Management of depression: A daily challenge in psychiatric emergencies

ABSTRACT

Depression is the most common psychiatric disorder in the general population, and emergency room visits for depression have been increasing for several years. In addition, the Covid-19 pandemic may lead to an explosion of psychiatric emergency room visits for this reason, with an overall prevalence of anxiety and depression that appears to be increasing since 2020. The Centre Psychiatrique d'Orientation et d'Accueil is a regional psychiatric emergency service located in Paris which records approximately 10,000 consultations per year. Among these consultations, the main symptoms are those of depression (depressive ideations, anxiety) and nearly 40 % are diagnosed with mood disorders, including depression. The management of the patient in the emergency room is based on a global evaluation, which should not be limited to the psychiatric interview. In the best case, and if compatible with the organization of the service, an initial evaluation by the nursing reception staff determines the context of the arrival of the patient, the reason and the degree of urgency of the consultation can thus be assessed from the outset. The request for care can come from the patient themself, but also from family and friends who are worried about a decline in the patient's previous condition. The consultation may also be triggered by the intervention of emergency services, particularly in the case of attempted suicide or agitation. The context of arrival, the environment, and the patient's entourage must be taken into account in order to achieve an optimal orientation. Particular attention must be paid to the first episodes (elimination of a differential diagnosis, screening for a possible bipolar disorder). The existence of an external causal factor or a comorbid personality disorder should not trivialize the consultation and lead to a faulty diagnosis of a characterized depressive episode. Drug treatment in the emergency room is usually symptomatic (anxiolytic treatment with benzodiazepines or neuroleptics, depending on the situation), and outpatient referral should always be preferred. Therapeutic adaptations can then be considered. The decision to hospitalize must always be justified, and consent for care must be rigorously evaluated. It is almost always necessary to take the patient's entourage into account as well as the potential support of the patient by the entourage. All these elements must be recorded in the file. Suicide risk assessment must be systematic for all patients consulting psychiatric emergencies, and the use of the RUD (Risk, Urgency, Dangerousness) grid can be useful. Any decision to release a patient with suicidal tendencies must be made strictly following certain conditionsa rapid psychiatric re-evaluation of the crisis, with for example the proposal of a post-emergency consultation, a supportive entourage, accepted symptomatic treatment. The registration of the suicidal patient in a monitoring system such as VigilanS can also be beneficial and reduce the risk of recidivism. (PsycInfo Database Record (c) 2022 APA, all rights reserved) Abstract (French) La depression est le trouble psychiatrique le plus frequent dans la population generale, et les consultations aux urgences pour depression seraient en hausse depuis plusieurs annees. Le Centre Psychiatrique d'Orientation et d'Accueil est un service d'urgences psychiatriques a vocation regionale situe a Paris qui recense environ 10 000 consultations par an. Parmi ces consultations, on retrouve pres de 40 % de diagnostics de troubles de l'humeur. La prise en charge du patient aux urgences repose sur une evaluation globale, qui ne doit pas se limiter a l'entretien psychiatrique. Le contexte d'arrivee, l'environnement et l'entourage du patient doivent etre pris en compte afin d'aboutir a une orientation optimale. Une attention particuliere doit etre portee aux premiers episodes (elimination d'un diagnostic differentiel, depistage d'un eventuel trouble bipolaire) et a l'evaluation du risque suicidaire. L'existence d'un facteur causal externe ou d'un trouble de personnalite comorbide ne doit pas faire banaliser la consultation et mener a un sous-diagnostic de depression caracterisee. Le traitement medicamenteux aux urgences est le plus souvent symptomatique (traitement anxiolytique par benzodiazepines ou neuroleptiques selon les situations), et l'orientation ambulatoire doit toujours etre privilegiee. Des adaptations therapeutiques peuvent alors etre envisagees. La decision d'une hospitalisation doit toujours etre argumentee, et le consentement aux soins rigoureusement evalue. La prise en compte et eventuellement l'accompagnement de l'entourage sont presque toujours necessaires. Tous ces elements doivent etre argumentes dans le dossier. (PsycInfo Database Record (c) 2022 APA, all rights reserved)