Emergency psychiatry encompasses the urgent evaluation and management of patients with active symptoms. The definition of emergency is determined by the ability of the patient or the patient’s social environment to tolerate these symptoms. Although these emergency evaluations are most commonly performed in hospital settings, mobile crisis teams permit completion of emergency assessment in community settings.

The goals of emergency psychiatric care are similar to those of emergency medical–surgical care: (1) triage, (2) expeditious, pertinent assessment, (3) accurate differential diagnosis, (4) management of acute symptoms, and (5) appropriate discharge planning.

Triage

The triage function determines the degree of urgency of the patient’s presentation and the initial pathway for evaluation of the patient. The triage clinician must first distinguish between situations that constitute a genuine emergency and those that, although perceived as such by the patient or others, can safely await later assessment.

Next, the triage clinician must correctly identify, among a variety of emergency situations, those that reflect a need for psychiatric evaluation as a first step. This is a critical decision as patients may have both medical and psychiatric complaints or exhibit behaviorial problems that may originate from a medical, neurological or substance induced disorder. A medical evaluation including a brief history of the presenting complaint and physical assessment including vital signs is a critical component of this triage function.

Lastly, the triage clinician must assure the safety of patients until they can be evaluated by a psychiatrist or other mental health professional. In emergency room (ER) settings where patients often present with severe injuries, it is possible to overlook the needs of a well-groomed patient arriving with no obvious disorder. However, this patient may have suicidal or homicidal ideation that can be as life threatening as any other medical emergency and requires immediate attention to ensure the safety of the patient and others.

While initial triage is most commonly undertaken by nursing personnel, the psychiatrist must assume an active role in the training and supervision of those clinicians and in the formulation of standards and clinical criteria applied during the triage “sorting” function. Triage is only as effective as the quality of the standards and the rigor with which they are applied.

Assessment

Assessment of psychiatric patients under emergency circumstances focuses on the need to quickly evaluate the pertinent aspect(s) of the patient’s presentation, with special attention to potential life-threatening issues. Although the patient may have had an initial brief medical evaluation and triage to psychiatry, the clinician should continue to be alert to the possibility that the patient has a medical disorder or substance induced disorder underlying their presentation.

The clinician should assemble as much data as possible before addressing the patient directly. For example, if information suggests that the patient may be dangerous to themselves or to others, appropriate security arrangements should be made. For example, the patient may need to have a staff member be assigned to sit with them to assure safety or be searched for potential weapons.

During the initial moments of the direct encounter with the patient, the clinician should form an overall impression of the patient. This impression may include data from sources like the patient’s level of consciousness, appearance, willingness to engage with the clinician, apparent mood, psychomotor retardation or agitation and initial conversation. This initial period of direct observation can be helpful in determining whether the patient has been triaged correctly or whether additional medical evaluation or security arrangements are required.

Despite the common pressure to proceed expeditiously, clinicians should attempt to be thorough in both their medical or psychiatric evaluations. Special attention should be focused on recent psychosocial stressors, which may have precipitated the patient’s presentation in the ER. These stressors may include disruptions in housing and work or disruptions in important relationships, including romantic relationships, family relationships, and the patient’s relationship with their current outpatient clinician. Events like an argument with a family member or friend, or the vacation of an outpatient clinician, can precipitate a patient’s presentation for emergency treatment. Clinicians in emergency settings should include information from others in patient’s life in their assessment; this collateral information may be quite pertinent to the overall evaluation of the patient.

The emergency assessment must include the presenting history and psychosocial stressors, past and current medical problems, current engagement in medical and psychiatric treatment, current medications and adherence to the medical regimen, history of past and current substance abuse, social history including the patient’s living and financial arrangements and current status of significant relationships, physical examination (including neurological screening exam), mental status examination, and screening laboratory workup. This assessment will help determine what other appropriate laboratory, toxicology, or imaging studies should be ordered.

Diagnosis

The pressures of the emergency setting do not allow the detailed diagnostic assessment possible in other settings. However, the clinician should construct a differential diagnosis which can be utilized to guide further emergency evaluation. In constructing this differential diagnosis a high priority must be given to medical, neurological and substance induced etiologies of the presenting complaint. Table 48–1 lists four sequential questions that must be considered in making a differential diagnosis.

Initial Treatment

Treatment interventions, when appropriate as an emergency procedure, will usually follow the diagnostic assessment. However, sometimes the clinician must intervene before gathering all the diagnostic information. This is particularly true when the patient must be kept safe due to concern about being a danger to self or others. In most circumstances, emergency interventions will fall into one or more of four categories: Environmental management, medication, crisis intervention, and education.

Environmental Management

As noted above, clinicians must be attentive to providing a safe environment for patients. These interventions often occur before a full evaluation is completed. In addition to ensuring a safe environment, patients may benefit from having diminished stimulation in their environment. Availability of a “quiet room” is often helpful to reducing psychomotor agitation.

At times, modifying the home environment of a patient may avoid a hospitalization. Providing alternative short-term housing during a crisis, respite care for an elderly patient or emergency placement of a child can decrease the patient’s symptoms.

Medication Interventions

Clinicians in ER settings should be careful about initiating pharmacological interventions for several reasons. First, initial diagnostic impressions may prove inaccurate. Second, the full laboratory assessment of the patient may not be complete. Third, treatment with medications may produce sedation which can mask other signs of medical illness. Lastly, the clinician in the ER will likely not be treating the patient in follow-up. Therefore, in general, pharmacological interventions should be limited to those needed to help manage the patient in the emergency setting.

Clinicians in the emergency setting utilize medications like benzodiazepines and antipsychotics in order to manage symptoms of psychomotor agitation. The use of benzodiazepines like lorazepam may be appropriate treatment for severe anxiety or for agitation associated with alcohol or sedative withdrawal. Treatment with an antipsychotic like haloperidol is sometimes useful for treating psychomotor agitation in patients with acute psychotic states. When a patient is acutely agitated or threatening these medications can be given intramuscularly to minimize time of onset.

Giving a patient medication to manage symptoms until the patient is seen in outpatient treatment requires careful consideration of several factors including the patient’s compliance, issues of safety, and the amount of time before outpatient follow-up care will begin. The possibility that the patient is seeking benzodiazepines or pain medication because of an addiction should be considered before prescription of benzodiazepines or narcotics. In general, patients should not be given more than a few days supply of medication at any one time.

Crisis Intervention

Psychological strategies based on a biopsychosocial understanding of the situation can often de-escalate a crisis. Such techniques include ventilation, identification of alternatives, clarification of interpersonal roles, interpretation of meaning, or simply empathic listening. Meeting with the patient and their family or significant other can help resolve difficulties that may have led to the patient seeking care in an emergency setting.

Education

An important but often overlooked component of treatment in the ER is the opportunity for preventive education. The patient, family members, significant others, and even other caretakers will sometimes benefit greatly from education about the disorder. For example a patient with new onset panic disorder may be able to avoid returning to the ER if sufficiently educated about the nature of their disorder. Clarification of the situation in a way that can avoids unwarranted guilt or confusion will be helpful to all involved. The patient and others important to the patient may avoid a sense of alienation, shame, and hopelessness by better understanding the diagnosed illness, its prevalence, and its prognosis.

Discharge Planning

Discharge planning from a psychiatric emergency depends on the resources that are realistically available. In general, at least four issues must be considered: (1) initial level of care, (2) the patient’s willingness to seek treatment, (3) timing of initial follow-up care, (4) interval provisions, and (5) communication with the patient and subsequent caretakers.

Initial Level of Care

As the most restrictive and expensive alternative, 24-hour inpatient care should be utilized only after careful consideration of several factors. Commonly accepted criteria for such care include mental illness associated with imminent danger to self or others, grave impairment of function to a degree that prohibits self-preservation in the most supportive environment available, and diagnostic uncertainty that could result in a lethal outcome.

Less restrictive alternatives include crisis housing with less intensive staff observation, partial or day hospitalization, and intensive or routine outpatient follow-up care. The objective is to provide the least restrictive level of care that meets the patient’s clinical needs. The patient’s ability to pay for different services is a factor which unfortunately can determine what follow-up care is able to be provided to the patient. In some settings, indigent patients may have access to more services than low-income patients without Title XIX entitlements.

The Patient’s Willingness to Seek Treatment

A patient presenting for psychiatric treatment may not have been brought to the ER voluntarily. Frequently, the police or the family members bring an individual to the ER for treatment. If a determination is made that the patient requires inpatient level of care, and the patient is unwilling to be admitted, the clinician may need to initiate an involuntary hospitalization process. While the administrative processes vary in each state, licensed physicians are able to involuntarily admit patients who meet standards of suicidality, homocidality, or who are unable to care for themselves due to their mental illness.

In general, patients with psychiatric disorders have the same right to refuse treatment that patients with other medical conditions have. In most instances, if a patient in an ER does not meet legal requirements for involuntary hospitalization and is unwilling to seek outpatient care, the patient’s decision must be respected. Patients who report not wanting outpatient treatment should be provided options for accessing care should they change their minds after discharge from the ER.

Timing of Initial Follow-Up Care

For patients interested in outpatient treatment, the discharge planning should include determination of the clinically permissible time interval before a less restrictive level of care is available. For example, a situation that requires urgent outpatient follow-up care should not be scheduled 2 or 3 weeks later.

Interval Provisions

If too much time will elapse before initial follow-up care can be scheduled, the patient and relevant others should be informed of what to do. In most cases, if a scheduled return to the ER is anticipated, the clinician who provided the initial emergency assessment is best prepared to handle return visits.

Communication with the Patient & Subsequent Caretakers

A breakdown in communication with clinicians providing outpatient care often frustrates the patient and can lead to nonadherence with the plan of care developed in the emergency setting. The precise discharge plan should be written out and given to the patient (and, when appropriate, to the family, significant others, and clinicians who will assume the patient’s subsequent care). An opportunity to raise questions, seek clarification of details, and better understand the clinical rationale of the discharge plan should be a routine part of this process.

Equally important is, the timely communication with other professional caretakers who are to provide subsequent treatment. This communication should provide enough detail for other clinicians to begin active treatment with the patient. A smooth transition in care gives the patient a reassuring sense of continuity from emergency onset to final initiation of outpatient treatment.

Four special issues merit special consideration in the setting of emergent psychiatric evaluation: Suicide, homicide and other violence, disaster psychiatry, and the medico–legal aspects of psychiatric evaluation and treatment in the emergency setting.

Suicide

Suicide accounts for about 30,000 deaths each year in the United States. The number of attempted suicides is many times larger. Up to 80% of individuals who commit suicide have seen a physician or other health care personnel within two weeks before their deaths; most often this health care professional was not in the mental health care field. Therefore it is extremely important that all health care professionals be alert to the signals of distress and risk factors for suicide; this is especially true in emergency psychiatry where assessment of patients with suicidal ideation is a common occurrence.

Perhaps the single most important element in the assessment of suicidal risk is constant awareness of the possibility that it exists. The patient may make no direct reference to self-destruction unless asked; this question is of course an essential component of any emergency psychiatric evaluation. Assessment of risk factors known to predispose to suicide is one method to quantify the risk that the patient will attempt suicide (Table 48–2). However, many patients with serious mental illness, especially those with dual diagnosis (mental illness and a substance abuse disorder) will have many of the risk factors known to predispose to suicide. Clinical judgment and the patient’s ability to work with the clinician to develop a treatment plan that mitigates certain stresses and risk factors will help determine whether the patient is able to safely leave the emergency evaluation setting or requires inpatient treatment. Clear documentation of the assessment, including risk factor assessment is critical in the evaluations of the suicidal patient.

Homocidal Ideation and Violence