Validity of psychiatric evaluation in intoxicated ER patients

[toothless rufus]

Are psychiatric assessments of intoxicated patients in the ER valid? My understanding was that they are not valid, until the patient is under the legal limit.

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[kugel]

Don't know of anything that states categorically that an eval is "invalid" until under the legal limit. And, of course, there's no "legal limit" for intoxications of anything but alcohol. Although I'm sure there are places that have incorporated that into policy in order to avoid perceived liability issues.

In CA, the involuntary commitment law ("5150") directly states that the psychiatrist performing the 5150 evaluation cannot be held criminally or civilly liable for anything the pt. does because the doctor upheld or dropped the 5150 application. In our psych ER, pt's certainly come in intoxicated. Our decision about whether to re-eval the pt later is decided in one of two basic ways:
A) if the conditions of the referral warrant admit no matter what the patient says, then we admit the pt. regardless of intoxication (unless of course the pt needs Emerg Dept level medical care). Our psych ER has no higher capability of managing pt's who are intoxicated than does our inpt unit.
B) if the pt might be able to discharge, but is clearly intoxicated - then we generally re-evaluate the pt after at least 6-8 more hrs in the psych ER.

We have no magic number about when a pt. intoxicated on ETOH can be referred from the ED to the psych ER. It is about whether the pt is able to participate in the interview and whether we medically manage the pt. If the VS are stable, then I ask the ED physician, "Is the pt. walking and talking? Can he walk at least 50 feet without assistance? (assuming he could before) Can he stay awake at least 15 minutes at a time?

After all, some chronic daily users start to go into acute withdrawal at levels well above the legal limit.

 

[Apollyon]

From the EM side, I was taught "suicidal when drunk" means nothing - that, if the patient is still suicidal when sober (or more sober), then call psych.

 

[nitemagi]

From the EM side, I was taught "suicidal when drunk" means nothing - that, if the patient is still suicidal when sober (or more sober), then call psych.

Interesting. My understanding from a review of the literature in the respective fields several years ago was that the specialty societies each had opinions that favored their specialty. EM said intoxication doesn't limit getting a psych eval. Psych says it's useless until sober. Neither really cited any research, just expert opinion.

 

[Apollyon]

Interesting. My understanding from a review of the literature in the respective fields several years ago was that the specialty societies each had opinions that favored their specialty. EM said intoxication doesn't limit getting a psych eval. Psych says it's useless until sober. Neither really cited any research, just expert opinion.

I learned that in NYC, at Elmhurst with Mt. Sinai EM attendings and Elmhurst psych staff (I don't know about MSH Ψ residents in the psych ED at Elmhurst, but the staff were attendings - including one female that was quite busty, and always dressed provocatively - I thought that, of ANY patients, the ones to not bend over in front of with nice cleavage were manics and psychotics) - I even remember one guy's name, 10 years later (and that is about 15K patients for me). It hasn't failed me yet, and no one has given me any pushback. To be quite candid, if ACEP said intox was not limiting, I was not aware. Since I can't make that work in my head, I'm OK with that, specialty society be damned! What I can do to help out specialists, I do.

 

[billypilgrim37]

I've done evals on "sober" guys with BALs>200, and I've waited on teenage girls with BALs of 40 to hit zero so they could quit giggling. An eval isn't so valid if someone is intoxicated, but the decision about intoxication is a clinical one, not a numerical one.

 

[digitlnoize]

Are psychiatric assessments of intoxicated patients in the ER valid? My understanding was that they are not valid, until the patient is under the legal limit.

Why do you ask?

My limited experience is similar to what everyone else has posted. Intoxication is not based on numbers, but on their behavior.

The only addition I have is to say that although sometimes an intoxicated patient doesn't give much useful info, there are many times where you can glean valuable tidbits about their life, and generalities about their overall mental state (although it may be exaggerated, you can still usually tell if someone is drinking because they're depressed or because they wanted to celebrate their recent match!), and personality (although it may be complicated somewhat by the intoxication). By using the lowered inhibitions in your favor, you may be able to find out social things they would otherwise not reveal sober (they're cheating on their spouse, they smoke pot daily, etc.)

As long as they're not violent, I love talking to drunk (or otherwise intoxicated) people. I had a lot of friends who abused various substances during my time in the music industry, and spent a lot of time with a lot of people who were high as a kite (I avoided these pitfalls myself, of course, mostly because I used to have a heart arrhythmia, now ablated, and was worried about what the drugs may do to it, and I didn't want to get in trouble, lol), and you would be amazed at the awesome things people say while high. I should write a book.

 

[nitemagi]

I was trained that "clinically sober" doesn't actually mean much. Chronic alcoholics, for example, can appear superficially sober with quite high BAL's but external behavior doesn't necessarily mean that the alcohol isn't affecting their mood or their decision making capacity. It would be nice to have actual research to back up the rescinding of suicidality once sober, or "drunkacidal," which we're all familiar with. At my old program we would eyeball the patient if they were intoxicated but indicate an actual assessment of suicide risk could not be made until the pt. was sober. I also would err on the side of caution -- One of the few known risk factors for suicide that we can control for via observation is alcohol intoxication. I don't think that observation has to be in a psych unit, though.

 

[tkim]

The psych evaluators at my ED just instituted a 'no eval until BAL <100' rule, which is really more for their convenience than actual evidence-based anything.

Plenty of people with BAL >100 that are clinically sober and vice versa, but they've taken that determination out of our hands. So the drunks sleep until the AM and get an eval then.

 

[F0nzie]

Gotta love it when they get signed in voluntary while intoxicated and they wake up the next morning not knowing they are locked in a psych unit. Its not a "winning" strategy as the great philosopher Charlie Sheen would say.

 

[nitemagi]

Some papers I found related to the topic. Don't give firm answers, of course.

http://www.ncbi.nlm.nih.gov/pubmed/15166633
http://www.ncbi.nlm.nih.gov/pubmed/16737458
http://www.ncbi.nlm.nih.gov/pubmed/19246050

 

[whopper]

Practically speaking,

It's of use to do an evaluation, albeit a superficial one to at least get a sense of where they are at while intoxicated if only to get a sense of where they are at in the moment and possibly give recommendations such as observations, wait till they are sober, PRNs, etc. I wouldn't spend too much time on this evaluation just like I wouldn't spend 5 hours talking to a manic person because after a much shorter period of time you'll likely get what you need to know to figure out what to do next.

As for if the person is suicidal, agitation, or what have you while intoxicated, and if they are then fine when sober, I wouldn't hold it against the person other than to consider they may have a substance use problem. It's regular practice in the psych emergency center I work at to have said a suicidal statment while drunk, but when sober they are considered safe to go if for several hours they showed no signs of danger.

I'm also of the theory (and this is anecdotal, I haven't seen studies backing this up), I that if someone is agitated while drunk they are more likely to become agitated when given a benzo because some people do get worse on a benzo, and the two chemicals work similarly on the brain. Someone who's a "bad" drunk I figure shouldn't be given Ativan PRN.

 

[toothless rufus]

Why do you ask?

Issue came up on an ER consult. It was my understanding from my job before med school that evals are not legally valid, at least for disposition, until pt legally sober.

Some papers I found related to the topic. Don't give firm answers, of course.

http://www.ncbi.nlm.nih.gov/pubmed/15166633
http://www.ncbi.nlm.nih.gov/pubmed/16737458
http://www.ncbi.nlm.nih.gov/pubmed/19246050

Thx! Will check them out.