbi.nlm.nih.gov/pubmed/23903675 http://www.ncbi.nlm.nih.gov/pubmed/22698827