Initiating Psychotropic Medications in the Emergency Department

Psychiatric presentations to Emergency Departments (EDs) are increasingly common and are associated with prolonged stays as well as increased rates of admission. Emergency physicians (EPs) often care for psychiatric patients and are faced with decisions regarding medication management. Initiation of psychotropic medications in the ED is a low-risk intervention with significant potential benefit to patient care. Rather than passive observation, it has been suggested that initiation of medications in boarding patients may be beneficial. It may also be advantageous to initiate medications for patients being discharged from the ED given often limited outpatient access. It is an easier argument to restart medications that the patient may have stopped using. These psychotropic medications including antidepressant medications (ADMs), second generation antipsychotics (SGAs) and anxiolytics are reasonable medications to prescribe from the ED. ADMs – primarily selective serotonin reuptake inhibitors (SSRIs) and bupropion – are reasonable to initiate following appropriate mania screening. SGAs such as quetiapine, olanzapine, and risperidone can be used for patients with psychosis, acute mania and as adjuncts in depression or anxiety. Though SSRIs are the mainstay of treatment for anxiety, short-term benzodiazepines, buspirone, gabapentin, and pregabalin may also be used. Re-initiation of psychotropic medications – including those discussed above as well as lithium, lamotrigine, and valproate – may be reasonable after consideration of prior response, duration of interruption and potential adverse effects. This presentation using case presentations will not present the advantages of starting or restarting psychiatric medications in the ED but also provide medication recommendations, dosing and potential side effects.