P s y c h i a t r i c Em e r g e n c i e s

Santina Wheat, MD, MPH*, Dorothy Dschida, MD,

Mary R. Talen, PhD

KEYWORDS
 Suicide  Homicide  Mania  Psychosis  Agitation  Psychiatric emergency

KEY POINTS
 Psychiatric emergencies, such as mania, psychosis, and suicidal or homicidal ideation,
present as an acute disturbance of thought, behavior, or mood that require prompt inter-
vention to prevent imminent danger.
 The first priority in a psychiatric emergency is ensuring the safety of the patient and those
surrounding.
 Initial assessment should consist of a thorough history and physical examination, to rule
out underlying medical causes, while simultaneously establishing a safe environment for
patient and clinician.
 It is imperative to debrief with the patient, family, and the health care team following the
treatment of a psychiatric emergency.
 There are important legal considerations, particularly concerning involuntary admission,
surrounding psychiatric emergencies.

INTRODUCTION

A psychiatric emergency is defined by the American Psychiatric Association as

“an acute disturbance in thought, behavior, mood, or social relationship, which
requires immediate intervention as defined by the patient, family, or social unit.”
Such emergencies require immediate intervention to save the patient and/or others
from imminent danger. Patients who present with a psychiatric emergency typically
have a diagnosis of mania, acute psychosis, suicidal ideation, or homicidal ideation.
The causes of these extreme disturbances in patients’ behaviors can be multifaceted
and caused by substance use, medical illness, mood disorder, or extreme anxiety and
trauma. Ninety percent of patients who have been suicidal also have a psychiatric
diagnosis, such as major depression, substance abuse, or schizophrenia. It is also
estimated that up to 50% of patients with psychiatric emergencies have a coexisting
medical disease. Thus, medical screening is important in identifying physical condi-
tions that may be the cause of, or contributing factors to, the psychiatric emergency.1

Northwestern McGaw Family Medicine Residency Program, Erie Family Heath Center, 2750 West
North Avenue, Chicago, IL 60647, USA
* Corresponding author.
E-mail address: swheat@eriefamilyhealth.org

Prim Care Clin Office Pract 43 (2016) 341–354

http://dx.doi.org/10.1016/j.pop.2016.01.009 primarycare.theclinics.com
0095-4543/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
342 Wheat et al

Psychiatric emergencies are frequent in hospital and outpatient settings. The

reported percentage of emergency department visits that are psychiatric emergencies
varies from 6% to 25%.1,2 Additionally, 10% of primary care visits are for psychiatric
emergencies.2 More importantly, medical providers are the front line in assessing pa-
tients who are at risk for suicide. However, primary care providers have not adequately
detected the level of risk of patients with suicidal thoughts and behaviors.3 Although
suicidal ideation is present in 2% to 7% of all primary care patients, primary care pro-
viders have low rates of inquiry, detection, and intervention.4–8 It is estimated that 50%
of patients who committed suicide had been seen by their primary care physician
within 1 month of their death,1,4 and 20% of adults who die by suicide visited their
primary care physician within 24 hours of their death.9 Consequently, medical pro-
viders, including nursing and support staff, need to be trained in the assessment,
treatment, and management of these patients.

SCREENING/DIAGNOSIS: PSYCHIATRIC AND MEDICAL ASSESSMENTS

The most important first step in the management of a psychiatric emergency is the
initial evaluation. An evaluation should take place in a quiet, private room where the
safety of the patient, provider, staff, and other individuals can be maintained. When-
ever there is a patient who is extremely agitated, aggressive, or suicidal, the health
care team needs to be aware and alert. Patients who need a crisis intervention in a
psychiatric emergency typically fall into three main categories: (1) acute psychosis
and mania, (2) suicidal and depressed patients, and (3) aggressive and homicidal pa-
tients. For each type of psychiatric crisis, the screening and management process
may differ and require specific types of interventions.

Acute Psychosis and Mania

Patients with acute psychosis and manic behaviors present with eccentric and exag-
gerated behaviors; unusual, disorganized, and paranoid thinking; and intense or
inappropriate emotional expressions. It is particularly important in the initial evaluation
of patients with mania and acute psychosis to screen for organic diseases that may be
causing these symptoms. These medical conditions may include delirium, infections,
metabolic/endocrine disorders, medications, substance abuse/withdrawal, and
central nervous system disorders (Table 1).1 This step is crucial to ensure correct
diagnosis and to exclude toxic substances or a medical disorder as the cause.10,11
Assessing the past medical history of the patient may assist in the detection of a
physical condition versus a purely psychiatric disorder (Boxes 1 and 2).1 If the mania
or psychosis is caused by a medical condition, the treatment is different. For example,
delirium is an acute state of confusion or disturbance of consciousness caused by
a medical illness, and this diagnosis changes the goals and medical management.
The four key elements that distinguish delirium from acute psychosis include (1) time
course, (2) disturbance of consciousness, (3) change of cognition, and (4) evidence
of medical cause.1
After safety is established for patient and staff, the next step of the evaluation is to
obtain a history of the incident; ask for a description of what happened during a crisis
event. This information should be obtained from the patient; family; friends; or even
individuals who observed the patient, such as bystanders, police, or neighbors. Pro-
viders should also review prior hospital records, if possible.1,4,10,11 Obtaining informa-
tion from family members and others involved in the life of the patient is particularly
important, especially when the patient is cognitively impaired, agitated, paranoid, or
having difficulty contributing to the history for other reasons.4
 Psychiatric Emergencies 343

Table 1
Differential diagnosis for patients with mania or acute psychosis

Infections Bacterial and viral Herpes simplex Symptomatic infections (urinary

meningitis encephalitis tract infections, Pneumonia)
Metabolic Hypothyroid Diabetes mellitus ––
derangements/ Hyperthyroid  Hyperglycemia
endocrine  Hypoglycemia
abnormalities
Medications Polypharmacy Anticholinergic ––
agents
Substance abuse –– –– ––
and withdrawal
Central nervous Epilepsy –– ––
system disorders

Data from Sood TR, McStay CM. Evaluation of the psychiatric patient. Emerg Med Clin North Am
2009;27(4):669–83, ix; and Hirschfeld RM, Russell JM. Assessment and treatment of suicidal
patients. N Engl J Med 1997;337(13):910–5.

After obtaining the history, the clinician should determine how alert and oriented the
patient is to person, place, and situation. The clinician can then assess for dissociation
from reality. This may include assessing for hallucinations and delusions, listening for
disorganized thinking or behavior, tangential speech, and observing for blunted affect
and avolition. This includes assessing activities of daily living, such as hygiene or
eating, and instrumental activities of daily living, such as shopping or managing
money. Next, the clinician should obtain the past medical history including psychiatric
history and history of substance use. The physical examination should include vital
signs, general appearance, attention, and interaction. A full neurologic examination
including assessment of alertness, orientation, strength, sensation, cranial nerves,
gait, cerebellar tests, and reflexes should be done. Finally, specific organ systems
should be assessed particularly looking for signs of infection, hepatic dysfunction,
trauma, and cardiac disease.1 Provisional diagnoses of the mental disorder and any
potentially contributing medical diagnoses or substance use should be made to guide
further evaluation and management decisions (Fig. 1).4
Screening tools can be useful for assessment of the patient with acute psychosis or
mania. The Mini Mental Status Exam and the Quick Confusion Scale are useful tools to
help providers evaluate a patient’s cognitive functioning.12 In addition, a patient’s level
of agitation is assessed using the Agitation Behavior Scale or the Behavioral Activity

Box 1
Patients likely to have coexisting medical illness

1. Elderly
2. History of substance abuse
3. No history of psychiatric history
4. Pre-existing medical illness
5. Lower socioeconomic status

Data from Sood TR, McStay CM. Evaluation of the psychiatric patient. Emerg Med Clin North
Am 2009;27(4):669–83, ix.
344 Wheat et al

Box 2
Key points of assessment of suicidal patient

 History
 Current circumstances
 Mental state
 Suicidal thinking
 Suicidal behaviors

Data from Practice guideline for the assessment and treatment of patients with suicidal behav-
iors. Am J Psychiatry 2003;160(11 Suppl):1–60.

Ratings Scale.1,13 Failure to refer to standardized criteria for assessing the level of risk
is a common pitfall and can lead to inadequately triaging the patient.14
After a history and examination have been completed, the clinician may consider
laboratory studies. If a patient has a significant psychiatric history, laboratory studies
are unlikely to add much useful information. However, certain tests can be done to rule
out common medical causes and substance use. The diagnostic evaluation should be
dictated by the specific psychiatric symptoms and the patient’s history and physical
examination.15 For example, a urine drug screen or blood alcohol level may be useful
in assessing for intoxication and specific substance abuse. A lumbar puncture is only
useful in the setting of suspected meningitis or encephalitis. Computed tomography
scan or other imaging is unlikely to add much information if there are no focal findings
on examination, except in the case of an elderly patient.1,16
Suicidal and Homicidal Ideation
The evaluation of a patient with suicidal ideation is different than that of a patient with
acute psychosis or mania. This evaluation is done to identify factors that increase or
decrease risk of suicide, to address immediate safety to determine the most appro-
priate setting for treatment, and to develop a differential diagnosis that can further
guide the plan of treatment. Throughout this evaluation, it is important for the clinician
to elicit details surrounding the patient’s history and situation, and to maintain a good
rapport with the patient while demonstrating empathy.4
Similar to the assessment of patients with other psychiatric emergencies, the
clinician should identify specific psychiatric signs and symptoms and assess for
immediate safety (Box 3). During questioning of the patient, the clinician should inquire
about past suicidal behavior and frequency of attempts and means. The clinician
should also assess for the consumption of drugs and alcohol, because these may
make the patient more impulsive, aggressive, and cognitively impaired. There should
be an assessment of what treatments the patient has had previously and their
response to interventions. An assessment of family history of mental illness and partic-
ularly of suicides of family members is important in determining risk. The clinician
should determine the current social situation and any recent losses of relationships,
status, or employment. The patient should also be evaluated for positive coping skills,

Fig. 1. Evaluation of patient with psychiatric emergency. (Data from Sood TR, McStay CM.
Evaluation of the psychiatric patient. Emerg Med Clin North Am 2009;27(4):669–83, ix.)
 Psychiatric Emergencies 345

Box 3
Risk factors for eventual suicide

 Male sex
 Age greater than 60
 Widowed or divorced
 White or Native American
 Lives alone
 Unemployed/financial problems
 Recent adverse event
 Depression
 Schizophrenia
 Substance abuse
 History of suicide attempts or ideation
 Feelings of hopelessness
 Panic attacks
 Severe anxiety
 Severe anhedonia

Data from Sood TR, McStay CM. Evaluation of the psychiatric patient. Emerg Med Clin North
Am 2009;27(4):669–83, ix; and Hirschfeld RM, Russell JM. Assessment and treatment of suicidal
patients. N Engl J Med 1997;337(13):910–5.

low self-esteem, cognitions (pessimistic thoughts or “all or nothing” thinking), and

dependent psychological needs that may increase or decrease suicide risk.
Ultimately, the clinician must specifically inquire about the patient’s intensity of
suicidal thoughts, lethality of suicidal plans, accessibility of the means to kill oneself,
and current suicidal attempts. Despite clinicians’ fears, they will not plant the idea of
suicide if they ask about the patient wanting to die or feeling suicidal. It may actually
provide a relief to the patient by opening an opportunity for discussion. The patient’s
specific plan should also be assessed. The patient’s belief of the lethality of the plan
may be as important as the actual lethality of the plan.4
It is important to identify factors that increase a patient’s risk for attempting suicide.
Some patient factors that generally increase or decrease risk for suicide are not
modifiable, but some are and can potentially serve as points of focus for intervention
in the short and long term. Scales have been developed to assess suicide risk.
Unfortunately, they have high false-positive and false-negative rates, and therefore
are not useful for prediction of who is at imminent risk. They can, however, be useful
to assist in communication with a patient with suicidal ideation.4 Other screening tools,
such as those for depression and anxiety, can also be useful in helping to develop a
treatment plan, although these are not adequate to identify whether the patient is
an immediate risk for attempting suicide.1
The assessment of the homicidal patient is similar to that of the suicidal patient.
Epidemiologic data are not available to determine who is likely to commit homicide.
The most reliable predictive risk factor a clinician should assess for is a history of
violence and access to weapons. While assessing a patient with homicidal ideation,
it is important for the personal safety of the provider to have a quick exit route that
cannot be blocked by the patient.4
346 Wheat et al

MANAGEMENT GOALS

Once the evaluation has been completed, the clinician must determine whether the
patient is willing to form an alliance that allows for successful assessment and treat-
ment. The clinician should determine if the patient is at risk of harm to self or others
and then if involuntary treatment and admissions are necessary. The clinician should
then develop a specific plan, which includes immediate treatment, disposition, and
follow-up.4
Acute Psychosis, Mania, and Agitated or Homicidal Patients
The first priorities regardless of the cause of behavior are stabilizing and ensuring the
safety of the patient, staff, and family or friends. After ensuring the safety of the patient
and staff, the initial approach to an acutely agitated patient should involve assisting the
patient to manage his or her stress. The methods of assisting the patient are via behav-
ioral interventions, pharmacologic interventions, or both if necessary.2,17,18 When the
patient has a comorbid medical illness contributing to the psychiatric emergency, it is
crucial for the clinician to also treat the medical illness. In some cases, the medical
illness is the cause of the psychiatric emergency and is therefore important for the
clinician to distinguish. The clinician must distinguish whether these emergencies
are secondary to substance or medication use or organic disease using certain clinical
criteria, including (1) greater than 30 years with no personal history of psychiatric
illness, (2) history of illness or substance use, (3) sudden onset or fluctuation of psychi-
atric symptoms, (4) confusion and disorientation to time and place, (5) symptoms not
corresponding to a specific psychiatric diagnosis, (6) abnormal vital signs, (7) coexist-
ing signs of specific organic illness, and (8) poor response to treatment.11 The pres-
ence of these clinical criteria alters the goals of care. Additionally, the provider must
determine the most appropriate location of care. The locations chosen must allow
the patient to be treated and have the least amount of restrictiveness while still main-
taining safety (Box 4).
Suicidal Ideation
Treatment of the patient with suicidal ideation should focus on mitigating risk and
strengthening protective factors that are modifiable (Box 5). Such modifiable factors
include patient safety, associated psychological or social stressors, social support
networks, and potentially treatable psychiatric disorders. When managing a patient
with suicidal ideation, the clinician must first foster a therapeutic alliance while
attending to patient safety. With use of the information gathered in the assessment,
a treatment setting should be determined and a treatment plan developed. The
clinician should promote adherence to the treatment plan with the patient and any per-
sons providing social support through education and should coordinate care and

Box 4
Criteria for psychiatric admission

1. There must be evidence of severe psychiatric illness

2. There must be a clinically indicated evaluation of any suspected medical illness
3. Any medical problems must be sufficiently stable to allow safe transport to and treatment at
the state-operated psychiatric facility.

Adapted from Zun LS. Evidence-based evaluation of psychiatric patients. J Emerg Med
2005;28(1):35–9.
 Psychiatric Emergencies 347

Box 5
Suicide treatment plan based on risk

Low Risk: Urgent

 Involve team and social support
 Medication: selective serotonin reuptake inhibitor, sleeping aid
 Close follow-up and community resources
 Remove medications, firearms, knives, and so forth
Moderate Risk: Crisis
 Safety plan: “watch”
 Intensive outpatient treatment
 Medication: selective serotonin reuptake inhibitor, sleeping aid
 Remove harm
High Risk: Emergency
 Inpatient treatment
 Petition for involuntary admission

Data from Practice guideline for the assessment and treatment of patients with suicidal behav-
iors. Am J Psychiatry 2003;160(11 Suppl):1–60.

collaborate with other clinicians as necessary. After establishing and beginning the
treatment plan, the patient should be continuously monitored for psychiatric status
and treatment response while also reassessing safety and suicide risk.4,19

NONPHARMACOLOGIC STRATEGIES
Acute Psychosis, Mania, and Agitated or Homicidal
When approaching a patient with acute agitation, behavioral strategies should be first
line. Behavioral strategies focus on using verbal de-escalation, such as described by
Richmond and colleagues,17 to help the patient to calm and self-regulate his or her
emotional state, and then allow the patient to begin to engage in his or her own treat-
ment plan. The general approach consists of first helping the patient to feel safe by
creating a nonthreatening environment, and speaking in calm, low tones. The inter-
viewer attempting to engage with the patient should also be aware of the need for
additional back up staff, should safety become a concern.2,17 Working from an estab-
lished rapport, the interviewer should then begin the discussion as to how to proceed
with treatment. The interview should be concise, clear, and to the point. The inter-
viewer should listen carefully to the patient and attempt to reach an understanding
if possible. When discussing next treatments, it is helpful to lay out the range of
options available and, if possible, allow the patient to choose. For instance, the inter-
viewer may discuss that she would like to give the patient a medication to help him
keep calm. The interviewer may then offer options, that is, would the patient rather
try a pill or an injection. When the plan has been decided on, the provider should
then review with the patient to gauge his or her understanding and engagement as
an active participant in their own care.17
Suicidal Ideation
The first aspect of management of a patient with suicidal ideation is to find a safe place
as the treatment location.1 The decision of where to treat a suicidal patient depends on
348 Wheat et al

several factors. The range of settings includes a continuum of involuntary inpatient

hospitalization to partial hospital and intensive outpatient programs to occasional
ambulatory visits. Factors affecting this decision include (1) clinician’s estimate of
current suicide risk and potential for danger to others; (2) medical and psychiatric
comorbidities; (3) strength and availability of psychosocial support network; and
(4) ability to provide adequate self-care, give reliable feedback to the clinician, and
cooperate with treatment.4 A common tool used when the decision is made to treat
in the outpatient setting is the no-harm contract. This contract should not be used
as a substitute for careful clinical evaluation and should not be used with patients
who are agitated, psychotic, impulsive, or under the influence of drugs or alcohol.4
Once a treatment location is decided on, the patient and belongings should be
searched for concealed weapons. In addition to weapons, the patient should be
relieved of items with which they can cause self-harm. With active suicidal or homi-
cidal ideation, 1:1 observation is useful and is commonly used.1
In the setting of depression, interpersonal psychotherapy and cognitive behavior
therapy is appropriate. Additionally, cognitive behavioral therapy can decrease hope-
lessness and suicide attempts among patients in the outpatient setting. For patients
with borderline personality disorder and suicidal ideation, psychodynamic therapy
and dialectical behavior therapy may be useful.4 Electroconvulsive therapy has
proved useful in patients with suicidal ideation regardless of psychiatric diagnosis.
It can even be used safely in pregnant women. Electroconvulsive therapy, however,
is not enough for long-term maintenance. Thus electroconvulsive therapy should
be done in combination with pharmacologic strategies. Finally, other strategies,
such as rapid intervention, follow-up outreach, problem-solving therapy, brief
psychological treatment, or group therapies, are thought to be useful despite limited
evidence of efficacy.4

PHARMACOLOGIC STRATEGIES
Acute Psychosis, Mania, and Agitation or Homicidal Ideation
Should medications become necessary in the management of an acutely psychotic or
agitated patient, there are numerous approaches, both general and specific. First-line
approach for an agitated, but cooperative patient should consist of oral medications
when possible. If rapid intervention or sedation is required, parenteral medications
should be used.15,16 A general approach to medications by suspected diagnosis, as
proposed by consensus guidelines, is outlined in Table 2 and Box 6.
In some cases when the agitated patient suffers from underlying medical comorbid-
ities, it is important to adjust medications used and avoid others to prevent further
complications. Benzodiazepines should be avoided in patients with chronic obstruc-
tive pulmonary disease, the elderly, and patients with known drug-seeking behavior or
history of dependence and/or abuse. For patients with history of neurologic side
effects, including akathisia, tardive dyskinesia, neuroleptic malignant syndrome, dys-
tonia, or parkinsonian symptoms, typical antipsychotic medications should not be
used (Table 3).10

Suicidal Ideation
The pharmacologic treatment of the patient with suicidal ideation depends on the
psychiatric diagnosis. In general, evidence for the use of antidepressants is inconclu-
sive for patients with suicidal ideation. Their proven benefits among patients with
depressive episodes and anxiety are, however, in support of their use with suicidal pa-
tients. When using an antidepressant, it is preferable to use one with little risk of
 Psychiatric Emergencies 349

Table 2
Pharmacologic treatments in psychiatric emergency

Oral Medications Parenteral Medications

Suspected cause First line Second line First line Second line
Medical None TA –– TA
BNZ BNZ
BNZ 1 AA
Substance
Stimulant BNZ BNZ 1 TA BNZ BNZ 1 TA
TA TA
Alcohol –– BNZ –– BNZ
Hallucinogen –– BNZ BNZ BNZ 1 TA
BNZ 1 TA
Opioids None recommended None recommended
Primary psychiatric
Unknown, no data BNZ BNZ 1 TA –– BNZ
BNZ 1 AA BNZ 1 TA
Schizophrenia BNZ 1 TA Risperidone BNZ 1 TA TA
BNZ 1 AA TA
Olanzapine
Mania BNZ 1 TA BNZ BNZ 1 TA TA
BNZ 1 AA TA BNZ
Risperidone
Olanzapine
Depression with psychosis –– BNZ 1 AA BNZ 1 TA BNZ
BNZ 1 TA
BNZ
Risperidone
Personality disorder –– BNZ –– BNZ
BNZ 1 TA
Posttraumatic stress disorder BNZ –– BNZ BNZ 1 TA

Abbreviations: AA, atypical antipsychotic; BNZ, benzodiazepine; TA, typical antipsychotic.

Adapted from Allen MH, Currier GW, Hughes DH, et al. The expert consensus guideline series.
Treatment of behavioral emergencies. Postgrad Med 2001;(Spec No):1–88; [quiz 89–90]; with
permission.

lethality by means of an acute overdose. For this reason selective serotonin reuptake
inhibitors or newer agents are preferable. For patients with insomnia, agitation, panic
attacks, or psychic anxiety, benzodiazepines can be used on a short-term basis; how-
ever, when used, long-acting benzodiazepines are preferable and should be tapered.
If benzodiazepines are not desired, other calming medications, such as trazadone, low
doses of second-generation antipsychotics, and anticonvulsants can be used. There
is evidence suggesting a benefit to the use of longer-term maintenance with lithium
salts in reducing suicide and suicide attempts among patients with bipolar disorder
and some evidence for use in major depressive disorder. Among patients with
schizoaffective disorder, clozapine has demonstrated decreased suicide risk. How-
ever, with the risk of agranulocytosis and myocarditis, this medication should be
reserved for those with frequent suicidal ideation or suicide attempts. Second-
generation antipsychotics, such as risperidone, olanzapine, and quetiapine, are pref-
erable to the first-generation antipsychotics.
350 Wheat et al

Box 6
Medications for agitation and psychosis

Benzodiazepines
 Diazepam, 5–10 mg po q 30–60 minutes (average dose, 20–60 mg)
 Lorazepam, 1–3 mg po or IM q 30–60 minutes
Typical Antipsychotics
 Haloperidol, 5–10 mg po or 5 mg IM every 30–60 minutes (average dose, 10–20 mg)
Atypical Antipsychotics
 Olanzapine, 5–10 mg po or 10 mg IM
 Ziprasidone, 20–40 mg po bid or 10 mg IM q 2 hours or 20 mg IM q 4 hours
 Risperidone, 2 mg po daily, increase by 1–2 mg q 24 hours until goal 4–8 mg; 25 mg IM q
2 weeks, start with po and continue oral for 3 weeks
 Quetiapine, 25–50 mg po bid, increase by 25–50 mg bid until goal of 300–400 mg daily

Adapted from Allen MH, Currier GW, Hughes DH, et al. The expert consensus guideline series.
Treatment of behavioral emergencies. Postgrad Med 2001;(Spec No):1–88; [quiz 89–90]; with
permission.

SELF-REGULATION STRATEGIES FOR PATIENTS

After any involuntary intervention with an agitated patient, it is the responsibility of the
clinician who ordered such interventions to try to restore the therapeutic relationship
and lessen the impact of any trauma from restraining interventions and prevent the risk

Table 3
Preferred medications for comorbid medical conditions

Preferred Alternate
Medical Condition Medication Medication Avoid
Chronic obstructive pulmonary disease TA AA BNZ
Cardiac (arrhythmia or abnormal conduction) BNZ TA ––
AA
Delirium TA AA ––
Dementia AA –– ––
TA
Elderly AA TA BNZ
History of akathisia BNZ –– TA
AA
History of tardive dyskinesia, neuroleptic malignant BNZ AA TA
syndrome, dystonia, parkinsonian symptoms
Mental retardation/developmental delay AA –– ––
History for drug seeking, abuse, or dependence –– AA BNZ
TA
History of seizures BNZ AA ––
Elevated blood alcohol and symptoms of withdraw BNZ –– ––

Abbreviations: AA, atypical antipsychotic; BNZ, benzodiazepine; TA, typical antipsychotic.

Adapted from Allen MH, Currier GW, Hughes DH, et al. The expert consensus guideline series.
Treatment of behavioral emergencies. Postgrad Med 2001;(Spec No):1–88; [quiz 89–90]; with
permission.
 Psychiatric Emergencies 351

of additional violence. Clinicians should start by explaining why a restrictive interven-

tion was necessary to the patient and the team. The team should explore alternatives
for managing aggression if the patient were to get agitated again. If possible, the
patient should be coached on how to request a time out and how to appropriately ex-
press his or her anger—using words, not physical force. Providers should explain how
medications might help the patient feel calmer and prevent them from acting violently.
Also, clinicians should continue to get the patient’s feedback on whether his or
her concerns have been addressed and then explain the plan, limitations, and
expectations.
After the patient is calm, the clinician can acknowledge and work with the patient to
help put the patient’s concerns into perspective, and assist him or her in problem
solving the initial precipitating situation. Because prevention of agitation is the best
way to treat it, planning with the patient is best: “What works when you are very upset
as you were today? What can we/you do in the future to help you stay in control?”17

DEBRIEFING AND TEAM-MANAGEMENT STRATEGIES

Managing a psychiatric emergency is emotionally and mentally taxing for patients,

family and friends, and the health care team. It is therefore important to debrief with
all, including the patient’s family, who witnessed the incident. The debriefing should
include the following themes:
 Common reactions
 Fear of one’s own emotional reaction
 Fear of patient’s emotional reaction
 Fear of being blamed for bad news
 Fear of not knowing all the answers
 Fear of the patient’s suffering/death
 Fear of one’s own mortality or that of a loved one
 Feeling of having failed or being powerless
 Identify your feelings
 Share your reactions with a trusted colleague or mentor
 Consider writing about your reactions
 Participate in restoring rituals or strategies
If restraint or force needs to be used, it is important that the health care team be
debriefed on the actions after the event. Staff should feel free to suggest what went
well during the episode, and what did not, and recommend improvements for the
next episode.20,21

LEGAL CONSIDERATIONS

There are special legal considerations concerning patients with psychiatric emergen-
cies. The 1975 US Supreme Court ruling in the case of O’Conner v Donaldson gave
persons with mental illness rights when it came to involuntary admission. This ruling
indicated that mental illness alone was not sufficient for an involuntary admission.1,11
Following this ruling, states also restricted the involuntary admission to a predeter-
mined time period of days to weeks after which time the patient was entitled to a court
hearing to determine if the involuntary admission should continue. This time is
commonly 72 hours and often known as the 72-hour hold (Box 7).1,11
In response to these criteria, the American Psychiatric Association developed a
model in which a patient must meet all six criteria to be eligible for involuntary
admission: (1) mental illness, (2) danger to self or others, (3) refusal to consent,
352 Wheat et al

Box 7
Criteria for involuntary admissions

1. Mental illness
2. Danger to self or others
3. Refusal to consent
4. Treatability
5. Lack capacity to make treatment decisions
6. Hospitalization is least restrictive treatment

From Sood TR, McStay CM. Evaluation of the psychiatric patient. Emerg Med Clin North Am
2009;27(4):669–83, ix; with permission.

(4) treatability, (5) lack the capacity to make treatment decisions, and (6) hospitaliza-
tion as the least restrictive treatment.1 To commit a patient, the physician has to com-
plete an initial certificate and hold the patient in a psychiatric facility until further legal
proceedings. When completing a petition for involuntary admission, the clinician
should make three copies for (1) medical record, (2) ambulance/police, and (3) hospital
records. Then the physician has 72 hours to hold a hearing for involuntary hospitaliza-
tion or the patient is allowed to leave. Involuntary commitment statutes vary from state
to state, thus it is important for clinicians to be aware of the statutes and processes in
their jurisdiction.1
For patients with homicidal ideation, clinicians should be aware of civil commitment
laws in their jurisdiction. In some jurisdictions, physicians are legally responsible for
informing the potential victim and/or the police.1

SUMMARY/DISCUSSION

The American Psychiatric Association defines a psychiatric emergency as “an acute

disturbance in thought, behavior, mood, or social relationship, which requires imme-
diate intervention as defined by the patient, family, or social unit.” These diagnoses,
which require immediate intervention to save the patient and/or others from imminent
danger, include mania, acute psychosis, suicidal ideation, and homicidal ideation. The
evaluation of patients exhibiting psychiatric emergencies starts by ensuring safety for
all, then proceeding with evaluation. It is also important to determine if there is a
comorbid medical diagnosis or a medical diagnosis causing the symptoms. The
management of psychiatric emergencies is first dependent on whether the patient is
a potential harm to themselves or others. This and other factors affecting urgency
determine the treatment location. Specific management of the patient then ultimately
depends on the cause of the psychiatric symptoms. Medications used focus first on
calming the patient and then treating the disease. The range of therapy modalities
also depend on cause. After dealing with psychiatric emergencies, it is important to
debrief with the patient and family to help ensure a continued effective therapeutic
relationship. Additionally, it is important to debrief with the health care team about
how the situation was handled. It is also important to debrief with providers and staff
to help restore mental health because psychiatric emergencies are emotionally taxing
for all involved. Finally, there are important legal considerations that a clinician must be
aware of, particularly in the setting of involuntary admission. Providers should be
aware of their local jurisdiction’s individual requirements. Psychiatric emergencies in
medical settings are frequent in hospital and outpatient settings. Therefore, primary
 Psychiatric Emergencies 353

care medical providers, including nursing and support staff, need to be trained in the
assessment, treatment, and management of these patients.

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