Psychiatric Emergencies

Psychiatric emergencies are a subset of medical emergencies. They can be defined as “clinical situations that acutely jeopardize a patient’s mental state or the safety of those around them.”

Psychiatric emergencies are common, affecting about 2% to 4% of people admitted to general hospitals and 8 to 10% of those admitted to psychiatric facilities. In psychiatric settings, the most common psychiatric emergencies are suicide attempts and acute psychosis.

Most patients presenting a psychiatric emergency have a psychiatric illness. However, this is not always apparent to clinicians at the beginning of assessment as they may be suffering from an acute exacerbation or side effect of their medication. In addition, some people without a psychiatric history experience a significant reduction in their resilience or coping mechanisms due to bereavement, become unemployed, substance abuse, or experience homelessness. These people may appear to have no psychiatric history, and therefore it can be difficult for clinicians to assess them with an accurate priority.

Clinicians need to be aware that the presentation of each psychiatric emergency is unique, which can make an assessment for mental health treatment more difficult.

Psychiatric Emergency Caused by Mental Disorders

Psychiatric emergencies can occur in all settings (inpatient, outpatient, emergency room) where mental illness exists. The most common cases in emergency psychiatry are suicide attempts, acute psychosis, and substance abuse withdrawal. Mental health professionals are skilled at treating and handling mental disorders and psychotic disorders such as:

Delirium

Symptoms: confusion, hallucinations, and disorganized behavior.

Treatment: Ensure the person is safe from themselves and others by employing supportive care such as providing hydration etc. If delirium is suspected or diagnosed, you must obtain a CT or MRI to rule out any organic cause, e.g., meningitis, encephalitis, etc.

The following medications will also help benzodiazepines (sprinkle helps but does not last as long and should be avoided in the elderly); antipsychotics (chlorpromazine and haloperidol are two examples); antiemetics; antihypertensive; anticonvulsants.

The prognosis for delirium is good – it should resolve within a few days or weeks; however, if the underlying cause of the fever persists, the patient may have an ongoing problem. In this case, they will require to follow up with their GP and possibly be referred to a psychiatrist.

Suicide Attempts

Symptoms: depression, feelings of hopelessness, and suicidal thoughts.

Treatment: The priority is to keep the patient safe from themselves- this includes not having access to any means or methods to harm themselves (e.g., razor blades). Suppose the person makes a suicide attempt while at the hospital, their life will be in danger. A psychiatrist should be informed immediately even if the medical staff are unaware of thinking about suicide.

Other medications that can help include those listed under delirium, as some people may have an underlying medical problem that has led them to feel depressed and suicidal. In this case, it is essential to consider these and talking therapies such as cognitive behavioral therapy for managing mental illness during recovery.

The prognosis for suicide attempts varies – some people make one attempt and recover while others will continue to make multiple attempts over their lives; 5% of people will not survive- many of these people are euthanasia cases or cases where the person has allowed themselves to become terminally ill (euthanasia is illegal in New Zealand).

Psychosis

Symptoms: delusions, paranoia. Disorganized speech and behavior may also occur.

Treatment: Administration of antipsychotics (effective in 70-90% of cases). Benzodiazepines may be used for associated anxiety or agitation but should not be used as the primary treatment due to their risk of dependency. The patient may require admission to a psychiatric ward for observation and assessment of their condition.

Cognitive impairment is common in psychosis – this can be assessed by the Mini-Mental State Examination (MMSE) test.

If antipsychotics are not effective, electroconvulsive therapy (ECT) may be considered an alternative therapy. ECT has been proven effective but may not be used in some patients (e.g., if they are perplexed due to delirium, elderly, pregnant, etc.).

The prognosis for psychosis is variable – it can last for a few weeks or months; however, hospitalization is often required if the symptoms are severe (e.g., the patient is at risk of suicide or needs urgent medical assessment).

Depression

Symptoms: depressed mood (unhappy, fearful, etc.), loss of interest in activities that they previously enjoyed; sleep disturbance; appetite disturbance; psychomotor agitation or retardation; decreased energy levels and suicidal thoughts. A person who is depressed may also have delusional beliefs, e.g., a depressive with low self-esteem may believe that they are responsible for a nuclear disaster, despite evidence to the contrary.

Treatment: The patient will require treatment using a combination of therapies, e.g., antidepressants (over 80% effectiveness), psychological therapies such as Cognitive Behavioural Therapy (CBT) and interpersonal therapy (IPT), group therapy, family therapy, etc. Psychotherapy is preferable to medication alone as it has been shown to provide a longer-term effect.

If the patient is at risk of suicide, they must be treated as a psychiatric emergency and referred urgently to a psychiatrist for assessment.

The prognosis for depression is variable – it can last for months or years; however, some patients may have a chronic illness. Patients with recurrent episodes of depressive illness are thought to be at increased risk of developing dementia later in life.

Bipolar Disorder

Symptoms: Mood changes, e.g., mania (elevated mood, over-activity, increased energy, etc.) and depression. The patient may also experience delusions and hallucinations.

Treatment: Lithium is used to reduce the severity of manic episodes; mood-stabilizing medication such as olanzapine is often used in addition to lithium to treat mania. Antipsychotics are used for psychotic Symptoms (e.g., delusions or hallucinations).

The prognosis for bipolar disorder is variable – it can last for months or years. However, some patients may have a chronic illness.

Alcohol or Drug Withdrawal

Symptoms: Symptoms will vary depending on the substance being abused, i.e., a person who has been abusing alcohol may experience delirium tremens (DTs). Generally, people who have been using substances for a long time and at high doses are most likely to experience severe withdrawal symptoms.

Treatment: If possible, the patient should be referred to an addiction treatment service for assessment and appropriate treatment. Involuntary admission to the hospital may be required in severe cases or if no other help is available.

If seizures occur due to alcohol withdrawal, they must be treated as a medical emergency, e.g., with the administration of diazepam rectal gel or intramuscular lorazepam in addition to intravenous fluids and nutrition.

The prognosis for substance withdrawal is variable as it depends on the patient’s circumstances. Some people may experience mild symptoms that resolve within hours or days; others can have severe Symptoms lasting weeks or months.

Personality Disorders

Symptoms: There are many different types of personality disorders, and they can be divided into three clusters: Cluster A (e.g., paranoid, schizoid), Cluster B (e.g., antisocial, borderline), and Cluster C (e.g., avoidant, obsessive-compulsive). Negative Symptoms will include low motivation, anhedonia, etc.; these are common in all psychiatric conditions but may present as the main problem, e.g., the patient believes that they lack empathy or have no feelings towards others even though this is not true – it may help to explain to them that everyone has feelings and this is not related to their relationships with other people I.

Treatment: The most effective treatment approach for personality disorders is long-term psychotherapy. However, if the patient is distressed or impaired by their symptoms, they may require admission to the hospital.

The prognosis for personality disorders varies – some people have stable patterns of behavior that improve over time with treatment, whereas others continue to experience significant impairment in functioning.

Borderline Personality Disorder (BPD)

Symptoms: BPD is characterized by emotional instability, impulsivity, and difficulties managing relationships with other people due to splitting (the patient believes that a person can be either ‘all good’ or ‘all bad). The patient may experience suicidal ideation and engage in self-harm, e.g., cutting themselves or burning themselves as a way of coping with these feelings. They may also engage in substance misuse and experience brief psychotic episodes.

Treatment: Long-term psychotherapy is the most effective treatment for BPD, and it will include time spent focusing on specific problems, e.g., self-harm, suicidal ideation, etc. Patients who are suicidal may need to be admitted to the hospital or referred to an emergency psychiatric service to ensure that they do not harm themselves.

The prognosis for BPD varies – many people have periods of stability interspersed with times when their symptoms worsen.

Schizophrenia

Symptoms: People with schizophrenia will experience several positive Symptoms, e.g., delusions, hallucinations, etc.; negative Symptoms are also common and may include social withdrawal, poor motivation, etc.

Treatment: In an emergency, it may be necessary to admit the person to the hospital – this will usually only be done in severe cases when they are at risk of harming themselves or others or need additional help from medical professionals. Inpatient admission is also used if the person has been withdrawing from substances causing physical health problems (e.g., alcohol, opioids).

The prognosis for schizophrenia varies – some people may experience one or two episodes during a lifetime and make a complete recovery. In contrast, others will continue to have psychotic experiences throughout their lives.

Epilepsy

Symptoms: The patient may experience seizures (usually characterized by convulsions). They will also have periods of confusion which can be distressing for them and others.

Treatment: The person may need to be admitted to the hospital if they have experienced several seizures or are at risk of injuring themselves.

The prognosis for epilepsy varies depending on the type– some people have no Symptoms between seizures, whereas others will experience ongoing problems with their mental health or substance use.

Anxiety

Symptoms: The patient will experience physical signs, e.g., sweating, trembling, shortness of breath, etc.; they may also feel emotionally distressed and may cry/shout/be unable to respond appropriately – these Symptoms can make it difficult for family members to understand what is happening to them.

Treatment: The patient may require admission to the hospital if they are anxious about being left alone, if their anxiety is very distressing for them and their family members or if they cannot cope with daily activities.

The prognosis for anxiety varies – some people may experience one or two episodes during a lifetime, whereas others will have ongoing problems.

Violence or Excitement

Symptoms: The patient may become aggressive and be a danger to themselves or others. They may also experience periods of great excitement during which they will need additional monitoring, e.g., someone experiencing mania/psychosis can harm themselves, other people, or property if they are not carefully watched…

Treatment: In an emergency, the patient may require admission to the hospital – their condition will be monitored closely, and any necessary medication is given to managing their Symptoms effectively.

The prognosis for violence varies – some people recover quickly from the episode, and others have more long-term problems with mood disorders such as depression or bipolar disorder.

Postpartum Psychosis

Symptoms: The patient will experience Symptoms similar to schizophrenia (e.g., delusions, hallucinations) and may also be highly agitated; this can place great strain on their family members, who may feel helpless in caring for them…

Treatment: In an emergency, the person may need to be admitted. If they are at risk of harming themselves or others, they may require sedation/restraint until they calm down; once the acute episode has passed (which could last days or weeks), they must receive ongoing psychiatric support.

The prognosis for postpartum psychosis varies – some women recover quickly, whereas others have long-term problems with mood disorders such as depression…

Mental Health Services: Emergency Assessment and Management

After a person comes to A&E in an emergency, an urgent psychiatric examination should be conducted as soon as possible – this will entail asking the patient questions about present circumstances/Symptoms, history, and so on; taking account of what has occurred, e.g., if they are suicidal, this should be recorded in great detail; diagnosing any immediate life dangers (e.g., self-harm), making arrangements for their future care, e.g., transferring them to another service.

Individuals who are medically stable and no longer in peril should have their mental state evaluated as soon as possible – this will allow staff to assess the person’s condition and see whether it is suitable for them to go home. It may also point out any issues, such as psychosis/mania, that need closer monitoring or care.

Organizing your inquiries into general background questions (e.g., age, current situation), physical examination, risk factors/safety plan, and treatment plan is helpful while assessing a patient with acute behavioral disturbance.

How to Assess Psychiatric Emergencies in Mental Health Care

The assessment of a psychiatric emergency involves using clinical skills to identify, assess and manage risk related to mental disorders. A systematic, stepwise approach is vital to ensure that promptly perform a thorough assessment.

Step 1: Introduction

• Introduce yourself by your role and explain why you are assessing them
• Provide reassurance as patients may be feeling anxious or fearful due to their presenting Symptoms
• Is this the first time you have felt like this?

If not, what has made you feel better before? Can they think of anything else that might help at the moment?

If yes, then ask: When was the first time that you had these feelings/Symptoms?

Step 2: Assess Level of Risk

• Ask the patient what they are thinking of doing?
• How did you think these thoughts up? Did it just ‘pop’ into your head, or had you been thinking about it for some time?
• Have you made any plans on doing this, e.g., taking medication or getting hold of some items?

If yes, ask: Has your plan got as far as what/when/how/where will you do it, i.e., some detail?

If no, ask: Do you have a plan at all, or is it just an idea that keeps popping into your head right now?

When someone talks about suicide in vague terms only (i.e., saying “I wish I were dead” or “I can’t cope anymore”), it is more likely that they are expressing a wish to die than attempting.

Step 4: Assess Medical/Physical Causes

• Ask if the patient has any current medical conditions? If yes, ask about their current level of function and medication compliance.
• Ask about any alcohol/drug use (including prescribed drugs) – both regular and ‘binge’ intakes.
• Have there been recently high levels of stress in the person’s life, e.g., death in the family, financial issues, etc.?

If yes, ask: Has this affected your sleeping pattern at all? Do you find yourself sleeping more than usual less than usual?

What do you think might be causing these feelings?

Perform a physical examination for any current medical conditions, including respiratory rate and heart rate

If you suspect the person may be acutely unwell and at risk of self-harm:

• Assess for risk of self-harm: Ask: Do you have any thoughts about hurting yourself or others right now?
• If yes to question 2 or 3, take immediate precautions to ensure they are kept safe. This may involve removing access to sharp objects such as kitchen knives, medication, etc.
• Assess if the person is intoxicated with alcohol/drugs (i.e., not ‘sleeping it off’) – assess for potential withdrawal Symptoms, e.g., tremors, anxiety, etc.
• If the person is acutely unwell and at risk of self-harm:

You will need to be seen by a doctor as soon as possible. In an emergency where it would not be safe or appropriate to transport the patient yourself, call for an ambulance immediately.”

Level of Risk

The level of risk depends upon the presenting Symptoms (see below) and how far these thoughts have gone, e.g., making a plan or accessing any medications/items needed to carry out the project. Risk should be considered high if:

• The patient has made a specific plan, even if it is vague
• Someone else might also be at risk (e.g., children and elderly)
• The patient is intoxicated with alcohol or drugs
• The patient is talking about suicide or self-harm

Patients who are not at high risk should be referred to the local mental health service. Generally, risk assessment tools are not recommended for low-risk patients as they often fail to identify high-risk patients.

Drugs that can cause psychiatric emergencies:

1) Alcohol intoxication – similar to alcohol withdrawal in that patients may experience confusion, agitation, and hallucinations. Hallucinations may be visual, tactile, olfactory, and auditory. Other Symptoms may include disinhibition, poor judgment, fatigue, and muddled thoughts.

2) Amphetamines (including dexamphetamine prescribed for ADHD) – patients may experience delusions, paranoia, and aggression (similar to amphetamine withdrawal). Hallucinations are also possible, e.g., auditory hallucinations.

3) Cocaine – may cause paranoia, panic, and perseverative thoughts (similar to cocaine withdrawal). Hallucinations can also occur, e.g., visual and tactile hallucinations.

4) Hallucinogens (e.g., LSD and magic mushrooms) – patients tend to experience confusion, sometimes agitation, and delusions; vivid hallucinations are common.

5) Synthetic cannabinoids (e.g., spice) – may lead to paranoia, delusions, and disorganized thinking.

6) Antidepressants – particularly SSRIs can cause agitation, confusion, and in some cases psychosis, e.g., patients may become deluded or have hallucinations related to their delusions, i.e., patients may experience paranoia where they believe that the hallucinations are real. Treatment involves supportive care, e.g., reducing stimuli and monitoring closely for seizures.

Treatment for Psychiatric Patients

Treatment always occurs in the context of risk assessment and management, i.e., at all times, you should use your judgment to determine whether or not to involve police or other agencies, e.g., protective services for children at risk, mental health service, etc. The first step is to identify which emergency it is (although this should be done concurrently with risk assessment) and provide supportive care. The two main strategies for supporting a patient in a psychiatric emergency are:

1) Minimise the need for physical intervention, e.g., providing a quiet, safe environment so that you do not have to restrain the patient. You can also employ staff or contact local services to remove a patient from a potentially unsafe environment.

2) Treat any underlying medical conditions, e.g., alcohol withdrawal, delirium tremens, and seizures. Refer to local guidelines/protocols for instructions on how best to manage this, i.e., the correct medications and doses that should be used, etc.

In some cases, you may need to physically intervene, e.g., if the patient is at risk of harming themselves or others are at risk of harm from the psychotic patient. In these cases, you should follow your local guidelines/protocols for physical intervention.

If symptoms do not improve after providing supportive care, further assessment and management may be required. This may involve psychiatric review via a mental health service/mental health triage etc. Initiating a telephone conversation with a family member or carer can also help determine how they were when the patient was not acutely unwell and may indicate whether there are any immediate precipitating factors.

If symptoms do not improve, you may need to undertake physical intervention, e.g., sedation with a benzodiazepine or physical restraint depending on the patient’s presentation, i.e., you may use one in combination with the other if necessary. Several treatments have been proposed for violent patients, including safe rooms, seclusion, and restraints, but there is limited evidence supporting their use.

In general, the approach to a patient in a psychiatric emergency is to ensure they are safe from themselves and others by employing supportive care until Symptoms resolve or an underlying cause has been identified, which can be treated. If this does not work, physical intervention should be used, e.g., drug treatment or physical restraint depending on the presentation.

What is Intensive Psychiatric Care?

Intensive psychiatric care hospitals provide 24-hour observation and treatment services for those patients who are both acutely unwell and responded poorly to standard management. The aim is to deliver intensive treatment for those with severe mental illness, e.g., schizophrenia, bipolar disorder, etc.

Some standard features of an intensive psychiatric care unit include:

1) Continuous availability of medical staff, i.e., no gaps in coverage/shifts with no medical presence. This reassures patients that they are being monitored closely and ensures all aspects of their care are being met.

2) Frequent assessments, e.g., every 4 hours by a medical staff member to assess the patient’s level of distress, whether they need any medications, what side effects they are experiencing, etc.

3) Treatment, e.g., medications physical interventions (if required), are immediately available to all medical staff.

4) Seclusion rooms are available, i.e., for those times when the patient is not safe to be with others, poses a risk of harm, or needs to be isolated from others due to their behavior. These are different from standard isolation rooms, which are used purely for safety, i.e., prevent the patient harming themselves or others by keeping them separated/isolated from others briefly while assessing whether they need any medications, what side effects they are experiencing, etc. The seclusion room is intended to provide calming influence on the patient by limiting stimulation, e.g., noise, visual stimuli, etc. It may also be beneficial for the patient to see that they are being cared for in some way, e.g. if they need help with toileting or personal hygiene.

5) A medical staff member is on-site 24 hours a day, i.e., this provides reassurance to patients that someone can immediately assist them with any concerns, problems, etc.

Intensive psychiatric care units are usually only available at public hospitals with emergency department/mental health services. They are staffed by psychiatrists, nurses, and psychologists specializing in mental health issues, e.g., intensive psychiatric care teams. They provide an essential service for people experiencing acute mental illness and those who require ongoing management of their condition, e.g., patients with schizophrenia bipolar disorder.

Patients in an intensive psychiatric care unit are typically voluntarily admitted by their family or are compulsorily detained under a psychiatrist’s Mental Health Act. Compulsory detention aims to protect the patient from harming themselves or others and can be done on the spot without further assessment, e.g. when the police bring the patient directly to the hospital. It should, however, not be confused with forensic psychiatry, which deals with those who have committed criminal offenses and require treatment as part of their sentence. Psychiatric emergencies may require immediate assistance such as calming/sedating the patient, ensuring they do not harm themselves or others, and undertaking physical interventions if necessary, e.g., sedation with benzodiazepine physical restraints.

Prevention is better than cure:

Patients at increased risk for psychiatric emergencies, such as those who have had bipolar affective disorder and are in the early phases of recovery who have just stopped taking lithium, should receive prophylactic benzodiazepine treatment. This will prevent manic episodes, which raises the risk of hospitalization. Patients on long-term therapy with drugs like lithium or valproic acid should monitor their blood levels to ensure that the medicine is still effective.

Treatments such as CBT (cognitive behavioral therapy) can help treat symptoms associated with psychological conditions, such as psychosis, mania, and delusions. They aid in recognizing triggers that might cause a relapse and offer coping methods for dealing with them. It is now evident that CBT may be just as effective as antipsychotics at managing schizophrenia Symptoms.

The risk of harm should be considered in every case of an unexpected psychotic episode, mainly when one has been incurred after the use or withdrawal of drugs. Patients at a higher risk will need a psychiatric evaluation by a psychiatrist specializing in treating psychiatric emergencies, which can include hospitalization.

Patients who are in severe discomfort and unable to communicate vocally owing to delusions/paranoia, have threatened suicide or exhibited violent outbursts, such as leaping from a window, require higher-level care that may necessitate hospitalization due to the risk they pose for themselves and others if their delirium persists. Patients who have suffered a closed head injury and subsequently develop mental illness should be evaluated right away by an expert mental health professional, such as a psychiatrist or nurse practitioner.

If a drug must be taken, an empathetic explanation for potential adverse effects should be offered before it is given. This will imply being put on the naloxone oral antidote in certain jurisdictions, which is a type of opioid antagonist.

Patients may notice a difference in their health condition within a few days following treatment. Still, they should remember that complete recovery from an acute episode might take several weeks or months, depending on their history, length of illness, and other factors. Symptoms might not entirely go away for up to six months in some instances.

While it is essential to ensure that the treatment of a patient does not cease once they have been admitted to the hospital, it is even more critical not to forget about them once they’ve been discharged. The Symptoms of mental health crises, such as psychosis and suicidality, can be distressing and difficult to deal with. However, it must be kept in mind that those experiencing these conditions are still human beings with feelings and emotions. It may take time for them to trust the doctor seeking to assist them in getting better, which might include developing rapport, using open-ended questions to empower patients, giving straightforward explanations regarding therapy/injuries, etc.

People who have been released from the hospital must regularly see a mental health professional to assess the situation and prevent relapse. This will generally be a community psychiatric nurse (CPN) or mental health expert who can see individuals at least once a week, more frequently if necessary.

Conclusion

A person experiencing a psychiatric emergency should seek medical assistance without delay. Calling 911 may be necessary in some cases, such as when suicidal behaviors are involved or when the individual is with someone else and cannot call themselves. It might also be required when the person lacks the mental capacity to make an informed decision about seeking help.