Curr Psychiatry Rep (2016) 18:41 DOI 10.1007/s11920-016-0670-9
COMPLEX MEDICAL-PSYCHIATRIC ISSUES (MB RIBA, SECTION EDITOR)
Child Psychiatric Emergencies: Updates on Trends, Clinical Care, and Practice Challenges Beau Carubia 1,3 & Amy Becker 1,2 & B. Harrison Levine 3
# Springer Science+Business Media New York 2016
Abstract Over the past 15 years, the number of pediatric patients presenting to the emergency room in psychiatric crisis has nearly doubled. Suicidality and aggression are among the most common presenting problems, making it important for providers to have up-to-date knowledge about the assessment and management of these frequently encountered clinical issues. Psychometrically sound suicide risk assessment tools are available for use in the emergency room setting, which can be administered efficiently with minimal provider training. Rates of off-label medication use in the pediatric population continue to increase and are often used in the management of acute agitation in the pediatric population. The current literature will be reviewed and summarized for application in emergent treatment settings. Overall, evidence to inform best practice is limited, leading to opportunities for innovation in health care delivery, the development of new research aims, and discussion of challenging clinical dilemmas.
Keywords Pediatric . Suicide . Agitation . Chemical restraint . Psychiatric emergency
This article is part of the Topical Collection on Complex MedicalPsychiatric Issues * Beau Carubia [email protected]
1
Department of Psychiatry, University of Colorado, Aurora, CO, USA
2
Psychiatric Emergency Service, Children’s Hospital Colorado, Aurora, CO, USA
3
B. Harrison Levine, MD, Inc., Denver, CO, USA
Introduction It is estimated that 10–20 % of children and adolescents suffer from a mental disorder or substance use problem, which translates into nearly eight million youth in need of care [1–4]. The Patient Protection and Affordable Care Act (ACA) signed into law in 2010 allowed states to expand Medicaid eligibility and simplify enrollment in the State Children’s Health Insurance Program, reforms that took effect in early 2014 with the potential to improve health care accessibility for children. In July of the same year, the US Department of Health and Human Services awarded over 54 million dollars in ACA funding to support the development of mental health services in 47 states and Puerto Rico, and a survey published by the National Alliance of Mental Illness in December 2014 demonstrated that 29 states and the District of Columbia increased funding for mental health services for the fiscal year 2015 [5]. In spite of these advances, however, it is estimated that as few as one in six youth with mental health problems receive needed treatment [6]. More than 3000 general inpatient psychiatric beds were lost between 2009 and 2012, and the average wait time for an appointment with a child and adolescent psychiatrist is estimated to be nearly 8 weeks [5]. These waits are likely due to the critical workforce shortage in child and adolescent psychiatry. The American Medical Association estimates that as of 2012, there are only 8300 practicing child and adolescent psychiatrists in the country, whereas the projected need is 30, 000 [7•, 8•]. In the context of an overwhelmed and shifting mental health system of care, pediatric patients are presenting to emergency rooms in psychiatric crisis in increasing numbers. Updated analysis of the National Hospital Ambulatory Medical Care Survey data demonstrates the percentage of emergency department (ED) visits for psychiatric conditions increased from 4.4 % in 2001 to 7.2 % in 2011. Among
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children, those between the ages of 12 and 17 account for the majority of psychiatric ED visits, and children who are publicly insured or have no insurance are four times more likely to be seen for a psychiatric emergency than those with private insurance [9, 10••]. The volume of child psychiatric emergency room visits tends to vary with the school calendar, with fewer visits occurring during the summer months, and presentations tend to occur most often in the evening [6, 11]. One Canadian study demonstrated that acuity ratings for pediatric patients presenting in psychiatric crisis has decreased between 2002 and 2012, a finding replicated during a 2010 review of ED pediatric psychiatric services in Virginia, suggesting that patients are utilizing the emergency department as a way to have their non-urgent mental health needs addressed because they are unable to access care in an alternate setting [12, 13]. Length of stay (LOS) in EDs averages about 5 hours, consistently exceeding pediatric ED visits for other conditions by over 1 hour. Longer LOS is associated with patients leaving before receiving assessment or critical intervention for their psychiatric crisis; key factors associated with greater LOS are the need for transfer and psychiatric admission. Length of stay also varies geographically and is negatively correlated with the availability of inpatient child psychiatric beds [14, 15]. There is a strong consensus among national professional organizations, including the Institute of Medicine, the American Academy of Pediatrics, and the National Institute of Mental Health, that standards of care and provider education are needed to address this burgeoning clinical need; however, clinical practice is currently heterogeneous, often based on available expertise and resources, and lacks evidence base to inform best practice [16, 17, 18•]. Pediatric patients present to EDs with varied chief complaints and psychiatric crises, the most common being depression, suicidal ideation, and violent behaviors [19].
Clinical Care: Suicide According to the results of the 2013 National Youth Risk Behavior Survey, 17 % of a sample of over 13,000 high school students reported having Bseriously considered attempting suicide^ during the 12 months prior to the survey. Nearly 14 % of students reported making a suicide plan, and 8 % a suicide attempt [20]. Suicide is the second leading cause of death for youth in the USA resulting in over 2000 deaths in the 10–19 age group in the year 2012 [21]. The emergency room is a crucial environment for suicide screening, intervention, and prevention to occur. Studies have shown that the children seeking health and mental health ED services are at high risk for psychiatric problems including suicidality. One study
Curr Psychiatry Rep (2016) 18:41
found that the frequency of visits to the emergency room by suicidal patients has increased in recent years from 0.8 to 1.5 per 1000 in the USA from 1992 to 2001 [22–24]. With over one million adolescents utilizing the emergency room as their primary source of medical care, clinical encounters in the emergency room present important opportunities to identify patients at risk for suicide that would not otherwise be seen by medical or mental health professionals. Additionally elevating the importance of suicide screening at the time of an emergency room encounter is the knowledge that a significant proportion of adolescents that go on to complete suicide seek medical attention within the year prior to their attempts [25–27]. While the public health and clinical concern for youth suicide compel pediatric providers to seize opportunities for potentially lifesaving intervention in the emergency room setting, systems of care are also required to respond to requirements of the Joint Commission on Accreditation of Healthcare Organizations to conduct suicide risk assessments with patients that present with emotional or behavioral problems [28].
Attitudes and Beliefs About Suicide Screening Despite the importance of identifying youth at risk for suicide in the emergency room, studies show that suicide screening is completed by only a minority of general and pediatric emergency room providers [23, 29]. Surveys of emergency room providers, including both physicians and nurses, demonstrate their awareness about the high prevalence of pediatric depression and suicidality and the need for suicide screening, but they often cite concerns regarding patient acceptability of screening, time constraints, and lack of training about suicide screening as barriers for incorporating such screening into routine clinical practice [29, 30]. Despite the concerns of providers, surveys of patients and caregivers presenting to emergency rooms with chief complaints that were both psychiatric and non-psychiatric in nature consistently report high levels of acceptability of mental health and suicide screening [27, 31]. A qualitative study of pediatric patients that were screened for suicide risk noted that screening was a way Bfor patients to feel known, heard and understood^ by an unbiased listener. They also described screening as an important way for Bindividuals who were at risk (to) receive help that would prevent later suicidal behavior.^ [32]. Studies of feasibility also suggest that provider-perceived barriers may be overstated. For example, a 2007 study conducted in a pediatric emergency room in an urban, tertiary care hospital analyzed the addition of a self-administered, computerized suicide screening to patient care. The screening was completed in parallel to medical assessment and treatment, and providers reported that the screenings did not impede their ability to complete their clinical work [27].
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Suicide Risk Assessment Tools
Clinical Care: Agitation
Multiple factors should be considered in selecting a suicide risk screening tool for use in the emergency room. Screeners should not only be valid and reliable and have high sensitivity and specificity for identifying those youth at risk but should also be efficient and require minimal training for administration and interpretation of results. The evidence base to support the preferential use of one screening tool remains limited. Below is an overview of several pediatric screening tools that have been used in ED settings. The Reynolds Suicide Ideation Questionnaire (SIQ) is a screening tool that has been studied in clinical and schoolbased samples of youth and has established psychometric properties in identifying the frequency and severity of suicidal ideation [33, 34]. It is often the criterion standard against which other rating scales are measured to determine their validity. The SIQ is a self-report measure and has the advantage of the availability of normative scores to aid in the interpretation of results. The SIQ is available in two versions for youth: a 30-item questionnaire for adolescents 15 years and older (SIQ), and a 15-item questionnaire for those under the age of 15 (SIQ-JR). It is estimated that the measure can be delivered in 10 minutes or less and is recommended that for successful administration and interpretation, providers have specialty training and experience in the use of clinical behavioral assessment instruments. The Columbia Suicide Severity Rating Scale is another screener that has been specifically studied in youth presenting to the emergency room with a psychiatric chief complaint [35••, 36]. It is a semi-structured interview that not only identifies current suicide risk but also appears to have validity in predicting future return to the ED with suicidal ideation or post suicide attempt. The length of time to complete the assessment is variable and dependent upon responses. Training is required to administer this scale; computer-based training is available. The Ask Suicide-Screening Questions (ASQ) may be particularly useful in pediatric ED settings as it is both psychometrically sound and brief. This four-item questionnaire was developed from a set of 17 candidate questions. The responses of 524 youth to the candidate questions were compared via logistic regression analysis models to the results of the lengthier SIQ to determine which four-question combination most accurately assessed suicide risk. The ASQ appeared not only to have good sensitivity, specificity, and predictive values but was estimated to take less than 2 minutes to administer [37••]. The instrument has the advantage of being studied with both psychiatric patients and those presenting to the emergency room with medical or surgical complaints. Further study is necessary to establish the best procedures for administering this screener.
As previously mentioned, pediatric patients present to EDs with various psychiatric crises, including depression, suicidal ideation, and violent behaviors [19]. When these behaviors threaten the safety of the patient or others, acute intervention becomes necessary. The desired outcome in the management of an agitated youth is the prevention of harm to self or others, including family members and ED staff [38, 39•]. As described by Sonnier et al., Bacute agitation is defined as a state of behavioral dyscontrol that will likely result in harm to the patient or healthcare workers without intervention^ [40]. A practitioner should strive to use the least restrictive means possible to provide this level of safety to a youth, but when this is not possible, physical and/or chemical restraint may become necessary. The use of restraint in the pediatric emergency setting has become more common. A retrospective observational study, conducted over two consecutive years, looked at youth who presented to an urban pediatric ED requiring an emergent psychiatric evaluation (n = 1125). Investigators found that 6.8 % of the youth required a restraint during their evaluation, of which 49 % were physical restraint, 25 % medication restraint, and 26 % both physical and medication restraint. In this study, out-of-control behaviors were correlated with restraint use [41]. Similarly, a retrospective chart review by Baeza et al. examined the management of Baggressive events requiring an intervention^ in an adolescent inpatient psychiatric unit over a 2-year period. Twenty-eight percent of the adolescents had at least one aggressive event recorded, and in 95.6 % of the cases, the first-line intervention used was pharmacologic, specifically 29.5 % antipsychotic alone, 38.8 % combination or alternation of antipsychotics and sedatives, 23.3 % antihistamines, and 5.6 % sedative alone [42]. A recent paper discussing the rising trends in antipsychotic prescriptions for youth with behavioral problems estimated an approximate twofold to fivefold increase in offlabel use of antipsychotics in preschool-aged children over the past 10–15 years [43]. Common off-label uses of antipsychotics in children and adolescents include treatment of disruptive behaviors, aggression in typically developed and developmentally delayed children, oppositional defiant disorder (ODD), conduct disorder (CD), posttraumatic stress disorder (PTSD), attention-deficit hyperactivity disorder (ADHD), sleep disorders, and depressive disorders [44, 45]. In a recent national survey sent to 1600 randomly selected child and adolescent psychiatrists, 36 % reported occasional off-label use of second generation antipsychotics (SGAs), 65 % felt the best option for management of aggressive behaviors in Autism Spectrum Disorder (ASD) were SGAs, and 29 % believed SGAs were the best option for management of children with aberrant behaviors, including assaultiveness and destruction of property [46].
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Considerations for Pharmacologic Management of Agitation Given the high prevalence of the use of emergency medications in the pediatric population, it is imperative that practitioners are afforded the ability to make evidence-based treatment selections in the management of behavioral emergencies. First, it is important to consider the evidence base for the most commonly used medication classes. Several systematic reviews (including meta-analyses) and guidelines have been published regarding the evidence-based treatments for acute agitation in the pediatric population in the last 5 years. Through a steering group of national experts, the Resource for Advancing Children’s Health (REACH) Institute and the Center for Education and Research on Mental Health Therapeutics (CERT) developed the Treatment of Maladaptive Aggression in Youth (T-MAY) guidelines [47••, 48••]. This group identified 28 placebo-control studies, 5 focusing on ASD, and the others on ODD, ADHD, and CD, that directly measured aggression and evaluated a pharmacologic intervention [48••]. They found the SGAs had the most
Table 1 FDA-approved firstand second-generation antipsychotics for use in the pediatric population
favorable number needed to treat (NNT) of 3 (compared to 4 for both lithium and stimulants). In the reviewed studies comparing risperidone to placebo, the mean effect size (ES) for aggression was 0.72 compared to 0.60 for stimulants and 0.47 for mood stabilizers. In the one, small study evaluating haloperidol versus placebo, the ES was noted to be 0.83 [48••]. Building from the T-MAY guidelines, a multidisciplinary Canadian consensus group also conducted a systematic review with the aim of developing evidence-based treatment guidelines for oppositional behavior, conduct problems, and aggression in children and adolescents [49••, 51••]. Studies were identified for risperidone, quetiapine, haloperidol, valproate, lithium, and carbamazepine versus placebo in children diagnosed with ODD or CD with or without ADHD [49••]. Valproate, lithium, and carbamazepine displayed little positive effect [49••]. The authors also found minimal supporting evidence for the use of haloperidol in the treatment of aggression in youth with CD and recommended strongly against its use [49••, 51••]. One small study evaluating the effectiveness of quetiapine on aggression in adolescents with CD with or without ADHD found a standard mean difference
Drug name
Age of approval
Approved clinical indication
FGA Chlopromazine
Age 1–12 years
Haloperidol
≥3 years of age
Thioridazine Trifluoperazine Thiothixene Molindone Perphenazine Pimozide Prochlorperazine
≥5 years of age ≥6 years of age ≥12 years of age ≥12 years of age ≥12 years of age ≥12 years of age ≥2 years of age and ≥ 20 lbs BChildren^
Schizophrenia; bipolar disorder, type I; severe behavioral problems (i.e., explosiveness, combativeness); hyperactive behaviors with CDs Severe behavioral problems and hyperactive behavior; schizophrenia; psychosis; Tourette’s syndrome Schizophrenia Schizophrenia Schizophrenia Schizophrenia Schizophrenia Tourette’s syndrome Schizophrenia
Droperidol SGA Risperidone
Aripiprazole
Quetiapine Olanzapine Asenapine Paliperidone
Age 5–16 years ≥10 years of age ≥13 years of age Age 6–17 years ≥10 years of age ≥13 years of age ≥10 years of age ≥13 years of age ≥13 years of age ≥10 years of age ≥12 years of age
Agitation Autism-irritability Bipolar disorder, type I Schizophrenia Autism-irritability Bipolar disorder, type I Schizophrenia Bipolar disorder, type I Schizophrenia Bipolar disorder, type I; schizophrenia Bipolar disorder, type I Schizophrenia
FGA first-generation antipsychotic, SGA second-generation antipsychotic, CD conduct disorders
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ES of 1.6; however, the authors cautioned against over interpretation of the large effect size given the very low quality of this study and provided a recommendation of conditional against its use [49••]. In trials of risperidone versus placebo, the authors found a standard mean difference ES of 0.72 in conduct problems and aggression in youth with low intelligence quotient (IQ) and ODD or CD, with or without ADHD, and a standard mean difference ES of 0.60 in disruptive and aggressive behavior in youth with average IQ and ODD or CD, with or without ADHD. In this review, risperidone was the only SGA or first-generation antipsychotic (FGA) to receive a recommendation of conditional in favor of use, with caution advised secondary to the potential side effect burden [49••]. Three years ago, Pringsheim et al. published a systematic review of SGAs for the treatment of disruptive behavior disorders in children and found weak placebo-controlled evidence for the use of SGAs other than risperidone, and also found weak evidence for the use of the SGAs in youth with average IQs [50]. Building off this initial review, Pringsheim et al. conducted another systematic review and meta-analysis evaluating trials of antipsychotics, lithium, and anticonvulsants in the treatment of youth with ADHD, ODD, and CD with aggression and conduct problems [51••]. In accordance with the Canadian review, the authors found limited empirical support for the use of haloperidol, quetiapine, and mood stabilizers. In the one study of thioridazine in youth with subaverage IQ and ADHD or CD, no primary outcome was Table 2 Pharmacologic agents to consider for pediatric chemical restraint
Drug class/drug name
measured. The authors concluded that risperidone has a moderate effect on conduct problems and aggression in children with average and sub-average IQ, with stronger evidence supporting its use with the sub-average IQ population [51••]. Seida et al. performed a comparative effectiveness analysis of studies identified through a systematic review to evaluate the efficacy and safety of antipsychotic use in youth with psychiatric and behavioral problems [52•]. The authors evaluated 64 trials and 17 cohort studies. They found minimal or insufficient evidence for all comparisons of FGAs versus placebo, FGAs versus other FGAs, and FGAs versus SGAs [52•]. They did find moderate evidence for SGAs versus placebo in improvement of Clinical Global Impressions (CGI) and decreased behavioral symptoms for disruptive behavior disorders. In regards to tolerability, key findings included olanzapine causing the highest levels of dyslipidemia and weight gain and risperidone causing the most prolactinrelated events [52•]. Another interesting FGA, droperidol, with a well-known FDA black box warning for proarrhythmic effects secondary to potential QT prolongation was recently reviewed in the adult literature [53]. The authors found doses up to 10 mg to be efficacious and safe for sedation and as an intervention for agitation [53]. The American Academy of Emergency Medicine recently released a position statement on droperidol use in the ED setting, finding that Bdroperidol is an effective and safe medication in the treatment of nausea, headache, and agitation^ [53]. Swank et al. conducted a chart review over
Administration routes
FGA Haloperidol
PO, IM, IV
Droperidol
IM, IV
Chlorpromazine SGA Risperidone
PO, IM PO, ODT
Olanzapine
PO, ODT
Benzodiazepine Lorazepam Midazolam
Antihistamine Diphenhydramine
PO, IM, IV PO, IM, IN
PO, IM
Initial dose rangea
PO: 0.5 to 5 mg IM: 0.05 to 0.15 mg/kg; max 5 mg/dose IM/IV: 0.03–0.07 mg/kg/dose up to max 2.5 mg/dose without cardiac monitor PO/IM: 0.55 mg/kg/dose PO: 0.25–2mg ODT: 0.25–2 mg PO: 2.5–5 mg ODT: 2.5–5 mg PO/IM/IV: 0.05–0.1 mg/kg/dose to max dose 2 mg/dose PO: 0.25–0.5/mg/kg/dose; max 20 mg IM: 0.1–0.15 mg/kg/dose; max 10 mg IN: 0.2–0.3 mg/kg to max of 10 mg PO/IM: 1 mg/kg/dose to max 50 mg/dose
PO oral, IM intramuscular, IV intravenous, ODT oral disintegrating tablet, IN intranasal a
Lexi-Comp Online, Hudson, Ohio: Lexi-Comp Inc.; 2015; Sept 26th, 2015. All doses should be determined individually based on weight, age, and pertinent medical conditions
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32 months for droperidol use in the ED setting for patients
COMPLEX MEDICAL-PSYCHIATRIC ISSUES (MB RIBA, SECTION EDITOR)
Child Psychiatric Emergencies: Updates on Trends, Clinical Care, and Practice Challenges Beau Carubia 1,3 & Amy Becker 1,2 & B. Harrison Levine 3
# Springer Science+Business Media New York 2016
Abstract Over the past 15 years, the number of pediatric patients presenting to the emergency room in psychiatric crisis has nearly doubled. Suicidality and aggression are among the most common presenting problems, making it important for providers to have up-to-date knowledge about the assessment and management of these frequently encountered clinical issues. Psychometrically sound suicide risk assessment tools are available for use in the emergency room setting, which can be administered efficiently with minimal provider training. Rates of off-label medication use in the pediatric population continue to increase and are often used in the management of acute agitation in the pediatric population. The current literature will be reviewed and summarized for application in emergent treatment settings. Overall, evidence to inform best practice is limited, leading to opportunities for innovation in health care delivery, the development of new research aims, and discussion of challenging clinical dilemmas.
Keywords Pediatric . Suicide . Agitation . Chemical restraint . Psychiatric emergency
This article is part of the Topical Collection on Complex MedicalPsychiatric Issues * Beau Carubia [email protected]
1
Department of Psychiatry, University of Colorado, Aurora, CO, USA
2
Psychiatric Emergency Service, Children’s Hospital Colorado, Aurora, CO, USA
3
B. Harrison Levine, MD, Inc., Denver, CO, USA
Introduction It is estimated that 10–20 % of children and adolescents suffer from a mental disorder or substance use problem, which translates into nearly eight million youth in need of care [1–4]. The Patient Protection and Affordable Care Act (ACA) signed into law in 2010 allowed states to expand Medicaid eligibility and simplify enrollment in the State Children’s Health Insurance Program, reforms that took effect in early 2014 with the potential to improve health care accessibility for children. In July of the same year, the US Department of Health and Human Services awarded over 54 million dollars in ACA funding to support the development of mental health services in 47 states and Puerto Rico, and a survey published by the National Alliance of Mental Illness in December 2014 demonstrated that 29 states and the District of Columbia increased funding for mental health services for the fiscal year 2015 [5]. In spite of these advances, however, it is estimated that as few as one in six youth with mental health problems receive needed treatment [6]. More than 3000 general inpatient psychiatric beds were lost between 2009 and 2012, and the average wait time for an appointment with a child and adolescent psychiatrist is estimated to be nearly 8 weeks [5]. These waits are likely due to the critical workforce shortage in child and adolescent psychiatry. The American Medical Association estimates that as of 2012, there are only 8300 practicing child and adolescent psychiatrists in the country, whereas the projected need is 30, 000 [7•, 8•]. In the context of an overwhelmed and shifting mental health system of care, pediatric patients are presenting to emergency rooms in psychiatric crisis in increasing numbers. Updated analysis of the National Hospital Ambulatory Medical Care Survey data demonstrates the percentage of emergency department (ED) visits for psychiatric conditions increased from 4.4 % in 2001 to 7.2 % in 2011. Among
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children, those between the ages of 12 and 17 account for the majority of psychiatric ED visits, and children who are publicly insured or have no insurance are four times more likely to be seen for a psychiatric emergency than those with private insurance [9, 10••]. The volume of child psychiatric emergency room visits tends to vary with the school calendar, with fewer visits occurring during the summer months, and presentations tend to occur most often in the evening [6, 11]. One Canadian study demonstrated that acuity ratings for pediatric patients presenting in psychiatric crisis has decreased between 2002 and 2012, a finding replicated during a 2010 review of ED pediatric psychiatric services in Virginia, suggesting that patients are utilizing the emergency department as a way to have their non-urgent mental health needs addressed because they are unable to access care in an alternate setting [12, 13]. Length of stay (LOS) in EDs averages about 5 hours, consistently exceeding pediatric ED visits for other conditions by over 1 hour. Longer LOS is associated with patients leaving before receiving assessment or critical intervention for their psychiatric crisis; key factors associated with greater LOS are the need for transfer and psychiatric admission. Length of stay also varies geographically and is negatively correlated with the availability of inpatient child psychiatric beds [14, 15]. There is a strong consensus among national professional organizations, including the Institute of Medicine, the American Academy of Pediatrics, and the National Institute of Mental Health, that standards of care and provider education are needed to address this burgeoning clinical need; however, clinical practice is currently heterogeneous, often based on available expertise and resources, and lacks evidence base to inform best practice [16, 17, 18•]. Pediatric patients present to EDs with varied chief complaints and psychiatric crises, the most common being depression, suicidal ideation, and violent behaviors [19].
Clinical Care: Suicide According to the results of the 2013 National Youth Risk Behavior Survey, 17 % of a sample of over 13,000 high school students reported having Bseriously considered attempting suicide^ during the 12 months prior to the survey. Nearly 14 % of students reported making a suicide plan, and 8 % a suicide attempt [20]. Suicide is the second leading cause of death for youth in the USA resulting in over 2000 deaths in the 10–19 age group in the year 2012 [21]. The emergency room is a crucial environment for suicide screening, intervention, and prevention to occur. Studies have shown that the children seeking health and mental health ED services are at high risk for psychiatric problems including suicidality. One study
Curr Psychiatry Rep (2016) 18:41
found that the frequency of visits to the emergency room by suicidal patients has increased in recent years from 0.8 to 1.5 per 1000 in the USA from 1992 to 2001 [22–24]. With over one million adolescents utilizing the emergency room as their primary source of medical care, clinical encounters in the emergency room present important opportunities to identify patients at risk for suicide that would not otherwise be seen by medical or mental health professionals. Additionally elevating the importance of suicide screening at the time of an emergency room encounter is the knowledge that a significant proportion of adolescents that go on to complete suicide seek medical attention within the year prior to their attempts [25–27]. While the public health and clinical concern for youth suicide compel pediatric providers to seize opportunities for potentially lifesaving intervention in the emergency room setting, systems of care are also required to respond to requirements of the Joint Commission on Accreditation of Healthcare Organizations to conduct suicide risk assessments with patients that present with emotional or behavioral problems [28].
Attitudes and Beliefs About Suicide Screening Despite the importance of identifying youth at risk for suicide in the emergency room, studies show that suicide screening is completed by only a minority of general and pediatric emergency room providers [23, 29]. Surveys of emergency room providers, including both physicians and nurses, demonstrate their awareness about the high prevalence of pediatric depression and suicidality and the need for suicide screening, but they often cite concerns regarding patient acceptability of screening, time constraints, and lack of training about suicide screening as barriers for incorporating such screening into routine clinical practice [29, 30]. Despite the concerns of providers, surveys of patients and caregivers presenting to emergency rooms with chief complaints that were both psychiatric and non-psychiatric in nature consistently report high levels of acceptability of mental health and suicide screening [27, 31]. A qualitative study of pediatric patients that were screened for suicide risk noted that screening was a way Bfor patients to feel known, heard and understood^ by an unbiased listener. They also described screening as an important way for Bindividuals who were at risk (to) receive help that would prevent later suicidal behavior.^ [32]. Studies of feasibility also suggest that provider-perceived barriers may be overstated. For example, a 2007 study conducted in a pediatric emergency room in an urban, tertiary care hospital analyzed the addition of a self-administered, computerized suicide screening to patient care. The screening was completed in parallel to medical assessment and treatment, and providers reported that the screenings did not impede their ability to complete their clinical work [27].
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Suicide Risk Assessment Tools
Clinical Care: Agitation
Multiple factors should be considered in selecting a suicide risk screening tool for use in the emergency room. Screeners should not only be valid and reliable and have high sensitivity and specificity for identifying those youth at risk but should also be efficient and require minimal training for administration and interpretation of results. The evidence base to support the preferential use of one screening tool remains limited. Below is an overview of several pediatric screening tools that have been used in ED settings. The Reynolds Suicide Ideation Questionnaire (SIQ) is a screening tool that has been studied in clinical and schoolbased samples of youth and has established psychometric properties in identifying the frequency and severity of suicidal ideation [33, 34]. It is often the criterion standard against which other rating scales are measured to determine their validity. The SIQ is a self-report measure and has the advantage of the availability of normative scores to aid in the interpretation of results. The SIQ is available in two versions for youth: a 30-item questionnaire for adolescents 15 years and older (SIQ), and a 15-item questionnaire for those under the age of 15 (SIQ-JR). It is estimated that the measure can be delivered in 10 minutes or less and is recommended that for successful administration and interpretation, providers have specialty training and experience in the use of clinical behavioral assessment instruments. The Columbia Suicide Severity Rating Scale is another screener that has been specifically studied in youth presenting to the emergency room with a psychiatric chief complaint [35••, 36]. It is a semi-structured interview that not only identifies current suicide risk but also appears to have validity in predicting future return to the ED with suicidal ideation or post suicide attempt. The length of time to complete the assessment is variable and dependent upon responses. Training is required to administer this scale; computer-based training is available. The Ask Suicide-Screening Questions (ASQ) may be particularly useful in pediatric ED settings as it is both psychometrically sound and brief. This four-item questionnaire was developed from a set of 17 candidate questions. The responses of 524 youth to the candidate questions were compared via logistic regression analysis models to the results of the lengthier SIQ to determine which four-question combination most accurately assessed suicide risk. The ASQ appeared not only to have good sensitivity, specificity, and predictive values but was estimated to take less than 2 minutes to administer [37••]. The instrument has the advantage of being studied with both psychiatric patients and those presenting to the emergency room with medical or surgical complaints. Further study is necessary to establish the best procedures for administering this screener.
As previously mentioned, pediatric patients present to EDs with various psychiatric crises, including depression, suicidal ideation, and violent behaviors [19]. When these behaviors threaten the safety of the patient or others, acute intervention becomes necessary. The desired outcome in the management of an agitated youth is the prevention of harm to self or others, including family members and ED staff [38, 39•]. As described by Sonnier et al., Bacute agitation is defined as a state of behavioral dyscontrol that will likely result in harm to the patient or healthcare workers without intervention^ [40]. A practitioner should strive to use the least restrictive means possible to provide this level of safety to a youth, but when this is not possible, physical and/or chemical restraint may become necessary. The use of restraint in the pediatric emergency setting has become more common. A retrospective observational study, conducted over two consecutive years, looked at youth who presented to an urban pediatric ED requiring an emergent psychiatric evaluation (n = 1125). Investigators found that 6.8 % of the youth required a restraint during their evaluation, of which 49 % were physical restraint, 25 % medication restraint, and 26 % both physical and medication restraint. In this study, out-of-control behaviors were correlated with restraint use [41]. Similarly, a retrospective chart review by Baeza et al. examined the management of Baggressive events requiring an intervention^ in an adolescent inpatient psychiatric unit over a 2-year period. Twenty-eight percent of the adolescents had at least one aggressive event recorded, and in 95.6 % of the cases, the first-line intervention used was pharmacologic, specifically 29.5 % antipsychotic alone, 38.8 % combination or alternation of antipsychotics and sedatives, 23.3 % antihistamines, and 5.6 % sedative alone [42]. A recent paper discussing the rising trends in antipsychotic prescriptions for youth with behavioral problems estimated an approximate twofold to fivefold increase in offlabel use of antipsychotics in preschool-aged children over the past 10–15 years [43]. Common off-label uses of antipsychotics in children and adolescents include treatment of disruptive behaviors, aggression in typically developed and developmentally delayed children, oppositional defiant disorder (ODD), conduct disorder (CD), posttraumatic stress disorder (PTSD), attention-deficit hyperactivity disorder (ADHD), sleep disorders, and depressive disorders [44, 45]. In a recent national survey sent to 1600 randomly selected child and adolescent psychiatrists, 36 % reported occasional off-label use of second generation antipsychotics (SGAs), 65 % felt the best option for management of aggressive behaviors in Autism Spectrum Disorder (ASD) were SGAs, and 29 % believed SGAs were the best option for management of children with aberrant behaviors, including assaultiveness and destruction of property [46].
41
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Considerations for Pharmacologic Management of Agitation Given the high prevalence of the use of emergency medications in the pediatric population, it is imperative that practitioners are afforded the ability to make evidence-based treatment selections in the management of behavioral emergencies. First, it is important to consider the evidence base for the most commonly used medication classes. Several systematic reviews (including meta-analyses) and guidelines have been published regarding the evidence-based treatments for acute agitation in the pediatric population in the last 5 years. Through a steering group of national experts, the Resource for Advancing Children’s Health (REACH) Institute and the Center for Education and Research on Mental Health Therapeutics (CERT) developed the Treatment of Maladaptive Aggression in Youth (T-MAY) guidelines [47••, 48••]. This group identified 28 placebo-control studies, 5 focusing on ASD, and the others on ODD, ADHD, and CD, that directly measured aggression and evaluated a pharmacologic intervention [48••]. They found the SGAs had the most
Table 1 FDA-approved firstand second-generation antipsychotics for use in the pediatric population
favorable number needed to treat (NNT) of 3 (compared to 4 for both lithium and stimulants). In the reviewed studies comparing risperidone to placebo, the mean effect size (ES) for aggression was 0.72 compared to 0.60 for stimulants and 0.47 for mood stabilizers. In the one, small study evaluating haloperidol versus placebo, the ES was noted to be 0.83 [48••]. Building from the T-MAY guidelines, a multidisciplinary Canadian consensus group also conducted a systematic review with the aim of developing evidence-based treatment guidelines for oppositional behavior, conduct problems, and aggression in children and adolescents [49••, 51••]. Studies were identified for risperidone, quetiapine, haloperidol, valproate, lithium, and carbamazepine versus placebo in children diagnosed with ODD or CD with or without ADHD [49••]. Valproate, lithium, and carbamazepine displayed little positive effect [49••]. The authors also found minimal supporting evidence for the use of haloperidol in the treatment of aggression in youth with CD and recommended strongly against its use [49••, 51••]. One small study evaluating the effectiveness of quetiapine on aggression in adolescents with CD with or without ADHD found a standard mean difference
Drug name
Age of approval
Approved clinical indication
FGA Chlopromazine
Age 1–12 years
Haloperidol
≥3 years of age
Thioridazine Trifluoperazine Thiothixene Molindone Perphenazine Pimozide Prochlorperazine
≥5 years of age ≥6 years of age ≥12 years of age ≥12 years of age ≥12 years of age ≥12 years of age ≥2 years of age and ≥ 20 lbs BChildren^
Schizophrenia; bipolar disorder, type I; severe behavioral problems (i.e., explosiveness, combativeness); hyperactive behaviors with CDs Severe behavioral problems and hyperactive behavior; schizophrenia; psychosis; Tourette’s syndrome Schizophrenia Schizophrenia Schizophrenia Schizophrenia Schizophrenia Tourette’s syndrome Schizophrenia
Droperidol SGA Risperidone
Aripiprazole
Quetiapine Olanzapine Asenapine Paliperidone
Age 5–16 years ≥10 years of age ≥13 years of age Age 6–17 years ≥10 years of age ≥13 years of age ≥10 years of age ≥13 years of age ≥13 years of age ≥10 years of age ≥12 years of age
Agitation Autism-irritability Bipolar disorder, type I Schizophrenia Autism-irritability Bipolar disorder, type I Schizophrenia Bipolar disorder, type I Schizophrenia Bipolar disorder, type I; schizophrenia Bipolar disorder, type I Schizophrenia
FGA first-generation antipsychotic, SGA second-generation antipsychotic, CD conduct disorders
Curr Psychiatry Rep (2016) 18:41
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ES of 1.6; however, the authors cautioned against over interpretation of the large effect size given the very low quality of this study and provided a recommendation of conditional against its use [49••]. In trials of risperidone versus placebo, the authors found a standard mean difference ES of 0.72 in conduct problems and aggression in youth with low intelligence quotient (IQ) and ODD or CD, with or without ADHD, and a standard mean difference ES of 0.60 in disruptive and aggressive behavior in youth with average IQ and ODD or CD, with or without ADHD. In this review, risperidone was the only SGA or first-generation antipsychotic (FGA) to receive a recommendation of conditional in favor of use, with caution advised secondary to the potential side effect burden [49••]. Three years ago, Pringsheim et al. published a systematic review of SGAs for the treatment of disruptive behavior disorders in children and found weak placebo-controlled evidence for the use of SGAs other than risperidone, and also found weak evidence for the use of the SGAs in youth with average IQs [50]. Building off this initial review, Pringsheim et al. conducted another systematic review and meta-analysis evaluating trials of antipsychotics, lithium, and anticonvulsants in the treatment of youth with ADHD, ODD, and CD with aggression and conduct problems [51••]. In accordance with the Canadian review, the authors found limited empirical support for the use of haloperidol, quetiapine, and mood stabilizers. In the one study of thioridazine in youth with subaverage IQ and ADHD or CD, no primary outcome was Table 2 Pharmacologic agents to consider for pediatric chemical restraint
Drug class/drug name
measured. The authors concluded that risperidone has a moderate effect on conduct problems and aggression in children with average and sub-average IQ, with stronger evidence supporting its use with the sub-average IQ population [51••]. Seida et al. performed a comparative effectiveness analysis of studies identified through a systematic review to evaluate the efficacy and safety of antipsychotic use in youth with psychiatric and behavioral problems [52•]. The authors evaluated 64 trials and 17 cohort studies. They found minimal or insufficient evidence for all comparisons of FGAs versus placebo, FGAs versus other FGAs, and FGAs versus SGAs [52•]. They did find moderate evidence for SGAs versus placebo in improvement of Clinical Global Impressions (CGI) and decreased behavioral symptoms for disruptive behavior disorders. In regards to tolerability, key findings included olanzapine causing the highest levels of dyslipidemia and weight gain and risperidone causing the most prolactinrelated events [52•]. Another interesting FGA, droperidol, with a well-known FDA black box warning for proarrhythmic effects secondary to potential QT prolongation was recently reviewed in the adult literature [53]. The authors found doses up to 10 mg to be efficacious and safe for sedation and as an intervention for agitation [53]. The American Academy of Emergency Medicine recently released a position statement on droperidol use in the ED setting, finding that Bdroperidol is an effective and safe medication in the treatment of nausea, headache, and agitation^ [53]. Swank et al. conducted a chart review over
Administration routes
FGA Haloperidol
PO, IM, IV
Droperidol
IM, IV
Chlorpromazine SGA Risperidone
PO, IM PO, ODT
Olanzapine
PO, ODT
Benzodiazepine Lorazepam Midazolam
Antihistamine Diphenhydramine
PO, IM, IV PO, IM, IN
PO, IM
Initial dose rangea
PO: 0.5 to 5 mg IM: 0.05 to 0.15 mg/kg; max 5 mg/dose IM/IV: 0.03–0.07 mg/kg/dose up to max 2.5 mg/dose without cardiac monitor PO/IM: 0.55 mg/kg/dose PO: 0.25–2mg ODT: 0.25–2 mg PO: 2.5–5 mg ODT: 2.5–5 mg PO/IM/IV: 0.05–0.1 mg/kg/dose to max dose 2 mg/dose PO: 0.25–0.5/mg/kg/dose; max 20 mg IM: 0.1–0.15 mg/kg/dose; max 10 mg IN: 0.2–0.3 mg/kg to max of 10 mg PO/IM: 1 mg/kg/dose to max 50 mg/dose
PO oral, IM intramuscular, IV intravenous, ODT oral disintegrating tablet, IN intranasal a
Lexi-Comp Online, Hudson, Ohio: Lexi-Comp Inc.; 2015; Sept 26th, 2015. All doses should be determined individually based on weight, age, and pertinent medical conditions
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32 months for droperidol use in the ED setting for patients
