Schizophrenia: Recognition and Management in the ED

The increase in psychiatric presentations to EDs is coupled with a lack of psychiatrists in many areas of the United States. The American Hospital Association has reported that 40% of American hospitals have difficulty maintaining adequate psychiatric coverage to meet patient demand in the ED, forcing many emergency medicine physicians to act as a primary psychiatrist.⁷

Differential Diagnosis

The characteristic symptoms of schizophrenia can be present in many other illnesses; therefore, the emergency clinician must be able to distinguish schizophrenia from other illnesses presenting with a psychotic component. Furthermore, schizophrenia is a diagnosis of exclusion as the diagnosis can only be made after all medical etiologies of the symptoms have been excluded.

Items on the differential include delirium, a substance induced psychosis,⁸ which can be caused by both substance intoxication and substance withdrawal; as well as psychosis caused by another medical condition.⁸ It should be stressed that a prior diagnosis of schizophrenia does not rule out a medical etiology of a patient’s current psychotic episode; therefore, a thorough history and examination is fundamental, even in patients with a known history of psychiatric illness. Moreover, many patients with schizophrenia present with a medical chief complaint, despite being symptomatic regarding their schizophrenia. In the latter case, providers must be vigilant regarding any medical comorbidities, particularly when patients are actively psychotic.

Finally, within the psychiatric disorders there are multiple disorders other than schizophrenia that may have psychotic features, including depression with psychotic features, bipolar disorder with psychotic features, and the other schizophrenia spectrum disorders; including brief psychotic disorder, schizophreniform disorder, schizoaffective disorder, and delusional disorder.

Emergency Department Evaluation

The process of evaluation of psychiatric patients who present to the ED should be directed towards a determination as to whether hospitalization is warranted, treatment of underlying medical condition is needed, or psychiatric care is indicated. New onset of psychiatric illness will commonly call for extensive evaluation, whereas patients with chronic schizophrenia may not need testing but may need psychiatric hospitalization.⁹ Additionally, emergency clinicians are frequently requested to preform “medical clearance” by their psychiatrist colleagues, before a patient can be transferred to a psychiatry department or psychiatric hospital. However, this is a poor term and a better nomenclature would be “assess for medical stability.”⁹ Emergency clinicians are, in essence, being asked whether the patient is medically stable enough for transfer to a unit or hospital where there is little or no medical support. Prior to transfer to a psychiatric unit, a patient’s non-psychiatric medical conditions should be stable enough for outpatient management.

Interacting with Patients Suffering from Psychosis

Although providers should not pretend to interact in the patient’s reality, they should express understanding in what the patient thinks or feels and kindly direct them back to the current situation.¹⁰ It is important for providers in the acute setting to be non-judgmental about reasons for relapse (in particular non-adherence to medication or substance misuse).¹⁰ Challenging the patient, while at times useful, is best done once the patient is stabilized and in a controlled environment.