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A clinician in the psychiatric emergency setting encounters many patients with mild forms of depression, including adjustment disorders and dysthymia. Such patients commonly seek help after suffering a considerable personal, occupational, or financial loss. For example, a patient might feel rejected by a lover, spouse, or parent. For these patients, crisis intervention can significantly alleviate depression and establish a framework for restoring psychological equi librium.
At the other end of the spectrum are patients enduring major depressive episodes with psychotic features. Patients who are psychotically depressed have severe social impairment and disturbed orientation manifested by delusions, hallucinations, and confusion. Psychotic depression is associated with suicide, repetitive self-destructive acts, and chronic self-neglect.
As with all psychiatric disorders, the clinician must be alert for an underlying medical cause of the patient's depressive symptoms. An organic mood syndrome must be considered part of the differential diagnosis for all depressed patients. Medication, endocrine or neurologic disease, electrolyte imbalance, infection, and substance abuse can also precipitate major depressive episodes, technically called organic mood syndrome.
Depression comprises several conditions that differ in clinical presentation, course, pattern of inheritance (some depressive illnesses are genetically inherited), and treatment response (see Major depressive syndromes for the features of each depressive disorder). Major depressive episodes usually begin when the patient is in his late 20s but can occur at any age. Symptoms develop over days or weeks. In some cases, however, onset is sudden, especially when depression is related to a psychosocial stressor, such as loss of a job or significant relationship. Duration of the depressive episode varies; untreated episodes can last 6 months or more (DSM-III-R, 1987).
Although spontaneous remissions occur in most depressed patients, the risk of suicide and serious medical complications secondary to self-neglect make treatment imperative. About 20% of depressed patients have symptoms that persist for 2 years, and about 15% of these patients commit suicide. Thus, major depression must be considered a life-threatening illness.
Suspect depression in a patient who exhibits the following symptoms (DSM-III-R, 1987):
A depressed patient requires a thorough mental status examination. Significant findings include persistent sadness, psychomotor retardation (ranging from slowed body movement and soft, slurred speech to extreme agitation, pacing, and handwringing), recurring thoughts of death and suicide, delusions, cognitive impairment (marked by poor concentration and deficits in recall and short-term memory), worthless ness or guilt (which may be delusion). and hopelessness (difficult to treat because the patient believes that no intervention can eliminate his current problems).
| Major Depressive Syndromes | |
| Major depressive episode | |
| · | Depressed mood |
| · | Diminished pleasure in most or all activities |
| · | Significant weight loss or gain |
| · | Insomnia or hypersomnia daily |
| · | Psychomotor agitation or retardation |
| · | Fatigue or loss of energy |
| · | Feelings of worthlessness |
| · | Inappropriate guilt |
| · | Poor concentration |
| · | Recurrent thoughts of death |
| · | Suicidal ideation, which may be accompanied by hallucinations and delusions |
| Bipolar disorder, depressed | |
| · | All the symptoms of major depressive episode |
| · | History of one or more manic or hypomanic episodes |
| Dysthymia (Less severe than major depressive episode) | |
| · | Depressed mood most days for at least two years |
| · | In addition, at least two of the following: depressed or overactive appetite, insomnia or hypersomnia, low energy or fatigue, tow self-esteem, poor concentration or difficulty making decisions, and feelings of hopelessness |
| Adjustment disorder with depressed mood | |
| · | Reaction to an identifiable psychosocial stressor (or multiple stressors) occurs within 3 months |
| · | Impairment in occupational or school functioning, or in usual social activities and relationships |
| · | Symptoms in excess of a normal and expectable reaction to the stressor |
| · | Maladaptive reaction persists no longer than 6 months, characterized by depressed mood, tearfulness, and feelings of hopelessness |
| Organic mood syndrome | |
| · | Prominent and persistent depressed mood resembling major depressive episode |
| · | Evidence from history, physical examination, or laboratory tests of a specific organic factor judged to be etiologically related to the disturbance |
| · | Not occurring exclusively during the course of delirium |
| Source: DSM-lll-R, 1987. Adapted with permission of the publisher. | |
The clinician should conduct a physical and neurologic examination to rule out possible medical causes of depression, including hypokalemia, hyponatremia, Addison's disease, Cushing's syndrome, diabetes, hyperparathyroidism, hyperthyroidism, hypoglycemia. hypothyroidism, encephalitis, drug toxicity, Alzheimer's disease. Huntington's disease, substance abuse, cirrhosis, tuberculosis, hepatitis, and renal failure (Slaby, 1981).
A blood chemistry profile, complete blood count, thyroid hormone level, and drug screen are essential. Order further studies based on index of suspicion for the disorders listed above.
If the clinician rules out an organic mood disorder, the focus of the clinical assessment shifts to whether the patient's depression is severe enough to warrant inpatient treatment. If hospitalization is not justified, initial interventions can begin in the emergency setting.
Patients who have dysthymia or an adjustment disorder with depressed mood usually arrive in the emergency department(ED) after an upsetting psychosocial stressor. The crisis intervention model of treatment often proves effective in managing nonpsychotic patients with depressive symptoms (Slaby et al., 1981). In a single interview, the clinician can help resolve a conflict by pointing out all options available to the patient. These options can include referral to a housing agency, if that is the patient's primary need. or to other social agencies that can assist the patient with financial, religious, or legal problems. Giving the patient enough time to work through the crisis is vital to the treatment's success. Ideally, other staff members trained in crisis intervention should participate, allowing the patient sufficient time to resolve the crisis without continuous staff involvement.
A clinician sometimes reacts negatively to depressed patients, whose problems may stem from a behavior or life-style not in accord with the clinician's values (for instance, a distraught woman whose relationship with a married man has ended, a man depressed about the breakup of a homosexual relationship, a businessman charged with embezzlement, or a man forbidden to see his children because he is a child abuser). Guard against a superficial, disinterested evaluation or a hostile, angry confrontation. Instead, acknowledge personal feelings of anger, disgust, anxiety, or even attraction and realize that these feelings can impede appropriate evaluation and treatment. If necessary, ask another clinician to speak with the patient.
Emergency management of a nonpsychotic patient with depression consists of instilling hope of improvement, clarifying available options, and explaining the benefits of ongoing psychiatric care. Conduct the interview in a quiet room, and pace the discussion so that the patient does not feel hurried. Try to convey warmth, empathy. understanding, and optimism (Tomb, 1988). Enhance the patient's self-esteem by highlighting past accomplishments and strengths. If appropriate, point out that the patient overcame earlier disappointments and adversity. With the patient's permission, contact family members or friends. The intervention is usually more effective when relatives or friends meet with the clinician and patient to plan the patient's next several days. A structured schedule can prevent the patient from dwelling on his problems.
The clinician's ability to empathize with the patient can have a substantial impact on the outcome of the intervention (Lane, 1986). Establishing empathy is not easy, though, especially in the ED. where severe illness, disruptive patients, and impending death may intrude. Over time, a clinician may become somewhat hardened to tragedy. To avert such emotional detachment, acknowledge your feelings and perhaps discuss them with colleagues.
An effective way to establish empathy for a patient is to imagine being that patient (Hanke, 1984). The clinician can confirm his understanding of the patient's situation by eliciting feedback from the patient. Feedback can be obtained directly, by asking if the comments about the patient are accurate, or indirectly, by observing nonverbal patient cues, such as good eye contact or nodding yes or no. Further, using key phrases ("It sounds like you..." or "I can see how you...") shows the patient that you are trying to understand his problems, helps gain his trust, gives the patient a chance to confirm or correct your impressions, and puts the patients experience into words, which may help him understand his feelings.
Empathy alone is insufficient for an effective intervention. The clinician must also take an objective approach to the patient. Such an approach can provide an alternative explanation of the patient's problem and serve as a guide for data collection and treatment. To illustrate how the clinician can combine empathy with objective observation, Hanke (1984) gives the following example:
A beautiful art student comes into the ED sobbing and distraught. She says, "I'm so ugly, everyone hates me. Ever since my boyfriend left, I sit and cry. When I look in the mirror, I look so old and ugly that I just want to scream." A clinician should respond, "It sounds like you've been feeling pretty bad about yourself since your boyfriend left, but I am a little puzzled how a beautiful young woman like you could see yourself as old and ugly. Do you think you'll always feel this way?"
The first part of the clinician's response indicates participation in the patient's view of herself; the last two comments illustrate the clinician's objective viewpoint. Displaying empathy first is the recommended approach because the patient must feel he is being understood before he will be receptive to an objective viewpoint.
Interpersonal interventions are much less effective in a patient with severe depression, such as psychotic depression with agitation or depression with severe psychomotor retardation. A severely agitated patient may require rapid tranquilization with high-potency antipsychotic drugs. Recommended doses for acute agitation are thiothixene (Navane) 20 mg oral concentrate or 10 mg I.M., haloperidol (Haldol) 10 mg oral concentrate or 5 mg I.M., or loxapine (Loxitane) 25 mg oral concentrate or 10 mg I.M. In elderly patients, the recommended doses are thiothixene 10 mg concentrate or 5 mg I.M.. haloperidol 5 mg concentrate or 2.5 mg I.M., or loxapine 10 mg concentrate or 5 mg I.M. Doses should be given at 30- to 60-minute intervals, and the patient's blood pressure should be taken before each dose is administered.
As a rule, antidepressants should not be given in the ED (Fuchs. 1984). The drugs do not begin to take their desired effect for 10 to 21 days and are associated with adverse side effects that require careful monitoring. Additionally, patients over age 40 (especially those over 65) must have a full medical evaluation before drug treatment is begun. Antidepressants should be limited to an ongoing therapeutic relationship in which adverse effects and clinical response can be observed.
Explain to the patient and family the positive prognosis for depression. Tell them that depression responds to psychotherapy and drug treatment, and encourage the patient to seek such additional treatment. Emphasize, however, that discontinuing treatment, even when the patient feels better, may cause a relapse. Teach the family that major depression is a biological illness. Some relatives assume that the patient could become well if he tried harder to overcome symptoms and that lack of effort indicates laziness.
At times, family members may feel emotionally depleted by a patient's long-standing illness. Encourage such members to meet with the treating clinician to express their concerns and feelings.
If the patient is discharged into the care of relatives, refer them to social service resources (such as home nursing or day-care programs) that can assume some of their daily responsibilities to the patient.
Encourage a patient suffering from an adjustment disorder or dysthymia to pursue psychotherapy rather than to rely on drug therapy to resolve distress. A depressed patient may become dependent on a benzodiazepine if the physician tries to alleviate insomnia and anxiety without attempting to change the psychodynamic conflicts that led to the patient's unhappiness.
Before discharging a patient, schedule a follow-up appointment, preferably the next day, for further evaluation and treatment. Outpatient therapy for depression should be based not only on the nature and severity of symptoms but also on the patient's psychological makeup and interpersonal style. Crisis intervention, behavior therapy, group and family therapy, and marital counseling are other therapeutic modalities to be considered. A patient requiring medication for anxiety or insomnia should be given a limited quantity of antianxiety drugs, with a prescription not to exceed a 3-day supply. Lorazepam (Ativan) 0.5 to 1 mg twice daily or oxazepam (Serax) 15 to 30 mg twice daily should suffice. Consider hospitalizing a depressed patient who:
Patients with depression commonly exhibit self-destructive behavior. Most states allow the clinician to begin civil commitment proceedings for a patient who becomes demonstrably dangerous. In some states, the clinician can commit a patient who cannot perform self-care or whose illness would be life-threatening in a less restrictive environment. Short of commitment, the treatment plan for depression should include safeguards against suicidal behavior, such as voluntary hospitalization or close observation by family members.
Because depressed patients are usually competent to make treatment decisions, the clinician may have to honor a patient's refusal of care. However, a clearly dangerous, psychotic, or demented patient jeopardizes his health by refusing treatment. In such cases, the clinician should work with the family to encourage the patient to accept treatment. Some clinicians apply for civil commitment at this point, thus shifting the burden for making a commitment decision to the judicial system. If the petition is denied, the clinician should make every effort to arrive at a treatment plan that protects the patient. As with all psychiatric emergencies, thoroughly document steps leading to the disposition to avoid future legal complications.
Whether the clinician is liable for the suicide of a depressed patient he discharges depends on the quality of the consultation and supporting documentation. A negligently performed examination-one in which the clinician should have looked for suicidal behavior but failed to do so-provides no sound defense. The clinician should not be liable if a thorough examination has revealed no evidence of suicidal thoughts. Beyond this, the clinician has no duty to control the behavior of patients outside of institutional settings.
Most people experience grief after the death of a spouse, parent, child, or other significant person. This response usually runs a benign course, and grieving persons rarely need the attention of a psychiatrist. In some cases, however, grief has a more pathological outcome, and the person requires psychiatric care.
Grieving is characterized by an intense and repetitive review of one's relationship with the deceased and may be accompanied by depressive symptoms, including fatigue, shortness of breath, dizziness, palpitations, irritability, restlessness, headache, insomnia. appetite loss, inability to organize daily activities, and self-blame. A grieving person may also be preoccupied with the image of the deceased, exhibit hostility toward medical personnel who cared for the deceased, and feel guilty about not having done enough for the deceased. These symptoms usually resolve spontaneously after 3 to 6 months and are part of a healthy response to the loss. Grieving helps the person to lessen attachments to the deceased and regain emotional attachments to others. When a grieving person shows signs of a major depressive episode or displays self-destructive behavior, such as alcohol or drug abuse, psychiatric intervention is necessary.
Initial interventions. The clinician should encourage a grieving patient to review in detail memories of the deceased. Explore the patient's initial reactions to the death and feelings about the deceased. If the patient admits to anger—perhaps because he feels abandoned by the deceased - reassure him that these feelings are normal and will resolve with time. Also, guard against oversedating a grieving patient. Some patients report being so sedated that they do not remember events that occurred immediately before, during, or after the funeral. As a result, they could not adequately express their feelings at the appropriate time.
A patient with a pathological grief reaction becomes withdrawn and isolated. To help such a patient overcome his anguish and maintain social contacts, suggest that he get up and dress even- day before noon, schedule household chores and free time for each day. spend time outside the house (running errands, gardening, walking), phone or visit a close friend or relative, and spend a half hour each day writing down feelings about the deceased.
Disposition. If the patient is not psychotic and can be discharged, schedule a follow-up appointment for the next day and, if possible. arrange for the patient to spend time with a family member over the next several days. A patient with extreme anxiety and insomnia may require a benzodiazepine, such as lorazepam 1 mg twice daily. If the patient has symptoms of a nonpsychotic major depressive episode, refer him for continued evaluation and possible treatment with an antidepressant. Some patients with a severe grief reaction may require hospitalization.
When a patient dies unexpectedly (such as from a heart attack or automobile accident), the clinician's primary task is to facilitate the survivors' grief (Dubin and Sarnoff, 1986). In most cases, do not inform family members of the death over the telephone but instead tell them that the patient is seriously ill or injured, ask them to come immediately to the hospital, and suggest that a family friend drive them. If a sole survivor is ill or does not have any social support, phone the police department and ask them to contact the survivor. With this approach, a responsible individual is present if the survivor has a catastrophic response to the death.
Initial interventions. Informing relatives of a loved one's death, especially when the patient dies unexpectedly, is one of the clinicians most difficult tasks. Because the physician can answer pertinent medical questions, this task should not be delegated to someone else. Before meeting with the family, prepare to present relevant events in chronological order so that the survivors will have a clear understanding of the circumstances - problems that occurred and actions that were taken. Staff members should be available to meet the family on arrival and escort them to a private area where they can talk with you. Initially, try to determine which survivors will be most stable in the face of devastating news. These persons will be able to make immediate decisions and can later repeat the facts to family members who did not hear or retain what was said. Inform them of the patient's death without using medical jargon or vague descriptions. A gentle but factually informative explanation usually reassures the family that everything reasonable was done to save the patient's life.
Family reactions. The family members' initial response is usually one of numbness, shock, and disbelief. After a few minutes, survivors have various emotional reactions. Some cry easily, while others react with anger, anxiety, guilt, or stoicism. In extreme cases, a survivor may decompensate into psychosis, use defenses such as denial or bewilderment, or have a severe anxiety attack. Encourage family members to express their feelings and to review their final moments with and last memories of the deceased. Refrain from making well-intentioned but ultimately insensitive comments, such as "Everything will be OK" or "It was God's will." Do not immediately offer sedation. Survivors may displace antagonism and anger onto staff members, sometimes accusing hospital staff of being negligent and not doing everything reasonable to save the patient. This anger may represent the survivors' rage at the deceased for abandoning them or their guilt about unresolved conflicts with the deceased. In any event, do not become defensive, guilty, or harried or attempt to counter their anger through rationalization or intellectual explanations. The survivors' anger will ultimately give way to sadness.
Viewing the body. Offer survivors the opportunity to view the body, but don't make them feel guilty if they are reluctant or unwilling to do so. If the body is mutilated, inform family members in advance. and be sure blood and emesis are removed. While the family is viewing the body, remain outside the room, available for support. Survivors should not be hurried. Most family members leave the viewing room within 15 minutes. After family members have viewed the deceased, they may need to sign appropriate papers. At this point, tell them what will happen to the body. If an autopsy is necessary, family members should be told why. Survivors should also be informed of arrangements for transporting the body from the hospital or the medical examiner's office to the funeral home.
Organ donation. The recent increase in organ transport programs imposes a new task on clinicians who deal with survivors of patients who have died suddenly. Such patients may have healthy organs that could benefit a patient waiting for a transplant. Broach the issue of organ donation before family members leave the hospital. For instance, you might ask, "Has your family ever discussed organ or tissue donation?" or "Our hospital offers organ and tissue donation.
Would you like to discuss this further with someone from the transplant program?" If the family expresses an interest, contact the appropriate hospital representative so that discussions can begin immediately. Consider organ donation if the patient meets the general criteria for donor acceptability (those aged 1 day to 65 years who are either brain-dead or on mechanical life-support with intact circulation and who are free from systemic infections, actively transmittable diseases, or cancer).
Concluding the meeting. Conclude the meeting with the patients survivors by reviewing symptoms of grief and reassuring them that these reactions are normal. Arrange for a family member or friend to stay with a close survivor for the next 24 to 48 hours because suicide is a possibility, especially for a spouse who has been married for many years. Additionally, encourage survivors to discuss the death with their children. An honest discussion can be a positive emotional experience and may help decrease the fantasies and distortions that children can have about death. Adults should not lie, distort the truth, or try to alter the child's feelings about the loss but should express their grief openly; such an approach shows children that an open expression of feelings is acceptable. If the deceased is a parent, young children may require constant reassurance that the surviving parent will not disappear. When adults avoid discussing death with children, they create an atmosphere of apprehension and anxiety, which can be intolerable for children.