Controversies Surrounding Medical Clearance in Psychiatry Patients: Evidence, Recommendations, and Potential Approach

Abstract

Background: Despite the evidence and guidelines recommending otherwise, routine testing remains pervasive in the management of patients presenting to the Emergency Department (ED) for behavioral complaints under the guise of Medical Clearance (MC). The aim of this review is to highlight the evidence available concerning routine laboratory testing in psychiatry patients presenting to the ED, underline available guidelines, list possible reasons for over-testing, and propose a possible approach based on all the evidence and recommendations. Methods: Electronic database searches were carried out in Medline/PubMed and Google Scholar, with the period set from January 1, 1990, to March 1, 2021. The search process was focused on studies in which MC was evaluated in the management of patients presenting for psychiatric complaints to the ED. The references listed in each identified article were also screened and manually searched. Results: A total of 14 relevant studies were found. The majority of the studies evaluated the impact of routine laboratory testing on the management and disposition of adults in the ED presenting for an acute psychiatric condition. Two studies investigated the use of a screening tool to rule out the presence of acute medical illness. Conclusion: While ED physicians are faced with many challenges, such as litigation and fear of diagnostic uncertainty, few solutions have been proposed. A suggested approach relies on history taking, physical examination, and assessment of mentation to evaluate for the presence of an organic etiology requiring further testing. Adequate communication between the ED physician and psychiatrist, along with shared decision-making, are also the key to optimizing care.