SGEM#285: And I See Your True Colours Calming You – From your Anxiety

Date: February 28th, 2020 Reference: Rajendran et al. Randomised control trial of adult therapeutic colouring for the management of significant anxiety in the Emergency Department. AEM February 2020 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Case: One night during an overnight shift, you are taking care of a patient who presented to the emergency department (ED) due to anxiety and vague suicidal ideation. The process for medical clearance and psychiatric evaluation can take quite a while, and you notice that this patient seems stressed and anxious. You wonder if there’s a way to assist them during the prolonged wait without resorting to sedative medication. Background: Psychological disorders are a common reason for presenting to the ED. Anxiety disorders are the most common (Marchesi et al EMJ 2004). However, we have only covered mental health issues a few times on the SGEM: SGEM#45: Vitamin H (Haloperidol for Psychosis) SGEM#178: Mindfulness – It’s not Better to Burnout than it is to Rust SGEM#218: Excited Delirium Syndrome SGEM#237: Screening Tool for Child Sex Trafficking SGEM#252: Blue Monday- Screening Adult ED Patients for Risk of Future Suicidality Patients with psychological disorders are often kept in the ED for a prolonged period of time. The ED itself can be a stressful environment and exacerbate anxiety. Emergency physicians have pharmaceutical options to treat anxiety. One of the most common medications to use is a benzodiazepine like lorazepam or diazepam. There is a need for non-pharmacological therapies to treat anxiety, and in some settings, art therapy has been studied. Specifically, adult coloring books have been used in the community and seem to function through cognitive easing (Rigby et al BMJ 2016 and Curry et al Art There 2005). Clinical Question: Can colouring decrease anxiety in adult patients presenting to the emergency department? Reference: Rajendran et al. Randomised control trial of adult therapeutic colouring for the management of significant anxiety in the Emergency Department. AEM February 2020 Population: Patients >15 years old with a score of >6 on the Hospital Anxiety and Depression Scale Anxiety (HADS-A). A score of >6 is considered moderate to severe anxiety. Intervention: Colouring pack (10 adult colouring pages and 36 pencil colours) Comparison: Placebo pack (10 plain sheets of paper, a Bic pen and instructions to draw or write freely) Outcome: Primary Outcome: Within-patient change in HADS-A score from baseline after two hours of therapy. Secondary Outcomes: Survey questions regarding value of therapy and level of engagement with treatment packs (length of time) Dr. Naveen Rajendran This is an SGEMHOP episode which means we have the lead author on the show. Dr. Naveen Rajendran is an intern at the Westmead Hospital in Sydney with a keen interest in emergency medicine and the investigation of novel therapies that could aid in alleviating the growing stress on modern emergency departments. This study was conducted when he was a medical student at the University of Sydney with Dr. Coggins (@coggi33) who was his research supervisor. Authors’ Conclusions: “Among ED patients, exposure to adult colouring books resulted in lower self-reported levels of anxiety at 2-hours compared to placebo.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patients were adequately randomized. Unsure The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). Unsure The patients in both groups were similar with respect to prognostic factors. Yes All participants (patients, clinicians,