Emergency Department Mental Health Management

It’s time. It’s time to stop complaining and get back to basics in the Emergency Department to provide great care to our mental health patients…

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At Westmead Emergency,  we are piloting a new half day mental health skills course in January 2019. The notes below will given you a taster on what’s on offer on our new course. This new approach to training is inspired by award-winning simulation training pioneered by the Maudsley in London.

These are the four target areas for the new training course:

  • Mental State Examination for Newbies (ED staff)

  • Key Aspects of New South Wales Law

  • Risk assessment – what is ‘risk‘ anyway?

  • Who is ‘medically clear anyway‘?

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Mental Health – Mental State Examination for Newbies

Mental State Examination (MSE) – a key skill for assessment and risk stratification.  On the course we will discuss planning an interview, doing the interview with a patient and presenting the history over the phone.

Here is a summary of the key components of the MSE:

ASEPTIC – appearance/behaviour, Speech, Emotion, Thoughts, Insight, Cognition.

Appearance and Behaviour:

  • Appearance
    • How is the patient dressed? (unkempt, appropriate?)
    • How is the patients body language and overall appearance?
  • Behaviours
    • Patient’s behaviour during the interview
      • are they distractable?
      • are they lethargic?
      • are they anxious?
      • how is the eye contact?
      • how appropriate is the patient?
      • are they hyperactive or furtive?
      • are they slow?


  • Quantity
  • Rate
  • Quality
  • Tone and Rhythm
  • Appropriateness
  • Is there a medical issue? (e.g. dysphasia)

Emotion (Mood and affect)

  • Mood
    • Do they describe feelings of depression, joy, anxiety etc.
    • How do they describe their current life?
    • Have they had thoughts/plans/attempts of self harm?
  • Affect
    • How do they react when talking about life?
    • Is the ‘affect’ consistent throughout the interview?


  • Hallucinations
  • Delusions


  • “One thought normally will give rise to a number of other related thoughts and so on and so on, in a goal-driven direction to complete a task (whether this is a conversation, and practical activity, learning/studying etc).  Normally, the ‘train of thought’ allows people to do this.  In thought disorder there is an inability to do this and patients are unable to do this.  This usually manifests as a change in rate of thought and the associations of thought.”
  • Schneider’s First Rank Symptoms – (ABCD):
    • Auditory hallucinations
    • Broadcasting of thought
    • Controlled thought (delusions of control)
    • Delusional perception


  • Is this intact?


    • Consider a full Mini-mental state examination.
    • Consider the need to differentiate between delirium and psychosis.
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Mental Health – Key Aspects of New South Wales Law

As part of our course one of resident psychiatrists will take us through the local law.  Always act within in the law…

A summary of the key aspects of New South Wales law pertaining to mental health:

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  • Emergency Treatment Law
    • Under of Duty of Care (Common Law)
    • Obligation to intervene to preserve life but this does not overrule self-determination
  • Mental Health Law
    • State Jurisdiction – CLICK HERE
    • In NSW patient can be “Mentally Ill” or “Mentally Disordered” (see above)
    • This is time limited and has specific legal requirements:

REQUIRED – patient must be at risk of ‘significant harm‘ and using the mental health act must be the ‘least restrictive‘ means of treatment

  • For medical issue management and treatment substitute consent is required for non-emergency treatment in these patients (NSW acts 1990 and 2007)…
  • Non-emergency Treatment
    • Must make an assessment of a patient’s capacity
    • Capacity is determined by
      • holding information, weighing information and making a decision based on the information (Informed consent)
    • Patient with capacity can refuse medical treatment for any reason or no reason at all
    • Patients over the age of 16 years old are treated as adults
    • Grey area at age 14-15 – providing they understand they can consent. It may be prudent to also discuss with the Guardianship Board or Parent(s).
  • Where there are issues with obtaining consent:
    • Are there alternative treatment(s)?
    • Offer a second opinion
    • Explain that emergency treatment may be required later
    • Consider if the patient in the case is a ‘child at risk’
    • A court order may be sought as a last resort

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Mental Health – Risk assessment – what is risk anyway?

Key Concepts

To cut a long story short there’s a bunch of rules, heuristics and urban legends – but not hard and fast rule works.

In fact by the very virtue of being in the ED with a mental health presentation you are at greater risk compared to the general population (A LOT HIGHER)…

Ultimately, while the risk may be ‘low’ or ‘high’, every patient needs a tailored management plan that balances the pros and cons of an acute psychiatric admission versus treatment and support in the community.

On our new course Dr Chris Ryan will dissect this area on our local course and teach us that the SADPERSONS score is a great mnemonic but not a validated suicide risk rule.

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Encouraging Data on the Role of ED

Improving Suicide Risk Screening And Detection In The Emergency Department Boudreaux, E.D., et al, Am J Prev Med 50(4):445, April 2016

BACKGROUND: Over the last two decades, the suicide rate in the United States has increased almost 30%. The prevalence of active ideation among emergency department (ED) patients has been reported to be 8%. It is important to identify suicide risk in patients during ED visits.

METHODS: These researchers, coordinated at the University of Massachusetts, conducted a multicenter three-phase interrupted time series study termed the “ED Safety Assessment and Follow-up Evaluation” (ED-SAFE). The phases were treatment as usual, universal suicide risk screening, and universal screening plus intervention. Active suicidal ideation in the previous two weeks or a suicide attempt within the last six months constituted a positive screen. The first primary outcome was documentation of any screening in the medical records. The second was a positive screen. The screening outcome was evaluated across the three study phases. Patients with a positive screen were interviewed.

RESULTS: Overall 236,791 ED visit records were reviewed, 10,625 patients identified who had a positive screen, and 3,101 interviews completed. Any documentation of screening increased from 26% in Phase 1 to 73% and 84% in Phases 2 and 3, respectively. Positive screen detection improved from 2.9% in Phase 1 to 5.2% and 5.7% in Phases 2 and 3, respectively. Interview data showed that 74% of patients screening positive reported suicidal ideation or attempt within the previous week.

CONCLUSIONS: The authors consider this to be a landmark study as it shows that not only can universal suicide risk screening be successfully implemented in the ED, but also that it leads to a substantial improvement in suicide risk detection, which in turn facilitates intervention.

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Mental Health – Who is ‘medically clear anyway‘?