Nidal Moukaddam

Catatonia secondary to synthetic cannabinoid use in two patients with no previous psychosis.

BACKGROUND AND OBJECTIVES Synthetic cannabinoids (SC) have become widely abused as recreational drugs, and are now known to carry risk of severe mental and physical health effects. Catatonia, spanning the gamut from motor retardation to agitation, can constitute a psychiatric emergency for which benzodiazepines are the mainstay of treatment. The purpose of this paper is to report on an unusual occurrence of catatonia in the context of synthetic cannabinoid use, and a discussion of treatment options that have been helpful as adjuncts to benzodiazepines. METHODS We present two cases of catatonia occurring in context of SC use. The first patient was using SC quasi-daily for 18 months. The second patient used a large quantity over a two-week period. Both patients were admitted to our emergency center with catatonia and no overt psychosis or mood symptoms. RESULTS The absence of pre-existing mood or psychotic disorder and the severity of catatonic symptoms separates these cases from other cases reported in the literature. Additionally, pharmacological management targeting gamma-aminobutyric acid (GABA) and serotonin neurotransmitter systems were used, specifically aripiprazole and valproic acid, supplementing benzodiazepine administration; these were needed for optimal symptom control. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE The above-reported cases are highly significant because of the severity of catatonic symptoms requiring inpatient hospitalization, the potential for rapid and severe decompensation with catatonia, and the atypical/unexpected development of catatonia with SC use.

New Drugs of Abuse and Withdrawal Syndromes

New drugs of abuse continue to emerge, including synthetic cannabinoids, synthetic cathinones, and hallucinogens. It is important to recognize their individual psychopharmacologic properties, symptoms of intoxication, and symptoms of withdrawal. Providers must be vigilant of acute medical or psychiatric complications that may arise from use of these substances. Treatment of the patient also includes recognition of any substance use disorders as well as comorbid psychiatric disorders. Although pharmacologic treatments for substance use disorder (of the drugs included in this article) are limited, there are a variety of psychotherapeutic modalities that may be of some benefit.

Down the Rabbit Hole: Emergency Department Medical Clearance of Patients with Psychiatric or Behavioral Emergencies.

Patients presenting with behavior or psychiatric complaints may have an underlying medical disorder causing or worsening their symptoms. Misdiagnosing a medical illness as psychiatric can lead to increased morbidity and mortality. A thorough history and physical examination, including mental status, are important to identify these causes and guide further testing. Laboratory and ancillary testing should be guided by what is indicated based on clinical assessment. Certain patient populations and signs and symptoms have a higher association with organic causes of behavioral complaints. Many medical problems can present with or exacerbate psychiatric symptoms, and a thorough medical assessment is imperative.

Addictive Disorders in Adolescents

Addictive disorders in youth represent a dynamic field characterized by shifting patterns of substance use and high rates of experimentation, while retaining the risky behaviors and negative outcomes associated with established drug classes. Youth/adolescents are also at the forefront of use of new technologies, and non-substance-related disorders are pertinent. These disorders present with similar pictures of impairment, and can be diagnosed following the same principles. An underlying mental disorder and the possibility of a dual diagnosis need to be assessed carefully, and optimal treatment includes psychosocial treatments with applicable pharmacologic management, the latter representing an expanding field.

Epic Fail! Poor Neuropsychiatric Documentation Practices in Emergency Psychiatric Patients

Background: There is a strong association between mental illness and poor physical health. However, research indicates that the standard of physical examinations performed on patients with psychiatric illnesses is sub-optimal, falling short of recommended/expected assessments. Objective: This study aimed to assess the completeness of the neurological and psychiatric examinations performed by emergency physicians in a level 1 trauma centre with a dedicated psychiatric emergency centre. Methods: A retrospective chart review of 50 consecutive emergency psychiatric patients was performed. Each of the 50 patients had been “medically cleared” and deemed stable for transfer to inpatient psychiatry. Results: The documented neurologic and psychiatric examinations were generally poor. Mood and affect were documented in less than 50% of cases. Suicidality was documented in less than 1/3 of the patients who presented with a chief complaint of suicidal ideation. Only one patient had a documented a mini-mental status examination. 16% of patients did not have their orientation status documented. More than half did not have a cranial nerve examination. Less than 25% had their gait or reflexes tested. 28% of patients had their strength tested and 12% had a sensory examination performed. Conclusions: Most psychiatric patients are not receiving a thorough neuropsychiatric physical examination by emergency providers, an alarming finding deserving more scrutiny. Additional research is needed to ascertain which components of the neurological and psychiatric examination are the highest yield and would have the greatest impact patient care outcomes and disposition. Interdisciplinary consensus must also be reached on what constitutes an adequate examination for patients with varying severity of neuropsychiatric presentations (e.g., suicidal ideation, altered mental status, frank psychosis).

Emergency Department Medical Clearance of Patients with Psychiatric or Behavioral Emergencies, Part 2: Special Psychiatric Populations and Considerations

Patients who present to the emergency department (ED) with mental illness or behavioral complaints merit workup for underlying physical conditions that can trigger, mimic, or worsen psychiatric symptoms. However, there are wide variations in quality of care for these individuals. Psychiatry and emergency medicine specialty guidelines support a tailored, customized approach to patients. Our group has long advocated a dynamic comanagement approach for medical clearance in the ED, and this article summarizes best-practice approaches to the medical clearance of patients with psychiatric illness, tips on history taking, system reviews, clinical/physical examination, and common pitfalls in the medical clearance process.

Shift, Interrupted: Strategies for Managing Difficult Patients Including Those with Personality Disorders and Somatic Symptoms in the Emergency Department

Difficult patients are often those who present with a mix of physical and psychiatric symptoms, and seem refractory to usual treatments or reassurance. such patients can include those with personality disorders, those with somatization symptoms; they can come across as entitled, drug-seeking, manipulative, or simply draining to the provider. Such patients are often frequent visitors to Emergency Departments. Other reasons for difficult encounters could be rooted in provider bias or countertransference, rather than sole patient factors. Emergency providers need to have high awareness of these possibilities, and be prepared to manage such situations, otherwise workup can be sub-standard and dangerous medical mistakes can be made.

True costs of medical clearance: Accuracy and disagreement between psychiatry and emergency medicine providers

Introduction: Medical clearance is required to label patients with mental illness as free of acute medical concerns. However, tests may extend emergency department lengths of stay and increase costs to patients and hospitals. The objective of this study was to determine how knowledgeable emergency and psychiatric providers are about the costs of tests used for medical clearance. Materials and Methods: We surveyed the department of psychiatry (Psych) and department of emergency medicine (EM) faculty and residents to obtain their estimates of the costs of 18 laboratory/imaging studies commonly used for medical clearance. Survey responses were analyzed using the Wilcoxon signed-rank test to compare the median cost estimates between residents and faculty in EM and Psych. Results: A total of 99 physicians (response rate, 47.8%) completed the survey, including 47 faculty (EM = 28; Psych = 20) and 52 residents (EM = 29; Psych = 23). Across all the groups, cost estimates for tests were inaccurate, off by several hundred dollars for three tests, and by

Difficult Patients in the Emergency Department: Personality Disorders and Beyond

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Emergency Department Medical Clearance of Patients with Psychiatric or Behavioral Emergencies, Part 1

80 for 15. Significant differences between EM and Psych providers for estimated median costs of specific tests included between residents for urine drug screens (EM: