Title: Psychiatry

Q: What proportion of ED presentations are for mental health?
A: 3%

Q: Risk factors for aggression
A: Alert on chart
Middle aged male
Previous history
Recent aggression
Aggressive thoughts/behaviours
Intoxicated
Psychiatric comorbidity

Q: Risk factors for absconding
A: Forced mode of arrival
Previous episodes
Alert on chart
Verbalising intent to leave
Lack of insight
Non-compliance with treatment
Irrational thought disorder
Disinhibited

Q: Difference between mood and affect?
A: Mood is internal feelings
Affect is external expression

Q: Prevalence of depression?
A: 2-5% of population at any time

Q: Formal diagnosis of depression
A: 2/3 of:
 - Anhedonia
 - Low mood
 - Loss of energy

Q: How much more common is depression in females?
A: 2x

Q: Risk of recurrence of depression?
A: 80% after one episode

Q: What proportion of depressive episodes resolve within 6 months?
A: 50%

Q: Proportion of elderly who have depression?
A: 10% over 65

Q: How can you differentiate pseudodementia from true dementia?
A: Pseudodementia tends to be rapid onset and fully aware of memory deficit with considerable anxiety around this

Q: Usual maximum duration of grief reaction?
A: 6 months

Q: Organic mood disorder DDx
A: Hypothyroidism
Hypercalcaemia
Pernicious anaemia
Cushings
Stroke
Alzheimers
Huntington
Parkinsons
AIDS
CNS tumor
MS
Neurosyphilis

Q: Medications associated with depression
A: Interferon
Beta-blockers
Isotretinoin
Methyldopa
Benzodiazepines
Digitalis
OCP
Corticosteroids

Q: What proportion of borderline patients have depression?
A: 50%

Q: Strongest indicators of borderline
A: Recurrent suicidal threats or acts of self-harm
Strong preoccupation with rejection/abandonment

Q: Completed suicide rate in borderline?
A: 8-10%

Q: How do men with borderline typically present?
A: Substance abuse

Q: How do women with borderline typically present?
A: Eating disorders
Self-harm

Q: What is the average time to remission of depression?
A: 12 weeks without pharmacotherapy

Q: How effective is CBT?
A: As good as pharmacotherapy for mild-moderate depression

Q: What is somatisation disorder?
A: Psychological stress communicated as multiple physical symptoms

Q: How is somatisation different from conversion disorder?
A: Somatisation have multiple symptoms
Conversion have one sudden and dramatic symptom e.g. paralysis

Q: What is hypochondriasis?
A: Disproportionate symptoms to demonstrable organic disease

Q: Red flag symptoms to suggest somatisation disorder?
A: Dysmenorrhoea
Globus hystericus
Burning genitals
Painful extremities
SOB
Vomiting
Amnesia for hours or days

Q: Incidence of missed medical diagnosis for abnormal behaviour?
A: 8-40%

Q: Causes of missed organic cause for behavioural disturbance?
A: Inadequate history
Inadequate examination
Inadequate collateral
Failure to monitor over time
Intoxicated
Absence of reasonable MSE

Q: Indicators of organic cause for behavioural disturbance
A: First presentation or abrupt change in pattern of presentation
Age >40 first presenter
Abnormal vital signs
Physical symptoms
Disorientation
Lack of personal privacy
Visual hallucinations
Fluctuant mental status
Altered sleep-wake cycle
Drug or alcohol use
Neurological signs/symptoms
FHx of medical illnesses that can present as psych (e.g. Huntington's/thyroid)
HIV+++

Q: Low risk patients for organic cause of mental illness
A: Age 15-55
No acute medical complaints
Normal vital signs
No new symptoms
No evidence of substance abuse pattern
Normal gait, speech, memory and concentration

Q: What proportion of ED visits are for psychosis?
A: 1%

Q: Prevalence of schizophrenia?
A: 0.2-0.5% of population

Q: Prognosis of schizophrenia
A: 20% recover
20% recurrent with recovery in between
40% recurrent with incomplete recovery in between
20% chronic severe

Q: Suicide rate of schizophrenia
A: 20% over 20 years

Q: Prevalence of bipolar?
A: 1%

Q: Chance of recurrence of mania?
A: 80% within 5 years

Q: Average rate of mania in bipolar?
A: Once every 2 years

Q: Suicide rate in bipolar
A: 15% in 20 years

Q: Causes of psychosis with clear consciousness and no cognitive impairment
A: Epilepsy
Hypo/hyperthyroidism
Wilson's
Huntingtons
Porphyria
B12 deficiency
CNS malignancy
Stroke
Viral encephalitis
Neurosyphilis
AIDS

Q: Classic cause of drug-induced psychosis
A: Steroids

Q: Positive symptoms of schizophrenia
A: Hallucinations
Delusions
Formal thought disorder

Q: Negative symptoms of schizophrenia
A: Withdrawal
Blunted affect
Apathy
Poverty of speech

Q: What is alcoholic hallucinosis
A: Chronic alcoholics with running derogatory commentary despite clear consciousness and not withdrawing

Q: What proportion of people who complete suicide are seen in ED in prior month?
A: 10%

Q: Proportion of deaths in Aus due to suicide?
A: 1.6%

Q: How much more common is completed suicide in males?
A: 4x

Q: What proportion of patients will complete suicide after an attempt in the following 12 months?
A: 1-2%

Q: Does hospitalisation prevent suicide?
A: In the short-term yes, but long-term no

Q: Does psychosocial assessment of self-harmers in ED prevent further episodes/
A: Yes

Q: How much higher is completed suicide risk in those with mental health diagnoses than general population?
A: 10x

Q: What proportion of completed suicides occur after discharge from hospital?
A: 1/3

Q: What is the most powerful predictor of attempted suicide?
A: Hopelessness

Q: High risk groups for suicide
A: Young and old men
Psychotic illness
Drug absue
Alcohol abuse
Chronic/terminal illness
Dementia
AIDS
Homosexual/bisexual

Q: SADPERSONS
A: Sex (male)
Age <19 or >45
Depression or hopelessness (2)
Previous attempts or psychiatric care
Excess alcohol or drugs
Rational thought loss (2)
Separated/divorced/widowed
Organised serious attempt (2)
No social supports
Stated future intent (2)

Q: SADPERSONS scores
A: 0-5: Maybe discharge
6-8: Psych consult
>8: Admit

Q: Medical admission for eating disorders
A: >1kg weight loss per week
High refeeding risk
SBP <80 (<70mmHg)
Postural BP >20mmHg
HR <40 (<50 if adolescent) or >120 or postural rise by 20bpm
Temp <35.5 or >38
Albumin <30
Na <125
K <3.0
Mg/Phos < normal
Any arrhythmia/ST/T changes
BSL <3.0
eGFR <60 or drop by 25% in 1 week
AST or ALT >500
Neutrophils  <0.7
BMI <12