1. It’s one of yours: Psychiatry in the emergency department Dr. Simon Hatcher University of Auckland

2. “Medical clearance” What does it mean? Focuses on disposal of patient and timing of assessments rather than need “Focused medical assessment” - medical cause excluded and acute care complete (but doesn’t address cognitive status)

3. “Medical clearance” Evidence that a careful history may be more effective in identifying medical problems One study found history alone had a 94% sensitivity Low yield for most laboratory tests

4. “Clues to distinguish between medical and psychiatric disorder” New symptoms, especially in older adult Abrupt presentation Presence of positive history in review of systems Extensive PMH Polypharmacy History of medication change

5. “Clues to distinguish between medical and psychiatric disorder” History of poor medication adherence No personal or family history of psychiatric disorder Visual, tactile, olfactory hallucinations Altered/variable level of consciousness Presence of abnormal vital signs, lab data or physical examination Lack of expected response to treatment Hillard and Zitek 2004

12. TREC studies BMJ Sep 23 2003; Oct 27, 2007 Midazolam (7.5-15mg) vs Haloperidol (5- 10mg) and Promethazine (50mg) Olanzapine (10mg) vs Haloperidol and Promethazine (NNS 5-8) Haloperidol vs Haloperidol and Promethazine

13. Suicide deaths and rates

14. Suicide death rates, by sex, three-year moving averages, 1984–2004

16. Two thirds of people who commit suicide will have been in contact with an emergency department in the months before their death 12% of people attending for non psychiatric reasons have suicidal thoughts 2% have plans 25 of the 31 patients planning suicide were undetected during their index visit; 4 attempted suicide within 45 days of the visit. All survived. Suicide