Introduction to

Psychiatric
Emergency
By Selam Abera, MD,
psychiatrist.
Nov, 2019.
What is psychiatric emergency?

 A psychiatric emergency is any unusual behaviour,

mood, or thought, which if not rapidly attended to,
may result in harm to a patient or others.
Epidemiology
 Psychiatricemergency rooms are used equally by
men and women .
 And more by single than by married persons.
 About 20 % of these patients are suicidal.
 and about 10% are violent.
 A psychiatric emergency may occur
 at home,
 on the street,
 at an outpatient department,
 at a psychiatric unit,
 at a medical or surgical unit of a general hospital,
 at the emergency department.
Common Psychiatric Emergencies
 Suicidalbehaviour
 Violence
 Abuse of a child or adult
 Alcohol intoxication or withdrawal
 Medication side effects (NMS, Akathisia, acute
dystonia)
 Delirium
 Catatonia
 The most common diagnoses are
 mood disorders (including depressive disorders and
manic episodes),
 schizophrenia and
 alcohol dependence.
 About40 % of all patients seen in psychiatric
emergency rooms require hospitalization.
Evaluation of a patient at the
emergency psychiatry
 The primary goal is the timely assessment of the
patient in crisis.
 The standard psychiatric interview—consists of
 a history,
 a mental status examination, and,
 when appropriate full physical examination and
 laboratory tests
 But can structure or terminate an interview to limit
the potential for agitation and aggression to wards
self or others.
 Ata minimum, the emergency evaluation should
address the following
 Is it safe for the patient to be in the emergency
room?
 Is the problem organic, functional, or a combination?
 Is the patient psychotic?
 Is the patient suicidal or homicidal?
 To what degree is the patient capable of self-care?
Psychotic patients
 All communication with patients must be
straightforward.
 All clinical interventions should be briefly
explained in language the patient can understand.
 Psychiatrists should not assume that the patient
trusts or believes them or even wants their help.
 U may terminate the interview early.
Assessing the risk of violence
 Patients may be violent for many reasons.
 Try to identify underlying cause of the violent
behaviour.
 History of violence is the best predictor of future
violence.
 Substance dependence or abuse carries an
increased risk.
Suicide
 Suicide is the primary emergency in psychiatry.
 You may provide optimal care, yet the patient may
die by suicide.
 Suicide is impossible to predict, but numerous
clues can be seen.
Risk factors
 Mental illnesses ( commonly depression )
 Older men (>65) particularly those who have lost a
partner
 Family history of suicide
 Past history of suicidal attempt
 Chronic illness and/or intractable pain
 Hopelessness
 Isolation
 Widows, divorce
Sad persons scale
• Sex - male
• Age - above 45 or below 18
• Depression
• Previous attempt
• Ethanol abuse - alcoholic
• Rational thinking loss -psychotic
• Social supports lacking
• Organized plan
• No spouse - unmarried
• Sickness –chronic/serious medical condition
< 5 low out patient
 5 to 6 medium consider admission
 > 7 and above

 Admission is required for high risk.

 How do you ask for suicidal ideation ?
 Detect suicidal behavior in every patient with
clinical interview.

 Not all such patients with suicidal ideation require

hospitalization. But
 the absence of a strong social support,
 a history of impulsive behaviour,
 and a suicidal plan of action are indications for
hospitalization.
 Treat the underlying psychiatric disorder , if any.
 Encourage the person to communicate with
clinicians, family or friends in case of suicidal
urge.
 Deal with interpersonal problems and psychosocial
stressors – current and ongoing
Rape and sexual abuse
 Rape is a psychiatric emergency that requires
immediate, appropriate intervention.
 Rape victims may suffer sequelae that persist for a
lifetime.
 Typical reactions in both rape and sexual abuse
victims include shame, humiliation, anxiety,
confusion, and outrage.
 Rape and sexual abuse victims are often confused
after the assault.
 Clinicians should be reassuring, supportive, and
non judgmental.
 It is legally and therapeutically important to take a
detailed and complete history of the attack.
Treatment at the psychiatric ER
1. Redirection/de-escalation
 Sit with a table between you and the patient
 Make sure you both have access to the door
 Avoid frustrating the patient
 Do not be judgmental(critical- disapproving)
2. Restraints
 Do not attempt without sufficient help
 Apply calmly
 Never take patients by surprise
 Quick, organized intervention to avoid injury
to self and other
 Use minimum restraint when necessary and
discontinue when it is no longer necessary
3. Seclusion
 Treat those patient you think can be a risk to self
or others separately.
 Make sure they are not neglected.
4. Pharmacotherapy
 The major indications for the use of psychotropic
medication include
 violent or assaultive behaviour,
 massive anxiety or panic,
 Extrapyramidal reactions, such as dystonia and
akathisia as adverse effects of psychiatric drugs.
Benzodiazepines
 Desired effects: sedation, decreased anxiety

E.g. Diazepam 10mg IV or lorazepam 1 to 2 mg IV

 Antipsychotics

E.g. Haloperidol 5mg IM

5.Manage the setting

 Weapons Screening – the patient and the

environment
Summary
 Safety is always the first concern in the emergency
setting.
 To maintain safety both physical restraints and
pharmacologic support may be needed.
 Assess carefully for suicide and homicide.
 Screen for addiction, affective, psychotic and
personality disorders.
Questions ??