A psychiatric emergency is any disturbance in thoughts, feelings, or actions for which immediate therapeutic intervention is necessary. Intervention is necessary to avoid permanent harm or further psychiatric or situational deterioration. Emergency psychiatry goes beyond general psychiatric practice to include other problems such as substance abuse, domestic and parental abuse, suicide, homicide, rape, homelessness, aging, and acquired immune deficiency syndrome (AIDS). Most emergency psychiatric evaluations are done by nonpsychiatrists in general medical emergency department settings, but specialized psychiatric services are increasingly favored. Although the emergency department is a poor substitute for continuing care by a mental health professional in an outpatient setting, many individuals without a usual source of care, particularly uninsured persons, use emergency care clinicians for primary care.

Psychiatric emergencies arise when mental disorders impair people’s judgment, impulse control, or reality testing. Such mental disorders include all the psychotic disorders, manic and depressive episodes in mood disorders, substance abuse, borderline and antisocial personality disorders, and dementias. There may also be emergencies related to particularly severe reactions to psychiatric medications, such as neuroleptic malignant syndrome or acute agranulocytosis, which must be recognized, diagnosed, and treated immediately.

Suicide is the primary emergency for mental health professionals. More than 30,000 persons commit suicide each year in the United States with more than 60,000 suicide attempts. Psychiatrists are, however, expected to carefully evaluate and document any suicidal risks in patients and to have acted accordingly. Suicide also needs to be considered in terms of the devastating legacy that it leaves surviving loved ones, as well as the ramifications for the clinicians who care for the decedents. Perhaps the most important concept in regards to suicide is that it is almost always a result of a mental illness and is amenable to psychological and pharmacological treatments.

Psychiatrists must learn how to evaluate suicidal and homicidal patients and must learn how to ask the questions that will help reveal suicidal or homicidal plans or intent. A skilled clinician will combine this information with a sense of the person’s overall risk based on detailed knowledge of the person’s history as well as overall knowledge of suicidal and homicidal behaviors in the context of mental impairment.

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