This is a blog post designed to disseminate the important work of Choosing Wisely, an initiative of the the American Board of Internal Medicine Foundation, the goal of which is the spark conversations between clinicians and patients about what tests, treatments, and procedures are needed – and which ones are not.

Acute-onset psychosis can occur due to an underlying medical cause or psychiatric disease and the two can be challenging to differentiate. However, the vast majority of pediatric patients with psychiatric complaints do not present with undifferentiated acute psychosis; rather, they are seen for behavioral concerns or suicidal ideation. When should the emergency physician obtain lab tests to medically clear such patients?

Decades ago, psychiatric complaints in the pediatric ED were infrequent. It was therefore common practice to obtain some or all of the following studies:

• Complete blood counts
• Chemistries (electrolytes, liver panel)
• Drug screens (urine drugs of abuse, acetaminophen, salicylate, ethanol)
• Urinalysis
• Thyroid studies
• EKGs
• Head CT

These were all obtained in an effort to make sure that medical interventions were not needed before admitting the patient to an inpatient psychiatric facility. These labs were not truly indicated, but it was common practice and viewed as “not a big deal.” Also, while evidence for lab evaluation based on history and exam findings was established for adults, children were considered to have a medical etiology (organic psychosis) until proven otherwise.  

Now, on any given day, a busy pediatric ED is expected to care for a multitude of patients with a variety of psychiatric complaints every day. In fact, some Emergency Departments note that as many as one tenth of their patient volume is mental health. These presentations include behavior concerns, depression, anxiety, and harm to self or others.  The vast majority of these patients have obvious psychosocial stressors and emotional dysregulation that are clearly not due to medical pathology. They carry existing diagnoses and are followed by outpatient mental health providers. Acute onset psychosis is relatively rare. There is abundant evidence showing that routine lab tests in such patients have a very low yield and are not indicated, in adults as well as in children.

What remains as relevant today as always is the importance of a thorough assessment in all such patients to exclude medical (quickly reversible) etiologies for their symptoms.  Life threatening non-psychiatric causes of acute psychosis include hypoglycemia, cerebral hypoxia, drug toxicity, CNS abnormalities (such as brain tumor, meningoencephalitis, injury, seizures, or stroke), metabolic conditions, electrolyte disturbances, hepatic failure, uremia, or thyrotoxicosis.  Patients with psychosis caused by medical illness usually have abnormal vital signs, altered mental status, and impaired orientation with compromised intellectual function. Visual and tactile hallucinations (as opposed to auditory) are frequently prominent. Attention to any toxidromes, any abnormal vital signs or mental status, eye findings, and neurologic examination provide the greatest help in narrowing the differential diagnosis. 

On the other hand, a patient with psychiatric etiologies typically has normal vital signs; normal orientation to person, place, and time; and intact memory with good cognitive functioning. Hallucinations, if present, are usually auditory in nature and neurologic exam is normal.

The key differentiating points in who needs lab tests and who does not are: ‘acute-onset psychosis’ and ‘any abnormal findings on history or exam’. If there are concerns after a thorough history and exam, appropriate lab tests are indicated. In those without psychosis, those with likely psychosocial issues, especially those with a prior history of psychiatric diagnoses, and with reassuring history and exam, lab tests are not necessary to exclude a medical condition.

Why then do we inflict more pain on an already suffering child when they need comfort and reassurance?  And we do this even when we know from years of growing evidence that the yield of these routinely ordered screening tests is very poor? The answer lies in old habits and, in many US states, inpatient psychiatric facilities that ‘require’ these tests for medical clearance before accepting the patient. In addition to the aforementioned tests, the COVID-19 pandemic has led many to request or require viral testing prior to inpatient admission, even in asymptomatic patients. 

The Choosing Wisely recommendation hopes to encourage change on both these fronts.

Do not obtain screening laboratory tests in the medical clearance process of pediatric patients who require inpatient psychiatric admission unless clinically indicated

 A pragmatic approach to this will take:

1. An individual commitment to (a) consider lab tests only for presentations where a medical etiology is in the differential, such as acute onset psychosis, and (b) order diagnostic tests directed by the patient’s history and physical examination. Routine laboratory testing does not need to be performed.
2. Systematic change so that routine laboratory testing is not required by facilities accepting patients for inpatient psychiatric treatment. Laboratory evaluation should be based on individual patient history and exam.

Pediatric behavior and mental health is an epidemic, and one that is likely to get even worse. We need to choose wisely and act prudently for our patients, as individual practitioners and as accepting inpatient psychiatric facilities.

This episode of PEM Currents: The Pediatric Emergency Medicine Podcast approaches the topic from another angle and also discusses how we can avoid sending lab studies to “medically clear” patients requiring psychiatric admissions featuring an in depth interview with Dr. Shabnam Jain and Dr. Shilpa Patel.

References

Thrasher TW, Rolli M, Redwood RS, et al. ‘Medical clearance’ of patients with acute mental health needs in the emergency department: a literature review and practice recommendations. WMJ. 2019;118(4):156-163

Donofrio JJ, Horeczko T, Kaji A, Santillanes G, Claudius I. Most routine laboratory testing of pediatric psychiatric patients in the emergency department is not medically necessary. Health Aff (Millwood). 2015;34(5):812-818

Chun TH. Medical clearance: time for this dinosaur to go extinct. Ann Emerg Med. 2014;63(6):676-677

Donofrio JJ, Santillanes G, McCammack BD, et al. Clinical utility of screening laboratory tests in pediatric psychiatric patients presenting to the emergency department for medical clearance. Ann Emerg Med. 2014;63(6):666-675.e663.

Santillanes G, Donofrio JJ, Lam CN, et al. Is medical clearance necessary for pediatric psychiatric patients? J Emerg Med. 2014;46(6):800-807

Santiago LI, Tunik MG, Foltin GL, Mojica MA. Children requiring psychiatric consultation in the pediatric emergency 

Berg JS, Payne AS, Wayra T, Morrison S, Patel SJ. Implementation of a Medical Clearance Algorithm for Psychiatric Emergency Patients. Hosp Pediatr (2023) 13 (1): 66–71