University of California

San Diego
Department of Psychiatry

Survival Guide
2016-2017

Name:

Pager number:

VERY IMPORTANT:
If found, please contact me!

1
Introduction

Each year, current resident(s) work to put this guide

together for the incoming PGY1 and 2s at University of
California, San Diego, Department of Psychiatry. As our
future colleagues start their training, we hope that this
guide will help in their transition period and ease their
work in providing help to those with mental health
needs. Each editor is indebted to past editors and each
version is unique and hopefully up to date. As with all
such guides, it is not to be mistaken as a replacement
for journals, textbooks or even lectures. It should be
noted as a helping hand from past PGY1s and 2s…

Good luck in the coming year!

Editor - version 2016-2017: Yuliya Proosaselts, MD
Editor- version 2014-2015: Vladimir Khalafian, MD
Editor- version 2013-2014: Mario Salguero, MD, PhD
Editor- version 2012-2013: Janna Alfery, MD
Editor – version 2011-2012: Robert Gorney, MD
Editor – version 2010-2011: Emily Gray, MD
Editor - version 2009-2010: Steve Koh, MD, MPH, MBA

Acknowledgments
(2012-13): Drs Allison Hadley, Louisa Steiger, Clara
Lee-Zimmerman, Shannon Robinson.
(2012-13): Drs. Robert Gorney, Louisa Steiger, Susan
Zink, Dave Larson, Nico Badre
(2011-12): Drs. Louisa Steiger, Allison Hadley, Emily
Gray
(2010-2011): Drs. Sheryllene Go, Robert Gorney, Anju
Hurria, Josh Kayman, Steve Koh,Clara Lee-
Zimmerman, Melissa Lorang, Jeanne Maglione,
Jennifer Nogde, I-Wei Shu

2
TABLE OF CONTENTS

Introduction 2
General 9
Mental Status Exam 10
MMSE 13
Neurological Exam 14

Legal 24
Confidentiality 25
Holds (5150, 5250) 26
Voluntary patient’s request to 29
leave
AMA discharge 29
Hearings (cert, writ of habeas 30
corpus, writ proceeding, riese)
Conservatorship 34
Behaviors indicating GD 34
LPS conservatorship hearing 35
Tarasoff 37
Reporting documentation 37

Psychopharmacology 39
First gen antipsychotics 42
Second gen antipsychotics 43
Treatment for EPS or neuroleptic 46
induced parkinsonism
Anxiolytics 47
Misc anxiolytics 48
Mood stabilizers 49
SSRI 51
Misc antidepressants 53
MAO-I 54
Heterocyclic antidepressants 55
3
 Substance dependence 57
Cognitive enhancers 58
Sympathomimetics and related 59
Misc 60
Clinically relevant cytochrome 61
p450 interactions
Psychotropic meds & smoking 63
Nicotine replacement orders 63
Neurological SEs of antipsychotic 64
meds
Drug-drug interactions 65
Drug interactions with MAO-Is 66
Relative contraindications for 66
psych meds
Medications for pregnant patients 67
* Psychotherapy 71
* Alternative treatment modalities 72

Patient Management Issues 73

ER patients 74
Intoxicated patients 74
Alcohol withdrawal or detox 75
Opiate detox 80
Drug screening tests 81
Manic or psychotic patients 82
Suicide assessment 82
Antipsychotic side effects 87
Treating EPS 88
NMS 89
Serotonin syndrome 89
HTN crises 89
Lifestyle pointers for depression 90
and anxiety
Relaxation techniques 90
Insomnia 91
4
 Dementia 92

General Medicine 95
AMS 96
Chest Pain 96
Constipation 97
Delirium 97
Diabetes 99
Diarrhea 103
Dyspnea 103
Electrolyte imbalances 104
Falls 105
Fever 105
Headache 105
HTN 106
Hypotension 108
Nausea/vomiting 108
Seizure 108
Stroke 108
Tachycardia 108

Ward Issues 110

Seclusion and restraint 111
ECT 113

UCSD 117
Sign in 118
Rounds 118
H+P and Charting 118
Call and NF schedules 119
Transfers and Telephone Calls at 119
UCSD
Psych Consults from ED 120
Suicidal Patient in ED 122
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 Admission Order sets in EPIC 123
Progress Notes 126
Discharges in EPIC 127
Crisis House info 128
Outpatient follow up from UCSD 130
Senior Behavioral Health 130
Consults 133
Competency v Capacity 135
Medical floors and holds 135
Dialysis center 136

VA 137
2-South 138
Important contacts 139
MAOD 140
Teams 140
Meeting Times and Rounding 141
Admissions at VA 141
Admission orders 142
Suicide risk 143
Notes/Encounter information 145
ADTP consults 147
1-W virtual admissions 147
ED patient supervision policy 148
Hand-offs 154
Discharges 155
Day to day 157
Clinics/VA resources 158
Computer hints 162
On call 163
Codes 170
Holds 171
Tandem call checklist 172
Suicide/adverse event protocol 175

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Misc 179
Pagers/Phones/Computers 180
IDs/Passwords/Door Codes 183
Important Addresses 186
Phone Directory 188
Most Useful Numbers and Codes 193

Notes 195

7
8
GENERAL

9
 GENERAL
Mental Status Exam
Appearance/Behavior: Grooming, level of hygiene,
characteristics of clothing. Unusual physical
characteristics or movements. Refers to both
quantitative and qualitative aspects of patient’s motor
behavior.
Psychomotor activity: agitation or retardation.
Attitude: patient’s attitude in interaction with the
interviewer; also, can comment on level of rapport and
degree of relatedness
Degree of eye contact.
Speech: quantity, rate of production, quality, tone,
appropriateness, volume, amount, rate, rhythm,
pressured, poverty
Mood: internal emotional tone of the patient
Types of mood: Dysphoric, Euphoric, Angry, Euthymic,
Anxious
Affect: external range of expression, described in terms
of quality, range and appropriateness; also, comment
on whether or not affect is congruent to mood
Types of Affect:
- Flat: absence of all or most affect
- Blunted: Moderately reduced range of affect
- Constricted: mildly reduced range of affect (ex:
constricted to depressed range)
- Labile: multiple abrupt changes in affect
- Full or wide range of affect: generally appropriate
Thought Processes: normally, TP would be linear,
logical and goal oriented
 Circumstantiality: unnecessary digression that
eventually reaches the point
 Overly detailed: unnecessary amount of detail
 Tangentiality: thoughts that wander from the
original point and don’t return
 Flight of ideas: accelerated thoughts that jump
from idea to idea, typical of mania. Topics are
generally connected
10
  Loosening of associations: relationship between
ideas disintegrates. Illogical shifting between
unrelated topics
 Blocking: sudden cessation of speech, often in the
middle of a statement
 Word Salad: little connection between words and
phrases
 Poverty of content: minimal responses, such as
answering just, “yes or no.
 Pressured speech: rapid speech, typical of
patients with mania
 Echolalia: automatic repetition of someone else’s
speech
 Perseveration: repetition of phrases or words, that
were the patient’s, in the flow of speech
 Neologisms: invention of new words by the patient
 Clanging: speech based on sound such as
rhyming rather than logical associations
 Ideas of reference: interpreting unrelated events
as having direct reference to the patient (television
talking to the pt)
Thought Content:
 Hallucinations: auditory, visual, tactile, gustatory,
olfactory.
 Delusions:
- Persecutory
- Erotomanic: false belief that a person, usually of
higher status, is in love with the patient
- Grandiose
- Somatic
 Illusions: misinterpretation of reality.
 Derealization: feelings of unrealness involving the
outer environment
 Depersonalization: as if one is outside of their body
Suicidal and homicidal ideation: must elaborate on
these (plan, intent, means.)

11
Sensorium / Cognition: Alertness, orientation,
memory, calculation, reading/writing capacity,
visuospatial ability, language / MMSE can be included
here / often derived from interview itself
Insight: the awareness of having an illness,
understanding factors contributing to illness,
recognizing signs and sx as part of a dz, recog impact
on others and need for treatment.
Judgment: cognitive awareness of dz (deciding that
you have a dz) and an action to care for dz.

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Mini-Mental State Exam (MMSE)
ORIENTATION
 Where are we: (state-1) (county-1) (city-1) (hospital
or clinic-1) (floor-1)? (5-points)
 What is the (year-I) (season-1) (day of the week-1)
(date-1) (month-1)? (5 points)
REGISTRATION
 Have patient repeat three words after you have
said them. Examiner says: apple, chair, Wisconsin
(1 second to say each). Give 1 point for each word
repeated correctly. (3-points)
ATTENTION & CALCULATION
 Serial 7s (begin at 100 & subtract backwards by
7).Stop after 5 answers. One point for each correct
(5 points). Or: spell "WORLD" backwards. Score is
# of letters in correct order.
RECALL
 Ask for the 3 words repeated above. One point for
each correct. (3-points)
LANGUAGE
 Name a pen & watch. (2-points)
 Repeat "no ifs, ands, or buts." (1-point)
 Follow a 3-stage command: "Touch your left ear
with your right hand two times.'" (3-points)
 Read & obey the following: "Close your eyes." (1-
point)
 Write a sentence. (1-point) Copy design. (1- point)

___ TOTAL SCORE [30-Points possible]

13
Neurological Exam
MENTAL STATUS: Alert with normal attention. In good
spirits. The patient gives a clear history and has normal
language output.
Verbal memory (John Brown 42 Market St., Chicago)
Immediate = 5/5
5 min = 5/5
Orientation:
()Date ()Place
()Year loor
()Month ()City
()Day ()County
()Season ()State

Attention: normal

Presidents =

Repetition =
()"No if's, and's, or but's."

Naming =
()watch ()pen
()band ()clip
()crystal/face ()point
()knob/crown
()buckle

Non verbal memory: (spiral, intersect triangles, broken

square)
Immediate = 3/3
5 min = 0/3

Similarities:
()apple/orange
()car/boat
()table/chair
()coat/suit
()poem/statue
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Calculations: $5.75 = 23 quarters

Naming
F-words =
Animals =

Visual Spatial drawings:

Drawing cube
( )Clock

Luria test (fist/edge/flat) =

3 step command = normal

CRANIAL NERVES
II: visual fields intact, discs yellow, margins sharp
III, IV, VI: PERRL, EOMI, no nystagmus, normal smooth
pursuit and saccades.
V: Facial sensation intact
VII: Eye closure and smile are normal. No facial droop
or flattening of
the nasal labial fold.
VIII: Hearing is normal to finger rub bilat.
IX, X: palate elevates symmetrically. Speech is normal.
XI: The sternocleidomastoid and trapezius have normal
strength.
XII: The tongue protrudes in the midline.

MOTOR:
1) Strength
Delt/Bic/Tri/I.Rot/W.Ex/W.Fl/F.Ex/F.Flex/Uln/Med
R 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5

HipF/HipEx/Quad/Ham/A.Dor/T.Dor/T.Plan
R 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5

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2) Bulk =
3) Tone =
4) Tremor =
5) Other movements:
6) Pronator Drift =

SENSATION:
Upper Extremities:
Lower Extremities:

COORDINATION:
Intact RAM/Fingertap/FTN bilaterally.

DEEP TENDON REFLEXES (0=absent, 1=diminished,

2=normal, 3=increased,
4=abnormally increased often with clonus):

R biceps = L biceps =
R brachiorad = L brachiorad =
R triceps = L triceps =
R knee jerk = L knee jerk =
R ankle jerk = L ankle jerk =
Babinski:
R plantar response =
L plantar response =
(-) Glabellar/palmomental/snout/root

POSTURE/GAIT:
Romberg =
Retropulsion =
Gait = normal base/step/arm swing. Normal
heel/toe/tandem walk

16
LEGAL

24
 LEGAL
Confidentiality
What a patient tells a physician is private. There are
some exceptions to this rule. If information must be
exchanged with other providers, consent must be
obtained. Providing information to insurance
companies also requires consent

The major exception to releasing information without

permission is when HARM is possible. Examples:
 Danger to self (DTS)
 Danger to others (DTO)
 Sexual abuse of children
 Physical abuse of elders or children

There is an obligation to report information if the patient

identifies a target & the provider believes that someone
is in danger. If this occurs, the potential victim should be
contacted & warned, as well as the local law
enforcement department. The persons contacted
should be noted in the chart (see Tarasoff example
documentation). If harm befalls a person who could
have been warned, liability may be incurred.

Reporting child abuse is not a question of clinical

discretion. If the patient is the abuser, abused, or
witness, it must be reported for investigation to Child
Protective Services. Remember you are a reporter, not
an investigator. Severe disciplinary action against the
clinician may occur if s/he does not report a case, and
subsequent victims may sue for that inaction.
Information gathered by the physician is the property of
the patient, but the physician owns the physical chart.

Reporting domestic abuse is necessary when the

patient wants to or when physical evidence is present.

25
HOLDS
* At UCSD only Psych and ED residents/attendings
can place holds. At Mercy, psychiatry residents
cannot place holds, only Psych Emergency Team or
Psych Attendings.
Only Psychiatry can DC holds.

5150 – the 72 hour hold

The 72-hr hold is called a 5150 because that is the
chapter in the welfare code of the state of California
dealing with involuntary commitment. Who can place a
5150? Any law enforcement officer, emergency room
MD, psychiatrist or a specifically named person who
has been designated (psychiatry residents have been
designated by the county) in LPS designated settings.

When to place a 72 hr hold:

If you have reasonable indication or probable cause
that someone needs to be held, then you place a hold.
A 72 hr hold is mainly time to observe the patient. The
indications are: danger to self (DTS or SI), dangerous
to others (DTO or HI) or gravely disabled (GD). For
more information on GD, see conservatorship section.

GD is only GD when secondary to psychiatric illness:

does not include dementia (unless there are
associated mood or psychotic symptoms), homeless
secondary to drug/alcohol use, or personal choice

How to place hold:

Fill out 5150 application form and fill out advisement
form (make a copy). There is no good reason to have
an incomplete advisement.
Be sure pt can’t leave. If needed, use sitter or restraints.
As soon as possible read advisement form to the pt.
Give pt the original advisement and put the copy in the
chart with the original 5150 form.
Write an order e.g., legal status 72 hr hold for DTS.
26
Holds can be d/c prior to 72-hr if clinically indicated.
Call attending prior to releasing/discharging patient.

Filling out 72 hour hold (5150) Application

 Check 'advisement complete' box
 'Advisement completed by your name,
Position, MD
 'To VAMC SD, CA or UCSD Medical Center
 'Application is....' Pt's name'
 'residing at' Pt's address’ or ‘homeless, SD,CA'
 'The above person's....' Pt was brought to the
psychiatric ER by SDPD who were called for...
& noted... “ or whatever
 'The following put here facts which justify
detention for evaluation of DTS. DTO or GD
(boxes checked here should match those
checked on the advisement)
 Check the appropriate box for DTS, DTO or
GD (boxes checked here should match those
checked on the advisement)
 Sign the next line with MD include here the
date, time & hospital phone number
 'Name of law....' hospital name then hospital
address

5250 – the 14 day hold

A 14 day hold is used when the treatment team desires
further involuntary treatment and the pt can be shown to
be DTS, DTO, and/or GD. The hold must be
CERTIFIED by the court or court representative. The
hearing takes place on the locked unit. The MD
presents evidence to the hearing officer as to why
continued involuntary confinement is justified while the
pt advocate typically argues the contrary.
 When filling out the form, on a 14 day hold you strike
out those indications that don’t apply (HI, etc.),

27
 The hold must be co-signed by a second clinician
(usually another MD on the treatment team, or
another clinical provider such as a nurse if a
second MD is unavailable).
 Both signers must each document in a chart note
why they feel patient meets criteria for the hold.
 Write an order updating the change in legal status
 The hold may be d/c prior to their expiration if
appropriate. Call attending prior to discharge.

If the pt needs to be held longer

1. If the hold is DTO, the next step is a 180 day hold.
2. If the hold is DTS, after the first 14 day hold, a
second 14 day hold can be placed.
3. If gravely disabled, then can apply for 30 day hold
(5270) or temporary conservatorship (TCON).
- file for TCON within the first week of
hospitalization if the pt continues to be GD.
4. For all holds and conservatorships: a pt can always
be released before the end of the hold if they
have improved significantly.

Possible confusing scenarios

1. If the patient has NEVER been on an involuntary
hold throughout entire hospitalization (including medical
hospitalization), patient may be placed on a 5150.

2. If the patient has been changed from a 5150 to

voluntary, but needs to be placed on an involuntary hold
again the 5150 can be RESUMED within the 72 hour
period of the initial 5150. If it is beyond 72 hours from
the start of the initial hold, patient must be placed on a
5250.

5270
Upon completion of a 5250 14-day period of
intensive treatment a patient may be certified
for an additional period of not greater than

28
 thirty (30) days for grave disability. The form is
very similar to the 5250. Check the “grave
disability” box, and delineate the specific facts
which lead you to believe the patient is GD.

If a voluntary patient asks to leave before the

recommended discharge date, do one of the following:
 Convince the pt to stay.
 Agree that pt is ok to leave, then discharge in
normal fashion; staff with the attending prior to
discharge.
 If you really think the pt needs to stay, but pt has
decision-making capacity and is not currently
DTS/DTO/GD, then discharge the pt AMA – see
procedure below; staff with attending prior to discharge.
 Pt lacks decision-making capacity or is
DTS/DTO/GD, then place a hold.

AMA Discharge Procedure if patient was voluntary:

 Write an order for an AMA discharge in the
order section.
 Document
 The patient has decision making capacity, is not
DTS, DTO, or GD.
 The patient was advised as to the risks of leaving
the hospital early.
 The patient accepted the risks of leaving the
hospital early.
 You attempted to convince the pt to stay both
through talking to him directly as well as by talking to
family/close friends, if we have permission to do this.
 Pt was given instructions about how to maintain
their safety when out of the hospital (i.e. given the
number for the San Diego crisis line; given advice to
call 911 if needed; given the phone number for their
outpt psychiatrist or established that the pt was able to
tell us that number; encouraged them to return to the
ED if they change their mind).
29
 You spoke with the attending psychiatrist who
agreed with the plan.

If you “lose” a cert or a writ you must d/c pt AMA if they

are not willing to stay voluntarily.

Documentation is somewhat less critical when you have

lost a cert hearing than for AMA d/c of voluntary
patients, since the decision is being forced on you, but it
is best to outline your opinion in case there is a bad
outcome.

Hearings
Certification Hearing
1. State your name, spell your last name, and state
your relationship to the pt
2. Has the pt received medication today? If so what,
when, and please describe the effects of the
medication on this pt and any possible side effects
that may impair the pt’s ability to participate in the
hearing
3. On what basis is this pt certified? DTS? DTO? GD?
Impt to know date/time of hold beginning and end
4. What are the patient’s current diagnoses?
5. They will ask to see the original cert application -
must take chart
6. They will hear evidence from the hospital staff first
7. Describe the circumstances surrounding this
admission and specific facts, which lead you to
believe this person is DTS, DTO, and/or GD.
8. The pt will be represented by a pt advocate who
will ask you questions after your presentation
9. The superior court officer facilitates the hearing
10. The advocate presents the pt’s situation and the
court officer makes a decision.

Writ Of Habeas Corpus

30
This is a proceeding wherein the MD/hospital must
prove justification to hold the patient against their will.
1. The officer will ask you the same questions as for a
cert hearing/proceeding.
2. Writs are held in the county court house in front of
a judge and both sides are represented by lawyers.
3. The patient can request a writ any time during a
hold except for during a 72hr hold.
4. If you “lose” a cert or a writ you must d/c pt AMA if
they are not willing to stay voluntarily.
- write AMA note in chart, documenting the
writ proceedings

Writ Proceeding
Counsel, will you stipulate that Dr. (psych resident) is
qualified to testify as an expert (psychiatrist). (if not,
qualify doctor by questions below under LPS
Hearing)
Have you had an opportunity to examine the patient?
Is he/she presently on a hold?
When did you examine him?
Did you form a diagnosis as to his mental condition?
What is that diagnosis?
In examining the pt what did you find that led you to
your diagnosis?
What else did you use in arriving at your diagnosis?
(medical records/ history/ comments from nurses or
family)
Under what circumstances did pt come to your facility?
Based upon your examination & diagnosis of pt, have
you formed an opinion as to whether the pt, as a
result of his/her mental disorder, is: (a) (unable to
provide his/her food, clothing or shelter; (b) a danger
to himself/herself; (c) a danger to others.
What is that opinion?
Why do you believe pt is (gravely disabled/ danger to
self/ danger to others)?
Does pt have any insight into their mental disorder?
31
Has pt been advised of the need for treatment?
Is pt receiving medications of the need for treatment?
Is he/she showing improvement on the medications?
Is pt taking the medications voluntarily?
In your opinion, would pt continue to take the
medications if released?
Has pt been offered voluntary treatment? Accepted or
refused?
In your opinion, is pt able to accept voluntary
treatment?
Is your facility a County designated LPS facility?
Can your facility continue providing the needed
treatment for pt?

Riese Hearing
A hearing to “force” patient to take medications. Patient
must be on a hold to have this hearing.

Discuss meds within each class you plan to use. Pick

meds that can be administered IM when possible
because we can’t actually shove a pill down someone’s
throat. Other than after a Riese hearing, the only time a
patient can be given medication against their will is if
they are imminently in danger of hurting themselves or
another person. In this hearing, the MD/hospital must
prove to the hearing officer that a pt does not
understand the risks and benefits of treatment vs. no
treatment. You need to give the patient written
information* and a written consent form. Multiple times
over a few days you need to verbally try to discuss the
issues about each class of medication you want to use.
Document in the chart what the pt’s specific response
was each time you tried to discuss meds with them.
*Website for patient medication information
handouts: www.cpip.gsm.com

Questions:
1) Doctor, on what basis is patient being detained?
2) What is the diagnosis?
32
3) With what antipsychotic medication do you seek
to treat patient?
4) Have you attempted to discuss the proposed
treatment with patient, if so, on what dates and
times?
5) In discussing your desire to treat patient with
antipsychotic medications, did you inform patient
of the potential risks, benefits, and alternatives to
treatment? When - dates and times?
6) Did you use a written advisement? When?
7) In response to the information you gave, what
did patient say or do and what was your
response to patient?
8) When you discussed, or attempted to discuss,
use of antipsychotic medications, what occurred?
9) Did patient object to the use of medication
because of allergies or side effects from prior
treatment with such medications, and if so, did
you investigate these complaints further?
10) Does patient believe that he suffers from a
mental disorder?
11) Without regard to patient beliefs that he has, or
does not have a mental disorder, does patient
understand his situation (who he is, where he is,
who you are, etc.)?
12) Is patient able to understand the risks and the
benefits of medication or alternative treatments,
and upon what do you base this opinion?
Usually patient understands some risks but
because they don’t understand the benefits, they
are not able to make a rational decision. Point
this fact out at the hearing.
13) Is it your belief that patient is, or is not, able to
rationally understand and evaluate information
about the proposed medication treatment and
the alternatives to such treatment? Upon what
do you base this opinion?

33
 14) During admission, was patient treated with
antipsychotic medication over his objection? If
so, what dates, and why?
* Know the side effects of the medications (common &
potentially serious) and their benefits.

Conservatorships
Conservatorship is removal of someone’s civil rights
due to inability to make decisions in their own best
interest.

LPS Conservatorship:
Conservatorship is for grave disability due to mood or
psychotic disorder**

 Temporary Conservatorship (Tcon): Granted

by the conservator’s office and lasts 30 days.
Is generally used to continue treatment at a
psychiatric facility and/or with intent to pursue
permanent conservatorship
 Permanent Conservatorship (Pcon): Requires
court hearing and lasts 1 year in duration

Probate Conservatorship:
Is used when someone is incompetent to make
decisions, due to impairment from non-psychiatric
illness (i.e. dementia, mental retardation, neurologic
illness, etc). Granted in court hearing and psychiatry is
generally not involved as it is not covered by LPS law.

Behaviors Indicating Grave Disability:

FOOD: Repeatedly eating items considered not fit for
human consumption, malnourished, dehydrated, unable
or unwilling to give realistic plan for obtaining meals,
refuses to eat, states no longer intends to eat.
Abnormal albumin, total protein or evidence of
dehydration.

34
CLOTHING: Unable/unwilling to dress self, repeatedly
destroys his clothing, unable/unwilling to dress in
keeping with climatic conditions, clothing repeatedly
grossly torn or dirty, no realistic plan to obtain needed
clothing. Doesn’t bathe or wash hair.

SHELTER: Unable/unwilling to obtain ordinary shelter,

frequently sleeps in doorways or prohibited areas,
repeatedly ejected from living quarters by landlord
because of inappropriate behavior or nonpayment of
rent, no realistic plan for obtaining shelter,
unable/unwilling to stay in supervised open setting
(board and care facility or shelter).

Being homeless if you choose to live in the streets

doesn’t constitute GD; however if you are
unable/unwilling to utilize or obtain/maintain shelter as a
result of your mental illness then that would be GD.
One example of this is a pt who has been in the hospital
four or more times in a year and is therefore considered
unable to maintain outside the hospital.

Note (from back of 5150 form):

**mental retardation or other developmental disabilities,
alcoholism, other drug abuse or repeated antisocial
behavior do not, by themselves, constitute a mental
disorder.

LPS Conservatorship Hearing

The doctor is sworn.
County Counsel requests pt's attorney to stipulate to
the doctor's qualifications to testify as an expert in
psychiatry. [If the Pt's attorney will not stipulate to
the doctor's qualifications, county counsel then asks
the following questions. A. Could you describe your
education & training? B. Are you supervised by a
doctor who is board certified? C. Did you discuss
this case w/them? Did you discuss your diagnosis &
35
 treatment plan? Do they agree?]
Doctor, did you have occasion to examine the pt?
When was that?
Did you form an opinion as to the pt's mental condition?
What is that diagnosis?
What did you observe that led you to that diagnosis?
What other things did you rely upon in arriving at
that diagnosis? Were there any particular facts in
the records or in conversations with others, which
you considered in forming your diagnosis?
Based upon your examination & diagnosis of pt, are you
able to offer an opinion as to whether the mental
disorder you described results in pt being able to
provide for his/her food, clothing, shelter?
What is your opinion?
What facts about pt led you to this conclusion?
Is pt unwilling or incapable of accepting treatment
voluntarily?
Are you aware of the past history of compliance or non-
compliance with psychiatric treatment?
Does pt understand that s/he has a mental disorder?
Do you know of suitable alternatives available to pt,
other than conservatorship at this time?
Describe the circumstances of the most recent
admission.
Is the pt improving under the current treatment
program? What is the prognosis for this patient if
he/she does not comply with the prescribed
treatment?
(Issues: placement I disabilities)
In your opinion, is the pt capable of
operating a motor vehicle?
entering into contracts?
making medical decisions unrelated to his/her
mental disorder?
making medical decisions related to his/her mental
disorder?
completing a voter registration form?

36
Would he/she be a danger to others if he/she
possessed a firearm?
Do you have an opinion as to what the most appropriate
setting would be for the pt in which he/she would
receive adequate treatment for his/her mental
disorder?
Why is that the most appropriate?
Is that the least restrictive treatment setting available to
the Pt at this time?

Tarasoff: Duty To Warn

(California Civil Code Section 43.92)
Tarasoff was a person killed by a psychiatric patient. In
Tarasoff vs. UC Regents, the Supreme Court ruled that
mental health professionals have a duty to warn
potential victims.
Within 24 hr, you must notify the person who was
threatened and the police (via phone call and in
writing). You can only tell the threatened person: the
name of the person who threatened them and that the
person is in the hospital.
At the time of DC you must notify the person
threatened that the person doing the threatening is
being released.

Reporting Documentation

REPORTING THERAPIST: ________________

DATE & TIME: _________
PATIENT’S NAME: ____________________
SS#: ________________
ADDRESS: _____________________
DOB: _____________
TELEPHONE: _______________
DESCRIPTION: ___________
HEIGHT: _______________
WEIGHT ________________
37
EYE COLOR: HAIR COLOR:
RACE: WBHA
ID MARKS ___________
NATURE OF THREAT: __________
TARGET OF THREAT: ________
TIME NOTIFIED: ________
ADDRESS: _____________________
PHONE ______________
POLICE AGENCY NOTIFIED: ___________
TIME: ______
CONTACT NAME: _____________
PHONE#: ______________

38
PSYCHOPHARMACOLOGY

39
First Generation (“typical”) Antipsychotics
FGAs are generally not used first line due to greater risk for EPS and TD (SGAs are 5-10x less likely to cause TD). EPS risk is dose-dependent, so low doses of high potency
agents are used at times to augment very weak D2 blockers (e.g. quetiapine, clozapine) when pos Sx are not controlled. PET data show risk of EPS occurs at striatal D 2
occupancies greater than 78%, hyperprolactinemia at D2 occupancy > 72%. All FGAs can cause QTc elongation.

Receptor t1/2 Dosing / equivalence to

Name Indication Side-effects (relative) Notes
/ Potency (hrs) 100mg chlorpromazine
Psychosis, - start 1-10mg/day div bid
Sedation (low), - can cause TD, dystonia, EPS, akathisia,NMS
agitation, or tid, to usu 6-20mg/day
hypotension (low), - gold standard of D2 blockade
Haloperidol Tourette’s, - depot – x10-20 of daily
D2 / High 12-36 anticholinergic (low), - decanoate available
(Haldol) rarely for po dose (start max at
EPS (high) , weight gain - available in all routes
choreaform 100mg); give qMonth
(+/-), lipids (-), glc (-) - high incidence of EPS
disorders - equivalence 2
- start 2.5-10mg/day to Sedation (med),
- can cause TD, dystonia, EPS, akathisia,NMS
max 40mg/day hypotension (low),
Fluphenazine Psychosis, - decanoate available
D2 / High 10-20 - depot – 12.5mg per 10mg anticholinergic (low),
(Prolixin) agitation - high incidence of EPS
po dose; dose q2wk EPS (high) , weight gain
- equivalence 2 (+/-), lipids (-), glc (-)
Sedation (low), - can cause TD, dystonia, EPS, akathisia
- start 2-5mg bid-tid to max
Thiothixene Psychosis, hypotension (low), (common),NMS
D2 / High 10-20 60mg/day
(Navane) agitation anticholinergic (low), - can cause ocular pigment changes so do periodic opth
- equivalence 5
EPS (high) examinations
Sedation (low),
- start 4-8mg tid to max hypotension (low),
Perphenazine Psychosis,
D2 / Mid 10-20 64mg/day anticholinergic (low), - can cause TD, dystonia, EPS, akathisia,NMS
(Trilafon) antiemetic
- equivalence 10 EPS (high), weight gain
(+/-), lipids (-), glc (-)
Sedation (high),
- can cause TD, dystonia, EPS, akathisia,NMS
Psychosis, hypotension (high),
- start 10-50mg bid-qid to - many active metabolites
Chlorpromazine n/v, anticholinergic (med),
D2 / Low 10-40 max 2000mg/day - lethal in OD, high risk for agranulocytosis
(Thorazine) intractable EPS (low), weight gain
- equivalence 100 - increased risk for seizure, jaundice, photosensitivity,
hiccups (+++), lipids (+++), glc
skin discoloration, granular deposits in lens and cornea
(++)

42
Second Generation (“atypical”) Antipsychotics (Serotonin-Dopamine antagonists)
Used commonly for many disorders. Effects seen within days, but continued improvement noted over 6 weeks. Common mechanism is potent 5HT2 antagonism (except
quetiapine) and relatively weaker D2 affinity than FGAs.
All SGAs have indication for acute mania, but studies have not yet been done for maintenance. Olanz, geodon & aripip have indication for maintenance in bipolar, but major
metabolic SEs and related deaths have significantly decreased use of olanz. Beware of added wt gain when combining mood stabilizers and SGAs.
Other uses with compelling data include augmentation to SSRI for major depression, PTSD (used at low doses to maximize 5HT2 effects with little D2) and bulimia.
FDA has issued warning in general about new onset DM or DKA with SGAs, but biggest offenders are clozapine & olanzapine and possibly risperidone and quetiapine. All schiz
pts should have baseline fasting gluc, lipids, BMI, waist circumference, then quarterly monitoring, with highest frequency for patients on olanz or cloz, esp if other DM risk factors
(e.g. ethnicity).
There is also an FDA warning about CVAs with SGAs and increased mortality with atypical antipsychotics when used in elderly dementia patients (.7-.9%, mech unknown).
Risperidone has most safety and efficacy data in children (tics, behavior control) and dementia (but not FDA approved for these uses).

Dosing / equivalence
Receptor / t1/2
Name Indication to 100mg Side-effects (relative) Notes
Potency (hrs)
chlorpromazine
Risperidone
(Risperdal) - not much benefit in increasing dose beyond 6mg/day
- start 1mg bid to max Low EPS w/ dose
Consta - decanoate and rapidly dissolving form available
16mg/day below 6mg, orthostatic
(depot), * paliperidone (Invega) is metabolized form of risperdal, has half-
- depot – 25-50mg IM hypotension, reflex
M-Tab Psychosis, mania, life of 23hr, reportedly has safer SE profile than risperdal, can be
3-20 q2wk tachycardia, insomnia,
(rapid mood disorders used for patients with extensive liver damage, shares most of the
- metabolized by 2D6 agitation, inc prolactin,
dissolving) characteristics as risperdal; start 3mg qday and titrate up by
- level inc by fluoxetine weight gain (+), lipids
See 3mg/day q6days to max of 12mg/day; like risperdal, it may not
and paroxetine (+/-), glc (+/-)
*paliperidone receptor be very effective after 6mg/day dose
(Invega) affinity
table Psychosis, mania, - start 50-100mg qday
Orthostatic
mood disorders, and inc by 50mg/3day - Very weak affinity for all receptors, profile similar to
hypotension,
GAD; many off label until max dose antihistamine at doses < 200 mg/d
Quetiapine somnolence, weight
uses including 800mg/day (seroquel - doses at 300mg/day has indication for bipolar depression
(Seroquel, 6 gain, dyspepsia, abd
agitation w/ XR can be dosed - Very weak D2 antagonist with low EPS. Slightly fewer metabolic
Seroquel XR) pain, dry mouth,
dementia, insom, starting at 300mg/day SEs than olanzapine.
weight gain (+), lipids
borderline to max 800mg/day) - XR can be used for bipolar depression
(+), glc (+/-)
personality - metabolized by 3A4
(cont)

43
SGAs, cont
t1/2
Name Receptor Indication Dosing / metabolism Side-effects Notes
(hrs)
- Twice as costly as other atypicals. Major metabolic SEs, avg >
Drowsiness, dry st
20 lb wt gain in 1 yr, DM and DKA (with deaths), sedation, ↑
Psychosis, - start 10mg/day to max 40mg/day mouth, akathisia,
Olanzapine lipids (get initial and frequent lipid panels)
mania, - metabolized by 1A2 insomnia, weight
(Zyprexa, 21-54 - least noncompliance per CATIE trial
mood - level dec by tobacco (x5) and gain (++++),
Zydis) - avoid IM use in elderly
disorders carbamazepine, inc by fluvoxamine lipids (+++), glc
- available as rapid acting IM and dissolving form, also as
(+++)
combination with fluoxetine for bipolar depression (rarely used)
Dizziness,
- start 20mg bid, up to 60 bid in 2
nausea, postural
days, to max 80mg bid
Psychosis, hypotension, - Minor QTc prolongation but no cases of Torsades ever
- must give w/ food (needs bulk to
Ziprasidone mania, prolactin reported, no mandatory EKG
7.5 slow down gastric emptying to
(Geodon) See mood elevation, - w/o food will decr absorp by 50%. Wk SNRI property. Not
allow for absorption; 300 calories is
receptor disorders sedation, weight effective at low dose. Metabolic neutral.
the general guideline
affinity gain (+/-), lipids
- metabolized by 3A4
table (-), glc (-)
Psychosis, - Agranulocytosis, salivation, orthostasis, seizure at high
- start 25mg bid then inc by 25- Orthostatic st
mania, dosages, avg > 10 lbs/ weight gain in 1 year, DM and DKA
50mg/2-3day to max 900mg/day hypotension,
mood (with deaths), ↑ lipids (get initial and frequent lipid panels), ↑
- refer to clozapine dosing sedation,
disorders, saliva production.
guideline for monitoring issues anticholinergic,
refractory - Weekly CBC for 6 mos, then biweekly after, shouldn't be used
Clozapine - metabolized by 1A2 tachycardia,
12 psychosis, with other bone marrow suppressants (Sulfonamides, Captopril,
(Clozaril) - level inc w/ cimetidine (use constipation,
some Propylthiouracil, Tegretol)
ranitidine), risperdal, fluvoxamine hypersalivation,
evidence - Quarterly monitoring of gluc, lipids
(up to x5-10), TCA can inc SEs weight gain
of - ONLY agent effective in refractory schiz (60% response rate,
(esp seizure), level dec w/ smoking (++++), lipids
reversing aim for serum level > 450 ng/ml)
(50%), carbamazepine dec by 50% (+++), glc (+++)
TD - Needs to be registered in the Clozaril national database

44
SGAs, cont
t1/2
Name Receptor Indication Dosing / metabolism Side-effects Notes
(hrs)
- Weak D2 partial agonist, may get stimulation at high doses.
Headache, n/v, Half-life 75 hrs-don’t stop primary drug too soon. Metabolic
- start 10-15mg qday to max sedation w/ high neutral.
See Psychosis, 30mg/day doses, anxiety, - poor metabolizers have 80% level inc
Aripiprazole receptor 75; 94 mania, - metabolized by 2D6 and 3A4 insomnia, - no QTc elongation or inc prolactin have been reported
(Abilify) affinity (metab) mood - level inc w/ quinidine, prozac, orthostatic - To switch, add at 10-15 mg hs for two wks before decreasing
table disorders paxil, ketoconazole; level dec w/ hypotension, primary agent
Tegretol weight gain (+/-), - Available as nonrefrigerated liquid, rapidly dissolving tab,
lipids (-), glc (-) rapidly-acting injectable
- 2D6 and 3A4 convert to active metabolite
18
(2D6 - titrate 1mg bid day 1, inc to 2,
D2, 5HT2
fast 4, 6, 8, 10, 12mg bid on
(high), orthostasis risk, - just approved in May 2009
Iloperidone metab) schizophr subsequent days as needed;
NE weight gain (+), - impact of 3A4 inducers not documented
(Fanapt) ; 33 enia max 16mg bid
(mod), H lipid (+/-), glc (+/-)
(2D6 - fluoxetine inc level x2-3,
(low)
slow paroxetine inc level x1.6
metab)

45
 Receptor Affinities of 2nd Gen Antipsychotics
RISP QUET ZIPR OLAN CLOZ ARIP
D2 ++++ + ++++ ++ + ++++ (prt ag)
5-HT2A +++++ + +++++ ++++ ++++ ++++
5-HT2C ++++ - +++++ ++++ ++ ++
5-HT1A + + ++++ - + ++++
5-HT1D + - ++++ + - N/A
α1-adrenergic ++++ ++ ++ ++ ++++ ++
M1-muscarinic - ++ - ++++ ++++ -
H1-histaminergic ++ ++++ ++ ++++ ++++ ++
5-HT reuptake - - ++ - - +
NE reuptake - + ++ - + N/A
For more detailed and updated table please go to http://cdn.neiglobal.com/content/practiceres/posters/50188_nei_009_bindings.pdf

Treatment for EPS or neuroleptic-induced parkinsonism

Name Receptor t1/2 (hrs) Indication Dosing Side-effects Notes
- relative contra indication for seizure
Augments
disorders or renal disease
Amantadine dopaminergic EPS (as effective as - start 100mg bid to max Insomnia, dizziness,
12-18 - overdose can cause toxic psychosis
(Symmetrel) neurotransmi anticholinergics) 400mg/24hr impaired concentration
and cardiopulm arrest
ssion
- avoid use w/ MAO-I
- not indicated for prophylaxis w/
Muscarinic Neuroleptic-induced
Duration Dry mouth, constipation, antipsychotic use
Benztropine acetylcholine parkinsonism, EPS, - start 0.5-1mg bid to max
of action urinary retention, - IM formulation use for acute dystonias
(Cogentin) antagonist; acute dystonia, 12mg/24hr
1-12hrs blurred vision - not as useful for akathisia as β-
antihistimine akathisia
blockers
Neuroleptic-induced - start 25-50mg tid or qid Sedation, hypotension,
- has some abuse potential
Diphenhydramine parkinsonism, EPS, to max 400mg/24hr dizziness, paradoxical
antihistimine 2-8 - not ideal for long-term treatment of
(Benadryl) acute dystonia, - start 50mg qhs for excitement and
insomnia
akathisia, insomnia insomnia agitation

46
Anxiolytics (Benzodiazepines)
Act on specific sites of (GABA) type A receptors. GABAA is the major type of brain GABA receptor, and is an integral membrane chloride channel comprised of 5 subunits.
[GABAB receptors are coupled to G-proteins, and are not acted upon by benzodiazepines.]
Unlike barbiturates, benzodiazepines do not directly open the GABAA receptors, but bind to a distinct site on the GABA receptor (the BZ site = omega site) and allosterically
modify GABA binding, potentiating the action of GABA. BZ 1 agonism is associated more with sleep, while BZ2 binding is associated with effects on cognition, memory and
motor control.
Benzodiazepines are effective agents but there is a concern for dependence with long-term use. USE SPARINGLY on pts with history of addiction to other substances.
Short-acting agents cause most abrupt withdrawal. Use of as little as two weeks may cause rebound insomnia upon d/c.
Receptor / side t1/2 Indication / onset of
Name Dosing / equivalence Side-effects Notes
chain group (hrs) action
- no active metabolite
Anxiety, agitation,
- not metabolized by 3A4 isoenz and so okay to
Lorazepam anticonvulsant, 1-4mg per dose as
3-OH 15 use w/ liver damaged pts
(Ativan) alcohol withdrawal / needed as tolerated / 1
- drug of choice for alcohol detox if liver
medium onset
damaged
- no active metabolite
Oxazepam Anxiety, agitation / 30-120mg/day in bid to - not metabolized by 3A4 isoenz and so okay to
3-OH 8
(Serax) slow onset qid dosing / 15 use w/ liver damaged pts

- no active metabolite
Temazepam Anxiety, agitation /
3-OH 11 7.5-30mg/day qhs / 5 - not metabolized by 3A4 isoenz and so okay to
(Restoril) medium onset
use w/ liver damaged pts
Sedation, dependence,
10-200mg per day
Chlor- Anxiety, agitation, withdrawal, confusion, ataxia,
safely as outpt; pt - drug of choice for outpt alcohol detox
diazepoxide 2-Keto 100 alcohol withdrawal / paradoxical disinhibition
needing higher doses - avoid use if severe liver damage
(Librium) medium onset
should be admitted
Diazepam Anxiety, agitation / 4-40mg/day bid to qid - long half-life makes it okay to do once a day
2-Keto 100
(Valium) rapid onset dosing / 5 dosing
Anxiety, agitation,
Clonazepam - 2:1 ratio dose equivalence and long half-life
Nitro 34 alcohol withdrawal / 1-6mg/day bid / 0.5
(Klonopin) make it ideal for conversion from lorazepam
medium onset
- fast onset of action makes it highly dependence
Alprazolam Anxiety, agitation / 0.5-10mg/day bid to
Triazolo 12 prone
(Xanax) medium onset qid dosing / 0.25
- withdrawal sx can be acute and severe
Triazolam Anxiety, agitation / 0.125-0.250mg qhs / - not commonly used because of short half-life
Triazolo 2
(Halcion) medium onset 0.1-0.03 - careful use in elderly population

47
Misc Anxiolytics
Name Receptor t1/2 (hrs) Indication Dosing Side-effects notes
Sedation, hypotension,
Hydroxyzine - start 50-100mg q6hr
antihistimine 20-25 anxiolytic dizziness, paradoxical - alternative for benzos as short acting anxiolytic
(Vistaril) prn to max 600mg/24hr
excitement and agitation
Partial agonist
Buspirone - start 5mg bid or tid to - takes about 2wk to get optimal therapeutic effect
serotonin 5-HT1A, 2-11 anxiolytic Restlessness, nervousness
(BuSpar) max 60mg/24hr - avoid w/ MAO-I
5-HT2, D2
- start 5-10mg qhs; for - rapid onset
Zolpidem
Binds to GABA CR start at 6.25 or Dizziness, GI upset, n/v, - avoid w/ other bezo or alcohol
(Ambien, 2-3 Insomnia
type 1 12.5mg qhs anterograde amnesia - can be habit forming
Ambien CR)
- do not crush/cut/chew CR formulation
- rapid onset
Zaleplon Binds to GABA Dizziness, dyspepsia,
1 Insomnia - start 5-10mg qhs - avoid w/ other bezo or alcohol
(Sonata) type 1 diarrhea
- can be habit forming
- start and maintain at - rapid onset
Eszopiclone Binds to GABA Headache, somnolence,
6 Insomnia 2-3mg qhs (1mg qhs if - avoid w/ other bezo or alcohol
(Lunesta) receptor complex dizziness, n/v
pt has liver damage - can be habit forming
* Notes on insomnia medications

Often new abstinence from CNS depressants result in insomnia; best tx is to continue abstinence, practice good sleep hygiene.
For insomnia with acute mania or psychosis, aggressive medication is indicated, including liberal use of benzodiazepines.
For a depressed inpatient, the insomnia should be documented before treating it. Maximize the sedative potential of other meds (antidepressants, neuroleptics, and mood
stabilizers).
trazodone and diphenhydramine (Benadryl) may sometimes be used and do not lead to dependence, but do disrupt the normal sleep cycle.
zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta) are newer agents with reportedly less abuse potential, although this is debated. They appear to be very effective
and safe (does not disrupt the normal sleep cycle) but are expensive and hard to get at the VA.
Sometimes clonidine 0.1-0.3 mg QHS is very helpful, although watch for hypotension.
Ramelton is a melatonin type 1 and 2 receptor agonist approved by the FDA for insomnia; not available at the VA.

48
Mood Stabilizers
Name Receptor t1/2 (hrs) Indication Dosing Side-effects Notes
- start 300mg bid and - preLi workup – chem10, cbc, TFT, EKG (if
GI distress, weight gain,
Bipolar titrate up till level of 0.6- older or w/ cardiac condition)
tremor, cognitive
disorder (not 1.2mEq/L (up to 1.5 for - use lower dose in elderly because of lower
impairment, diabetes
as good for acute mania) Cr clearance
insipidus can occur,
May act by bipolar - monitor level after - rare cases of Ebstein’s anomaly from use in
Lithium thyroidtoxic, T-wave
inhibiting depression), 5days (12 h trough), first trimester of pregnancy)
(Lithobid, 20 flattening, leukocytosis
inositol-1- unipolar mood qwkly for 1-2mo then - medications that inc or dec renal clearance
Eskalith) - toxicity (n/v, diarrhea,
phosphatase disorder, biweekly for 2mo then influence Li level
tremor, inc DTR, ataxia,
impulse q3-4mo - Lithobid and Eskalith CR are both slow
confusion, arrhythmia)
control - QHS dosing is release and are rarely used due to increased
severe >2.5 and mild/mod
disorders preferred to minimize risk of long-term renal SEs. May have fewer
1.5-2.0
polyuria. GI SEs.
Bipolar - loading – 20mg/kg st
- 1 line agent for acute mania
disorder (good divided tid or 30mg/kg
- depakote is coated and better tolerated
Valproic acid for acute for ER (dosed qday);
Acts on protein n/v, sedation, tremor, low - follow cbc and LFTs
(VPA; mania, rapid max 60mg/kg/day
kinase C and plts, pancreatic and hepatic - depakote ER's level should be checked at
Depakote, 8-10 cycling and - alternatively, start
GABA, Na toxic, hair loss, hyper- 24hr trough (usually 1800 or prior to next
Depakote ER, mixed), mood 500mg bid and titrate up
channel blocker ammonemia dose)
Depakene) lability, as needed
- high risk of causing many different birth
impulsive - level (50-125µg/mL)
defects if taken during pregnancy
behavior check after 3days
- start 25mg/day for 2wk,
Effects Na
Bipolar 50mg/day 2wk,
channels that
depression, 100mg/day 2wk then - Multiple drug interactions- including oral
modulate
not very good 200mg/day Dizziness, sedation, contraceptives decreasing Lamictal by 50%.
glutamate and
Lamotrigine for acute - no need to check headache, diplopia, ataxia, - If on VPA start at 25 qod for 1 week, 25mg
aspartate 25
(Lamictal) mania or rapid serum levels dec coordination, rash (SJS qhs for 1wk and increase by 25mg q wk to
release, weak
cycling - carbamazepine will can occur) 100-150 mg qd with no one dose greater than
inhibitor 5-HT3,
enhance Lamictal 75 mg. VPA increases levels several fold.
reduce GABA-A
metabolism
transmission
(cont)

49
Mood Stabilizers, cont
Name Receptor t1/2 (hrs) Indication Dosing Side-effects Notes
Prolong - pre workup – chem20,
- Less efficacy data than Li or VPA for acute
inactivation of cbc, EKG in older pts
Bipolar mania or maintenance
voltage- - start 200mg bid to level GI complaints,
Initially 25- disorder (good - use lower dose in elderly
dependent Na 8-12µg/ml after 5day use sedation, dizziness,
65 then w/i for rapid- - do not use in pregnancy (inc risk of spina
channels, - monitor level qwkly for ataxia, confusion, rash
Carbamazepine one mo, cycling and bifida)
reduce current 1-2mo then biweekly for (can cause SJS),
(Tegretol)* 12-17 mixed), - can cause fatal thrombocytopenia,
of NMDA 2mo then q3-4mo toxicity (confusion,
(auto- cyclothymia, agranulocytosis, aplastic anemia
channel, - metabolized by 3A4; stupor, trmor, dilated
induction) impulse control - contraindicated for bundle branch block
antagonize induces its own pupils, n/v)
disorders - there is now XR version that is dosed
adenosine A1 metabolism (need higher
st similarly to max 1600mg/24hr
receptors doses after the 1 month)
Oxcarbazepine
For sz do starting dose is Less sedating than
(Trileptal; No double-blind studies, only open-label or
300bid and increase by carbamazepine, but
active metabolite retrospective data. Efficacy and optimal dosing
300 every 3 d to sz may cause
of unknown
control or 1200mg bid. hyponatremia.
carbamazepine)
acute mania
Equetro
and mixed
(extended
states for
release Tegretol)
bipolar pts

Also, second generation antipsychotics can be used for mood stabilization.

Also, calcium channel blockers (e.g., diltiezem) have mood stabilizing properties.

Topiramate (Topamax)
 Ineffective in double-blind studies as adjunctive agent for mania.
 SE - fatigue and psychomotor slowing
 Dizziness, ataxia, nausea, wt. Loss, speech disorders, blurry vision.
 Precaution kidney stones, acute angle glaucoma, 25% develop metabolic acidosis.

50
SSRI Antidepressants
Chosen mostly on basis of half-life and potential for drug-drug interactions. No difference in efficacy, but occasionally difference in tolerability.
Commonly higher doses are often used for anxiety disorders (occasionally above FDA max rec dose- impt to document consent)
Most SSRIs have the potential of causing withdrawal if d/c too quickly; use w/ MAO-Is can cause serotonin syndrome (in order of appearance: diarrhea, restlessness,
agitation, hyperreflexia, autonomic instability, seizure, myoclonus, hyperthermia, coma, delirium, death)
The FDA has a warning on all antidepressants that they can cause suicidality in children and adolescents. There is also a warning for Paxil in adults about suicidality.
Any young person (<25 years) should be monitored weekly for the first month after starting an SSRI
Dosing / p450
Name Receptor t1/2 (hrs) Indication Side-effects Notes
inhibition
- few p450 interactions
Citalopram Block presynaptic - start 20mg qday to - SSRI of choice to minimize
Depressive disorder,
(Celexa) serotonin 33 max 40mg/day interaction w/ other meds
anxiety disorders
avail as generic reuptake - 2D6, 2C19 (weak) - FDA warning, dose
dependent increase in QTc
Block presynaptic - start 10mg qday to - expensive ‘S’ isomer of
Escitalopram Depressive disorder,
serotonin 30 max 30mg/day GI effects, insomnia, citalopram, somewhat fewer
(Lexapro) anxiety disorders
reuptake - 2D6, 2C19 (weak) sedation, sexual side effects than citalopram
- start 20mg qday to dysfunction, headache. - can be activating
Fluoxetine Block presynaptic Depressive disorder, max 80mg/day - metabolites are active and
(Prozac) serotonin 15days anxiety disorders, - 2C9, 2C19, 2D6, 3A4 Can cause mania, so self tapers; overdose is
avail as generic reuptake anorexia nervosa, bulimia (mod) (increases TCA, restlessness, increased relatively safe
SGA levels) anxiety.
- start 50mg/day to
Block presynaptic Has significant
Fluvoxamine Depressive disorder, max 300mg/day (usu - most interactions w/ other
serotonin 22 antiplatelet effect
(Luvox) anxiety disorders in bid dosing) meds through p450
reuptake (bleeding risk).
- 1A2, 2C19, 3A4
- start 10-20mg qhs to - can be sedating
Paroxetine max 80mg/day; need Rare hyponatremia in - shortest half-life, to avoid
Block presynaptic
(Paxil) Depressive disorder, slightly higher doses elderly (especially withdrawal, take time to taper
serotonin 21
avail as generic anxiety disorders for CR formulation women). off
reuptake
avail as CR - 2D6 (increases - preferred agent if
digoxin levels) breastfeeding
- moderately activating and
Block presynaptic - start 50mg qday to
Sertraline (Zoloft) Depressive disorder, sedating
serotonin 26 max 200mg/day
avail as generic anxiety disorders - preferred agent if
reuptake - 2D6 (mod)
breastfeeding

51
Affinity Of Antidepressants For Neurotransmitter Receptors

Drug H1 Musc 1-Adren 2-Adren D2 5-HT2

SRI NRI 5HT2 2 MAOI
SSRIs citalopram/
+++
fluoxetine +/- +/- +/- +/- + +/- escitalopram
paroxetine 0 ++ +/- +/- 0 0 fluoxetine +++
sertraline 0 +/- + + +/- 0 fluoxetine +++
NDRI-bupropionSR +/- 0 +/- 0 0 0 paroxetine ++++
SNRI-venlafaxineXR 0 0 0 0 + 0 sertraline +++
SNRI-duloxetine 0 0 0 0 0 0 nefazodone + + +++
5HT2/SRI venlafaxine ++ +
nefazodone 0 0 + +/- 0 +++ duloxetine +++ +++
trazodone + 0 ++++ ++ + +++ mirtazapine +++ +++
2/5HT2/5HT3 TCA-3º Amine +++ ++
mirtazapine +++ + + ++ 0 ++ TCA-2º Amine ++ +++
MAO/selegiline +++
C Bolden-Watson et al, 1993; E Muth et al, 1991; E Richelson, 1991; B Cusack et bupropion Nobody really knows
al, 1999

52
Miscellaneous Antidepressants
Name Receptor t1/2 Indication Dosing Side-effects / interactions Notes
- start 100mg bid then - increased seizure risk if dose
Inhibit norepinephrine titrate 100mg/day every Insomnia, CNS stimulation, >450mg/day and w/ electrolyte
Bupropion MDD, ADHD, as
reuptake and 3d to max 450mg/day headache, constipation, dry disturbance
(Wellbutrin adjunct w/ SSRI,
dopaminergic - SR form: 150mg qday mouth, n/v, tremor - no sexual, weight gain, sedation side-
IR, SR, less risk of inducing
neurotransmission, 4-24 then titrate to 150mg bid effects
XL, Zyban) mania in bipolar
noncompetitive until max 200mg bid inhibits 2D6, carbamazepine, - second line agent for ADHD
avail as depression,
inhibitor nicotinic - for smoking cessation, Phenobarbital, phenytoin can - do not use in patients w/ eating disorder
generic smoking cessation
acetylcholine start 2wk prior to q then dec level - do not use w/ MAOIs as it can lead to
cont for 7-12wks serotonergic syndrome
Venlafaxine Blocks 5HT and NE MDD, GAD, social - can see discontinuation syndrome w/
- start 37.5mg bid then Dose dependent HTN,
(Effexor, reuptake (120:1 anxiety, panic abrupt cessation
5-10 inc to max 375mg/day insomnia, n/v, anxiety, dizzines
Effexor ratio), very little disorder, dysthymia - avoid w/ MAOIs
- XR – qday dosing Metabolized by 2D6, inhib 2D6
XR) anticholinergic or H1
n/v, dec appetite, dry mouth,
MDD, somatization
dizziness, constipation, - can see discontinuation syndrome w/
Blocks serotonin and disorders, pain
Duloxetine - start 20mg bid then fatigue, insomnia, sexual SEs / abrupt cessation
norepinephrine 12 syndromes,
(Cymbalta) titrate to max 60mg bid metbz by 2D6 (inc level of - there are reports of liver toxicity
reuptake (9.4:1 ratio) peripheral
TCA, SGA) and 1A2 (will inc
neuropathy
level by 2.5x and 1/2-life 3x)
5-HT2, 5-HT3, α2 MDD, dysthymia, - low sexual SE
- little effect on p450
Mirtazapine adrenergic 20- anxiety disorder, - start 15mg qhs to max - inc appetite, dry mouth,
- good choice for elderly w/ depression
(Remeron) antagonist, some H1 40 bulimia, chronic 60mg qhs constipation, fatigue,
- some risk for agranulocytosis
receptor antagonism pain dizziness, orthost hypotension
Inhibits presynaptic n/v, dry mouth, dizziness, - few sexual side effects; no priapism
Nefazodone MDD, dysthymia,
serotonin reuptake - start 50-100mg bid sedation, agitation, - black box for rare fatal hepatotoxicity
(Serzone) premenstrual
and postsynaptic 2-18 then titrate every few constipation, headache / - analogue of trazodone
avail as dysphoric disorder,
5HT-2A, some α1 days to max 600mg/day inhibits 3A4 (inc levels of- do not use w/ MAOIs
generic PTSD
antagonism triazolam and alprazolam) - does not suppress REM
Inhibits presynaptic
Trazodone - start 50-100mg qhs - metabolizes to nefazodone
5HT reuptake, Depressive Sedation, orthostatic
(Desyrel) then increase by - commonly used for insomnia; too
postsynaptic 5HT2, 6-11 disorders, anxiety, hypotension, priapism (doses
avail as 50mg/day as tolerated sedating to use as primary antidepressant
antagonizes α agitation, insomnia >150mg)
generic to max 600mg/day - avoid using w/ MAOIs and w/ ECT
adrenergic and H1
* Symbyax is combination of fluoxetine and olanzapine – approved for bipolar depression (usefulness of 5HT2 antagonism and SSRI) SE profile makse it difficult to use

53
Monoamine Oxidase Inhibitors
An MAO-I irreversibly inhibits the MAO enzyme; type A (CNS, sympathetic terminals, liver, GI, skin), type B (CNS, liver, plts); tyramine accumulates when type A is blocked which
accounts for the major SEs of MAO-Is; patients on MAO-Is must adhere to low tyramine diet to avoid hypertensive crisis
It takes 2wks after d/c medication to replenish body of MAO, so avoid TCA, SSRI until after 2wk washout period (otherwise might get Serotonin Syndrome)
As a general rule, avoid the following: antiashmatics, antihypertensives, buspar, levodopa, opioids, sympathomimetics, SSRI, SNRI, TCA
Name Receptor t1/2 (hrs) Indication Dosing Side-effects* Notes
Depressive disorders (esp - start 15mg bid and titrate up Higher incidence of
Phenelzine useful w/ atypical features), by 15mg/wk until max weight gain, drowsiness,
MAO 11.6
(Nardil) anxiety, panic disorder, 90mg/day dry mouth, sexual
social phobia, OCD dysfunction
Depressive disorders (esp
Tranylcypromine useful w/ atypical features), - start 10mg bid and titrate up More likely to cause
MAO 2.5
(Parnate) anxiety, panic disorder, by 10mg/wk to max 60mg/day insomnia than phenelzine
social phobia, OCD
- start 10mg bid and titrate up
Isocarboxazid Similar SE profile as
MAO ? Depressive disorders 10mg/day q2-4d x1wk; max
(Marplan) above
60mg/day
Depressive disorders (esp - start 6mg/24hr patch then Transdermal patch will avoid GI; lower
Selegiline
MAO-B 18-25 useful w/ atypical features), inc by 3mg/24hr q2wk to max dietary restrictions (only for 9, 12mg dose,
(EmSam)
anxiety 12mg/24hr; do not cut patch none for 6mg)
MAO-A selective reversible inhibitors (RIMAs) are not available in US; they require less dietary restrictions; moclobemide and befloxatone
MAOI Food Interactions: (pts on MAOIs should avoid these foods) Pt education is important regarding diet and other medications because of risk of acute hypertensive crisis.
 Aged cheeses
o English stilton, blue cheese, old cheddar, Danish blue, parmesan, gruyere, brie, Swiss, camembert, etc.
o Because 80% of all hypertensive crises are secondary to aged cheeses, they are called “cheese reactions.” Even some of the more moderate tyramine cheeses (e.g., brie, emmantaler,
and gruyere) should be avoided; Some cheeses are allowed: cottage, processed cheese slices, mozzarella (currently a debated issue), ricotta, and cream cheeses are safe.
 Chianti wine and tap beer should probably still be avoided, despite questionable findings; Fava (Italian, broad) beans (because of DOPA content)
 Avoid concentrated yeast extracts, especially Marmite; Brewer’s yeast is safe; avoid pickled herring, brine and other processed packaged fish, like anchovies; Fresh fish is safe.
 Avoid sauerkraut, eggplant, dried fruits and overripe fruits; Avoid sausage: salami, mortadella, air-dried sausage, bologna, pepperoni, summer sausage, chicken liver, corned beef,
liverwurst, and pastrami should be avoided.
 Avoid Chinese foods, oriental soup stocks (e.g., miso) should be avoided until more evidence becomes available.
 Avoid Tofu and all soy products, including soy sauce (there is some dispute that soy milk and tofu are ok).
 Avoid Aspartame, the artificial sweetener, may cause a hypertensive reaction; Consume less than 1 gram of aspartame in beverages per day.
Foods thought to be no longer at risk (still recommend caution)
 Tea, coffee, cola, and other caffeine-containing beverages (some experts limit these to 3 cups/glasses a day). Chocolate should also be limited.
 White and red wine, other spirits (wine should be under 3 oz/day).
 Yogurt, caviar, snails, tinned fish (that isn’t pickled or brined), canned and packaged soup

54
Heterocyclic Antidepressants
Avoid use with MAO-I
TCAs and Therapeutic Blood Levels
Largely irrelevant, except for nortriptyline, which has a maximally effective dose (larger than 150 is less effective). If in doubt about whether pt is toxic, get an EKG and check for QT
prolongation.
t1/2 Dosing / therapeutic level Side-effects** /
Name Structure Indication Notes
(hrs) (includes metabolites) metabolism
MDD, dysthymia, anxiety - start 25mg qhs then inc q1-4wk - widely used for pain, sometimes for
Amitriptyline 1A2, 2C19, 2D6
3º amine 10-50 disorder, bulimia, chronic to max 300mg/day insomnia
(Elavil, Endep) (less 2C9, 3A4)
pain, insomnia - 100-250 - used for migraine prophylaxis
- higher doses and longer treatment for
MDD, dysthymia, anxiety - start 25mg qhs then inc q1-4wk
Clomipramine - higher risk of OCD
3º amine 20-50 disorder, bulimia, chronic to max 250mg/day
(Anafranil) seizures - maybe useful for depression w/
pain, OCD - 100-450
obsessional traits
Doxepin MDD, dysthymia, anxiety - start 25mg qhs then inc q1-4wk
- antihistamine effect make it good
(Adapin, 3º amine 8-24 disorder, bulimia, chronic to max 300mg/day - very sedating
antipruritic agent
Sinequan) pain, insomnia, pruritus - 120-250
MDD, dysthymia, anxiety
- start 25mg qhs then inc q1-4wk
Imipramine disorder, panic disorder, - good for panic disorder and enuresis
3º amine 5-25 to max 300mg/day 1A2, 2C19, 2D6
(Tofranil) bulimia, chronic pain, in children
- 150-300
enuresis in children
MDD, dysthymia, anxiety - start 25mg qhs then inc q1-4wk - mildly CNS
Desipramine - least sedating and anticholinergic
2º amine 12-24 disorder, bulimia, chronic to max 300mg/day activating / 2D6 (less
(Norpramin) - first line TCA for elderly
pain - 50-400 3A4)
- least likely to cause
Nortriptyline MDD, dysthymia, anxiety - start 25mg qhs then inc q1-4wk - antidepressant effects is related to
orthostatic
(Pamelor, 2º amine 18-44 disorder, bulimia, chronic to max 150mg/day serum level
hypotension / 2D6
Aventyl) pain - 50-150 - widely used for pain
(less 3A4)
MDD, dysthymia, anxiety - start 75mg qhs for 2wk then inc - higher rate of
Maprotiline - avoid in patients w/ seizure d/o, avoid
tetracyclic 21-25 disorder, bulimia, chronic by 25mg to max 200mg/day seizure, arrhythmia,
(Ludiomil) meds that lower seizure threshold
pain - 50-500 fatality w/ overdose
MDD (esp w/ psychotic
- start 25-50mg qhs then inc q1- - higher rate of
Amoxapine features), dysthymia, - metabolite is the antipsychotic
tetracyclic 8 4wk to max 300mg/day seizure, arrhythmia,
(Asendin) anxiety disorder, bulimia, loxapine and can have related SEs
- 200-400 fatality w/ overdose
chron pain
Receptor profile: see below SE profile: see below

55
 Tertiary amines are more sedating/anticholinergic than secondary amines
Tertiary amines have more SRI activity than NRI activity
Secondary amines have more NRI activity than SRI activity
Tetracyclics have primarily NRI activity

Receptor blockade profile of heterocyclic antidepressants

Drug Reuptake Blockade Receptor Blockade
NE 5-HT Muscarinic Ach H1 H2
imipramine + + ++ + +
desipramine +++ + + - -
trimipramine + + ++ ++ ?
amitriptyline + ++ +++ ++ ++
nortriptyline ++ + + + +
protriptyline +++ + + +++ -
amoxapine ++ + + + ?
doxepin + + ++ +++ +
maprotiline +++ - + + ?
clomipramine + ++ + ? ?

Side-effect profile of heterocyclic antidepressants

Drug Anticholinergic Sedation Orthostatic hypotension Seizure Conduction abnormality
Tertiary Amine
amitriptyline ++++ ++++ +++ +++ ++++
clomipramine ++++ ++++ +++ +++ ++++
doxepin +++ ++++ ++ +++ ++
imipramine +++ +++ ++++ +++ ++++
trimipramine ++++ ++++ +++ +++ +++++
Secondary Amine
desipramine ++ ++ +++ ++ +++
nortriptyline +++ +++ + ++ +++
protriptyline +++ + ++ ++ ++++
Tetracyclics
amoxapine +++ ++ + +++ ++
maprotiline ++ +++ ++ ++++ +++

56
Substance dependence
Name Receptor t1/2 (hrs) Indication Dosing Side-effects Notes
- start after atleast 12- Can cause CV
24hr after last drink; collapse w/ large - causes n/v, headache, hypotension,
Aldehyde
Disulfiram Adversive conditioning for start 500mg qday for alcohol intake; w/o flushing, blurred vision, pain,
dehydrogenase 60-120
(Antabuse) alcohol dependence 1-2wk then alcohol, it can cause tachycardia, dyspnea after alcohol
inhibitor
maintenance dose of fatigue, dermatitis, ingestion and can last upto 30min
125-250mg qday AMS
Lightheadedness, - half-life depends on pt’s tolerance to
- start 15-20mg qday
Detoxification and dizziness, sedation, opioids
Methadone Opioid receptor and titrate up as
8-59 maintenance of opioid constipation, - for maintenance, need special
(Dolophine) agonist needed; max
dependence tolerance, enrollment in methadone
120mg/24hr
dependence maintenance program
Can cause opioid w/d
- start 5-10mg while sx if not abstinent;
- has active metabolite 6-β-naltrexol
assessing for w/d sx independently,
Opioid receptor - often used w/ clonidine and benzos
Naltrexone 4, 13 for Opioid dependence, and then titrate up to naltrexone can cause
antagonist - ensure there is no signs of w/d; can
(ReVia) metabolite alcohol dependence 50mg/day and/or cramps, n/v, elevate
(potent µ) do narcan challenge to ensure
100mg every other transaminases, can
abstinence
day cause hepatotoxicity
w/ high doses
Interact w/
Acamprosate glutamate and - 666mg tid; 333mg tid Diarrhea, n/v, - exact mechanism unknown
20-33 Alcohol dependence
(Campral) GABA if renal impairment insomnia, anxiety - continue even if relapse
neurotransmission
- induction – subutex
- suboxone is combination of
8mg on day 1 then Respiratory and CNS
Partial agonist at buprenorphine and naloxone
Buprenorphine 16mg thereafter depression can occur,
µ and antagonist - induction w/ subutex should occur
(Subutex, 37 Opioid dependence - maintenance – withdrawal and
at κ opioid only under MD supervision
Suboxone) suboxone w/ 2-4mg dependence, possible
receptor - suboxone is sometimes preferred
inc per day w/ target hepatocellular injury
because it contains naloxone
16mg/24hr

57
Cognitive enhancers
In 1996 the International Psycho geriatric Association introduced the term Behavioral and Psychological Signs and Symptoms of Dementia (BPSD). This term is used to label the
wide spectrum of possible behavioral complications that accompany dementia (e.g. depression, psychosis, wandering, ADL refusal, agitation, sexual disinheriting, etc.). It is
absolutely essential to rule out previously unrecognized and untreated medical illness whenever patient who has dementia develops a behavioral problem.
If medical illness is ruled out, then the current strategy to decide which class of psychotropic medication to use for BPSD involves the concept “psycho behavioral metaphor”. The
idea is conduct an evaluation that helps place the problem behavior or behaviors in the context of a recognized psychiatric syndrome e.g. Is the patient’s irritability part of an
episode of a previously unrecognized and untreated depression episode? Is the patient’s irritability secondary to a delusion that family members are stealing from him or her? If
you can “build a case” for depression, then a trial of treatment with an anti-depressant is the best first pharmacological intervention. Keep in mind that both age and dementia will
change the way a person’s depression appears. For example, a dementia patient who has severe language impairment may not be able to say “I have low self-esteem”. If your
evaluation reveals that the irritability is triggered by delusions, then a trial of treatment with an atypical antipsychotic is the best first step. You will learn more about all of this during
your Senior Behavioral Health Inpatient Unit Rotation during your second year.

Name Receptor t1/2 (hrs) Indication Dosing Side-effects Notes

Reversible inhibition - start 5mg qday - least peripheral action in GI
Donepezil Cognitive impairment in Nausea, diarrhea,
of AChE and 70 x4wks then inc to - phenytoin, phenobarbital, carbamazepine,
(Aricept) dementia vomiting
butyrylcholinesterase 10mg qday rifampin can increase metabolism
- start 10mg qid then Elevation in
Reversible inhibition - nonselective; has peripheral action
Tacrine Cognitive impairment in increase by 10mg per transaminases,
of AChE and 2-4 - can cause hepatotoxicity
(Cognex) dementia dose every 6wk up to nausea, diarrhea,
butyrylcholinesterase - follow LFTs
max 160mg/24hr vomiting
Reversible inhibition - start 1.5mg bid, inc
Rivastigmine Cognitive impairment in Nausea, diarrhea, - gets bound to AChesterase and gets
of AChE and 1 by 1.5mg/day/2wk to
(Exelon) dementia vomiting therapeutic activity for 10hr
butyrylcholinesterase max 6mg bid
Reversible inhibition
- start 4mg bid x4wk
Galantamine of AChE and Cognitive impairment in Nausea, diarrhea, - enhances sensitivity of acetylcholine
7 then 8mg bid x4wk to
(Reminyl) butyrylcholinesterase; dementia vomiting, syncope receptor
max 12mg bid
nicotinic agonist
- start 5mg qday and Dizziness, confusion,
Memantine Cognitive impairment in - protects neurons from excessive
NMDA antagonist 60-80 inc 5mg/wk; max headache, HTN,
(Namenda) dementia stimulation by glutamate
20mg/24hr vomiting, nausea
Free radical Cognitive impairment in No common side - protects neurons from free radical
Vitamin E unknown - 1000 IU BID
scavenger dementia effects damage

58
Sympathomimetics and related
Mechanism: methylphenidate block DA reuptake, while amphetamines block DA reuptake and stimulate presynaptic monoamine release.
Name Receptor t1/2 (hrs) Indication Dosing Side-effects Notes
- start 5-10mg bid or tid and
- Ritalin is immediate release w/ SR
titrate to max 20mg qid
version and Concerta is extended
- for SR, start 20mg qday and
release
2-3 (IR), titrate to max 60mg/24hr
Methylphenidate - also weakly inhibit catecholamine
4-6 (SR), - for ER, start 18mg qday and
(Ritalin, Concerta) reuptake and monoamine oxidase
6-8 (ER) titrate up to max 72mg/24hr
- dec metabolism of coumadin,
- narcolepsy – usually
phenytoin
between 20-30mg/ 24hr in
- avoid MAO-I
divided doses of IR
ADHD, narcolepsy, - ADHD – start 2.5mg qday Anxiety, irritability, - narcolepsy dose not established
Indirectly acting
Dexmethylphenidate depressive and titrate to max 60mg/24hr insomnia, - dec metabolism of coumadin,
(α and β 7
(Focalin) disorders in divided doses tachycardia, phenytoin
adrenergic
(specifically in arrhythmias, - avoid MAO-I
agonists) to inc
palliative care or dysphoria, anorexia, - also weakly inhibit catecholamine
dopamine and
treatment - ADHD – start 5-10mg qday dizziness, reuptake and monoamine oxidase
norepinephrine
resistant) then titrate to max 40- dependence - about twice as potent as
Dextroamphetamine
6 60mg/24hr in divided doses methylphenidate
(Dexedrine)
- narcolepsy – usu 5- - dec metabolism of coumadin,
60mg/24hr in divided doses phenytoin
- avoid MAO-I
- ADHD – start 5-10mg qday - also weakly inhibit catecholamine
Amphetamine + to max 40-60mg/24hr in reuptake and monoamine oxidase
3 (IR),
Dextroamphetamine divided doses - dec metabolism of coumadin,
7 (ER)
(Adderall) - narcolepsy – usu 5- phenytoin
60mg/24hr in divided doses - avoid MAO-I
weak inhibitor of Narcolepsy, shift
- start 200mg qday to max Abuse potential, - metabolized by CYP 2C9 and
Modafinil (Provigil) dopamine 15 work sleep d/o,
400mg/24hr headaches, nausea induces 3A4
reuptake daytime sedation
only nonstimulant - start 40 mg qd for 3d, then
Atomoxetine SNRI > 5HT - metab by 2D6, so beware of
5 approved for up to 80mg qd, can divide bid Least abuse potential
(Strattera) (80:1) interaction with 2D6 inhibitors
ADHD - requires 4 wks for effect

59
Miscellaneous
Name Receptor t1/2 (hrs) Indication Dosing Side-effects Notes
- (adult) start 0.1-
reduce sx of opioid, - withdrawal – anxiety, restlessness,
0.2mg bid to qid
alcohol, benzo palpitation, tremor w/i 20hr
Clonidine α2-adrenergic (1.2mg/24hr max)
6-20 withdrawal; treat Sedation, hypotension - overdose – coma, constricted pupil, similar
(Catapres) agonist - (child) start 0.05mg
Tourette’s disorder; to opioid overdose
qday to max 0.3mg in
ADHD - avoid in pts w/ arrhythmias
divided doses
reduce sx of opioid, - withdrawal – anxiety, restlessness,
alcohol, benzo palpitation, tremor w/i 20hr
Guanfacine α2-adrenergic - start 1mg qhs to max Sedation, hypotension
10-30 withdrawal; treat - overdose – coma, constricted pupil, similar
(Tenex) agonist 3mg/24hr (less than clonidine)
Tourette’s disorder; to opioid overdose
ADHD - avoid in pts w/ arrhythmias
anxiety disorders, - start 10-20mg bid or
Propranolol β-adrenergic Hypotension, - contra indicated for asthma, IDDM, AV
3-6 akathisia, postural tid to max 30-140mg
(Inderal) antagonist bradycardia conduction defects, hyperthyroidism
tremor bid
Direct muscle - can cause hepatitis, seizure, pleural
relaxant Treatment for NMS, - usu 1mg/kg po qid or Muscle weakness, n/v, effusion w/ pericarditis w/ long-term use
Dantrolene
beyond 9 catatonia, serotonin 1-5mg/kg IV; up to diarrhea, drowsiness, - do not initiate use until supportive care for
(Dantrium)
myoneural syndrome 10mg/kg/day dizziness pt is started and neuroleptic is removed
junction - do not give w/ CCB
- do ABCs first; should be administered w/
Antagonist at - 0.2-0.5mg IV over
Flumazenil Treatment for benzo Seizure, arrhythmia, rapid response team present
benzodiazepine 54min 30sec until max 3mg
(Romazicon) overdose resedation - there is no added benefit after 3mg
receptors cumulative dose
cumulative dose
Neuropathic pain, pain - start 300mg tid and
syndromes, no evidence titrate up to max Somnolence, fatigue, - not indicated for mood stabilization (many
Gabapentin Related to
5-7 of effectiveness as 3600mg/day ataxia, n/v, dizziness, mistakenly use it in community)
(Neurontin) GABA
single agent or adjunct - no need to check can cause rash - very good agent for treatment of pain
for mania serum levels
- start 25-50mg qhs Fatigue, somnolence,
Migraine headaches,
then inc by 25- dizziness, n/v, anorexia, nd
Inhibits Na bulimia, weight loss, no - not first or 2 line agent; no evidence as
50mg/wk to max rash, psychomotor
Topiramate channels and evidence of single agent use for bipolar d/o
21 400mg/day in divided slowing, can develop
(Topamax) potentiates effectiveness as single - no need to check serum levels
doses metabolic acidosis,
GABA-A agent or adjunct for - if renal impaired, use half doses
- Tegretol and VPA will acute angle glaucoma,
mania
lower level kidney stones

60
 Clinically Relevant Cytochrome p450 Interactions
Substrates
1A2 2B6 2C8 2C19 2C9 2D6 2E1 3A4,5,7
amitriptyline bupropion paclitaxel Proton Pump NSAIDs: Beta Blockers: Anesthetics: Macrolide
caffeine cyclophosphamid torsemide Inhibitors: diclofenac carvedilol enflurane antibiotics:
clomipramine e amodiaquine lansoprazole ibuprofen S-metoprolol halothane clarithromycin
clozapine efavirenz cerivastatin omeprazole meloxicam propafenone isoflurane erythromycin (not
cyclobenzaprine ifosfamide repaglinide pantoprazole S-naproxen=>Nor timolol methoxyflurane 3A5)
estradiol methadone E-3810 piroxicam sevoflurane NOT azithromycin
fluvoxamine suprofen Antidepressants:
haloperidol Anti-epileptics: amitriptyline acetaminophen Anti-arrhythmics:
imipramine N-DeMe diazepam=>Nor Oral Hypoglycemic clomipramine =>NAPQI quinidine=>3-OH
mexiletine phenytoin(O) Agents: desipramine aniline (not 3A5)
naproxen S-mephenytoin tolbutamide imipramine benzene
olanzapine phenobarbitone glipizide paroxetine chlorzoxazone Benzodiazepines
ondansetron ethanol :
phenacetin=> amitriptyline Angiotensin II Antipsychotics: N,N-dimethyl alprazolam
acetaminophen=>NAP carisoprodol Blockers: haloperidol formamide diazepam=>3OH
QI citalopram losartan perphenazine theophylline midazolam
propranolol clomipramine irbesartan risperidone=>9OH =>8-OH triazolam
riluzole cyclophosphamide thioridazine
ropivacaine hexobarbital Sulfonylureas: Immune
tacrine imipramine N-DeME glyburide/ alprenolol Modulators:
theophylline indomethacin glibenclamide amphetamine cyclosporine
verapamil R-mephobarbital glipizide atomoxetine tacrolimus
(R)warfarin moclobemide glimepiride bufuralol (FK506)
zileuton nelfinavir tolbutamide chlorpheniramine
zolmitriptan nilutamide chlorpromazine HIV Antivirals:
primidone amitriptyline codeine (=>O-desMe) indinavir
progesterone celecoxib debrisoquine nelfinavir
proguanil fluoxetine dexfenfluramine ritonavir
propranolol fluvastatin glyburide dextromethorphan saquinavir
teniposide nateglinide encainide
R-warfarin=>8-OH phenytoin=>4-OH flecainide Prokinetic:
rosiglitazone fluoxetine cisapride
tamoxifen fluvoxamine More 3A4,5,7
torsemide lidocaine Miscellaneous: Antihistamines:
S-warfarin metoclopramide alfentanyl astemizole
methoxyamphetamine buspirone chlorpheniramine
mexiletine cafergot terfenidine
nortriptyline caffeine=>TMU
minaprine cocaine Calcium Channel
ondansetron dapsone Blockers:
perhexiline codeine- N- amlodipine
phenacetin demethylation diltiazem
phenformin dextromethorphan felodipine
propranolol eplerenone lercanidipine
quanoxan fentanyl finasteride nifedipine
sparteine gleevec nisoldipine
tamoxifen haloperidol nitrendipine
tramadol irinotecan verapamil
venlafaxine LAAM
lidocaine HMG CoA
methadone Reductase
nateglinide Inhibitors:
odanestron atorvastatin
pimozide cerivastatin
propranolol lovastatin
quinine NOT pravastatin
salmeterol simvastatin
sildenafil Steroid 6beta-
sirolimus OH:
tamoxifen estradiolhydrocorti
taxol sone
terfenadine progesterone
trazodone testosterone
vincristine
zaleplon
zolpidem

from David Flockhart, PhD

61
 Inhibitors
1A2 2B6 2C8 2C19 2C9 2D6 2E1 3A4,5,7
amiodarone thiotepa trimethoprim chloramphenicol amiodarone amiodarone diethyl- HIV Antivirals:
cimetidine ticlopidine quercetin cimetidine fluconazole bupropion dithiocarbamate delaviridine
fluoroquinolones glitazones felbamate fluvastatin celecoxib disulfiram indinavir
fluvoxamine gemfibrozil fluoxetine fluvoxamine chlorpromazine nelfinavir
furafylline fluvoxamine isoniazid chlorpheniramine ritonavir
interferon? indomethacin lovastatin cimetidine saquinavir
methoxsalen ketoconazole paroxetine clomipramine
mibefradil lansoprazole phenylbutazone cocaine amiodarone
ticlopidine modafinil omeprazole probenicid doxorubicin NOT azithromycin
paroxetine sertraline fluoxetine chloramphenicol
probenicid sulfamethoxazole halofantrine cimetidine
ticlopidine sulfaphenazole red-haloperidol ciprofloxacin
topiramate teniposide levomepromazine clarithromycin
trimethoprim metoclopramide diethyl-
zafirlukast methadone dithiocarbamate
mibefradil diltiazem
moclobemide erythromycin
paroxetine fluconazole
quinidine fluvoxamine
ranitidine gestodene
ritonavir grapefruit juice
sertraline itraconazole
terbinafine ketoconazole
mifepristone
histamine H1 receptor nefazodone
antagonists norfloxacin
diphenhydramine norfluoxetine
chlorpheniramine mibefradil
clemastine verapamil
perphenazine
hydroxyzine
tripelennamine

Inducers
In
1A2 2B6 2C8 2C19 2C9 2D6 2E1 3A,4,5,7
broccoli phenobarbital rifampin carbamazepine rifampin dexamethasone ethanol HIV Antivirals:
brussel sprouts rifampin norethindrone secobarbital rifampin isoniazid efavirenz
char-grilled meat NOT pentobarbital nevirapine
insulin prednisone
methyl cholanthrene rifampin barbiturates
modafinil carbamazepine
nafcillin glucocorticoids
beta- naphthoflavone modafinil
omeprazole phenobarbital
tobacco phenytoin
rifampin
St. John's wort
troglitazone
pioglitazone
rifabutin

Genetics
1A2 2B6 2C8 2C19 2C9 2D6 2E1 3A4,5,7

Chromosome 15 Chromosome 19 Chr. 10 Chromosome 10 Chromosome 10 Chromosome 22 Chromosome 10 Chromosome

7

N/A Polymorphic Polymorphic Polymorphic Polymorphic N/A N/A

3-5% Caucasian
3-4% Caucasians 1-3% Caucasian
N/A PMs , 15-20% 5-10% Caucasian PMs N/A N/A
PMs PMs
Asian PMs
For more up to date info go to www.drug-interactions.com

62
Psychotropic medications & smoking
Metabolism of many drugs is affected by tobacco
smoke. In most cases it is the tobacco smoke itself
(not the nicotine) that causes these drug interactions.
Substances in tobacco smoke induce the cytochrome
P450 system, primarily CYP 1A2. These drug
interactions most commonly become an issue on our
unit because NBMU is smoke-free, so patients stop
smoking when they come into the hospital and this
may need to be accounted for when adjusting their
medication dosages.

Most frequently encountered drug interactions:

 Thorazine: decrease dose by 25% if patient
stops smoking
 Clozaril: may or may not need to decrease
dose (check with attending and pharmacist)
 Haldol: decrease dose by 50% if patient
stops smoking
 Zyprexa: decrease dose by 50% if patient
stops smoking
 Propranolol: decrease dose by 50% if patient
stops smoking

Nicotine replacement orders

 If patient smokes < ½ pack per day
Nicotine transdermal patch 7mg q24h
 If patient smokes ½ to 1 pack per day 
Nicotine transdermal patch 14mg q 24h
 If patient smokes 1-2 packs per day 
Nicotine transdermal patch 21mg q24h
 Plus - Nicotine lozenges 2mg q2h prn
nicotine withdrawal (in addition to any
strength patch

63
Neurological SEs of antipsychotic medications
- Acute dystonia - spasm of musc of tongue, face,
neck, back
o time to develop – 1-5d; young and neuroleptic
naïve at risk
o mechanism – acute dopamine antagonism
o txt – antiparkinsonian agents
- Akathisia - Sub/obj restlessness
o time to develop – 5-60d
o mechanism – unknown
o txt – reduce dose or change med; clonazepam
and propranolol > antiparkinsonian agents
- Parkinsonism - Bradykinesia, rigidity, variable
tremor, mask facies, shuffling gait
o time to develop – 5-30d; elderly at risk
o mechanism – dopamine antagonism
o txt – reduce dose or change med;
antiparkinsonian agents
- NMS - Extreme rigidity, fever, unstable VS,
myoglobinemia, can be fatal
o time to develop – wks-months; can persist for
days even after d/c med
o mechanism – dopamine antagonism
o txt – stop antipsychotic agent; supportive care;
dantrolene and bromocriptine
- Perioral tremor - Perioral tremor (maybe late variant
of parkinsonism)
o time to develop – after months or years of txt
o mechanism – unknown
o txt – antiparkinsonian agents
- Tardive dyskinesia - Orofacial dyskinesia; rarely
widespread choreoathetosis or dystonia
o time to develop – after months or years of txt;
elderly at x5 risk; risk proportional to D2
blockade potency
o mechanism – postsynaptic D receptor
supersensitivity, upregulation
o txt – prevention crucial; txt unsatisfactory;
maybe reversible w/ early recognition and drug
discontinuation

64
Drug-drug interactions

It is a good idea to check the list of side effects with

new meds you are starting and make sure that the
pt isn’t already on a med with that side effect. I.e.
it isn't rec to use 2 meds with sedation as a side
effect unless sedation is the goal. …it isn’t a good
idea to use 2 meds with constipation as a side
effect…

Mood stabilizers
 Li level decreased by: Hypernatremia,
Theophylline, Psyllium, Acetazolamide.
 Li level increased by: iodine, thiazide diuretics,
ACE inhibitors and Ca channel blockers,
and 50% increase with NSAIDS
 Tegretol induces 3A4 and decreases drug levels
of many agents
(can produce oral contraceptive failures and
failure of protease inhibitors in HIV pts)
 Tegretol levels increased by erythromycin, Ca
channel blockers, Isoniazid, grapefruit juice.
 VPA increases level of 10,11 epoxide metabolite
of Tegretol
 Don't give Tegretol with other bone marrow
suppressants
 VPA increases coumadin and aspirin effects
 VPA increased lamotrigine (therefore, only
requires ½ dose of lamotrigine)

Grapefruit juice inhibits 3A4 and causes increases in

the following psych meds: buspirone, carbamazepine,
fluoxetine, fluvoxamine, midazolam, sertraline,
triazolam

65
Drug interactions with MAOIs
 Amphetamines, appetite suppressants, stimulants
 Decongestants, Epinephrine/ ephedrine
 Asthma drugs esp bronchodilator inhalers
 Ginseng, tryptophans, tyramine
 Anesthetics (general & local), Opioids (meperidine)
 Serotonergic agents including tryptophan, SSRIs,
TCAs, SGAs, and Triptans (5HT1D agonists)
 Tegretol, Buspirone, Dopa & dopamine
 Antihypertensives,
 Flexeril, Antabuse
 Insulin, Sulfonylureas
 Isoniazid and linezolid are each an MAOI and
therefore should also be watched for potential HTN
crisis and serotonergic syndrome

Relative Contraindications For Psych Medications

(use with caution)

Glaucoma (narrow angle)

Any drug that is anticholinergic, such as TCAs, low
potency
phenothiazines, topiramate, clozapine, olanzapine
Cardiac conduction abnormalities
TCAs, thioridazine, mesoridazine, pimozide,
droperidol prolong QTc and other intervals, and
give nonspecific ST changes tachycardias and
blocks of all varieties.
Tegretol is contraindicated in bundle branch
blocks.
Decreasing seizure threshold
Clozapine increases risk above 600 mg/d and
Wellbutrin: predisposing factors include-
preexisting seizure disorder, abnormal EEG
without evidence of seizure disorder, preexisting
CNS pathology, rapid increase in dose.

66
Medications for Pregnant Patients
Some basic points:
1. Pregnancy is NOT protective against mental
illness: women with preexisting mental illness
have high relapse rates if off meds during
pregnancy, and pregnancy and the postpartum
period are vulnerable times for new onset of
illness, especially MDD and bipolar disorder.
2. The goal of treatment of maternal mental illness
is to minimize fetal/infant exposure to BOTH
medications and maternal illness—both have the
potential to harm a fetus/infant.
3. Pregnancy is not the time for experimentation: if
a woman has a complex history of mental illness,
with few exceptions she should be maintained on
her current medication regimen, unless there is
an overwhelming need/reason to change
medications or doses.
4. The exposure of infant to medication in breast
milk is orders of magnitude lower than in utero,
so (except for lithium), do not change medication
from pregnancy to postpartum to avoid breast
milk exposure

Basic embryology: major organ formation is weeks 5-

10 after LMP, so if medication exposure has already
happened by the end of this period, the damage is or
(more likely) isn’t done. If starting after week 10, the
fetus is basically formed, so cannot create major
malformations at this time. Neural tube closure is by
5 weeks. Neurobehavioral toxicity is major concern
from 12 weeks on.

Depression:
68% of women with MDD who stop their meds will
relapse during pregnancy.

67
(Depression cont.)
SSRI’s and TCA’s: no pattern of congenital
malformations or neurobehavioral toxicity found in
multiple studies
- possible incr risk of persistent pulmonary
hypertension of the newborn (risk increases from
1/1000 to 6/1000 with third trimester use). Still
controversial.
- Paroxetine: FDA class D, but prospective studies
negative for ASD/VSD incr risk, so if a woman is
stable on it, safest thing is to continue.
- Clearance of SSRI’s incr with later pregnancy,
one study with 2/3 women needing incr dose (avg
at 27wks) to maintain euthymia.
Venlafaxine, bupropion: no major malformations with
limited data
Duloxetine: no malformations in animals, but no
human data

Anxiety/Insomnia:
Benzodiazepines: no major risk congenital
malformations, include cleft lip/palate
- consistent use at high doses to time of birth can
lead to neonatal resp depression and “floppy
baby” but resolves with metabolism
- Good option for insomnia in pregnancy: 0.5-1mg
(or more) lorazepam qhs
- be careful with breastfeeding: small amts get into
breast milk and can cause neonatal sedation and
resp depression
- preferred lorazepam or clonazepam over
diazepam (very long t1/2) and alprazolam (rapid
onset/offset action)
Benadryl: class B, effective for many women with
insomnia who are psychotropic-naïve, can cause mild
neonatal sedation with breastfeeding

68
Bipolar disorder:
Rapid tapering of mood stabilizers (<2 weeks) leads
to higher rate relapse. If women are off mood
stabilizers and do not relapse during pregnancy,
nearly 100% will relapse in the first few mos
postpartum. If pt stable off meds during pregnancy,
consider restarting immediately PP to decr risk of
relapse.
VPA: 5-9% risk neural tube defects, 8.9% risk major
anomalies, also with learning disabilities,
developmental delays/retardation, neonatal
hepatotoxicity. This is the only medication that
absolutely SHOULD NOT be used in pregnancy.
Lithium: risk Ebstein’s anomaly 1/1000, much lower
than prev thought (downward displacement of
tricuspid valve), can cause maternal hypothyroid, rare
DI, rare fetal goiter. Lithium should be dosed bid-tid
to avoid high peak levels, and will need incr dose
nd rd
during late 2 and 3 trimesters 2/2 incr GFR.
Neonatal toxicity common, with “floppy baby” and
resp depression lasting until lithium metabolized by
neonate. This can be avoided by holding lithium at
onset of active labor or 24hrs prior to scheduled
induction or C/S. Mother needs IVF to prevent
dehydration and toxicity during labor. Needs to be
restarted immediately PP. Relatively high passage
into breastmilk, with possible infant toxicity, so not
recommended for breastfeeding.
CBZ: 1% neural tube defects, 3x increase in
cardiac/craniofacial anomalies (3%), 20%
developmental delay. Mother needs vitamin K 10-
20mg PO qd for 4-6 weeks before delivery 2/2 poss
neonatal coagulopathy or thrombocytopenia from liver
toxicity.
Lamotrigine: no incr major congenital malformations,
except for possible incr cleft palate (0.37/1000 incr to
nd
8.9/1000 in one study). Will need incr dose in late 2

69
 rd
and 3 trimesters 2/2 incr GFR. Restart lower dose
immediately post partum

Breast feeding:
- VPA and CBZ safest in breastfeeding,
increasingly favorable data on lamotrigine, not
recommended with lithium.
- Antidepressants: Sertraline and Paroxetine have
the lowest penetrance into breastmilk, and should
be started preferentially in treatment-naive
patients requiring an antidepressant. However, if
a patient has failed these medications, please
consult the lactmed database for information on
all other meds: http://toxnet.nlm.nih.gov/cgi-
bin/sis/htmlgen?LACT (or google Lactmed)
- Antipsychotics: Haloperidol generally considered
lowest risk, but all antipsychotics penetrate
breastmilk (except for quetiapine<100mg). See
LactMed database for data on individual meds.

Psychosis:
Postpartum psychosis 0.1% of women (rare), mostly
in women with undiagnosed bipolar disorder. Often
responds well to low-dose antipsychotics; consider
mood stabilizer based on history.
Schizophrenia: high fertility rate with incr risk LBW,
poor neonatal outcome and SIDS regardless of
medication.
FG antipsychotics: higher-potency are safest, limited
data but no long-term sequelae found, haldol most
frequently used.
SG antipsychotics: Quetiapine with lowest placental
passage, limited data on all of them with no human
data on ziprasidone or aripiprazole.
Few cases of BF with atypicals; quetiapine with no
penetrance into breast milk <100mg/dose

70
Few cases of BF with atypicals; QUETIAPINE WITH
NO PENETRANCE INTO BREASTMILK
<100MG/DOSE.

UCSD Maternal Mental Health Clinic: at Gifford, sees

all patients regardless of insurance status, usually
within 1-2 weeks. PAGE KATIE HIRST (4982) for
urgent referrals (daytime please), otherwise call 619-
543-6250 for less urgent to schedule at Gifford

Psychotherapy

Important modality of treatment with increasing

evidence in therapeutic uses with and without
medications.

There are 2 kinds of therapy documented to be

helpful in depression and anxiety: CBT and IPT.
CBT stands for Cognitive Behavior Therapy; it
focuses on your thoughts and behaviors and how they
interact with you mood. If you are not doing
homework outside of therapy you are not doing CBT.
The more you practice the skills from therapy the
faster you will get better. IPT stands for Interpersonal
Psychotherapy; it focuses on your relationships and
the interaction with your mood.
Many people benefit from books that they can read &
work through with or without their therapist:
“10 Days to Self Esteem” by David Burns or “Mind
over Mood” by Greenberger & Padesky.

For borderline personality disorder:

Transference-focused psychotherapy – aims to
correct distortions in patient’s perceptions; emphasis
on txt contract between client and therapist; patient is
engaged as a collaborator; borderline personality

71
structure is analyzed as it unfolds in relation with the
therapist as perceived by the patient.
Dialectical-behavior therapy – directly targets suicidal
and other self injurious or destabilizing behaviors;
increases behavioral capabilities as problems come
up in day-to-day life; focuses on functional behavior

Alternative treatment modalities

ECT and Vagal Nerve Stimulation (FDA approved as

adjunctive tx for chronic or recurrent treatment
resistant depression) are also good treatments for
depression. Additionally, transcranial magnetic
stimulators are being studied for vascular depression.

Herbs/ Food supplements

 St. John’s Wort, an herb that is currently not well
standardized, does contain some SSRI properties,
especially at very high doses. For this reason it is
important to ask all pts about all substances they
ingest, including teas. We have seen a case of
serotonergic syndrome in a UCSD ER because
someone was taking St. John’s Wort and Prozac.
St John’s Wort also decreases serum levels of
Indinavir, Cyclosporin, oral contraceptives and
alprazolam by 3A4 induction and increased
metabolism of these drugs.
 Ginseng/tyramine, & tryptophan all interact with
MAOIs and some with SSRIs.
 Many of the above & other herbs like yohimbine
and Ma Haung can lead to anxiety symptoms, even
panic attacks.
 Other herbs are anxiolytic like Kava, a South Pacific
drug that greatly potentiates benzos.

72
 PATIENT
MANAGEMENT
ISSUES

73
 PATIENT MANAGEMENT ISSUES
ER Patients
 First Look: Safety!
1) Always make sure the patient is gowned and
has been searched for weapons.
2) Always make sure an exit is readily
available. Keep the door open if the patient
is agitated.
3) Never try to be the hero – when in ANY
doubt, request help.
 Leave the room calmly:
- if you feel uncomfortable
- if the pt makes any threat (verbal or
physical)
- if the pt does not do as told, e.g. “please
sit down”
 Call for back-up – UCSD security or VA
police (even if you just want them to stand
there while you interview the pt.).
 Second Look: Dx & Dispo! Agitated pts are
often one of these:
- Psychotic
- Intoxicated
- Delirious
- Manic
- Suicidal
 If you are seeing an agitated patient and
medicating him/her, he/she will likely need
admission.

Intoxicated pts
Request an alcohol level (breathalyzer or blood is
used at the VA or breathalyzer at the U) and urine
tox (blood and breath concentrations of EtOH
correlate more closely than urine concentrations
with CNS impairment).

74
See the pt as soon as possible, within 15-20 minutes,
but realize you can’t really assess someone until
the breathalyzer is <0.08 (80) (the legal limit in CA)
or half of what it was when the patient came into
the ER, whichever happens first.
Intoxication in and of itself is not an appropriate
reason for admission but it will often be the safest
option to admit the pt when they complain of
depression + SI. Remember: an intoxicated male
with no social contacts is at high risk for
completed suicide.
If the UCC/ER is pressuring you to dispo the pt, ask
the ER doc to start a “banana bag” (1 liter NS
mixed with MVI 10mL, thiamine 100mg, folic acid
1mg, IV, over 2 hours) which will buy the pt time to
sober up and you time to get a better evaluation.
This option also should be considered if waiting for
labs to come back and if there is question of
disposition.

Alcohol Withdrawal/Detox
We frequently must detox patients who are
withdrawing from ETOH. A patient can die if this is
not done properly.
a. Acute Alcohol Withdrawal: a syndrome occurring
in alcohol dependent patients following the
cessation or reduction of regular, high dose
alcohol ingestion. This syndrome starts usually
within 6-24 hours after cessation or reduction in
alcohol consumption.
b. Withdrawal Symptoms such as, tremors, nausea
and vomiting, anxiety, mild agitation, tachycardia,
hypertension, insomnia, and diaphoresis may
occur. These symptoms usually peak between
24-36 hours and resolve within a few days. Milder
more protracted withdrawal symptoms can last

75
 days to weeks. Hallucinations occur in 3-10% of
patients.
c. Convulsions, usually 1 or 2 grand mal seizures,
occur in less than 5% of patients in acute
withdrawal and typically occur within 24-48 hours.
The risk of withdrawal complications e.g.
seizures, increases with the duration of alcohol
dependence and the number of previous
withdrawal episodes. Patients with a history of
withdrawal seizures are at greatest risk.
Concurrent medical conditions can complicate the
withdrawal process and medications can mask
withdrawal signs. The onset of withdrawal can be
postponed by the actions of various anesthetics,
narcotics and benzodiazepines used in medical
and operative procedures.
d. Delirium Tremens: a syndrome characterized by
disorientation, confusion, and autonomic
hyperactivity that occur in less than 5% of patients
undergoing alcohol withdrawal. The onset is
usually within 2-5 days after cessation of alcohol
and can last several days. The overall death rate
is as high as 10% from cardiovascular, metabolic
or infectious complications in untreated patients.

On the inpatient unit, for those having alcohol

withdrawal, remember to give multi-vitamin po qday,
thiamine 100 mg po qday
(consider IM thiamine for 3 days first), and folate 1
mg po qday. (Give thiamine before pt eats because
of risk of Wernicke's encephalopathy).

The VA and UCSD are moving toward symptom

triggered therapy using rating scales like CIWA (at
UCSD) or MINDS (at VA). Symptom-triggered therapy
prescribes medication based on symptoms present,

76
and the patient’s response to medication. An
assessment tool such as the MINDS can help guide
therapy. This method reduces the risk of over and
under-medication, and for most patients enables
individualized treatment. Studies have shown that this
form of treatment requires less treatment and has a
decreased length of stay.

The VA will begin to use a standardized order set for

either Valium or Ativan, which will be used across all
services (medicine/psychiatry/surgery).

Outpatient detox
For patients who can be detoxed as outpatients, give
a 24h supply of the benzo taper, and have them come
back daily for the next day’s doses. Keep this up until
the taper is complete, doing a breathalyzer each day.
Patients will be instructed to come on the weekends
for daily detox appointments. PATIENTS MUST BE
SEEN FACE TO FACE by the weekend resident
before meds are ordered.

Because of VA’s inpatient detox protocol, The

preferred medications for VA Outpatient detox are
either Valium or Ativan (rationale: if the patient needs
to be admitted inpatient later on, Ativan or valium can
be easily converted to IV dosing).

For Valium, (if they are appropriate candidates based

on age less than 60yo, no cirrhosis/severe liver
inflammation, no severe COPD)
VALIUM SAMPLE DOSING:
Day 1: 10 mg PO Q6H x 4 doses
Day 2: 10 mg PO Q8H x 3 doses
Day 3: 10 mg PO Q12H x 2 doses
Day 4: 10 mg PO once

77
For Ativan: select this if they have cirrhosis or severe
liver inflammation, or are older than 60.
(Because Ativan half life is not as long as Valium,
Dosing should not be more than Q8H)
ATIVAN SAMPLE DOSING:
Day 1: 2 mg PO Q6H x 4 doses
Day 2: 2 mg PO Q8H x 3 doses
Day 3: 1 mg PO Q6H x 4 doses
Day 4: 1 mg PO Q8H x 3 doses
Day 5: 0.5 mg PO Q6H x 4 doses
Day 6: 0.5 mg PO Q8H x 3 doses

LIBRIUM TAPER: Librium can still be used when the

patient has a history of responding well to Librium,
with known previous dosing.
LIBRIUM 50 mg po q4° x 24hours**
50 mg po q6° x 24hours
50 mg po q8° x 24hours
25 mg po q6° x 24hours
25 mg po q12°, x 24 hours
25mg x1d then DC

**Only give 50 mg q4h as an inpatient. If pt needs

more than 50 mg q6h, you should admit pt for
detox. As rule of thumb, if pt is not reliable, we do
not give more than 200mg Librium to take home.
If patient has evidence of cirrhosis, then give
lorazepam instead, 1mg of lorazepam = 25mg
Librium = 5 mg Valium.

If a detox patient tests positive on his/her breathalyzer

test during a f/u appointment after being given benzos
the day before, then pt cannot be detoxed further at
the VA, as an outpt. Instead, you would have the
patient call VOA (Volunteers of America) for a bed,
and discharge the veteran with a SEALED bag of the
full benzo taper. The taper will then be administered
to them by the VOA staff.
78
SPECIAL NOTE ABOUT VOA: They won’t take
anyone on Valium. So in this case, use only
Librium. If patient has liver disease or other
contraindication for Librium, you can prescribe
Ativan BUT MUST INCLUDE a doctor’s note
explaining why (for example, “pt with liver
disease, cannot be on Librium”.
If the patient is unwilling to go to VOA, or no beds are
available there, then they should be asked to return
when they have gotten a bed at VOA for themselves,
at which point the sealed bag containing the taper will
be given to them.

MINDS (Score greater than 10 indicates further

treatment is necessary)

Pulse
0 <90
1 90-110
2 >110

BP (Diastolic)
0 < 90
1 90-110
2 >110

Sweating
0 No sweat visible
2 Barely perceptible, moist palms
4 Beads of sweat visible
6 Drenching sweats

Hallucination (auditory vs tac)

0 None
2 Mild
4 Moderate or intermittent
6 Severe, Continuous

Agitation
0 Normal activity
2 Somewhat more than normal activity
4 Moderately fidgety and restless
6 Pacing, or thrashing about continuously

79
Delusions
0 Absent
4 Present

Tremor
0 None
2 Not visible, can be felt fingertip to fingertip
4 Moderate w/arms extended
6 Sever even w/arm not extended

Seizures
0 None since last rating
6 Have occurred since last rating or at all if first rating

Orientation
0 Oriented to time, place, person
2 Oriented only to place and person
4 Totally disoriented

Opiate Detox
Symptoms: chills, diarrhea, piloerection, big pupils
when withdrawing, bone pain, runny nose, pain.
“Everything runs.”
Record vitals.
Meds:
 Imodium 4mg 1-2 tabs q1 hr prn diarrhea, NTE
16 mg/day
 Bentyl 10 mg qid prn abdominal cramping. Used
infrequently.
 Motrin 600 mg q6hr prn bone pain
 Compazine (prochlorperazine) 10mg qid prn n/v.
Give by any route available. May use Phenergan
(promethazine) also 25 mg q8h.
 Benadryl 25-50 mg q6hr prn nasal congestion,
insomnia, or anxiety.
 Clonidine: start at 0.1 mg bid for bone pain and
autonomic arousal, may increase but watch for
hypotension. Often used as 0.1 bid to 0.3 bid
must be observing pt daily and check vitals.

80
  Valium: for muscle spasms and insomnia, one
night at a time; use your discretion (is pt drug-
seeking?), usually 10-15 mg hs.

Drug Screening Tests: EtOH detected more

accurately in blood and breath than in urine. Blood and
breath are usually close to the same value but urine is
higher because it concentrates there (unless they just
started drinking EtOH, then it wont be higher in the
urine).
Drug Duration May cause false
Detectable positive
Amphetamines Chronic user: Ephedrine, Vicks,
7 days. pseudoephedrine,
Infrequent user: chlorpromazine,
2-3 days. trazodone,
bupropion,
desipramine,
amantadine,
ranitidine.
Cocaine Chronic user: 7-8 Topical anesthetic
metabolites days containing
Infrequent user: cocaine.
2-3 days
Marijuana metab. Chronic user: 20- Ibuprofen,
30 days naproxen,
Light user: 1-7 dronabinol, hemp
days seed oil. Not from
passive inhalation.
Opiate metab. 1-3 days (3-15d Rifampin,
for chronic fluoroquinolone,
methadone use) poppy seeds,
quinine in tonic
water.
Phencyclidine 7-14 days Ketamine,
dextromethorphan
Benzos Short: 3days Oxaprozin
Long:
2-4wks
Report the results of the UTOX early in your HPI.
81
Manic/psychotic patients
Basically, use scheduled & prn antipsychotics.
May also need benzodiazepines.
In the ER or when putting someone in restraints on
the unit, use one of the following IM’s:
- Zyprexa 5-10 mg
- Haldol 5mg
- Geodon 20mg (note: this IM takes longer to
prepare for administration than the other IM’s)
- Abilify IM 9.75 mg (at UCSD)
- Also, can add Benadryl 50mg and/or Ativan 2mg.
The Benadryl is used to prevent EPS and also to help
sedate. If the patient is extremely agitated and/or
very large, then Droperidol is more effective than
Haldol. Give IM in emergency situation when no IV is
available and pt refuses PO meds. Note: DO NOT
GIVE droperidol or Geodon to recent MI patients
because they can prolong the QT interval, cause
electrolyte disturbances.

Suicide Assessment

A Suicide Assessment is when a clinician evaluates a

patient’s imminent risk of suicide in order to direct the
patient to an appropriate level of care. The clinician
notes this assessment in the chart. The clinician
assesses suicide risk when initiating care with a
patient, when patients are in crisis, and when starting
or stopping medications. The assessment includes
information about the patient’s Risk Factors versus
Protective Factors and Warning Signs versus Signs of
Hope. The clinician notes the level of risk (nil, low,
moderate, and high) as it relates to the patient’s
history, and makes (and notes) the appropriate
interventions.

82
Risk Factors are objective patient characteristics that
have been shown in published studies to be
associated with a risk of suicide in long-term follow-
up. Though they are objective, they are less helpful in
predicting imminent risk. Non-modifiable risk factors
might raise or lower concern, but do not, alone,
suggest that a patient needs hospitalization. Non-
modifiable risk factors include a history of previous
suicide attempts/self harm, previous psychiatric
hospitalizations (especially with recent discharge),
family history, history of trauma, or recent divorce.
The presence of modifiable risk factors suggests
avenues for treatment. Examples of modifiable risk
factors include the Axis I disorders (e.g. treat the
depression and suicide risk goes down), poor social
support, easy access to lethal means (e.g. owning a
gun), and intoxication.

Suicide Risk Assessment - SAD PERSONS Scale

Score a 0 or 1 on each of the following factors:
S - Sex of the patient - Males commit suicide more
frequently than females. (Males score a 1)
A - Age- (Anyone under 19 or over 45 scores a 1)
D - Depression- Severe clinical Depression with
hopelessness and helplessness.
P - Previous Attempt(s)
E - Ethanol Abuse or Dependence, currently using
R - Rational Thinking Loss- Psychoses, brain injuries,
Bipolar Affective disorders, cognitive impairment.
S - Social Supports Lacking- (No family, community or
other relationships available scores a 1)
O - Organized Plan- (Detailed plan as to how, when,
where, etc., Score 1) Access to a firearm (score 1)
N - No Spouse- single, divorced, widowed, separated
or marital difficulties. (Score 1 if any are true)
S - Sickness- presence of chronic debilitating illness
(Cancer, Chronic Pain, Stroke, etc.)
Total Score:
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No Risk (0-2) Low Risk (3-4)
Moderate Risk (5-6) High Risk (7-10)

Protective Factors are objective patient characteristics

that lower suicide risk, such as social support,
relationships with friends or family, cultural or religious
beliefs that discourage suicide, restricted access to
lethal means, access to ongoing, effective clinical
care, and pregnancy.

SUICIDE PROTECTIVE FACTORS

1. Social/Family Support
2. Religiosity/Cultural Beliefs
3. Positive Life satisfaction
4. Children in the home/responsibility to family
5. Intact Reality testing
6. Coping skills/Problem Solving Skills (Strong)
7. Planning for the Future
8. Established positive therapeutic alliance
9. If female, is pregnant
10. If has suicidal ideation, it is contingent
Total Protective factors:

Warning Signs are subjective, observable signs and

symptoms that raise the clinician’s concern about
imminent suicide. Anything that gives the clinician a
sense of concern about a patient’s imminent self-
harm can be a warning sign. Examples include
frequent persistent thoughts of suicide, plans to
attempt suicide, recent increase in drug/alcohol use,
new recklessness, feeling trapped, withdrawal from
friends and family, a lack of reason to live, dramatic
mood shifts, and inability to sleep/sleeping all the
time.

Signs of Hope are subjective patient characteristics

that suggest to the clinician that the patient is not an
imminent threat to her own safety. Examples include
the patient seeking appropriate emergency services,
84
compliance with medications/appointments, plans for
the future, active social engagement with
friends/family or the clinician, and abstaining from
alcohol or drugs.

Address discrepancies, as in the patient who displays

warning signs but denies that she will attempt suicide.
One way to clarify: “I’m not sure I understand. You
have been researching ways to kill yourself and you
also said you don’t want to harm yourself. How do
those things fit together?”
Call someone who knows the patient well (and ideally
has seen them recently), and note the content of the
conversation in the chart.

Suicide Prevention
Limit access to lethal means. Does the patient have a
gun at home? What medications (fatal in overdose)
are in their possession? Ask that they be removed.
Increase clinical/social resources. Treat Axis I
disorders, attempt to house patients, etc.
Create a safety plan with the patient. Safety contracts
have no evidence that they are effective. Instead,
create a written, easily accessible plan for any crisis.
–Note when the plan should be used: “What
warning signs do you have that you are in crisis?”
(e.g. using substances, feeling trapped, withdrawing
from others)
–Ask the patient to name activities they use
to manage their suffering, and specifically note these
soothing activities, such as exercise, watching TV, or
prayer.
–Sometimes activities aren’t enough. List
names & numbers of supportive people.
–For the situation when none of the above
strategies work, list a suicide hotline, the appropriate

85
health provider’s phone number, specific emergency
dept., and 911.
–Rehearse the plan. “Where are you going
to keep this plan?” “How likely are you to use this plan
in crisis? Why?”
Educate friends or family members, giving concrete
examples of warning signs and familiarizing them with
the Safety Plan and how to respond during a crisis.

Example Documentation
“Assessment: 54 y.o. homeless man with alcohol
dependence and depression NOS. The patient has a low-
moderate level of risk of suicide. His risk factors include
homelessness, a history of suicide attempts of low to
moderate severity, and alcohol dependence, and his warning
sign is that he is thinking about suicide. However, he does
not have a clear plan or access to a gun. With his written
permission, I called his sister, and she says that he has
expressed suicidality in the past many times without making
a suicide attempt. He shows signs of hope about getting a
place to live, has plans to get SSI, and demonstrates an
ability to access care by bringing himself to the Emergency
Department today. He was smiling and joking with me during
the interview. I will try to get him a bed at a crisis house, and
if that does not happen, provide information about shelters in
the area. I have also provided him with resources on getting
sober and given him the San Diego crisis line so that he can
obtain follow up services. Finally, we made a safety plan
together.” Include a copy of the safety plan in the chart.

Sources and Resources

•Essential Reading: Rudd MD. Suicide warning signs in
clinical practice. Curr Psychiatry Rep. 2008 Feb;10(1):87-90.
•Bostwick JM, Pankratz VS. Affective disorders and suicide
risk: a reexamination. Am J Psychiatry. 2000
Dec;157(12):1925-32.
•Gunnell D, Saperia J, Ashby D. SSRIs and suicide in
adults: meta-analysis. BMJ. 2005 Feb 19;330(7488):385.
•Kroll J. Use of no-suicide contracts by psychiatrists in
Minnesota. Am J Psychiatry. 2000;157:1684-1686.

86
•Nock MK, Borges G, Bromet EJ, Cha CB, Kessler RC, Lee
S. Suicide and suicidal behavior. Epidemiol Rev.
2008;30:133-54.
•American Association of Suicidology: www.suicidology.org
•Suicide Prevention Resource Center: www.sprc.org

Antipsychotic Side Effects:

These are frequently seen in the ER.
All antipsychotics have side effects. The major types
of side effects of the first generation antipsychotics
(FGAs) are
- extrapyramidal (EPS, i.e. motor)
- anticholinergic (and histaminic)

EPS refers to motor-movement problems resulting

from antipsychotics use. It is useful to remember
them in the time frame that they usually present:

Minutes to hours: Dystonia

Days to weeks: Akathisia (severe restlessness)
Weeks to months: Parkinsonism
Months to years: Tardive Dyskinesia (TD)
“Rabbitism” has also been described as separate
from the above. It is rabbit-like mouth movement
separate from TD.

- Neuroleptic Malignant Syndrome: muscle

rigidity, fever, autonomic instability and cognitive
changes such as delirium; has an elevated CPK
- Anticholinergic side effects include: dry mouth,
urinary retention, constipation, blurred vision,
orthostatic hypotension, & delirium (esp in the
elderly).
Blind as a bat (blurred vision)
Dry as a bone (dry mouth = xerostomia)
Red as a beet (flushing)
Mad as a hatter (delirium)
Full of feces (constipation)
87
 If pt becomes delirious remember that
delirium is a medical emergency which
needs to be treated on medical floor.

Treating EPS:
- Dystonias, tongue swelling, jaw locking, oculogyric
crisis etc. Risk increases with young age male
gender and high potency neuroleptics. This is an
emergency: use Cogentin 2mg or Benadryl 50mg IM.
Meds must be IM or IV. PO takes too long to be
effective & this is an emergency.
- Akathisia (severe restlessness): propranolol 20mg
PO tid unless they also have Parkinsonism. Then
use Cogentin 2-6 mg/d first and add propranolol 10-
30mg PO tid if Cogentin alone ineffective. May
require high potency benzos.
- Parkinsonism (shuffling gait, cogwheeling,
bradykinesia, masked facies): decrease dose of
neuroleptic or Cogentin 1-2mg PO. Must be bid if
really for EPS because drug is very short acting.
May also use Benadryl 25-50mg.
- EPS gets worse with increased dose of neuroleptic.
- TD (late onset stereotyped movements, usually
mouth or face such as lip-smacking):
o 15-20% of patients get TD
o Risk factors: female, smokers, African
American (non-Caucasian), age > 50
y.o., mood d.o., increased dose,
increased duration, brain injury.
o DC meds: 1/3 get better, 1/3 no
change, 1/3 get worse.
o TD worsens with anticholinergics or
removal of antipsychotic.
o TD improves with increased dose of
neuroleptic, at first. Need to switch to
new class of antipsychotics.
o Vit E as tx for TD was used by some.
o There is no reliable tx.

88
Neuroleptic Malignant Syndrome
Can be fatal (causes rhabdomyolisis, which may lead
to renal failure)
Sx: delirious, increased vitals (temp, HR),
rigid/tremor, increased CPK
- Tx: IVF, cooling blanket, Dantrolene.
Always on a medicine service, not psych.
- Difficult to treat.

Catatonia: give 2mg Ativan IM/IV and wait 30 mins.

SSRI withdrawal: Dizziness, lethargy, paresthesias,

nausea, vivid dreams, irritability, depression. Give
SSRI.

Serotonin syndrome
Risk with MAOIs, TCAs, SSRIs, & other serotonin
antidepressants.
Mental status change, confusion, hypomania,
restlessness, myoclonus, hyperreflexia,
diaphoresis, shivering, tremor, diarrhea,
incoordination.
Potentially fatal but much less often than HTN crisis,
although serotonin syndrome more common than
HTN crisis.
Medicine service will treat symptomatically.

HTN crises
Risk with MAOIs and symphathomimetics or other drugs or
food contraindicated with MAOIs. See HTN section.
Because this is life threatening, call a Medicine consult.
Potentially fatal from intracranial hemorrhage, cardiac
arrhythmia, or cardiac arrest.
Sxs: Increased BP, palpitations, headache.
Medicine service will treat this condition aggressively.

Lifestyle Pointers for Depression and Anxiety

89
Sleep: 7-9 hours, no naps, wake up at the same time every
day. See instructions for insomnia for more info.
Eat: small amounts of good food often, more fruits &
vegetables, less fat.
Exercise: Stretching and warming up and cooling down are
important. Current recommendations include 30 minutes per
day, four times per week, at 60-80% of your maximum heart
rate (cardiovascular/aerobic exercise). Exercise has been
shown to help depression in clinical studies.
Strength can be worked on in several ways including free
weights or exercise machines and therapeutic rubber bands.
Light: Exposure to light has been studied in people & the
benefits are remarkable. Living in a sunny climate alone is
not enough. To benefit from natural light you must actively
expose yourself to it. For depression, morning light, as soon
as possible after awakening is best. From 10 am to 3 pm the
sun is at its most intense, increasing risk of sunburn. To
avoid sunburn & increased risk of skin diseases, try early
exposure & always use the appropriate sunscreen. Light
boxes are available for about $300.

Relaxation Techniques
These are very important for anxious people. These
techniques can be helpful to teach patients even in an ER
setting. Different types of described in brief below.

 Progressive Relaxation

This technique is often most useful when patients tape

the instructions beforehand and listen to the tape. You
can tape these instructions, reading them slowly and
leaving a short pause after each one. Technique
emphasizes progressively, intentionally relaxing
different parts of the body from toes to head.

 Toe Tensing

This one may seem like a bit of a contradiction to the

previous one, but by alternately tensing and relaxing
your toes, you actually draw tension from the rest of the
body.
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 Deep Breathing

By concentrating on our breathing, deep breathing

allows the rest of our body to relax itself. Deep
breathing is a great way to relax the body and get
everything into synchrony. Relaxation breathing is an
important part of yoga and martial arts for this reason.

 Relaxed Breathing

This technique involves timing your breathing, with a

certain number of seconds to inhale, a certain number
of seconds to exhale. You should start with a count of
about 3 seconds to inhale to start, 6 seconds to exhale.

 Guided Imagery

In this technique, the goal is to visualize yourself in a

peaceful setting.

 Mental Mantra – Numbers

In this technique, you focus on counting a number

repeatedly and rhythmically to distract your mind and to
eventually help with anxiety and stress.

 Vipassana Meditation (The Thought Bubble)

In this technique, you meditate on a thought and

imagine it in a bubble and allow it to float away. This
process is repeated in meditative manner until
distressing thoughts leave our minds.

Insomnia
Insomnia is common (about 11% of adults). Usually is
related to some other problem; often bad sleep habits or
psychiatric problem.

91
Insomnia is usually a co-morbid condition of something else
that needs to be treated (i.e. depression, mania, and
psychosis).
Insomnia is assessed as
INITIAL (can't GET to sleep)
MIDDLE (can't STAY asleep)
TERMINAL (wakes up too early & can't get back to
sleep, aka “Early morning awakening”
(Shorthand: “+/-/-“ means: trouble getting to sleep, no trouble
staying asleep, no early morning awakening).
* See psychopharm section for meds for insomnia

The vast majority of cases of insomnia in the

elderly/demented population are co-morbid insomnia.
Causes include dietary factors, physical pain, medical
problems like orthopnea etc.
 Instructions for Sleep Hygiene
o Sleep only when sleepy; if can’t sleep after
being in bed for about 20min, get out of bed
until sleepy
o Don't take naps
o Get up and go to bed the same time every
day
o Refrain from exercise at least 4 hours before
bedtime
o Develop sleep rituals
o Only use your bed for sleeping or sex
o Stay away from caffeine, nicotine and alcohol
at least 4-6 hours before bed
o A light snack before bed is okay
o Take a hot bath 90 minutes before bedtime
o Make sure your bed and bedroom are quiet
and comfortable, and most important, dark
o Use morning sunlight to set your biological
clock
o Avoid TV in the bedroom

Dementia
Admit them to inpatient psychiatry if they are exhibiting
psychotic symptoms, severe depression, suicidality, etc. Try
to avoid admitting someone just for memory trouble without
Grave Disability 2/2 depression or psychosis (at NBMU
consider calling Dr. Feifel/Perry before admitting one of
these pts). Those at UCSD who are semi-voluntary (not
92
fighting too hard to leave) can be evaluated for admission to
Senior Behavioral Health (a nonlocked med-psych ward).
Voluntary demented patients without behavioral problems
are usually admitted to medicine for whatever acute medical
issue with which they present.

Medications for Treating the Behavioral Complications

of Dementia
In 1996 the International Psycho geriatric Association
introduced the term Behavioral and Psychological Signs and
Symptoms of Dementia (BPSD). This term is used to label
the wide spectrum of possible behavioral complications that
accompany dementia (e.g. depression, psychosis,
wandering, ADL refusal, agitation, sexual disinheriting, etc.).
It is absolutely essential to rule out previously unrecognized
and untreated medical illness whenever patient who has
dementia develops a behavioral problem. 34% of older
patients being referred to Senior Behavioral Health (SBH)
with behavioral symptoms were found, within about 24 hours
of admission, to have at least one medical condition that was
felt was likely to be solely or, at least partially, related to the
behavioral symptoms.

Next, ask if the collection of behavioral signs and symptoms

were occurring in a patient who was not experiencing
dementia, what would the syndrome most resemble?
Depression? Mania? Psychosis? Then try a medication that
treats that diagnosis. Then, step back and evaluate the
impact of the treatment and attempt to determine if the
benefits of the treatment are outweighing any “costs”
including side effects or worsening of symptoms. Lastly, try
to educate the patient and/or family members about what we
are doing and why and we document in the record that this
discussion has taken place.
Keep in mind that both age and dementia will change the
way a person’s depression appears. For example, a
dementia patient who has severe language impairment may
not be able to say “I have low self-esteem”. If your
evaluation reveals that the irritability is triggered by
delusions, then a trial of treatment with an atypical
antipsychotic is the best first step.

93
Be aware that the use of trazodone in dementia for either
agitation or insomnia is common but controversial.

Since research findings showed increased morbidity and all-

cause mortality (1.6x) when antipsychotics (typical and
atypical) are given to older patients and, especially, to older
patients with dementia, there has been a great deal of
reluctance to use these to treat the above problems.
However, they can often be effective, and are usually given
to these patients in low doses. VPA use in the demented
patients also carries a warning for oversedation.

Trazodone, on the other hand, does not have very good

efficacy data in this population. Moreover, it has side effects
that pose severe safety risks in an elderly population, such
as sedation, dizziness, and psychomotor impairment.

There is no right answer; just be sure to document your

understanding of the risks of giving these medications and
the risks of not adequately treating the symptoms.

94
GENERAL
MEDICINE

95
 GENERAL MEDICINE
Medical issues you frequently get called about
either on call or that may occur on your
inpatients:

Altered Mental Status (AMS)

- Differential – MOVE STUPID (Metabolic, Oxygen,
Vascular, Endocrine, Seizure, Structural, Tumor,
Trauma, Temperature, Uremia, Psych, Infection,
Drugs)
- work-up – look over med list, FSG, chem10, cbc,
TSH, NH3, LFTs, UA, UCx, BCx (consider Utox, EKG,
ABG, CT head, LP)
- consider consult w/ medicine or neurology; have low
threshold for transferring pt off psych unit

Chest Pain (CP)

- Worry more about cardiac etiology if patient has
multiple cardiac risk factors, pain with exertion,
nausea, diaphoresis or crushing substernal chest
pain
- Risk factors for ACS: Prior MI/CABG or known
CAD, diabetes, smoking, family hx, >45(m), >55(f),
male, hyperlipidemia
- Characterize CP
- Typical – chest pressure with radiation to left
jaw/arm, any diaphoresis, SOB, N/V
- Atypical – stabbing or reproducible by
palpation of chest
- Assess for MI, PE, aortic dissection, tension
pneumothorax
- Get current vitals (including O2 sat)
- Get stat CXR and EKG and compare w/ old
ones if available, EKG can be normal in a
patient with unstable angina with no current
symptoms! Thus need for serial markers

96
 - Serial cardiac markers (CPK, CKMB, Trop I
q6hrs x 3), chem10, cbc, BNP (if suspected
heart failure), coags, CXR
- If SBP >90, give trial of nitroglycerin 0.4mg SL
(this does not r/o GI etiology of CP)
- If most likely GI, give Maalox 30cc and assess
- If suspected cardiac give ASA 325mg to chew,
O2 and call medicine consult or rapid
response, and prepare to transport patient

Constipation
- R/o obstruction and acute abdomen with exam
and acute abdominal series
- Stool softener – colace 250mg bid
- Motility agent – senna 8.6-13.2mg, dulcolax 10mg
PR, enemas, MoM 30ml qid, miralax qd to bid,
Mag citrate.
- Miralax (polyethylene glycol) is Dr. Sewell’s choice
for elderly patients.

Delirium
20-25% mortality – fluctuating level of consciousness,
can be hypoactive (quietly delirious patient who is
disoriented) or hyperactive (agitated patient)
Delirium is often a consult from medical or surgical
services. Remember it is a medical disorder with
psychiatric manifestations, including psychosis.
The underlying medical disturbance may not yet be
known but it will probably declare itself if proper
work up is undertaken.
Post-op: think 50% of ICU pts. 25% of med/surg
ward pts may be delirious.
ER: think drugs – intox or withdrawal
Patient may need restraints.
Patients benefit from sensory stimuli like clock,
calendar and being near window; also need
frequent orientation.
97
Delirium Etiology/ Differential diagnosis
“I WATCH DEATH”:
Infections (including pneumonia & sepsis)
Withdrawal
Acute metabolic (CO2; uremia, dialysis; hepatic
failure; pancreatitis; alk/acidosis; electrolyte
problem: Na, Ca, Mg, Glucose!)
Trauma
CNS pathology (O2 tumor, BP bleeds, trauma, post
ictal, CVA, emboli infection)
Heavy metals
Deficiencies (Anemia, porphyria, B12, folate,
thiamine, etc.)
Endocrinopathies
Acute vascular accident (stroke or hypotension)
Toxins (drugs or meds: anticholinergics, sedatives,
steroids)
Hypoxia or hypercarbia: PE,  BP, CHF

Delirium Workup
- Risks  with age, >65, <10, malnutrition,
dementia, above causes, etc.
- History from significant others, physical &
neurological examination.
- Labs: start with Tox screen, CBC, chem10, NH4
(if hepatic encephalopathy possible), UA; can
also get B12, folate, ABG, EKG, chest x-ray, drug
levels, head CT, consider blood culture
- TX: risperidone 0.5 to 4 mg po bid or Haldol 1-
5mg (po or IV) for psychosis. AVOID BENZOS.
Start with low dose in elderly patients.
- If significant agitation can give Haldol 5mg IV q
10-15mins until calmed down. Most medical
floors require telemetry if IV Haldol given.
- Consider Naloxone IV, flumazenil if suspected
narcotic or benzo toxicity.

98
Diabetes Mellitus (DM)
Hypoglycemia:
- Almost always iatrogenic
- Give orange juice, food and then recheck; if
severe (<40), consider giving D50 but this may
require pt to be on medicine floor

Hyperglycemia:
In gereral, if a patient is symptomatic from
diabetes, you should call medicine to help with
management.

Is pt symptomatic (i.e. N/V, dehydrated, tachycardic,

altered mental status)? If so, consider DKA (usually
Type I diabetics, BS not necessarily that elevated)
or HONK (hyperosmolar non-ketotic) (type II
diabetics BS>600, usually >1000).
If blood sugar too high for glucometer to read (i.e.
>400) order stat Chem10 and urinalysis.
If HCO3 <15meq/L or ketones in urine may have
DKA. Call medicine consult.
If extremely high glucose (>600) and symptomatic
may have HONK. Call medicine.

If known diabetic is hyperglycemic and asymptomatic,

what is pt’s blood sugar generally? Is this a
significant change from normal for this pt?
Is pt on diabetic diet? If not, change to one (generally
ADA 2000cal with QHS snack). Is pt normally on
diabetic meds? If so, restart anything they are
supposed to be on. Remember if pt due for contrast
imaging study should not be on metformin
(Glucophage). If unsure what oral regimen pt
should be on, start regular insulin preprandial
correction (see below) and make sure ordered for
qac/qhs finger sticks.

99
If pt type I diabetic, needs to be on scheduled insulin:
total daily dose 0.2-0.4units/kg/day, give half as
long-acting (lantus) once daily, and divide rest as
tid regular or lispro.

Insulin Preprandial Correction Dose

(prev known as Sliding Scale: ISS or SSI)

At the VA, use the “insulin sliding scale” template

under inpatient medications. Can use regular insulin
(onset 30mins, peak 2-4 hrs) or lispro (onset 5-
15mins, peak 45-75 mins) with scheduled + correction
at meals, or just correction depending on control.

This is one example of an Insulin Correction schedule

QAC/QHS:

FBS Action
<50 30gm oral liquid glucose call HO
51-80 give juice, repeat in 30min
81-150 no coverage
151-200 2 Units insulin SQ
201-250 4 Units insulin SQ
251-300 6 Units insulin SQ
301-350 8 Units insulin SQ
351-400 10 Units insulin SQ
>400 12 Units insulin SQ, call HO

For BS >400 repeat in 1 hour and cover again with

sliding scale continue until BS under control.

Treatment of DM2:
If patient is admitted to 2S and already on oral
hypoglycemic agents, does not need fsg qac and
hs, or insulin correction scale.
Check A1C to assess level of control, if not done
already in last 3 months.
Order of starting oral medications for DM2 is:

100
 1. metformin 500mg bid, increase to 1000mg
bid after 1 week
2. glyburide 5mg qday, can increase as needed
up to 20mg bid; do not use if renal insuff
(use shorter-acting glipizide 5-10mig bid)
3. actos 15mg qday, can increase to 30mg
qday (do not use avandia 2/2 incr cardiac
risk)
4. If still with poor control, add lantus 10u qhs
and stop sulfonylurea.

Consider a medicine cosult prior to beginning steps 3

and 4.

Hold sulfonylureas if pt is NPO to prevent

hypoglycemia.

101
 Start Max Contraindicated Advantages Disadvantages
Med (class)
dose dose in of of
Cr>1.4
No
500 CHF GI SE’s
metformin 1000 hypoglycemia
mg Liver dsfxn (diarrhea)
(biguanide) mg BID Wt loss
BID Iodine contrast Lactic acidosis
cheap
Met acidosis
2.5-5
glyburide, glipizide 10 mg DKA Hypoglycemia
mg cheap
(sulfonylurea) bid CrCl<50 Wt gain
qam
CHF Expensive
thiazolidinediones No
DKA Wt gain
(TZD): hypoglycemia
Liver dsfxn Follow LFTs
15-30 45 mg
Actos (pioglitizone)
mg qd qd

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Diarrhea
- Is the patient having “loose stool” or “watery stool”?
Loose stool is not diarrhea, watery stool is diarrhea.
- General rule is to treat the underlying cause: consider
new medications as cause or infectious
o stool culture, WBC, ova and parasite
exam and C Dif toxin
- Acute diarrhea – loperamide 4mg x1 then 2mg after
each loose stool (NTE 16mg/day); do not give if pt
febrile or with bloody diarrhea

Dyspnea
- What is the patient’s baseline O2 sat and pulmonary
status (do they have asthma or COPD, etc?)
- Do a full set of vitals, including O2 sat.
- Do focused PE.
- Check O2 sat, make sure getting good reading, must
be picking up consistent pulse on machine when you
read O2 sat (try to see the reading yourself to
confirm). Make sure pt isn’t wearing finger nail polish.
If pt wearing nail polish or has peripheral vascular
disease, then use ear lobe to check sat.
- If O2 sat normal, this is reassuring and you have
more time to dx, think 1.Asthma attack 2.COPD
3.Pneumonia 4.Pneumothorax 5.Pulmonary
Embolus 6.Pulmonary Edema 7.MI 8.Panic attack
9.Aspiration
- If O2 sat abnormal (<94%)
- What is pt’s baseline O2 sat? If has COPD may
have chronic hypoxia. If this is case O2 sat <93%
may be normal for pt.
- If pt has tachypnea with new desaturation: consider
calling rapid response team. If not yet warranted,
act quickly to try and figure out cause, get stat
portable CXR and ABG. If O2 sat consistently low
with good reading, then place pt on oxygen
(maintaining O2 sat above 93%) and call medicine
consult for possible transfer.

103
Electrolyte imbalances
Almost all significant electrolyte imbalances should warrant
a Medicine consult. Also, before you treat an electrolyte
disturbance or call Medicine to do so, it’s probably a good
idea to re-check electrolytes if you notice a disturbance.

Calcium
Hyper - >10.5mg/dl, give fluids as most pts are
hypovolemic; consider medicine consult
Hypo - <8.5mg/dl, check albumin to make sure this is
true hypocalcemia
Magnesium
Hypo - <1.8mg/dl, can make repletion of Ca and K
difficult, for every 0.2mg/dl below normal, give 1g
MgSO4 IV (most likely on medicine service)
Phosphate
Hyper - >4.5mg/dl, can give calcium carbonate,
calcium acetate, sevelamer (usually pt with CRI)
Hypo - <2.6mg/dl, oral preparations (K-phos-neutral,
neutral-phos-K, neutra-phos) can give BID to QID;
consult medicine if IV repletion is needed
Sodium
Check volume status of patient, mucous
membranes, urine output, edema, skin turgor,
etc.
Hyper - >145meq/L, correct w/ vol repletion; correct
slowly (never more than 12meq/day)
Hypo - <135meq/L, place on free water restriction,
most likely will need IVFs and so consult medicine
Potassium
Hyper - 5.1-6meq/L, make sure that this is not 2/2
lysed blood sample; if not then check EKG and give
kayexalate (takes 2-3hr to work; 30g will lower by 1);
>6.0meq/L, same as above and give 1amp calcium
gluconate, 10U insulin and 1amp D50 (lowers by 0.5
to 1.5 transiently), 1amp sodium bicarbonate, and
consult medicine
Hypo - <3.5meq/L, check EKG, for every 0.1meq
below, replace w/ 10meq KCl

104
Falls
- If trauma or LOC involved, get head CT w/o contrast;
consider cardiac causes for LOC
- If elderly or alcoholic, there is increased risk of subdural
- If osteoporotic, there is increased risk of fracture
- Assess for possible seizure
- Examine any injured limb, check for range of motion
(passive/active), point tenderness. If knee or ankle injury,
walked immediately after, and no point tenderness to
joint, likely does not need X-Ray. If any question, get
plain films of joint or bone at least 2 views (if unsure what
to order can call radiologist).
- If hit head, do neuro exam. If any abnormalities, get
non-contrast head CT.
- Decide whether you should initiate fall precautions,
seizure precautions, or regular neuro checks.

Fever
Need to get history and full PE to look for etiology of
fever.
Everyone has different cut off for fever, conservative cut
off is T>100.4.
If T>101.5 would suggest full w/u: UA, urine culture, blood
culture x2, CXR, CBC with diff. If sx’s of meningitis, then
pt needs LP with studies (call medicine).
Tx fever with Tylenol (650 mg) and repeat 650 mg in 2
hours if temp still elevated. NTE 4 g daily or less in liver
pts.
Consider: EtOH withdrawal, pyelonephritis, pneumonia,
cellulitis, bacteremia, endocarditis (esp if IVDU, artificial
valve), appendicitis, diverticulitis, viral syndrome, pelvic
inflammatory disease.

Headache
Things to r/o acutely (consult medicine urgently):

105
 - Meningitis- red flags: fever, photophobia, N/V,
nuchal rigidity, any neurologic sx’s, or abnormality
on neuro exam (esp. cranial nerves)
- Subarachnoid hemorrhage- red flag: worst
headache of life
- Hypertensive emergency (see HTN section)
- Temporal arteritis – palpate temporal region (get
ESR)
Treatment based on acuity and suspected etiology:
- HTN related headaches should be managed by
lowering BP
- Fever should be managed with Tylenol or
ibuprofen
- For migraine headaches try Imitrex 25-50mg PO x
1 or 6mg SC x1 (if nl BP). Caution repeated use in
patients on SSRIs/seroternergic agents.
- Cluster headaches (asymmetrical, rhinorrhea,
lacrimation) - try oxygen.

Hypertension (HTN)
- Make sure patient is not having hypertensive
emergency (si/sx of end-organ damage)
- Get full vital signs including temp, O2 sat if indicated
- Compare with baseline BP
- If pt symptomatic (headache, chest pain, blurred vision),
examine pt, do neuro exam, look in eyes (for
papilledema). If suspect HTN emergency (elevated BP,
usually >200/120, with end organ (brain, eye, heart,
kidney) damage), call medicine consult immediately for
evaluation.
- If BP is 220/110 and asymptomatic then give clonidine
0.2 mg and check BP in 2-3 hours. Repeat once if BP
still >180/100. If BP does not come down, then
consider calling medicine.
- If pt asymptomatic and BP is less than 220/110, pass on
to primary team in AM.
If this is one of your inpt’s and BP sig elevated from
baseline but asymptomatic, make sure pt has received
any scheduled HTN meds. If BP continues to be
>180/100, could consider starting HTN med.
106
 Anti-HTN Starting Max Avoid if Good Notes
(class) Dose Dose Choice
for
Metoprolol 25-50mg 100mg Asthma BB not good first-line choice 2/2 incr
(-blocker) bid bid Bradycardia risk glucose intolerance, CAD and CVA
AV block in recent studies
HCTZ 12.5mg 50mg Electrolyte edema Previously first-line, now 2nd or 3rd
(Thiazide qd qd imbalance choice
diuretic) Sulfa allergy
gout
Lisinopril 10mg qd 60mg Pregnant Diabetic Make sure baseline Cr, and recheck
(ACE-inhibitor) qd Hx angioedema CAD one week after starting; not much
Hyperkalemia CHF benefit above 40mg
Renal Failure
Norvasc 5mg qd 10mg Edema BLE edema most common side effect.
(Ca Channel qd
Blocker)
First line for otherwise healthy person is more controversial in last year, now likely ACEI if no contraindications.
Diabetics/CHF with stable renal function should be on an ACE inhibitor.
Calcium channel blockers generally added on for HTN not controlled with Beta blocker, ACE and HCTZ.
Check EKG before and after adding to BB to screen for AV block.
Combining low dose anti-HTNs more effective than maxing out dose on one med, but must consider SE

107
Hypotension
Make sure the reading is accurate; don’t forget your eyes
are more reliable than any report
- Compare with baseline BP and check med list
- Workup labs: CBC, chem10, EKG (r/o Afib, SVT,
Vtach), cardiac markers (consider lactate, ABG,
BCx)
- Major differentials: septic/hypovolemia/cardiogenic
- Perfusion defects (shock): AMS (brain), CP (heart),
decreased urine output (GI), LFT/lipase leak (lactate
level indicate hypoperfusion)
- Depending on cause, you can fluid bolus or if IVF
and supportive care is indicated, consult medicine

Nausea/Vomiting
- r/o acute abdomen, MI, DKA, AAA
- workup: cbc, chem10, lipase, LFTs, UA, consider
radiological study, U/S
- treat w/ ondansetron 4-8mg PO or IM q4hrs (5HT3
blocker), prochlorperazine 10mg q6hr (D2 blocker),
promethazine 12.5-25mg q4-6hr (H blocker),
metoclopramide 10mg q4-6hr (dopamine blocker)

Seizure
- Call rapid response and prepare to transfer pt
- Assess ABCs, evaluate meds, vitals, chem20, FSG, cbc
- Initial acute treatment is to use ativan IM to control

Stroke
- Call stroke code
- Assess ABCs, evaluate meds, vitals, chem20, FSG, cbc
- Prepare to transport pt. Time is of the essence.

Tachycardia
Compare with baseline pulse; check med list
- If pulse >120, get EKG to r/o AFib/SVT/Vtach
- If sinus tachycardia, think of possible causes and
correct if possible

108
Differential: 1.EtOH withdrawal 2.Anxiety 3.Pain
4.Fever 5.Dehydration 6.Med effect (esp antipsychotics)
- consider medicine consult

If you are unsure of an EKG reading, you can try asking

an ER doc to take a look to confirm/clarify.

109
WARD ISSUES

110
 WARD ISSUES
Seclusion and Restraint
 Seclusion involves locking patient in a room
 Restraint is the application of straps to
immobilize limbs
 One OR the other may be used, never both
 Rationales for restraint include
o Medical: To promote medical healing.
Restraints are used to limit mobility,
temporarily immobilize a patient, or
prevent patient from walking before
medically appropriate.
o Behavioral: The patient’s behavior
presents an immediate and serious
danger to the safety of the patient or
others
 Restraint note
o Date/Psychiatrist on call/time
o “Patient placed in restraint (or
seclusion) at __p.m. Restraints were
needed because ___. Alternatives to
restraints were tried including
redirection, 1 to 1 interaction, time out,
PO medications, and seclusion.
Patient will be evaluated at ___
intervals and released when no longer
exhibiting behaviors for which seclusion
and restraints were initiated.”
o Signature and provider number
 Orders
o Medical: Every 24 hours there must be
a face-to-face MD encounter,
documentation, and renewal of restraint
orders
o Behavioral: Guidelines for seclusion or
restraint due to a behavioral issues are
more stringent as follows below

111
Seclusion or Restraint for Behavioral Rationale:
Physician Responsibilities
 Initial order (obtain within 1 hour): Use pre-
printed form at UCSD or computer template at VA.
Duration limits for initial order vary by age.
o ≥ 18 yo: 4 hour limit for each order
o 9-17 yo: 2 hour limit for each order
o 1-9 yo: 1 hour limit for each order
 Initial face-to-face MD assessment (obtain within
1 hour): Document in chart with note
 Face-to-face MD reassessment: Frequency varies
with age. Document in chart with note
o ≥ 18 yo: Every 8 hours
o < 18 yo: Every 4 hours

Misc Documentation
On Call Note: Write observations, patient exam and any
changes to treatment plan on the incident form. Put note
in progress notes. If patient dies, write Death Note,
contact the attending and unit director.

Death Note: No pulse, respirations, BP. Pupils fixed and

dilated. No gag reflex. Time of death.
Attending ____________informed. Family member
_________ informed.

112
Electroconvulsive Therapy

Preparing for ECT

 Two attendings must evaluate the patient and
document a recommendation for ECT in the
chart
 Detailed psychiatric and medical assessments
including examination of dentition should be
documented in the chart
 Necessary medical work-up required to clear the
patient for ECT must be complete and
documented in the chart (varies by patient –
discuss this with your team)
 Patient consent form must be signed and in the
chart
 Any medication changes necessary should be
addressed ahead of time (for example,
medications that raise seizure threshold, such
as benzodiazepines and lidocaine, are generally
tapered/discontinued/avoided; similarly, lithium,
known for increased postictal delirium and
seizure prolongation risk, is generally
discontinued; clozapine, bupropion and
theophylline are generally discontinued for late-
appearing and prolonged seizures, respectively;
reserpine is generally discontinued for risk of
respiratory and cardiovascular compromise --
from Sadock’s Synopsis, 2007 -- discuss this
with your team)
 Patients should be NPO for 8 hours before the
procedure
 The day before the procedure
o Make sure you will have access to the
ECT machine at the scheduled time
o Verify that you will have the appropriate
supplies (electrodes, BP cuff, electrode
gel, bite block) and that there is enough
printer paper in the machine

113
  Remember
o No metal or jewelry on body
o Bite block face up
o Apply gel
 Attendings will give you guidance on parameters
for ECT (i.e. settings to be used)

ECT at VA
 24 hours before ECT, (1) verify with PACU that
ECT is on their schedule for tomorrow (generally
AM; you can generally book sessions in
advance, say, MON, WED, FRI mornings for 2
weeks) and (2) verify that the following forms are
complete (ask RN where to find these):
o ECT informed consent form
o ECT procedural checklist
 The machine is on its own cart, located in the
exam room off B pod
 There are instructions taped to the machine
regarding placement of electrodes and changing
the percent energy (again, can discuss with
attending)
 The supplies (electrodes, BP cuff, etc.) are
located in drawers in the cart
 When ready, with another staff member, say,
nurse or assistant, wheel the cart up with the
patient to the PACU, which is located on 5 West.

ECT at UCSD
 The ECT machine belongs to Senior Behavioral
Health (SBH).
 Nurse manager at NBMU will help with
scheduling ECT.
 If on NBMU, nursing or an assistant will usually
bring ECT machine from SBH to NBMU,
although, depending on staffing issues, you may
need to do it.

114
  The supplies (electrodes, BP cuff, etc. ) are
usually in the cart -- there are extra supplies in
the storage room on Senior Behavioral Health
 When ready, with another staff member, say,
nurse or assistant, wheel the cart and the patient
nd
to the PACU, which is located on the 2 floor of
main hospital

ECT Post-Op Note

 Must be done within 24 hours at UCSD because
it is considered a surgical procedure. If you do
not do this, your attending will be called.
 For outpatient ECT, a short history and physical
form must be completed for each treatment
 Procedure
 List names (self, attending, anesthesia)
 Indication
 Discussed risks and benefits
 Patient is/is not in agreement with the procedure
(if not, discuss legality)
 Consent in chart
 ECT, EKG, EEG leads placed
 Patient sedated with XXX (e.g.Brevital 100mg)
IV and XXX (e.g. Succinylcholine 140mg) IV
used for paralysis
 XXX mg of XXX given to control/prevent HTN
 Bite block placed
 Tonic/Clonic seizure induced using following
parameters: either % energy & ohms at VA or
pulse width & total energy at UCSD. Seizure
duration by visualization ___, by EEG ___.
 Maximum BP and heart rate
 Patient tolerated procedure well and resumed
breathing
 Wheeled to recovery area without incident
 Next scheduled ECT: ____

115
 Somewhere in the procedure note include Beck
and Hamilton Score done on admit and prior to
each ECT.

116
UCSD

117
 UCSD
SIGN IN
8 am. Attended by the on-call intern/resident, NBMU
interns, NBMU chief, C/L residents, C/L attendings and
medical students.
The on-call person who is signing out reports the
following:
 Emergency Department: presents patients still in
the ED. Presents any administrative problems.
 Consults: presents new consults on hospitalized
patients seen overnight.
 NBMU: presents issues arising on the psychiatric
unit. Include medical and administrative issues.
 Telephone calls: presents any calls from outside
patients to the on-call pager.
 Admissions: are NOTpresented until rounds unless
there is something that requires emergent attention
like a serious medical issue or a hold.

ROUNDS
Schedule varies based on attending coverage, but
typically formal rounds are Monday/Wednesday/Friday at
9:30. Informal card-flip on Tuesdays. No rounds on
Thursdays. Attended by interns, medical students, chief,
ward attending, social work, nurses, pharmacist and
pharmacy residents.

HISTORY AND PHYSICAL

 Use template in Epic
 Absolutely do NOT delete anything in the template.
ALL components are required.

CHARTING
 Nearly all charting is done in the EPIC system.
Within epic, there are pre-made “SmartText” templates
for all notes, just type “psych” into the SmartText
search box. You MUST use these templates for your
notes, do NOT make your own!
 If something that you are writing has obvious legal
118
 implications (e.g. domestic violence, assault ,etc) be
sure to qualify your statements of accusation with
the source - e.g. <Patient states that he sometimes
'comes home drunk & beats his wife'> or <the pt's
wife says that he 'always comes home & beats her
up'> not <He often beats his wife>.
 Avoid incriminating or inflammatory statements.
Remember that the medical record is a document
frequently used in court.
 It is unprofessional to squabble and bicker between
services in writing. If you have questions about
another provider regarding decisions, ask in person,
gently. If you disagree even after you've talked it
over, keep it to yourself until supervision.

CALL/NIGHTFLOAT SCHEDULE
 Nightfloat covers Sunday-Friday. Night float begins
at 6 PM on all nights except Sunday night when it
begins at 8 PM. Saturday and Sunday shifts are 12
hours beginning at 8 AM and 8 PM.

TRANSFERS FROM OTHER HOSPITALS TO UCSD

 It is your responsibility to ensure the patient is
medically stable (vitals, labs, physical exam) once
they are admitted.
 CMH, PERT, Gifford Clinic, VA, and Thornton can
direct admit to NBMU. CMH will not medically clear
patients. VA and Thornton will medically clear
patients while in the ER at those facilities.

TELEPHONE CALLS AT UCSD

While on call, you will occassionally get phone calls from
Gifford Clinic patients and other outside patients.
These calls can range from an acutely suicidal patient,
to someone who has a simple medication concern.
Your only role is as an emergency contact. You should
focus only on safety issues. You should never refill
medications for patients who call or give medical

119
 advice other than come to ED or call crisis line. This is
for emergencies only. Keep the calls very brief!
1) Get the name, telephone number and address of the
patient BEFORE you engage in further conversation.
This is so you can send emergency services out if
there is any indication that the person is
DTO/DTS/GD. If patient will not give you this info,
end the conversation.
2) Get a brief description of the reason the person is
calling.
3) Triage the call: a) If the patient is acutely homicidal or
suicidal have one of the nurses call 911 or hang up
and call 911. b) If the patient is appropriate for further
evaluation and cooperative have them go to their
nearest ED; c) If they are non-acute, give county
crisis line 1-800-479-3339).
4) Log the call on the phone call list in ishare.
5) If the call was from a Gifford patient, please leave the
Giffod MD a voicemail letting them know about the
call.

PSYCH CONSULTS FROM THE ED AT UCSD

 Only MDs can request a Psych consult.
 Ask if the person has been medically cleared; if not,
this process should have been started. At a minimum,
history and physical, vitals, breathalyzer and utox. The
ED is not required to get labs for medical clearance
unless indicated by signs/symptoms.
 The patient MUST be gowned and have their
belongings removed. This is for your safety. Do NOT
see a patient unless these have been done.
 Intoxicated patients: See them briefly and write a quick
note as soon as ED calls you. Wait to do your full
evaluation and make recommendations until the patient
is sober. Calculate the projected time of sobriety
based on the BAL and that 0.025 is metabolized per
hour. Return to reassess the patient when they are
sober.
 Medical clearance: ensure that you feel the patient is
truly stable. ED docs are human, and they can miss
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 things. You are a link in the net of cross-checking
safeguards. Ask for labs for particular signs or
symptoms as appropriate.
  Meds are easy to give in the ER, so “premedicate”
your admissions from the ED before they are
transferred.
 If the patient needs to stay in the ED overnight,
recommend the ED treat the patient with appropriate
medication.
 Document a "Comprehensive Suicide Risk
Assessment" on all ED and Floor consults
 "Level 2" is a designation that we use for ED patients
who are not on a hold, but would require psych to re-
eval them if they were asking to leave. "Level 2" should
be your default for any psych patient that is not on a
hold but has not been staffed with an attending for
discharge to own recognizance. This includes patients
waiting for a crisis house.
 All the patients in the ED on a level 2 or a hold need a
sitter.
 After each consult there is a face to face interaction
with the ED resident/attending.
 Patients boarding in the ED must have a note every
shift.
 If the patient received a psychiatry consult in the ED,
but is admitted to another service in the hospital, make
sure that the consult note is put into Epic by the
following morning and that the patient is added to the
floor sign out.

SUICIDAL PATIENTS IN THE ED

 If a patient is identified at any point during the ED stay
to be suicidal or at risk of harming themselves, they will
have an orange and white checked wrist band placed.
All patients will be screened for suicide at triage. They
will be evaluated by the ED attending. The ED
attending will consult psychiatry if necessary.
 Perform usual suicide risk assessment. In addition to
usual documentation and communication, inform the
121
 ED attending about assessment of the current risk and
legal status.
 If the patient is deemed to be at low risk, will inform the
ED attending of this and they can make the decision to
remove the arm band. ONLY AN ED ATTENDING
CAN REMOVE THE WRIST BAND.
 If during your assessment you are the first person to
identify suicidal thoughts or risk, INFORM THE ED
ATTENDING IMMEDIATELY and they will place the
band.

Before Admitting a patient, check with NMBU nursing

staff if the patient is on the Special Needs Patient
List.
The patients are on the list because in the past they have
proved not to be appropriate for admission and/or do not
benefit from admission. If you think someone from the list
needs admission, then discuss the issue with an NBMU
attending.

NBMU ADMISSIONS
 Call the NBMU charge RN for a “bed hold” – will be
asked patient’s name, DOB, SSN, psych dxs,
medical conditions, whether independent with ADLs,
mobile, etc.
 Inform ED resident and RN of plan
 ED nurses will give NBMU nurses their report (if
NBMU gets “report” before getting a bedhold,
confusion and agitation ensue).
 Security will take patient to unit.
If the patient is admitted voluntarily, make sure they
sign the voluntary form while in the ED.

Admission Orders Set in Epic

 If you don't use the “Admission to Neurobehavioral
Medicine Unit” Order Set, very important orders will
be missed (level of the observation, treatment level,
risk of suicide, risk of wandering and risk of assault).
 If you don't use the Epic admission order, the
admission cannot be billed!
122
1. Select patient (using patient name or medical record
number)
2. Click on "Admit-Transfer-Discharge" button at the
bottom of left panel.
3. Select "Admission" (left most option in the main pane)
4. Enter Problem List, including all psychiatric and
medical problems that we are addressing. Make sure the
“principal problem” is the main reason for admission.
5. Enter patient allergies. No further orders can be made
without doing so!
6. Select "Order Recon-Admit"
A. You will see a list of medications that patient
was known to have been prescribed as an
outpatient in the past. Select when patient last
took the medications and at the bottom select
from drop down “Physician: Med hx – complete”
and click on “Mark as Reviewed.”
B. Then click “Next” and select either "continue,"
"reorder," or "modify" as appropriate for all
medications.
C. Click “Next” and select “Admission to
Neurobehavioral Medicine Unit” Order Set -
ALWAYS use this order set for NBMU
admissions!!! You will miss orders if you do not
use this order set!
 Risk levels:
- Give a separate number for suicide risk, assault
risk, and AWOL risk. Suicide risk of “high”
requires 1:1 immediate proximity monitoring.
AWOL or assault risk of “high” requires “constant
eye” monitoring by nursing staff. Default: Q15
checks

123
 RISK LEVEL ASSESSMENT
0 = NONE I = LOW II = MODERATE III = HIGH
No current No current Currently/recently ***Is now actively
suicidal suicidal expressed SI suicidal.
thoughts, thoughts, AND may be May be using self-
Gestures gestures or using non- injurious behavior
or plans plans injurious gestures AND
SUICIDE

AND AND AND May have a

No history Prior Patient has no specific plan or be
of suicide suicidal specific plan and highly impulsive or
history, is not exhibiting behaviorally
gestures severe behavioral reactive.
and impulsiveness/
ideation. Reactivity.
No current No current Currently or ***Is now
thoughts/ thoughts/ge recently expressing desire
gestures stures of expressed to leave, exhibiting
of elopement thoughts of behaviors of
elopement AND elopement AND elopement, or has
WANDERING

AND Prior history Exhibiting recently AWOLed

AWOL/

No history of running behavior of or run away within

of running away or wanting to leave last 7 days
away, or wandering. AND history of AND
wandering running away May be severely
AND may have impulsive
no specific plan. or reactive
AND
may have a
specific plan.
No current No current Currently or *** Is now
aggressive aggressive recently Assaultive.
behaviors behaviors expressed AND
AND AND thoughts/threats Is using dangerous
ASSAULT

No history Prior history of aggression or injurious

of assault of AND behavior resulting
aggression Maybe exhibiting in serious injury
towards anger or warnings and/or property
people, towards others. destruction
objects or Is not reactive or AND is explosive,
animals. impulsive. impulsive or
reactive.

Admission labs
 HIV screen on all patients. Only verbal consent is
needed. Order this as default on all admissions.
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 CBC with diff, checking for infection or anemia which
can look like many psychiatric disorders.
 CMP includes LFTs, Mg, Phos. Order ammonia if
suspect delirium – VPA can elevate ammonia without
affecting LFTs.
 TSH – if abnormal can mimic any psych DO & can be
interfered with by Lithium.
 Fasting lipid panel – Required for anyone admitted to
NBMU. Especially important for anyone on a
neuroleptic or mood stabilizer considering the SEs of
those meds.
Hemoglobin A1C for all new admissions to screen for
diabetes.
 Urine pregnancy test (UPT) – for any female with
child-bearing potential.
 UA – Very helpful in elderly and anyone who is GD
 UTox – always
 Baseline EKG
 Consider Viral Hep panel, RPR, B12, folate
 Drug levels for lithium, Depakote, some TCAs.
Please check at the appropriate time, but before
administration of the med!
 Consider prealbumin if suspicion for malnutrition
exists (can help build in the case for GD during
hearings).
Paperwork for chart
- Have pt sign med consent for psychotropic
medications. Need to use specific medication names.
- Voluntary patients – Voluntary Form
- 5150 - original and copy of advisement
- If patient is on a permanent conservatorship, copies of
the conservatorship paperwork must be placed in the
chart before legal status can reflect this. Until then,
patient must officially be put on a 5150. Conservator
must sign the med consent form, sign special permission
form for admission. Conservatorized patients cannot be
voluntary (a legal status) even if they are amenable to
hospitalization.

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Medication administration times:
 BID is given at 6:30AM and 9PM.
 QHS is given at 9 PM.
 Q12h is spaced literally 12h apart (important for
some antibiotic dosing); usually 9 am and 9 pm. If
you order a medication Q12h at 4AM, the computer
will instruct staff to administer at 4 AM and 4 PM,
which is not good for the patient or staff.
 PRNs always require an Indication and a “Not to
Exceed” specification. Please make sure there are
no duplicate medications, such as more than one
PRN for anxiety.

PRN admit meds to consider

Dyspepsia:
- Mylanta 30 mg PO q4h PRN indigestion NTE
90mg/24h (Keep in mind that Mylanta and MOM
interfere with the absorption of other medications)
Constipation:
- MOM 30cc PO q4h PRN constipation NTE 90cc/24h
- magnesium citrate ½ bottle PO BID
- Dulcolax 1 supp q4h NTE 3x24h
- Colace 100mg BID
Mild pain:
- acetominophen 650mg PO q4h PRN pain NTE
2000/24h
- ibuprofen 400-800mg q6h NTE 3200/24h)
Insomnia:
 document insomnia before treating it.
- trazodone 50 mg (up to 200 mg)
- Benadryl or Vistaril 50mg

Progress Notes

After a patient is admitted, use the "Notes" tab to

complete daily progress notes. In first available field, type

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"Progress Note." In the smart text box type "psych" for a
progress note template.

Transfers from UCSD

See protocols on ishare for instructions for transferring
patient to CMH or other outside hospital.

Social work notes:

If a patient has been admitted to the NBMU previously,
the information in social work notes can assist you when
these patients return to the hospital. Information about
conservatorship, financial support, living situation, case
manager, outpatient providers, important phone contacts,
etc. will be contained in SW notes. This information can
be very helpful in disposition planning, etc., especially
when on call.

NBMU DISCHARGES IN EPIC

1. Select patient (using patient name, medical record

number or patient unit census)
2. Clinic on "Admit-Transfer-Discharge" button at the
bottom of left panel.
3. Select "Discharge" (right most option in the main pane)
4. Review Problem List. Indicate whether problems are
"resolved" or "not resolved."

***NUMBERS 5 AND 6 MUST BE COMPLETED

BEFORE PATIENT CAN BE DISCHARGED***

5. Select "Order Recon Discharge"

A. Page 1: For each medication, indicate
Modify/Refill, Prescribe, or Don’t Prescribe. If
you would like to continue an outpatient
medication but don’t need to give patient a refill,
click on Modify, mark the medication as
“historical”, and add an indication. All prescribed
medications must have an indication!

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 B. Page 2: REQUIRED ORDER SET: "IP Gen
Discharge Patient." Patients absolutely
CANNOT BE DISCHARGED without completing
this order set.
B. page 3: Prescribe any new medications that
patient did not receive as an inpatient or place
consults for outpatient medical follow up.
C. Page 4: "Review and Sign" all orders area.
You MUST SELECT A PHARMACY (UCSD
discharge pharmacy or otherwise) before your
orders will be accepted.
6. Select "Discharge Instructions" in left list of buttons. In
the smart text box type "psych" and select "Psychiatry
Discharge Instructions." Fill in all required fields. You can
use the yellow arrows, which will guide you through the
required smart text fields.
7. Discharge summary: Start a new note, add “Discharge
Summaries” in Note Type field and select the Psychiatry
template from the yellow list.

UNPLANNED DISCHARGES

If a patient needs to be discharged outside of the

regularly planned time (e.g., asks to leave and is not
holdable), you must clear this with an attending.

IF THE PATIENT DOES NOT NEED ADMISSION

Crisis houses
Crisis houses are a good option for the patient who may
not need to be in a locked psych hospital, but is at a
certain level of distress where going back home or
waiting for an outpatient appointment is not a good idea.
Crisis houses have nursing staff to provide meds and
counselors to provide counseling and groups. A
psychiatrist (often UCSD/VA faculty/fellows) visits a few
times per week. The facilities are not locked, are not just
for shelter, but are essentially non-locked hospitals in the
community. The patient can stay for up to 2 weeks at a
crisis house. Typically, the patients are required to stay in

128
the house for the first few days. After that time period
they can leave.
Should the pt go to a crisis house?
 They must be able to contract for safety to go to a
crisis house.
 Alert the ED MD and RN
Fill out Transfer form from ishare and give to the ED
HUSC.
 Medi-Cal patients have additional beds held in
reserve for them, only available through Optum
Health. You or the HUSC need to call Optum to
reserve a bed.
 If you don’t think the pt really needs a crisis house
bed immediately, then you can give them the list and
tell them to call the crisis houses on their own.
Sometimes all a patient needs is the prospect of
resources being available to them in the near future
to tide them over until they get actual help.
 Do they just need a place to stay? Give them a list
of shelters.
 Should the pt go to detox? Only if they are not
actively suicidal/homicidal or GD. Send to VOA.
 Does the pt need a Librium taper? See EtOH w/d
section. The ER MD can give a Librium taper Rx, but
the bag must be sealed or the pt will not be accepted
at detox.
 If you are sending a pt home, then make sure they
know where to go for follow-up or future
emergencies- i.e. CMH if they don’t have insurance.

NOTE: Any disposition to a non-locked facility (crisis

house, friend’s house, mom’s house, street, etc.) must be
staffed with on-call attending prior to discharge.
Document in your note that the attending concurs with
plan.

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Outpatient follow-up from UCSD
If the pt has private insurance refer them to UCSD
Outpatient Psychiatric Services in am, referral line (619)
543-7946. If the pt has Medi-Cal or is unfunded, give the
list of providers in their zip code from iShare. Patients
can present to the walk-in clinics designated for their zip
code. Homeless patients go to the Jane Westin clinic
downtown.

SENIOR BEHAVIORAL HEALTH (SBH)

Clinical Criteria for admission:
1) Over age 65 years unless an early onset memory
illness is present or suspected.
2) Voluntary status: no 5150s plus the patient must be
accepting of oral medications and must be willing and
able to sign a psychotropic medication form.
3) Because they are licensed as a voluntary unit, they
can not give parenteral psychiatric medications except
in an emergency and then only once or twice. They
can not use seclusion or restraint for psychiatric
indications. In addition, a patient can not be an
excessive flight risk or an imminent danger to
him/herself, to other patients or to staff. Please
consult with the SBH attending, if the patient is under
an LPS conservatorship.
4) A patient must be judged to have the potential to
benefit from the therapeutic milieu. At a minimum, this
requires that a patient is able to leave his or her room
via ambulation or via wheelchair.
5) A patient can not have an acute or serious medical
condition (including delirium) that would interfere with
psychiatric treatment. If a patient is so medically ill
that majority of their day needs to be spent
undergoing tests or procedures, then this person is
too ill to be on the SBH inpatient unit.
6) The patient must not be able to have his or her needs
met in a less restrictive setting (SNF or other
placement).

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7) Examples of psychiatric conditions sufficiently acute
for SBH:
a. active expression or preoccupation with suicidal
thoughts
b. feelings, thinking or behaving in such a way as to
endanger the person, his reputation or resources
(e.g. psychosis preventing eating or good
hygiene; financial abuse; upsetting hallucinations
or delusions)
c. combative, aggressive or self-destructive
behavior, presumably due to a mental illness
(including dementia)
d. persistent incapacitating psychiatric
symptomatology of such severity as to interfere
with patient’s normal and usual activities and/or
not responsive to outpatient, partial
hospitalization or other less intensive and less
costly therapeutic interventions (constant crying,
excessive anxiety in the context of pain and/or
prescription drug misuse; dementia related
psychosis)
e. symptoms or behavior of such severity that
temporary removal from the living situation
appears advisable for the patient’s welfare, (i.e.
inability to maintain nutrition; driving while
demented; dangerous wandering – out into traffic,
not redirectable; not sleeping)

Administrative Criteria:
1) The patient must have insurance that will pay for his
or her care at UCSD or must be willing to pay out-of-
pocket for care. A number of seniors in San Diego
County have signed over their Medicare benefits to an
HMO. In these instances, the patients must receive
inpatient psychiatric care according to the
requirements of the HMO insurance contract which
the patient signed. For example, patients who have
insurance with Kaiser Permanente must receive

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 inpatient care at Sharp Mesa Vista Psychiatric
Hospital.
2) The SBH inpatient unit is required by state law to
maintain a certain nurse to patient ratio. If SBH does
not have enough nurses on-duty, then SBH can not
admit patients.

Process for admitting to SBH from Medicine or ED:

1) Psychiatric consultation is requested.
2) If Psych CL finds patient psychiatrically appropriate for
SBH:
a. M-F 8am-5pm: Ccontact Tanya at SBH 33772
i. Bed availability;
ii. Information gathering (psych consult write up;
social history from staff & family; clarification of
goals for admission);
iii. Financial clearance;
iv. Doctor to Doctor/or SBH geriatrician review in
system to establish medical stability and
clearance;
v. Acceptance by geriatric psychiatry attending;
vi. SBH admission coordinator reports back to CL
or case manager for patient.
b. Sunday-Thursday after 5 PM: If the patient is
appropriate for SBH admission, then the night float
psychiatry resident should contact the SBH
attending on-duty. The best way to contact the on-
duty SBH attending is to speak the SBH Inpatient
Unit charge nurse at 619-543-7505. The night float
resident is responsible for the H&P.
c. Friday 5 PM-Sunday 5 PM: Emergent admissions to
SBH will be handled by the geriatric psychiatry
attending on-duty for the unit. Patients who have
been screened, accepted and scheduled for
admission on any day of the week will also be
handled by a geriatric psychiatry attending.
However, always call the SBH attending prior to an
admission to ascertain their desired admission
procedure.

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 d. If the night float resident is not certain what
disposition may be best for a patient, then the
resident should contact the SBH attending to obtain
assistance with making this determination.
3) When accepted, the patient is DISCHARGED from the
medicine service and admitted to SBH with nursing
report, etc.

Contact Information:
Dr. Daniel Sewell, Medical Director 619-543-3779
Debbie Crutchfield, Nurse Manager 619-471-0600,
pgr 9655
Sarah Beiber, Social Worker 619-543-3253
7E Unit 619-543-7505

CONSULTS
 Data sources to review before seeing the patient:
- Requesting physician (summary of case and question
being asked)
- Nurses and other staff
- Chart
- Old records
- Miscellaneous: family, friends (only after consent
obtained from patient)
 Clarify the question asked
 Form hypotheses about reason for referral
 Note interaction between patient and staff
 Note patient’s problems dealing with the illness

Consult Note
 Follow template in Epic
 Recommendations
- Medical: Medications or further medical tests or
treatments recommended.
- Psychological: pharmacotherapy +/-
psychotherapy
- Behavioral: Specific behavioral treatments, or
recommendations to staff to use specific
behaviors.
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 - Social: Day care, home nursing, decreased
visiting hours. Pictures from home, increased
sunlight, bring hobbies to hospital.
- Address whether a patient needs to be on a hold
- Address whether the patient need a sitter or
camera.
- Record risk level for suicide (“A comprehensive
suicide risk assessment was performed and the
patient is deemed…”), AWOL/ wander and
assault.
 FU plan- will the pt be seen the next day and do you
have any outpatient recommendations?

When making preliminary recommendations in your

consult notes, please keep your recommendations
(especially medication choices) general, unless you have
discussed the case with an attending.

You can recommend using classes of medications rather

than specific ones, dose ranges rather than specific
doses, and usually use language such as: "May consider
addition of ______ to target ____. Formal
recommendations to follow once staffed with attending."
You can also just state in your note that the case needs
to be discussed by the team and make no specific
recommendations.

If you need to make an urgent recommendation, please

consult the attending. But remember, most consult
recommendations can wait to be finalized when the
attending staffs the patient during rounds the following
day.

HANDOFF FOR ED AND FLOOR CONSULTS

-The consult service has two separate patient lists in
EPIC: ED and floor consults. You can add and remove
patients from the lists as appropriate.
-For both patient lists, follow the Handoff template in
EPIC and update it prior to sign out

134
-Patients on a 5150 must be seen and have a note
written every day, including the weekends. This needs to
be passed along to the residents on call over the
weekend. If a 5150 is expiring, the resident must see the
patient and decide if a 5250 is needed. The paperwork
must be given to the social worker for that floor of the
hospital to be faxed to the court.

For child consults see the instructions on the ishare

site.

Competency
At times we are consulted to determine a patient’s
“competency”. “Competency” can only be decided by a
judge. We can merely give an opinion as to whether the
person is informed of procedure, risks, benefits, &
alternative and what we think about their decision making
capacity:
Are they making a rational decision (not just the one you
think they should make)? Do they understand (and can
explain) procedure, risk, benefits, and alternatives and is
their decision impaired by mental illness including
psychosis, affective states, have decisional capacity.
Any MD can determine decision-making capacity, not just
psychiatry. In today’s litigious society, however, it might
reassure the other service (who is requesting the consult)
to have a second opinion and documentation in the chart.

Medical floors & holds:

When a patient meets criteria for a psychiatric hold and is
admitted to the general hospital, they need a sitter or
camera sitter unless they are in the ICU. It is good
practice to comment in your note on the need for a hold
or sitter (can have either or neither or both). Pt must
have a sitter or camera or direct observation unit if on a
hold. If pt is on a hold and trying to leave, they can be
restrained on med/surg floor. Sometimes it may be
appropriate to restrain a pt if they are refusing medical
care, such as a delirious patient, but these are

135
considered medical restraints not behavioral/ psychiatric
restraints.

If you place someone on a 14 hold on the medical floor,

please fill out the paper work and notify the floor SW staff.
 The floor social worker should fax the paper work to
the county.
 The floor SW needs to call Mental Health Hearing
Desk@619-557-2127 at leave a message.
 They then fax the copy of 14 day hold at 619- 557
2089.
 They need to provide: patient name, DOB, hold
criteria, MD name and call back.
 Our consult team will do the hearing, so you can give
them the pager number 619-290-5050.
 Please, do not bring the hold paper to the WW staff;
this is not their responsibility.

DIALYSIS CENTER
Occassionally you will receive pages to the 5050 pager
requesting that you come to see a patient in the Dialysis
Center, which is located inside the UCSD Hillcrest
Hospital, but technically is part of outpatient services. If
the patient is an OUTPATIENT and his treating physician
feels he/she needs emergency psychiatric care, please
tell them to send the patient to the emergency room for
evaluation. Explain that our C&L service is not
allowed/does not see outpatients.

136
VA

137
 2 SOUTH

This is the VA locked inpatient psychiatric unit. In general

you have more responsibility at the VA compared with the
NBMU. Here are some things that may help ease the
adjustment to working there.
2 South Main Station: room 2186 ext: 3005
This is where you will find legal forms, letterhead, copier,
printer, fax machine. Our ward mailboxes are here. The
2S Clerk, will either be here or in the main nursing station
between B and C pod. Patients’ paper charts are also
located in the main nursing station. Copies of what is in
the paper charts is stored in team notebooks on each pod
in the nurse’s station (legal forms, medication consents
etc); one notebook for each team, for each pod.
The Pods:
A-pod: x 3787. Patients with dementia and patients with
greater ADL and medical needs are usually placed here.
B-pod: x 3795. Generally ALL new admissions are sent
to this pod first. It is considered the “acute” pod. No
shoelaces, belts, canes. Oxygen tanks/tubing and CPAP
machines are allowed only in special circumstances (i.e.
too acute for A pod or no room there), and only if the
patient has a single room.
C-pod: ext: 3815. The “step-down unit.” Pts must be
without SI (or at least contracting for safety) to be placed
on this pod and cannot be on a hold for SI or HI. Pts have
the greatest freedom here. There are more groups and
more educational opportunities here.
D-pod: This is where the Psychiatry Primary Care Clinic
is held on Tuesdays and Fridays. Katheryn Gideon (ext:
3983) is the coordinator.

138
Important Contacts
VA Main Number: 858-552-8585 (you can dial your
extention at any time)
Nursing Station: 3005
VA Resident On Call: The VA On call phone is 858-642-
6353 or x6353 from any VA phone. The pass code to
check voice mail is 1111.
VA Police
Dial x3333 for an emergency (or to call a code) or 858-
552-7596 for non-emergencies. These are federal police
officers with guns. They are very helpful in Codes, in
helping you get unruly patients to cooperate, and, when
needed, to escort patients out of the UCC. If you get a
feeling that a patient may be dangerous, only interview
them once the police are present, or AT LEAST other 2S
staff. They can attend hearings on the ward, accompany
you when you give a patient hold paperwork, etc.
San Diego Police: non-emergency number (used for
welfare checks): 619-531-2000. You cannot dial 911
from the VA. That is the CODE LINE.

Main station
Ward clerk and legal expert: Jim is usually the daytime
ward clerk and Judy Tellez is the day time legal expert

Clerk: Keeps track of admissions, which resident is

assigned the patients, helps arrange for follow-up
appointments after discharge, and much, much more!
The ward clerk is actually located in the main nursing
station between B and C pod to help facilitate patient care
with nurses more efficiently

Legal expert: Makes sure all of the legal documents are

in order. If your patient is on a hold, or if you place a hold
on a patient anywhere in the hospital this person must be
notified.

139
MAOD: ext: 4344. This person is great. He or she helps
you place patients when they don’t need admission, need
transportation somewhere, if you need info from other
hospitals, etc. They sit in an office across from the UCC.
Printer Names:
2-South Main Station: “2S-C”
2-South Main Nursing Station: “Happy”
2-North: Freud and Jung
2-West: Main2W
ED Doc box: UCARE

Teams:
There are 3 teams with 3 different attendings. Team I is
headed by Dr. Lehman, Team II is headed by Dr. Rao,
and Team III is headed by Dr. Printz. Each team has its
own occupational/recreational therapist, its own
pharmacist, its own senior resident, its own junior
residents (typically 2), and its own medical students
(typically 2). There are currently 2 social workers on 2S
(John Borges and Jenny Martinez), split among the 3
teams.

Other people may sit in the meetings as well. Team

rounds are held 3 times per week (M-W-F). New patients
are presented at the first team rounds following
admission; formal treatment plans are drawn up and
signed. Continuing patients are reviewed once weekly,
formally, and the formal treatment plan is updated and
signed. Patient issues may of course be discussed
informally at any time as needed.

140
Meeting Times and Rounding:
Mon Tues Wed Thu Friday

8AM: 8AM: 8AM:

Signout Signout Signout
2438 2438 2438
9AM: 9AM: 9AM:
Team 1 Team 1 Team 1
B-pod B-pod B-pod
conf rm conf rm conf rm
10AM: 10AM: 10AM:
Team 2 Team 2 Team 2
OT rm OT rm OT rm
2010 2010 2010
Team II Team II B- Team II
B-pod pod conf B-pod
conf rm rm conf rm
11AM: 11AM: 11AM:
Team 3 Team 3 Team 3
B-pod B-pod B-pod
conf rm conf rm conf rm
Noon: Noon:
Journal Journal
club or club or
lecture lecture
Rm 2011 Rm
2011

Admissions at the VA
First make sure we have beds/staff can handle the acuity,
etc., by calling the charge nurse at 858-864-2684.

Who Gets Admitted

The criteria for admission at the VA are much LESS
stringent than at the NBMU. Anyone who fulfills criteria
for a hold should be admitted. Essentially anyone who
you believe may BENEFIT from an admission can be
141
admitted. We use admission much more frequently than
Crisis House placement at the VA (it is cheaper for the
VA that way).

Who Admits?: All 2South residents take admissions until

4:30pm. Between 4:30pm and 6:00pm, admissions are
covered by the ED/CL resident, and after 6:00pm it is the
responsibility of the night float resident. If a 2South
resident is informed of an admission at 4:20, he/she is
responsible for doing the admission even if the patient is
not yet on the unit. He/she can go to PEC or the ED to
start the admission; however, physical exams can be
deferred to the on-call resident if after 4pm.

Admission Orders
Nurses appreciate admission orders before the patient
comes to 2-South. This is frequently impossible, do your
best.
Given the above request, you need to know about writing
“delayed orders.” Such orders do not become effective
until the ward clerk enters the patient into the computer. If
you don’t write them as, “delayed”, they get erased when
the ward clerk enters the pt into the computer.
Hit the “Write Delayed Orders” button at the upper left of
the screen. It asks when you would like them to become
active. Highlight, “admit to ward.” That way, when the pt
is actually admitted to the ward by the clerk, they begin
being valid and don’t get erased.
Now you can write the rest of the admission order set.
There is a special pre-formatted order set for Psychiatry
(2-South) and another pre-formatted set for ADTP.

Risk assessment: Global scale of 1-4; A pod and B pod

start with level 4. You may also need close observation
or a 1:1 sitter, while on the unit. If you are severely
concerned about suicidality discuss this with the RNs.
Patients must be at level 3 to transfer to C pod. Anything
below 3 does not need locked placement, so is never
appropriate for 2S (just discharge them). Patient must be

142
at level 3, preferably C pod, to be eligible for hospital
group meetings, such as ADTP.

Hold Status: if the patient is on a hold, fill out this order.

CPRS won’t let you put the real time/date the hold started
because it has already passed. There is a text comment
section, write in the true time the hold started there. You
can make sure the expiration time and date are correct in
CPRS.

Comfort Medications: once you have determined that

the pt’s liver and kidneys are working okay and that they
are not allergic to anything, order basic comfort meds so
the On-Call does not get called at 3am for Tylenol.
Consider meds for pain, constipation, diarrhea, cough,
sleep, anxiety, and agitation. Be sure to check if your
patients are taking these too often.

Suicide Risk Orders:

1. Comprehensive Suicide Risk Assessment
(CSRA): All patients admitted to the unit need
an H+P as well as medication reconciliation
and a Comprehensive Suicide Risk
Assessment (otherwise called CSRA, which is
a separate note that’s often completed by staff
during the admissions process, but not always).
Any psychiatric patient you see, in the ED, on
the medical floor, ANYWHERE in the VA,
needs a CSRA. An ED or PEC SW or nurse
may also put in a CSRA, but if they do not do it
it is your responsibility to get it done. This can
be found in CPRS. Type “suicide” in the
progress note title box after clicking on “new
note” and you will find the note titled
“suicide/comprehensive suicide risk
assessment.”
2. Suicide Consult: Patients who, on CSRA, are
labeled anything other than nil or low in terms
of suicidality need a suicide consult placed to

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 ensure they get adequate recognition in the
chart and appropriate follow up.
3. Suicide Behavior Report: Patients who have
made ANY suicidal gestures (this can be as
benign as walking over to a bridge where they
have thought of jumping, or buying a rope, etc)
need a suicide behavior report note in CPRS.
4. Safety Plan: For suicidal patients, a Safety Plan
must be created prior to discharge; this is
usually done by nursing staff prior to discharge.
5. Follow-up Appointments: A patient who is
flagged as High Risk for suicide will need 4
appointments within 30 days post discharge.
An face-to-face appointment needs to be within
2 weeks. A phone call or “Aftercare
Appointments” can serve as other
appointments. Patients who are not at high risk
for suicide need a face-to-face follow-up
appointment within 7 days of discharge or 2
weeks with a phone call within the first 7 days.

Plan Discharge: Start discharge planning during

admission in order to have all these appointments (listed
above) ready by discharge. Place a consult and place a
text order asking the ward clerk to make a follow-up
appointment.

Admission H+P: There is a VA Psych H & P template.

Create a “new progress note” & click “Psychiatric H & P.”
Include the patient’s outpatient psychiatrist as an
“additional signer”. To do that, right click and select
“identify additional signer” and type in the name. This way
they are notified of the admission and if they feel strongly
about making treatment rec’s then they could call the inpt
team.

Renew Medications: If your patient is admitted by the

PEC resident or overnight, they will already have their
admit orders and medications in. When transferring the
patient to your care (either when starting a service or

144
receiving a patient from the on-call resident), renew the
medications for each of your patients so that the meds
are reviewed by you and then are officially under your
name.

Nicotine: 2 South is a smoke-free environment, please

order nicotine replacement accordingly (see p. 63).

Notes/Encounter Information: All H+P’s, daily progress

notes, PEC notes, ADTP notes, and all notes regarding
patient care require “encounter” information. This Links
the notes to the appropriate encounter in the CPRS
system.

Encounter Info:
BEFORE WRITING NOTE:
1. Click on location (box at top of CPRS to the right
of patient name)
2. Click “New Visit”
3. Type:
a. LJ 2S PSYCH INPATIENT-X for notes
on 2S patients
b. LJ 2N PSY EMERG CONSULT
CLINIC for ED consults
c. LJ PSYCH CONSULT SERVICE-X for
floor consults
d. LJ 2W SARRTP PSYCH IND for 2W
notes
4. Click “Ok”

NOW START NOTE:

1. Click “new note”
2. Write note
3. Click sign note now
4. Change primary provider to Attending
5. Click “yes” to enter encounter info

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 6. Under “Visit Type” tab – Make sure boxes are
checked YES OR NO if SC or MST
7. Under “Diagnoses” tab – Make sure diagnosis
is selected
8. Under “Procedures” tab – Type relevant CPT
code (see below)
9. A menu will pop up on the right – scroll down
and select “service by VA resident”
10. Click Ok
11. Enter signature code

Congratulations! You are done.

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ADTP consults: For patients who needs ADTP consults,
place a formal consult. Order CXR (if not done within the
past 3 months), PPD, and make sure screening labs are
done which include Chemistries, CBC, LFTs, TSH, RPR,
and Hepatitis Panel. You will need to write 2 text orders:
"Patient can leave unit with escort for CXR" and "Patient
can leave unit with escort for ADTP groups."

1-West virtual ward admissions

The following process will be followed by the on-call

psychiatry resident when a decision has been made to
admit a patient seen in the Emergency Room to an
inpatient psychiatry unit and there is no bed available in
2South, other VA hospitals, or in the community.

1) A patient in the Emergency Room is seen by the on-

call psychiatry resident and a determination is made
that the patient requires inpatient psychiatric
hospitalization.
2) The psychiatry resident requesting admission of a
patient to 2 South must coordinate the admission
with the Admissions Coordinator.
3) If there is no bed available in 2S, the psychiatry
resident initiates a consult to the Transfer
Coordinator (outpatient) during work hours or to the
MAOD during off hours to secure a bed for the
patient in other VAs or community hospitals.
4) If the transfer of the patient does not occur within 6
hours of the patient's stay in the ED, the patient will
need to be admitted to the virtual unit - 1 West.
5) The psychiatry resident writes delayed admission
orders to 2S which is then administratively changed
to 1W.
6) The psychiatry resident will notify the faculty back-up
attending of the admission to the virtual unit and
identify the on-call attending as the attending on
record.

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7) During work hours (8-5 pm, Monday through Friday),
the attending on record is the PEC Attending.
Overnight, the attending of record is the on-call
attending. Thusly the patient MUST be staffed with
the backup attending if you are admitting to 1W
8) In the morning after the patient is seen in the ED,
and there is still no available bed, the ED SW will
reassess the patient and coordinate with the PEC
attending regarding the patient's most recent
assessment and determine whether the patient still
requires admission.
9) Until the patient's transfer has been decided, the
patient will be under the care of the Psychiatry
Service in 1W and any medical issues will have to be
referred to the Medicine consult service.

Supervision Of Emergency Department Patients Who

are DTS, DTO, or GD

1. POLICY: It is the policy of the VASDHS to provide

1:1 supervision to patients who are a danger to self,
a danger to others, or gravely disabled. The
supervision will be provided in the Emergency Room
by a qualified sitter while the patient(s) is/are
undergoing evaluation, treatment, and/or awaiting
transfer to another facility. In addition, it is the policy
of the VASDHS to expedite the evaluation and
treatment of patients on 1:1 supervision status.

2. DEFINITIONS:

a. Danger to Self - a patient is considered to be a

danger to self when he/she threatens to or
attempts to harm him or herself.
b. Danger to Others - a patient is considered to be
a danger to others when he/she threatens to or
attempts to harm another individual or
individuals.

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 c. Gravely Disabled - a patient is considered to be
gravely disabled when he/she lacks the physical
and/or mental capability to provide basic survival
needs for himself/herself. These basic survival
needs include, but are not limited to, the ability
to:

(1) Obtain adequate nutrition;

(2) Clothe himself/ herself;
(3) Recognize and seek shelter from
environmental elements;
(4) Perform basic hygiene;
(5) Recognize the need for healthcare, and/or
(6) Comply with necessary healthcare
treatment plan(s).

d. A 5150 designee - any provider who has

successfully completed the prescribed San
Diego County Mental Health Services training
and meets the requirements for designation
under the provision of Section 5150 of the CA
Welfare and Institutions Code. A 5150 designee
may place a patient on an involuntary hold for 72
hour treatment and evaluation.
e. A sitter - an individual who has completed the
appropriate competencies and is qualified to
provide continuous supervision and/or
observation for the patient(s) under the clinical
supervision of a registered nurse (RN).

3. RESPONSIBILITIES:
a. The ED triage nurse will perform the initial
suicide/homicide or gravely disabled screening
for all patients who present to the Emergency
Department.
b. The ED Social Worker (present 8AM-11PM, 7
days/week) will be responsible for the initial
evaluation of the patient within 20 minutes of

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 presentation to the ED. The Social Worker is
responsible for completing a Comprehensive
Suicide Risk Assessment as part of this initial
evaluation.
c. The ED physician will medically evaluate all the
patients and provide a medical clearance for the
patient. The ED physician will make the final
decision on the need to consult the on call
psychiatrist.
d. Any provider who is a certified 5150 designee
may place a patient on a 5150 hold for Danger
to Self, Danger to Others, or Grave Disability.
(The ED social worker usually has the ability to
place holds in the ED).
e. The on-call psychiatrist is responsible for
performing a psychiatric evaluation of patients
when consulted by the ED attending.
f. The ED charge nurse will be responsible for
notifying the Clinical Services Director (CSD) or
designee (or the Nursing Supervisor during non-
business hours) when additional staffing
resources are needed to provide 1:1
supervision.
g. An ED RN will be appointed to serve as the
primary RN for the patient and as a resource to
the sitter for care issues and guidance.
h. The sitter is responsible for monitoring the
patient's safety and immediately summoning
assistance from the ED care team if the patient
exhibits any behaviors that compromise or have
the potential for compromising the patient's or
other individual's safety. These behaviors can
include, but are not limited to: unauthorized
attempts by the patient to leave, verbal threats
of violence by the patient directed toward others
or himself/herself, and/or actual attempts by the
patient to harm himself/herself or others. The
sitter can summon immediate assistance from
VA Police by pressing one of the multiple "panic
buttons” just inside the ED or asking for

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 assistance in calling a Code Green or Code
Yellow.

4. PROCEDURES:
a. All patients who present to the ED will be
screened by the triage RN for homicidal or
suicidal ideation or gravely disabled. The
patients' answers will be recorded in the
electronic ED triage note.
b. Any patient who presents to the ED with a
primary diagnosis or complaint of an emotional
or behavioral disorder and is found to be gravely
disabled, a threat to others, and/or a threat to
themselves or who answers positively to the
suicide screen:
(1) Will have immediate safety needs
addressed.
(2) The ED triage nurse will notify the ED
charge nurse of resource needs for special
1:1 supervision and the patient will be
placed in a room as soon as possible.
(3) The Triage nurse will have face-to-face
hand off communication with the primary
ED nurse assigned to the patient.
(4) If necessary, the triage nurse will ask a
5150 designee to place the patient on a
5150 hold and obtain from a physician an
electronic order for 1:1 supervision..
(5) The triage nurse will notify VASDHS police
x3333 to request assistance as needed.
(6) The triage nurse will initiate an ESI Level 2
(high priority patient) and notify the ED
Social Worker between 0800-2300 and the
ED Attending.
(7) The triage nurse will initiate mental health
protocols for medical screening
(8) The ED social worker or psychiatrist on call
will administer a Comprehensive Suicide
Risk Assessment.

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c. If a patient from a VASDHS Medical Center
ambulatory care area (including the Psychiatric
Emergency Clinic) is suspected to be (1) gravely
disabled; (2) a threat to others, and/or (3) a
threat to himself/herself, the patient will be
transferred to the ED for further evaluation. The
ambulatory care area provider must contact the
ED physician and nursing staff regarding the
imminent transfer of the patient. The patient will
be escorted to the ED by staff, and the staff will
utilize Situation, Background, Assessment, and
Response or Recommendation (SBAR) hand-off
communication. The ED nursing staff will triage
the patient as an ESI Category 2 with high
priority assigning the patient to an Emergency
Department room. The staff that escorts the
patient to the ED from clinic will need to stay
with the patient until the patient is placed in an
ED treatment room with a sitter. The patient will
then be evaluated as described above.
d. A patient who either verbally expresses intent or
physically exhibits behaviors harmful to
himself/herself or others will be asked by the ED
RN if he/she has any items that can be used as
weapons. If any such items are surrendered,
the VA police will be immediately called to take
custody of the items.
e. All patients on 1:1 supervision will be placed in a
gown in the treatment room and separated from
their belongings, including medications. If the
patient refuses to put on a gown for
examination, the VA police and the on duty
psychiatrist will be notified for further action
appropriate to the situation. The treatment room
will not be in an isolated area. It will be free of
equipment that could be used as a weapon.
f. The ED attending will elicit a medical history and
examine the patient, and review lab data
obtained from the mental health protocol for
medical screening. The ED attending will

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 provide any necessary medical care to the
patient.
g. The on-call psychiatrist is responsible for
performing a psychiatric evaluation of these
patients. The on call psychiatrist will develop an
initial treatment plan and document the plan in
the CPRS progress notes. The psychiatrist will
communicate and coordinate this plan with the
ED charge nurse and ED attending physician.
The plan will include detailed interventions to
maintain the safety of the patient. If this
includes continued supervision/observation by a
sitter, the psychiatrist will write an electronic
order for supervision/observation. The plan will
include interventions should the patient become
agitated.
h. In order for a patient to be placed on 1:1
supervision, the patient must meet at least one
of the following criteria: gravely disabled, threat
to others, and/or threat to himself/herself. 1:1
supervision is appropriate for both patients who
seek voluntary treatment or those on a 5150
hold.
i. Patients who exhibit high or imminent risk
despite treatment interventions will be offered
voluntary admission to the psychiatric inpatient
unit or will be detained involuntarily on a 5150
hold. If there are no available beds within the
VASDHS Medical Center, the patient will be
expeditiously transferred to an appropriate
qualified VA or community hospital.
j. Patients who present with suicidal ideation,
which resolves, will develop a safety plan with
the ED Social Worker or the on call Psychiatrist.
The Safety Plan will be given to the patient and
will include information about the National
Suicide Hotline. When appropriate, any
physician can discontinue the observation
status.

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 k. If at any time the patient displays increasing
anxiety or agitation, the RN should refer to the
individual distress treatment protocol designed
for the patient. This may include use of
medications, manipulation of the physical
environment to provide a calming effect for the
patient, and/or requesting a police presence to
de-escalate the patient. If necessary, restraints
may be used with a physician's order.
l. If a voluntary patient who is under 1:1
supervision attempts to leave, the ED RN or
physician should call a Code Green or Code
Yellow.
m. If an involuntary patient (on a 5150 hold) who is
under 1:1 supervision attempts to leave, the ED
RN or physician should call a Code Yellow.

Handoffs at the VA – ADTP and 2S residents:

1. Residents should use the Shift Handoff Tool in

CPRS under “Tools”, making sure to update the
yellow areas at least once per week and the “To
Do” area nightly.
2. If you leave before 5pm you need to be available
by pager and designate someone who knows
your patients who you could call to assist with
issues that may arise on the unit (ie your fellow
resident on your team, your senior resident, etc)
– it is not OK for the ED/CL resident to be
getting called about your patients at any time
under any circumstances.
3. Sign out in person either to the person you
would call from your team should an issue arise
(if you leave prior to 5pm), or to the ED/CL
resident. If you sign out after 6pm you will need
to contact the overnight resident directly and
sign out face-to-face. Sometimes you will need
to wait until the ED/CL resident or overnight
resident is done with what they are doing to sign

154
 out. It is not OK to interrupt them if they are in
with a patient so that you may sign out.
4. You must sign out anything that the resident
must follow up on that evening, and any
concerns or other issues that the overnight
person should be made aware of (ie what to use
as prn in case of agitation or pain, allergies or
adverse reactions to medications)
5. In the morning, the resident designated to come
in at 8 am will need to get signout from the
overnight resident. It is expected that when 2S
and ADTP residents come in in the morning, that
they find the 8 am resident and pick up their
signout to see if anything has happened
overnight.
6. The overnight resident is tasked with both
leaving a note in CPRS and making a notation
on the signout if there is an issue with a patient.

Discharge “To Do’s”

 Order the patient’s medications as soon as possible,
but at minimum one day in advance, before noon.
Even if you are not sure what the final medication
dose will be, pharmacy would prefer imperfect orders
that come in early than perfect orders that come in
late. If you order them over one week in advance,
however, they will disappear and not be available
upon the patient’s d/c, and you will need to re-order
them. To do this, highlight the active inpatient
medications you want the patient to have, and click
Action Tab, Transfer to Outpatient, Release
Immediatley, Pick up at Window, 30 days, 2 refills,
priority ASAP.
 Reconcile Medications: All outpatient medications
and/or discharge medications should be ordered
and/or reconciled prior to patients being discharged,
aim for at least 24 hours prior to discharge. To do
this, look under the “meds” tab in CPRS, and

155
 discontinue old outpatient medications the patient is
no longer using.
 Make follow-up appointments for the patient to be
seen within 1 week of d/c. There are several options
to ensure patients are seen within 1 week. Under the
orders tab in CPRS, click on “discharge time (for
planning)”. You will then enter the anticipated
discharge date and time. You can enter your
preferred discharge plans in the next screen.
 The clerk will ensure the patient will need to be seen
in after care clinic or group for a follow up appt within
7 days of discharge. If a patient is flagged in CPRS
as “high suicide risk” they will need to have 4
appointments scheduled within the month after their
discharge. The ward clerk will schedule these
appointments once you place the order but double-
check as some ward clerks are more responsive
than others.
 Also make sure to place “Discharge Instructions”
which the nurses will go over with patient
 Let your patient know that standard discharge time is
10 AM, not 5 AM or 5 PM. This is helpful for the
nurses as any earlier discharge time will be the
responsibility of the P.M. shift. Special arrangements
can be made if you communicate with nursing staff
first.
 Social Workers should be kept up to date on
discharge planning. When you know the planned
discharge date (ie patient is likely to d/c on Friday for
instance, not necessarily the anticipated discharge
date initially enterned in CPRS), you can alert the
SWs by putting them as a cosigner on the note. If
placement is going to be difficult (ex. aggressive
patient with dementia) get social work involved very
early.
 Transfers to SARRTP must be done as a
DISCHARGE from 2S (including your discharge
summary); they will be readmitted to SARRTP by the
2W resident. Discharge patients from 2S at 7:30am if
they are going to be transferred to SARRTP. This will
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 give the patient time to check into ADTP at the ED
window. If a patient is “transferred” from ADTP to 2S,
they will need admission orders to 2S and an H&P.
 Discharge summaries should be completed within 24
hours of discharge and must be completed prior to
leaving the service. If you discharge a patient over
the weekend, you must either complete the
discharge summary yourself, or identify the person
who should be responsible for the discharge
summary and alert them.

Day to Day:
 Progress Notes: Patient's need daily notes for
the first 5 days of admission, or if they are on a
hold. If a patient has been in the hospital >5
days, and is not on a hold, notes need to be
written every other day.
 All notes need Encounter Information as
described in the admissions process above.
 Discharge planning orders should be made as
soon as possible and updated at each treatment
team meeting.
 Presentations: Ideally the average patient
presentation should take no more than 5
minutes, pithy, concise and not overly inclusive.
Reading the H+P to the attending is the least
useful way of presenting, both from the
perspective of efficiency as well as learning
good presentation skills and modeling them for
medical students. Presentations do not need to
be overly inclusive. Occasionally a utilization
review manager will be in rounds to discuss
whether the patient meets acuity definitions for
admission. DO NOT TAKE HER QUESTIONS
PERSONALLY. Just give an honest opinion
about how acute the patient is.
 Working with Medical Students: Spend time
observing their skills interviewing patients and
review their notes. Also, help prepare them for
157
 rounds by prepping them on questions attending
may ask.
 Staying Safe:
o When doing physical exams, you must
have a staff member present to
observe.
o Residents are most likely to get
attacked when placing a hold. Error on
the side of having police present when
you are placing a hold.
o During a Code Green situation, stay out
of the way of the code green team.
Although you may want to try to calm
the patient yourself, once the code is
called, you must let the team leader
lead the process.
o
Clinics/VA Resources:

There is a handy booklet in the 2S D pod offices (“VA

San Diego Healthcare System Resource Book”) that
explains the following in more detail. In addition, the
nursing supervisors (Kathy Lyttle is spearheading the
effort) have come up with a resident’s guide for making
mental health referrals during clinic, PEC, on 2S or 2W.

PEC: Psychiatric Emergency Clinic, Ext: 3391; Located

on 2N.
Attendings: Dr. Peter Leong, Dr. Jose Porras, Dr. Alana
Iglewicz .
Residents, nurse practitioners, and social workers run
this very busy walk-in emergency clinic.
ED/CL: Covers ED consults from 8AM-6PM, staffs with
PEC attending. Resident phone 858-642-6353.
ADTP: 3W clerk ext 3011. Alcohol and Drug Treatment
Program. Located on 2-North and 2-West. John Sevik
and Dr. Steve Groban run this program.

158
Further information specific to the ADTP rotation is
given to residents by the ADTP chief at the start of
rotation.

The following is pertinent for VA Call.

Since 10-2012, the 28 day residential treatment
program on 2W is designated as an “outpatient
program”. As such, we are not able to obtain
inpatient consults from other services such as
medicine /surgery /neurology/ etc.
Patients are able to attend outpatient appointments
and to be seen as an outpatient consult. But consult
teams cannot see patients in 2W.

The ADTP residents are responsible for patient care

and will be on site until 5pm. If there is a patient care
issue, they will sign out to the ED/CL resident or On-
call Resident prior to leaving.

NOTE FOR ON CALL RESIDENTS:

Nursing may contact the psych-on-call if there’s a
psychiatric issue for the patients, or medical issue
(just as always).

IF A PATIENT IS HAVING AN ACUTE MEDICAL ISSUE

– The resident will assess the patient first to
determine if it can be handled on 2W or if a higher
level of care is needed. If it is after hours, the psych-
on-call will be paged to evaluate the patient.

If the patient is having a medical issue which is more

than the resident is comfortable addressing → THEN
Psych resident or psych on call MUST first call down
to ER & DESCRIBE THE SITUATION & discuss with
ER attending what is best plan of action. After having
this doctor-to-doctor phone interaction, then patient
can be sent to ER if appropriate OR in some cases
the ER may recommend a direct admission to

159
medicine: in this case the medicine admitting pager
(7173) can be contacted.

If the patient gets med changes, or new orders, then

the on call doctor can enter them as “inpatient”
orders in CPRS.

Please write an on-call note documenting what has

been done, flagging Dr Groban & the resident to the
note as co-signers for review.

TRANSFERS TO OTHER SERVICES:

When the SARRTP patients are in need of in-patient
treatment it is called ASIH (Absent Sick in Hospital).
This is considered a transfer from SARRTP.
When the patient is admitted to one of the medical
centers in-patient Ward/Unit (For example,
medicine/surgery), it will be consider an admission to
that area and when the patient returns to SARRTP
they will be discharged from the medicine/surgery in-
patient stay.
The receiving in-patient area provider will be
responsible for writing New Admission Orders and
when the patient is ready to return to SARRTP, they
will write discharge orders.
When the patient comes back, The SARRTP provider
will write Delay Transfer Orders (UNDER “Return
from ASIH”). They will need a progress note to accept
them back to the 2W program, not a new H&P. These
movements are completed in the Vista ADT computer
system (Admission/Discharge/Transfer) by the Ward
Clerk.
The only time you would discharge SARRTP patients
requiring in-patient stay in the VA Medical Center is
when the patient is not going to return to SARRTP to
complete the program after their in-patient stay.

Detox: ADTP also does outpatient detox of EtOH/benzos

and opiates. Dr. Peter Leong, the other addiction MDs

160
and nurse practitioner, Christine Geniza, and residents
see the detox patients. Detox patients are frequently
asked to come to UCC over the weekend for one day
supply of benzodiazepines, to check their vitals, and to
ensure that they are not still using & are engaging in
recovery. Residents see the patients on the weekends,
you will be flagged to the Friday Detox note, so as to
know who to expect.
SAMI: Substance Abusing Mentally Ill: Located on 2-
North. Many of the VA patients can benefit from this
clinic. This is for patients with dual diagnoses. SAMI
provides additional CBT therapy as well as substance
treatment.
MOOD: 2-North, ext 3391. Many different mental health
providers see patients through the MOOD clinic. Patients
with mood disorders should be directed here.
Mental Health Clinic (MHC): Mission Valley generic
psychiatry outpatient clinic.
Mental Health Intensive Case Management (MHICM):
Intensive Case management, 2S D pod. Reserved for
patients with high recidivism rates.
Cognitive Disorders Clinic: 2-North, ext 3391 Patients
with illnesses in the psychotic spectrum (schizophrenia)
see providers in this clinic.
STEP (“Special Treatment and Evaluation Program”):
This is primarily a research clinic for Bipolar Disorder, but
they also serve as a normal treatment clinic. Patients
with bipolar disorder and unipolar depression can go
here. Pts get SCID dx and some group CBT exposure.
Located on 2-West.
PCT: PTSD clinic. This is only for combat-related PTSD.
They have groups and individual providers.
Other kinds of PTSD do not have a special clinic, and are
treated along with the patient’s other mental health
needs.
OEF/OIF: Operation Enduring Freedom (Afghan)/
Operation Iraqi Freedom. Groups, individual therapy and
meds.

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CBT: Cognitive Behavioral Therapy: Mainly groups and a
few individual providers (long wait list).
DBT: Dialectical Behavioral Therapy. Group and
individual.
WAVE: vocational rehabilitation. Very important, get the
vets back to work! They also have “healthy living”
educational and exercise classes that can be helpful.
Anxiety Disorder Clinic: Med mgt at MV (Murray Stein)
but La Jolla has meds and therapy (Emmanuel Espejo).
MST (Military Sexual Trauma): Run by Carrie Rodgers at
MV- individual and group therapy. Pts can get meds in
other clinics.
Behavioral Medicine Clinic: CBT for medical conditions
(diabetes, pain, htn, etc.) and CBT for anxiety disorders.
Smoking Cessation Clinic: bupropion, nicotine
replacement and therapy. All nicotine patch prescriptions
must be coordinated through this clinic, since vets are not
supposed to get them without going through the
educational component.

Computer Hints
Tracking Medications: There are 2 different ways to
check it on CPRS. You can right click on individual
medications under the “meds” tab and see the
"administration history" or when the specific med is
given. Or you can look under the “Reports” tab, then
under, “BCMA Med Admin Log”.
Scheduled meds are viewed at the top, PRN meds are
next. Next to each administration time for a single letter
indicating: G: given R: refused H: held
If you want the reasons for medication refusal
documented in CPRS by nurses you can write a text
order requesting the nursing staff to document reason for
refusal. Do this if you are planning on RIESEing the pt.

Renewing Medications: Check when your patient’s

meds are going to expire on the Meds page in CPRS.
Highlight the medication, right click, click “Renew”. If the
medication is a “complex order” you can instead click
“copy to new order.” If you forgot to renew them before

162
they expired, just highlight the expired meds, right click,
and click, “copy to new order.”

Templates: These are automatic, pre-formatted notes

that you create once and can re-use over and over for
different patients simply by adding the pertinent info and
deleting the non-applicable info. Many second year
residents have templates already made and can easily
copy them for you. For example, you may have a
template for admissions, consults, PEC pts, mental status
exam of a normal/depressed/psychotic pt, criteria for
depression/mania/decision making ability, and so on.

Templates may also contain:

-Questions you always ask: SI/HI/AVH, paranoia or
delusions, tolerability of medications, new complaints.
-Normal physical exam for the physical exam you always
perform.
-Warning about medication adverse effects that you
always should mention anyway

Patient Data Objects make the templates even better.

These are things such as vital signs, lab values, and
active medications. CPRS will automatically insert the
current vitals, labs, meds, whatever into your template
each time you apply it to a new note. You can copy
patient data objects into your personal templates to make
them easier to access. Ask a second year for help with
this.

VA-on-call

Handoff: get the handoffs from all residents on ADTP

and 2S. The ED/CL resident may have some of the
handouts if people left before 6pm.

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PEC residents are responsible for all patients signed into
PEC during PEC operational hours. The agreement is
that the on-call resident will only handle after-hours
patients that are signed into the ED.

Schedule:
Night float (PGY2s) Sunday- Friday, 6PM-8AM. Except
Sunday start at 8PM.
Weekend days (PGY2s) 8AM-8PM Saturday/Sunday.
Saturday nights: PGY-4s cover 8PM until 8AM.

Food: Cafeteria closes at 4:30 pm. It is closed on

Saturdays and Sundays. From Saturday morning to
Sunday night, there is food catered just for residents on
rd
the 3 floor kitchen in the the room across from the DOU
th
on the 5 floor; food arrives at 8am and 630pm. Try to be
there on time to ensure you get to eat otherwise it may be
gone.

Sleeping: Our call room is in the 3E Resident On-Call

Suite. You can get access to the room using VA PIV
card.The main door access code changes on the first of
every month. The psychiatry room # is 3296 with the
access code 9116. There is one printer in the suite
located in conference rm 3299. The VistA printer name is
3299. Call x4767 for assistance.

Attending back-up: You must staff all patients being

sent out of the VA and all consults on the floor with SI
with the VA back-up attending. In addition, any patient
asking to leave AMA who is not holdable should be
staffed. For any patient staffed, attach the backup
attending you discussed the case with to your note as an
additional signer.

2S Responsibilities for weekend call: For any call

night, you are responsible for issues regarding 2S and
2W (ADTP) patients, and codes (green and/or yellow) on
all patients in the hospital. Additionally, on weekend calls
you have to write brief notes on the following 2S pts: pts

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 st
in their 1 five days of admission, pts on 5150’s, and pts
on 5250’s. The back-up attending will write notes on the
remaining pts.

ER Evaluations: - Door code 6141 (this changes often).

If at any time, you notice that the patient has a behavioral
flag stating that he/she has to check in with security
every time they are in the building, you MUST notify VA
security immediately about the presence of the patient
(preferably before you see him/her.)

Medical Clearance/Service Agreement/Psychiatric

Consult: A service agreement has been passed at the
VA making psychiatry the consulting team instead of the
primary team for UCC patients. This transition has been
difficult but improving as more VA UCC docs are placing
consults. According to the service agreement, all UCC
patients should be seen by the UCC attending and
medically cleared before psychiatry is consulted. See
below for instructions on how to complete a consult.
- The ER nurse will have the patient change into a
gown, with all of their belongings put in a plastic bag
located outside of the room (for safety reasons) and
the UCC attending will see the patient and page you
once the patient is cleared.
- The ER MD will place a “Psychiatry – Emergency
Consult” and typically the the Emergency Dept Social
Worker/licensed psychologist sees the patient first
before the psychiatry resident, similar to PEC and
determine if you will need to see them for admission,
meds or Crisis Home placement
- MSW Tracy McGuire, Ruth Murphy, Vanessa,
Kristin, or Lauren: pager (858) 347-1610 ext 6316.
They are there 0700-2300 seven days/week. They
are very helpful as they provide resources to non-
emergency patients and help direct patients to the
appropriate VA psychiatric services

165
Double check that the patient is actually a psychiatric
patient and not acting crazy because they are delirious or
have some other medical problem! Make sure they are
medically cleared by you, as well as by the ER doctor.
This happens, so be careful!

In PEC, you should at least get vitals prior to admission,

as the 2S nurses will ask for them. Send pts through
UCC for medical clearance if you are at all unsure about
their medical stability.
 Get LABS: Urine tox screen (UTOX), blood EtOH
level (BAL), Chem panel, LFTs, GGT, CBC (look at
the MCV), UA w/ C+S, medication levels if the
patient is on applicable meds (valproic acid, lithium,
carbamazepine, etc.), TSH, RPR, pregnancy test if
female.
 Current rec’s are for all psych pts to have a once in a
lifetime hepatitis panel. Do hep panel yearly if the pt
cont to use drugs.
 Review the labs before the patient comes to the unit.
 Check the vitals.
 We cannot have patients with catheters, intravenous
lines, oxygen lines, etc. on B-Pod. Some of these
appliances (not IVs) are allowed on A-Pod and C-
Pod.
 Intoxicated patients: 2-South nursing will resist
taking patients until the BAL is less than 250,
although technically it will be your call. If the BAL is
above this they should probably stay in the ED or be
admitted to medicine. Patients can start to withdraw
from alcohol even if the still have a positive BAL!
 Ordering meds to be given in the ED: Click on the
orders tabs. Under Main Outpatient menu and Main
Inpatient menu on the left, there is a list of specialty
services. Select “Emergency Department” and select
“Medications Emergency Dept.” You can order any
meds or IV fluids you want. If you order meds any
other way the ED pharmacist on call will not see it.

Completing a Consult:
166
o An ED attending will need to submit a CPRS consult
to psychiatry prior to a psychiatrist evaluating a
patient in the ED. The consult is titled "Psychiatry -
Emergency Department." The ED attending must
document that the patient has been medically
evaluated and the ED attending should comment on
any medical condition that could be influencing the
patient's presentation to the ED. In the event of an
actual psychiatric emergency the patient must be
gowned and have all personal belongings removed
from their person.
o The psychiatrist completing the consult will need to
click Encounter->New Visit->. LJ 2N PSY
Emergency Clinic. Kassab’s name will show up
on top panel where 2South usually is
o Click “New note”->The progress note title will be
PSYCH<CONSULT/PSYCH/GEN>. Then highlight
psych consult listed below co-signers name
which will link your note to the consult (if nothing
is there, tell ED attending to place consult
because you cannot attach a note to the consult
without a consult order by the ED attending)
o After writing the note the psychiatrist will go to File,
then Review/Sign Changes.
o The Encounter Form will be completed. Skip Visit
Type… no need to put anything under Visit Type.
Under Diagnosis either click appropriate diagnosis
or enter another one using menu at left or "Other
Diagnosis." Then go to Procedures at the top and
click one of the following initial ED consult Encounter
Codes: 99243 (simple patient), 99244 (medium
patient), or 99245 (complex patient).
o Sign the note. Your backup attending is the cosigner.
o If you follow up the same patient during the same ED
visit, coding is as follows: 99213: 15 min visit; 99214:
25 min visit; 99215 40 min visit.

167
Where the patients come from: Patients usually self-
present via the public transit system. Thus, if you are not
going to admit them try to get them out before the bus
stops running at midnight. Patients also frequently come
from CMH or other outside hospitals by ambulance.
Generally, only VA attendings do direct admissions.
Often, the MAOD will call you first, letting you know that a
hospital needs to transfer a vet to us. If the unit is full you
can deny the transfer. In fact, you can deny any transfer
that you feel is not warranted (not medically stable, not
fully assessed, not warranting psychiatric admission, etc).
If you accept a transfer, you could have them go through
ER before getting admitted to 2-South if you feel that their
medical issues could be concerning. This is smart
because you can medically clear them and make sure
they actually need to be hospitalized.

Forms: Before patient is brought to the unit, have their

legal status finalized. Generally, at the VA this means
having them sign a “voluntary consent to treatment”
form or filling out hold paperwork. You can find
these forms in the filing cabinet in the 2-South main
station or in the file holder hanging on the wall in ED,
across the hall from the workroom.
Hold Papers: If the patient is on a hold, make sure we
have the original paperwork, a copy of the advisement,
and that the patient has the original advisement. Make
sure all names, dates and times are legible and
consistent across the forms.
“Consent for Psychotropic Medications” form (aka
iMed consent) is the other form that should, in nearly all
cases, be filled out and signed on admission.
Call Admissions or the MAOD to have pt sign more
forms for admission to the hospital and get placed into
the VA computer as an inpatient. Admissions ext 5755
M-F before 2300, MAOD ext 4344 or 2949 all other
times.
Call the charge nurse handling admissions: 858-864-
2684. Nursing will want to know the pt’s name, last

168
 four digits of the social security number, the diagnosis,
if they are on a hold, and if they need help with ADLs.
Escort: 2 people must escort the patient. The doctor and
a nurse who is PART-trained (able to handle an
assaultive patient in the elevator) will take the patient
upstairs in a wheelchair. If you think the patient is
potentially dangerous, have the police come too. If you
are very busy in the UCC you may ask a nurse and a
police officer to escort the patient.

Floor consults: At night and on the weekend residents

must see any new consults that are requested. This is
similar to at the U. Ask the consulting resident to place a
psych consult request in CPRS. Staff all floor consults
with the back-up attending immediately if the patient is
going to be discharged on a weekend. Flag all notes to
the appropriate CL attending. The attending covering the
CL service for that week, usually Dr. Beizai or Dr. Hsu,
will be posted in the 2S front station. Do not hesitate to
call Dr. Rao or Dr. Beizai if there are questions about the
CL service or patients over the weekend.

“Additional Signer” on Notes

CPRS allows you to include an “additional signer” on
your note (aka “flagging a note”). When the person signs
it, the computer reflects this by saying “Receipt
acknowledged by:” and then their name. Do not put your
regular ward attending as an “additional signer” for your
normal daily floor progress note, unless you have a
specific reason (however, do mention that they are
supervising the case). For all call notes, flag the backup
attending, and other care providers as appropriate.
- Dr. Beizai or Dr. Alan Hsu for CL patients
- Dr. Groban for inpt ADTP patients
- Dr. Iglewicz for Psych Primary Care patients
- Corresponding attending for outpatients, and
either the chief resident or appropriate ward
attending for 2S floor issues at night unless they
are minor, in addition to the pertinent resident.

169
Codes
To call a code Green or Yellow Dial 3333.

Code Green: Psychiatric Emergency. This is frequently

called for handling an agitated patient located on a
medical floor or in the ED. It can also be called for a 2S
inpatient if the medical staff needs police back-up.
Code Yellow: Combative patient. This is a higher
acuity emergency, called when a patient is being actively
violent and someone is in imminent danger of being
harmed. Code Green team responds, but all Code
Yellows are handled initially by the police.

Code Green Team: This is a special team of psychiatric

nurses from 2-South, a resident, and the VA security
police. When on call or working in PEC you are the code
green MD. The nurses will bring a bag full of restraints
and some medications. Police will be there for back-up.
All code greens and code yellows that are called for
outside the main building are attended ONLY by the
police, not the rest of the code green team.
Team Leader: This a NURSE who is assigned to
communicate with the patient, give directions to the code
team, assign limbs to hold in the event of a take down,
and eventually call off the code. Once everything is calm,
the code team leader will have a debriefing session in
which feedback is obtained and the plan is reviewed.
You must not leave the scene until the code is over. It is
not over until the team leader has finished the debriefing.
Remember that you are NOT the leader of the code
green team.
Other nurses and doctors: Unfortunately, the people
who call the code are often not readily available or willing
to give assistance when we arrive on the scene. It is
helpful to clearly and firmly request that the person who
called the code provide important information (the
patient’s name and last four, diagnosis, brief HPI, current
med regimen, etc).
Our code green nurses are not able to access the med
machine (PYXIS) on other floors. Thus, it is very

170
important to have the floor nurse available and aware that
they need to act quickly.
Meds: Given the acuity of the situation it is helpful to only
request meds that can be obtained quickly. On other
floors and in the ER this generally means you are
restricted to haloperidol, lorazepam, and
diphenhydramine. But, the patient may be on other
antipsychotic meds or benzos that will be available for
your use in the floor’s PYXIS.

Holds:
Psych holds: Generally before a patient can be
restrained, they need to be placed on a hold for either
DTS, DTO, or GD. If you place someone on a hold on a
medical floor or anywhere else in the hospital you must
notify the Psych 2S legal coordinator: Lewana Betts. On
the weekend leave her a phone message. You must fill
out the paper work, do the advisement, and place an
order in CPRS. The originals go to the 2S main office,
and copies go in the chart on the floor. (Except original
5150 advisement goes to patient!, copy goes to 2S, and
copy goes in floor chart.)
If the patient is on a hold in the ED, they must have a
one-to-one sitter.

“Medical Holds”: These do NOT exist in a legal sense. A

patient may, however, be restrained and held against
their will if it is needed for medical reasons. Generally
medical reasons include: immediate threat of death if they
don’t receive treatment, acute delirium and confusion
causing pulling out IV’s and trying to get out of bed. The
medical doctor needs to assess if the patient should be
held for medical reasons, i.e. will they die or get seriously
injured if they do not get this tx, and does the pt
understand they will die or get seriously injured. If they
don’t understand then they can be held. If they do
understand risks, benefits, alternatives then they can
decline treatment or leave the hospital AMA.

171
Tandem Call Checklist

172
The following list summarizes the oncall experience to be done
together during PGY1 year call with a senior resident. It is
provided here so to be reviewed and referred to. Actual
checklist should be done while on call with the senior resident.

 Sign out
o Receive 5050 pager and get floor/ED signout
o Review following components of signout: seen,
staffed, not staffed
o Learn to access and edit patient lists in EPIC
o Learn to udate Handoff in EPIC.
o Review relevant f/u issues during overnight call
 On-call contact information
o Attending, senior resident, MS3
 Hospital locations
o NBMU – 2 doors to NBMU, nurses’ station, utility
room, call room
o Main hospital – how to get to NBMU, hosp floor
codes, ED, cafeteria
 Phone numbers – see this guide
 ED consults
o Response to page – get relevant info for consult
o Gather information from Epic, WebCharts
o Interview patient
o Develop disposition – refer to algorithm in ishare
o Presention to attending over phone
o Determine appropriate status level of patient
o Reassess “old” patients in ED
o Dealing with 24hr unfunded ED pt requiring
admission

173
 Hospital consults
o Respond to page from floor, doing consult on
floor, determine appropriate/inappropriate
consults, locate paper charts on floors
o Perform consult, writing consult note,
communicate w/ primary team
 Disposition algorithm
o Review different possible dispositions and know
how to execute each one
 Forms
o Learn to find (nurses’ station and/or ishare) and
to do the following: hold paperwork (5150, 5250,
vol), med consent, templates (H&P, consult),
disposition (CMH, crisis house, outside psych
hosp)
 NBMU admissions
o Insurance status, alerting appropriate staff,
admit orders, forms completion, additions to
signouts
 Conclusion of overnight call
o f/u of pending studies/orders, edit sign out

174
Suicide/ Adverse Event
Protocol

175
Suicide/Adverse Event Protocol:
This protocol was created to ensure that residents get
proper support in situations where their patient has had a
completed suicide, attempted suicide or serious adverse
event. As a junior resident, please follow the following
checklists. These are divided based on the site you are
at. If you are at the hospital, like WW or VA, you would
use the hospital checklist. If you are at Gifford clinic or an
outpatient clinic, you would use the outpatient checklist.
The checklist and protocol can be found on I-share.

Junior Resident Suicide or Adverse Event Checklist

(Hospital)
-Senior resident and attending involved with patient were
notified
-Immediate check-in with either senior resident or
attending occurred
-Discussion about how patient family interactions should
be handled (junior resident, senior resident, attending)
-Resident assisted with immediate duties and given
option to leave (If during business hours treatment
team and senior resident will facilitate this. If on call,
second call system may be utilized)
-Resident offered days off as appropriate and offered up
to 5 days without call
-eQVR filed for UCSD cases, Suicide Behavior Report
filed for VA cases
-Team debriefing including involved attending, all
involved residents, involved medical students, an
nursing if appropriate within 1 week of event
-Individual meeting with designated check-in/support
person within one week of event
-Follow up meeting with check-in support person within 8
weeks following event
-Additional treatment arranged for resident if indicated
(resident/check-in person decide together)
-Completed checklist submitted to quality assurance
representative within 10 weeks
176
Guidelines for Checklist

1. Checklist is to be completed after any serious suicide

attempt, adverse event or completed suicide.
2. Junior resident and senior resident should work
together to complete the checklist. On services where
there is no senior resident junior resident and attending
should work together to complete the checklist.
3. Senior resident is responsible for helping junior
resident at each step and for turning in completed
checklist. On services where there is no senior
resident, attending is responsible to helping junior
resident and for turning in completed checklist.

Check-In Support Persons Options

Richard Avery, LCSW 619-543-0064
Nancy Downs, M.D. 858-232-4660
David Garmon, M.D.858-535-9121
Julie Kuck, Ph.D. 619-281-1932

UCSD Outpatient Psychiatric Services

Suicide or Adverse Event Checklist
-Residents and Psychology/MFT/Social Work Interns and
supervisor/faculty attending involved with patient were
notified as quickly as possible. Primary clinician and
supervisor/attending assume responsibility to inform
other team members
-Supervisors/attendings and trainees (ie residents and/or
interns) meet/talk for immediate brief check-in
-Determine how patient family interactions will be handled
(intern/resident, senior resident, fellow,
supervisor/faculty attending, Medical Director,
together)
-Trainee(s) assisted with immediate duties and option to
leave was assessed (If during business hours
177
 treatment team and senior resident/faculty will facilitate
this)
-Trainee(s) offered days off as appropriate and offered
days without call
-eQVR filed by trainee or supervisor
-Supervisor or faculty attending telephones Program
Director (Gifford or COD)within 24 hours who will report
to County QI staff
-Supervisor or faculty attending completes County
Serious Incident Report within 48 hours and give to
Program Director to fax to County QI staff.
-Department chair’s office was notified by
supervisor/attending
-Team debriefing occurred including faculty attending, all
involved residents/interns, medical students, other
trainees and nursing if appropriate within 1 week of
event
-Trainee had an individual meeting with designated
check-in/support person within one week of event
-Trainee had a follow up meeting with check-in support
person 4-8 weeks following event
-Additional treatment arranged for trainee if indicated
(resident/trainee check-in person decide together)
-Case reviewed during team meeting or special meeting
to include all trainees, staff and supervisors/attendings
involved in patient’s care and the County Serious
Incident Report Case Summary completed by
supervisor/attending and given to Program Director
within 30 days of the event
-Case presented at the Departmental Peer review
meeting
-Completed checklist submitted to Department of
Psychiatry Quality Improvement Representative within
10 wks

178
MISC

179
 PAGERS/PHONES/COMPUTERS
Pagers
Only 619-290-xxxx and a few of the VA pagers (i.e. the
call pager) take text pages. The 858-347-xxxx VA pagers
usually do not.

To text page a UCSD pager (619-290-xxxx) go to

www.myairmail.com and enter pager number (without
dashes) in the To: section. If >1 recipient, separate
numbers by commas with no spaces. Or from
webpaging.ucsd.edu. Or if in hospital, can just click on
desktop link for “UCSD Paging System.” (at this website
you can look people up by last 4 of their pager number,
last name, department, & this is where you find the
pagers for “on call” people or “consult pagers” for
other services). Regardless of the internet site you
use, text pages will only show first 240 characters.

See “beeper etiquette” section (last page of this tab) for

the format of a sample text page.

To text page the VA psych call pager go the VA home

page on any computer- when you click internet explorer
this pops up.

Phones

Hillcrest:
 to dial local numbers (619 or 858):
o dial 8  then phone number
o if you need to use the keypad at all during
your call you need to activate it by pressing
9
after you’ve dialed the phone number &
before you enter an extension or page
someone to the number you are at.
 to dial long distance:
o dial 0  tell operator this is “Dr. ------ from
(input service you are on at the time)” and
180
 I would like to dial out.
o you’ll get a dial tone, no need to dial 8
o still need to press 9 to activate keypad as
stated above
o The first three digits to a UCSD Hillcrest
number is 543-xxxx

VA in La Jolla:
 dial 9 to dial out  can proceed to dial locally or long
distance

To pick up your messages in NBMU intern offices: if red

light is blinking, you have a message. Push the button
near the light. Prompt will say “enter number, followed by
pound key”: use 5-digit extension of that phone.

U Computers

PACS: radiology viewing program. We are not

automatically given logon IDs and passwords for this
system. To get one, you file a special application to the
Radiology department, and then probably have to
shepherd the application through the system to get
results. The ED has a dedicated PACS station that is
always logged in.

Beeper Etiquette
 Turn mode to vibrate when you are in meetings.
 Use the * button to separate parts of your call-back
number. When you do this, the number appears
with dashes where ever you placed a *. So if you
are putting an area code before the number, use
the star 858*552*8585 (appears as 858-552-8585).
 Put the extension where you are followed by * and
your pager number, in case the person you are
paging can’t answer you right now. They will have
your pager number and page you as soon as they
can.

181
  Don't page to a page number, unless you don't
mind implying to whomever you are paging that
your time is more valuable than theirs.
 When using voice pagers always remember that
others around the pager can hear the message.
Never use the name of the pt or discuss a problem
on a voice pager. Your name, extension & level of
urgency is all that is needed. For example 'Leslie
paging Dr. Smith, please call extension X, when you
get a chance' (or 'as soon as possible', or 'now' for
reasonably urgent matters).
 If you are paging on an emergency issue, it is
acceptable to put *911 after your extension to
indicate importance.

Sample Text Page: Hello this is (first name) or Dr. (last

name) from psychiatry re: pt Sigmund Freud (MRN:
12385987), wanted to discuss (very very brief: e.g
medications), x37982 or page (appropriate pager
number e.g. 5050) when convenient. Thanks.

Access to Online Clinical Library (E-journals,

UpToDate, etc.)
 Change proxy server to:
libraries.ucsd.edu/proxy
 Go to URL: gort.ucsd.edu/clinlib
 Enter network userid and password:
same as for your email
 If working from Mercy library computer, when
finished, change proxy server back to:
webproxy.ucsd.edu/proxy.p1

182
IDS/PASSWORDS/DOOR CODES
Provider # (PID):
License #:
National Provider ID (NPI):
DEA #:

E-mail: Go to URL: hsmail.ucsd.edu

Username:
Password:

UCSD copier code:

Ask ward clerk set up your account
Code will be your SSN – can use on any copier at UCSD
MC

Computers:
UCSD
EPIC:
User ID:
Password:

PACS (radiology viewing program)

User ID: weboutlook user id
Password: weboutlook password
Help pager: (619) 290-3936

183
Computers, cont’d:
VA
Network login: vhasdc_________
st
usually 1 five letters of last name
st
and 1 letter of first name
Password (changes often):

CPRS:
Access:
Verify (changes often):

ESC:

IT help desk: x4767

Andy Mosley (CPRS guru): x1034

Mercy: all computer logistics will be provided for you

when you begin your rotation there:
ID (aka “dictation number”):
(assigned by MedEd)

Password:

Dominator (image viewing):

ID:
Password:
You don’t get a set for yourself, but you may
borrow from a friendly categorical intern

184
Door Codes

UCSD
ER: 035* ER supply rm 25#
NBMU: 6 digit employee ID # + UCSD ID
SBH: 8631
th th
CCU (10 fl): 619* MICU (9 fl): 1234
nd th
SICU (2 fl): 642 BURN ICU (5 fl): 543
nd nd
PACU (2 fl): 7788 L&D (2 fl): 8710*
nd
Main OR (2 fl): pick up phone
House-staff lounge/gym (WW): 4512
House-staff lounge(next to cafeteria) 142 enter
Urgent Care 413*

VA

Resident lounge (rm 3207B): 3208

Psych resident call room:
Medical student call room:
ER supply room: 7302
ED cabinet: 1346
ER (changes frequently):

Mercy
ER: 019
Endoscopy 760
Chest Pain Center: 19
IntermediateCU: 323
SICU: 0234
MICU: 234
th
5 fl copier room: 235
th
8 fl supply room: 521
nd
Intern call room (2 fl): needs a key from MedEd

185
Important Addresses:
VA Medical Center
3350 La Jolla Village Drive
Dept. of Psychiatry – 116A
San Diego, CA 92161
858-552-8585
858-534-4040 (RTO)

UCSD Dept of Psychiatry

UCSD Mail Code 0603R
9500 Gilman Drive
La Jolla, CA 92093
(only collected once per week)

NBMU – Neuropsychiatry & Behavioral Medicine Unit

200 W. Arbor Dr
Mail Code 8620
San Diego, CA 92103
(619) 543-6350
(619) 543-5732

UCSD Outpatient Psychiatric Services (Gifford Clinic)

140 W. Arbor Dr
San Diego, CA 92103
(619) 543-6250

Scripps Mercy Hospital

4020 5th Ave
San Diego, CA 92103
(619) 294-8111

186
CAPS
6535 Alvarado Road
San Diego, CA 92120
(619) 229-3700

Children’s Hospital
3020 Children’s Way
San Diego, CA 92123
(858) 576-1700

Children’s Outpatient Psych Clinic

Children’s Plaza Building
3665 Kearny Villa Road
San Diego, CA 92123
(619) 282-3970

Scripps Chula Vista

435 H St
Chula Vista, CA 91910
(619) 691-7000

St. Vincent de Paul Medical Center

1501 Imperial Avenue
San Diego, CA 92101
(619) 233-8500 ext 1421

Child Protective Services

858 694 5191
http://www2.sdcounty.ca.gov/hhsa/ServiceCategoryDetail
s.asp?ServiceAreaID=83

Adult Protective Services

1 800 510 2020
http://www2.sdcounty.ca.gov/hhsa/ServiceCategoryDetail
s.asp?ServiceAreaID=165

187
PHONE DIRECTORY
Residency Training Office at the VAMC
(858) 534-4040 fax: (858) 822-0231

UCSD
Many extensions can be dialed from an outside line:
(619) 54X-XXXX (with Xs representing extension #s)

Main number (619) 543-6222

On call pager (619) 290-5050
NBMU (619) 543-6350 (3-6350)
Fax: (619) 543-5732\
Optum/UBH (800) 798-2254
Office 1 3-2480
Office 2 3-2481
Chief’s office 3-2482
Dr. Becker 1-0360 (voicemail)
Pager (619) 290-4174
Dr. Feifel 3-2485
Cell (619) 405-5929
Dr. Perry 3-5573
Pager (619) 290-9599
Drs F&P’s secretary 3-2827
Dr. Sewell 3-3779
SBH RN station 3-7505
SBH admissions 3-3741 pager: 3569
Neuro call pager (619) 290-2354
Neuro MedEd 3-6266 (Sheila, Judy)
Arpi Minassian pager: (619) 290-5331
Marc Norman pager: 3125
ED MD work room (aka “doc box”) 3-2130
Fax number 3-3122
Page operator 3-6737
Owen Back Line 3-3999
Owen Triage RN 33855
Loan Deferments 3-7820
Information Services 3-7474
Translators pager: 3060
Patient advocate (619) 543-9998
188
 Medical Records 3-6704 (days)
Back line 3-6700
Fax 3-3287

Gifford Clinic (619) 543-6250

CAPS (619) 229-3700
fax (619) 229-1516
ESU (Emergency Screening Unit) –dispo of pts < 18
(858) 493-6394
Child consult (858) 494-7437 (8am-4pm)
(858) 493-6394 (4pm-8am)

voice mail 3-7880 then follow instructions

RTAS 3-7140

UCSD Labs
(619) 543-9600
chem 3-6020
heme 3-5950
tox 3-5780
EKG 3-6399
EEG 3-5760
radiology file room 3-6586

Thornton 858-657-7000

189
VA
Main number (858) - 552- 8585
(automated menu)
To reach an extension, press 4, 4-digit ext., “#”
To reach operator, press 0
To call an extension directly from o/s hosp:
(858) 642-xxxx
VA pagers all start with (858) 347-
Online phone directory: start…7 with lightning bolt
On call phone 858-642-6353
2S Charge RN 858-864- 2684
Psych consult 858-230-2080

2S pharmacist 3490
Pager-days 347-1414
Pager-nights 347-1408
Pager-outpatient 347-2060
Susan Leckband 5537 Pgr 347-1917

UCC workroom 3388

UCC fax (858) 642-3494
MAOD 4344

2S main clerk 3005

2S fax (858) 552-4338
A pod 3786, 3787
B pod 3795, 3796
C pod 3815, 3816
2S D pod offices: Rm 2227 (5457, 6429)
2227A (5458, 5462)
2227B (2417, 3802)
2W Inpt ADTP 3011 or 3665
Fax (858) 642-6379
ADTP A pod resident 3943
B pod resident 3942
Senior 3929
PEC resident 3649
SW 6316 pg 858-347-1610
ED Doc Box 1096, 2391, or 2348

190
 Dr. Lehman 3674 Pgr (619) 290-4706
Dr. Rao 1270 Pgr 347-1218
Dr. Printz 3045
Dr. Robinson 3409 Pgr 347-1559
Dr. Groban Pgr 347-0117
home (858) 755-0099
cell (858) 245-2323
Dr. Banta 3418 cell (619) 296-8419
Dr. Flood 3844 Pgr 347-1968
cell (415) 794-9070

2N OP clinics 3391/3665
PEC, Mood, Cognitive, ADTP
SAMI 7300
Frank Garcia 3771
2W STEP 3724
Gerri Smith 1196
2E Geropsych 3046
Psych /PC Clinic 3983
Kathy Lyttle pgr 347-1782
Maureen Grone 3800 pgr 347-1661
Main Psych Office 3576

Medicine (admitting/consult) (619) 290-7173

Neuro call pager (619) 290-2361
Mission Valley clinic (619) 400-5000
SPID 3168
Hep C (Access) 3157
TB nurse 1017
FIRM (4N) 2500
Establish FIRM 1600
DOU (Direct Observation Unit) 7979
PACU 3611
4N FIRM main desk 2907
Smoking cess clinic 3903
RTAS 4302 (code: 1999, then #, then
SSN, then #
Housekeeping 3281
Sandy Bee 3345

191
 Notary Public 3474

Labs
Phlebotomy 2380
Lab Processing 7707
Add on labs 3426 or 7707
Chemistry 7751
Microbiology 3367
Heme 3420
EEG 3306, 3688
Lab corp (619) 295-9327

Information Technology
IT help desk 4767 (contracted o/s hospital)
Jesse Christmas (remote access): 6200
Andy Mosley (CPRS guru): 1034

Mercy
Main number (619) 294-8111
Med Ed (619) 260-7200 or 7220
th
X floor (619) 260-72X0
th
e.g. 5 floor is (619) 260-7250
th
11 floor (619) 260-7211
Med records (619) 260-7190
ER fax (619) 260-7369
Mercy Clinic (619) 260-7087
Mercy Clinic PCC nurse’s desk (3rd fl) (619) 260-7110
Intern call pager: none (will use your own pager)
nd
Intern 2 call pager: (619) 290-6866
nd
Resident 2 call pager: (619) 290-6875
MD line (619) 686-3900 or ext 4111

Pharmacies
UCSD DC (619) 543-3279
Thornton (858) 657-8610
UPAS (619) 297-1677
Hillcrest (619) 260-1010
Priority (619) 688-2222

192
Most Useful Numbers and Codes
San Diego Crisis Line (24hr/7day) (888)724-7240

UCSD Admitting (can call to verify insurance status)

ext 36570 (business hrs)
ext 36331 (after hrs)
UCSD Nursing Supervisor (for Crisis House tx)
pager: 290-2616
fax: 32454
UCSD Transfer Coordinator (for inpatient tx)
phone: 35709
fax: 37448
CMH (to reach nurses station) (619) 692-8222
CMH (to reach social work) – this is person to call to
find out where a patient in line for transfer is on the
waiting list (619) 692-8818
Public Conservator’s Office (619) 692-5664

NBMU front desk 36350

NBMU fax 35732
NBMU office 1 32480
NBMU office 2 32481
NBMU Chief’s office 32482
NBMU conference room 33263

RTO ph: 858-534-4040 fax: 858-822-0231

UCSD Door Codes

ER: 035* ER supply rm 25#
NBMU: Name badge +6 digit employee ID
SBH: 8631
th th
CCU (10 fl): 619* MICU (9 fl): 1234
nd th
SICU (2 fl): 642 BURN ICU (5 fl): 543
nd nd
PACU (2 fl): 7788 L&D (2 fl): 8710*
nd
Main OR (2 fl): pick up phone
House-staff lounge/gym (WW): 4512

193
VA Numbers
Dr. Lehman 3674 or p: 619-290-4706
Dr. Rao 1270 or p: 858-347-1218
Dr. Printz 3045 or p:

2S Clerk 3005
2W Clerk 3011
Pharmacy 3490 or p: 858-347-1414
Admission Nurse c: 858-864-2684
PEC Resident x3649

A-pod x3786 or 3787

B-pod x3795 or 3796
C-pod x 3815 or 3816
D-pod (Kathy Lyttle) x3983 or 5466

194
NOTES

195
NOTES

196
NOTES

197