9781585629411 Clinical Manual Of Emergency Psychiatry

User Manual: manual pdf -FilePursuit

Open the PDF directly: View PDF PDF.
Page Count: 436 [warning: Documents this large are best viewed by clicking the View PDF Link!]

BOOK OF THE MONTH TERMS OF USE
PsychiatryOnline.org currently offers access in PDF format to a
free book each month from the APP Bookstore. This offering is
intended as a promotional tool, to give subscribers a chance
to review books they might be interested in purchasing sepa-
rately for continued access. As such, the “Book of the Month”
is governed by the following terms of use:
The Book of the Month is supplied as PDF; no other formats will be
supplied. Subscribers have access to the Book of the Month for only
as long as the “download” link appears on the PsychiatryOnline.org
home page (usually one month). This feature may be discontinued
at any time without notice or reason to subscribers.
The User license does not cover storing the book in any format be-
yond the one-month period. Users may not copy, modify, reproduce,
publish, transmit, display, broadcast, rent, lend, sell, catalog, or
otherwise distribute the Book of the Month.
Click here to continue on to the Book of the Month.
Clinical Manual of
Emergency Psychiatry
This page intentionally left blank
Washington, DC
London, England
Clinical Manual of
Emergency Psychiatry
Edited by
Michelle B. Riba, M.D., M.S.
Divy Ravindranath, M.D., M.S.
Note: The authors have worked to ensure that all information in this book is accurate
at the time of publication and consistent with general psychiatric and medical standards,
and that information concerning drug dosages, schedules, and routes of administration
is accurate at the time of publication and consistent with standards set by the U.S.
Food and Drug Administration and the general medical community. As medical
research and practice continue to advance, however, therapeutic standards may change.
Moreover, specific situations may require a specific therapeutic response not included
in this book. For these reasons and because human and mechanical errors sometimes
occur, we recommend that readers follow the advice of physicians directly involved in
their care or the care of a member of their family.
Books published by American Psychiatric Publishing, Inc., represent the views and
opinions of the individual authors and do not necessarily represent the policies and
opinions of APPI or the American Psychiatric Association.
If you would like to buy between 25 and 99 copies of this or any other APPI title, you
are eligible for a 20% discount; please contact APPI Customer Service at appi@psych.org
or 800-368-5777. If you wish to buy 100 or more copies of the same title, please e-
mail us at bulksales@psych.org for a price quote.
Copyright © 2010 American Psychiatric Publishing, Inc.
ALL RIGHTS RESERVED
Manufactured in the United States of America on acid-free paper
1413121110 54321
First Edition
Typeset in Adobe’s Formata and AGaramond.
American Psychiatric Publishing, Inc.
1000 Wilson Boulevard
Arlington, VA 22209-3901
www.appi.org
Library of Congress Cataloging-in-Publication Data
Clinical manual of emergency psychiatry / edited by Michelle B. Riba, Divy
Ravindranath. — 1st ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-58562-295-5 (pbk. : alk. paper)
1. Psychiatric emergencies—Handbooks, manuals, etc. I. Riba, Michelle B.
II. Ravindranath, Divy, 1977–
[DNLM: 1. Emergency Services, Psychiatric—methods. 2. Emergency Services,
Psychiatric—organization & administration. 3. Mental Disorders—diagnosis.
4. Mental Disorders—therapy. WM 401 C6405 2010]
RC480.6.C55 2010
616.89′025—dc22
2009051640
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
Contents
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . xxvii
1Approach to Psychiatric Emergencies . . . . . . . . . 1
Katherine Maloy, M.D.
Kishor Malavade, M.D.
A General Approach to the
Emergency Psychiatric Patient. . . . . . . . . . . . . . . . . . . . . .2
The Emergency Psychiatric Interview . . . . . . . . . . . . . . .12
Medical Clearance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
Substance Abuse and Withdrawal Syndromes . . . . . . .17
Documentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Special Situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
2The Suicidal Patient . . . . . . . . . . . . . . . . . . . . . . . 33
Felicia Kuo Wong, M.D.
Ana Wolanin, M.S., R.N.
Patrick Smallwood, M.D.
Demographics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40
Psychiatric Management of Suicidal Behaviors . . . . . . .46
Documentation and Risk Assessment . . . . . . . . . . . . . .52
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59
3Violence Risk Assessment. . . . . . . . . . . . . . . . . . 61
Vasilis K. Pozios, M.D.
Ernest Poortinga, M.D.
Violence and Mental Illness. . . . . . . . . . . . . . . . . . . . . . .62
Clinical Assessment of Risk for Violence . . . . . . . . . . . .64
Legal Precedents for Violence Risk Assessment . . . . . .69
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76
4The Catatonic Patient . . . . . . . . . . . . . . . . . . . . . 77
M. Justin Coffey, M.D.
Michael Alan Taylor, M.D.
Definition of Catatonia . . . . . . . . . . . . . . . . . . . . . . . . . . .78
Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .78
Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . .80
Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92
5Depression, Euphoria, and Anger
in the Emergency Department . . . . . . . . . . . . . . 93
Philippe-Edouard Boursiquot, M.D.
Jennifer S. Brasch, M.D.
General Approach to Mood States . . . . . . . . . . . . . . . . .93
Depressed Mood States . . . . . . . . . . . . . . . . . . . . . . . . . .94
Elevated Mood States. . . . . . . . . . . . . . . . . . . . . . . . . . 102
Angry and Irritable Mood States . . . . . . . . . . . . . . . . . 106
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
6The Psychotic Patient . . . . . . . . . . . . . . . . . . . .115
Patricia Schwartz, M.D.
Mary Weathers, M.D.
Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Initial Survey of the Patient . . . . . . . . . . . . . . . . . . . . . 116
Evaluation of the Psychotic Patient. . . . . . . . . . . . . . . 122
Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Risk Assessment: Important Risk Factors
in the Psychotic Patient . . . . . . . . . . . . . . . . . . . . . . . . 132
Making a Decision About Appropriate Treatment . . . 135
Role of the Emergency Psychiatrist as
Psychoeducator. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
7The Anxious Patient. . . . . . . . . . . . . . . . . . . . . . 141
Divy Ravindranath, M.D., M.S.
James Abelson, M.D., Ph.D.
Panic Attacks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Panic Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Acute Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Other Anxiety and Anxiety-Related Conditions . . . . . 160
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
8The Cognitively Impaired Patient . . . . . . . . . . . 165
James A. Bourgeois, O.D., M.D., F.A.P.M.
Tracy McCarthy, M.D.
Evaluation of the Patient . . . . . . . . . . . . . . . . . . . . . . . 167
Psychiatric Disorders Characterized
by Cognitive Impairment . . . . . . . . . . . . . . . . . . . . . . . 170
Clinical Management . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
9Substance-Related
Psychiatric Emergencies . . . . . . . . . . . . . . . . . . 187
Iyad Alkhouri, M.D.
Patrick Gibbons, D.O., M.S.W.
Divy Ravindranath, M.D., M.S.
Kirk Brower, M.D.
Epidemiology, Prevalence, and Impact
of Substance-Related Emergencies. . . . . . . . . . . . . . . 188
Initial Evaluation of Patients . . . . . . . . . . . . . . . . . . . . 189
Syndromes of Substance-Related Emergencies. . . . . 190
Guiding Patients With Substance Use Disorders
to Make a Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Disposition Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
10 Child and Adolescent
Emergency Psychiatry . . . . . . . . . . . . . . . . . . . .207
B. Harrison Levine, M.D., M.P.H.
Julia E. Najara, M.D.
Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Initial Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
Psychiatric Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . 214
Common Presentations . . . . . . . . . . . . . . . . . . . . . . . . 215
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
11 Seclusion and Restraint
in Emergency Settings . . . . . . . . . . . . . . . . . . . . 233
Wanda K. Mohr, Ph.D., A.P.R.N., F.A.A.N.
Gem Lucas, D.O.
Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
Patient Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
Choosing Seclusion or Chemical or
Physical Restraint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
Training Requirements . . . . . . . . . . . . . . . . . . . . . . . . . 238
Contraindications to Seclusion and Restraint . . . . . . 238
Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
Forced Chemical Restraints:
Indications and Controversy . . . . . . . . . . . . . . . . . . . . 241
Observation (Including the 1-Hour Rule). . . . . . . . . . 249
Release From Restraint and Debriefing . . . . . . . . . . . 250
Death and Other Adverse Effects . . . . . . . . . . . . . . . . 251
Documentation and Legal Considerations. . . . . . . . . 253
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Suggested Readings and Web Sites . . . . . . . . . . . . . . 258
12 Legal and Ethical Issues
in Emergency Psychiatry . . . . . . . . . . . . . . . . . .261
Nancy Byatt, D.O., M.B.A.
Debra A. Pinals, M.D.
Confidentiality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
Hospitalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Capacity to Make Medical Decisions. . . . . . . . . . . . . . 269
Informed Consent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
Transfer of Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Liability Management. . . . . . . . . . . . . . . . . . . . . . . . . . 275
Managed Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
13 Disposition and
Resource Options. . . . . . . . . . . . . . . . . . . . . . . .283
Zoya Simakhodskaya, Ph.D.
Fadi Haddad, M.D.
Melanie Quintero, Ph.D.
Divy Ravindranath, M.D., M.S.
Rachel L. Glick, M.D.
Discharge to Inpatient Treatment . . . . . . . . . . . . . . . . 284
Discharge to Outpatient Treatment . . . . . . . . . . . . . . 288
Disposition of Challenging Populations . . . . . . . . . . . 295
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
14 Getting Patients From the Clinic
to the Emergency Department . . . . . . . . . . . . . 305
Divy Ravindranath, M.D., M.S.
Rachel L. Glick, M.D.
Preincident Preparation . . . . . . . . . . . . . . . . . . . . . . . . 306
Acute In-Office Evaluation . . . . . . . . . . . . . . . . . . . . . . 308
Immediate Management . . . . . . . . . . . . . . . . . . . . . . . 309
Disposition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
15 Supervision of Trainees
in the Psychiatric Emergency Service. . . . . . . .315
Erick Hung, M.D.
Amin Azzam, M.D., M.A.
Diagnose and Treat the Patient. . . . . . . . . . . . . . . . . . 318
Diagnose and Treat the Learner . . . . . . . . . . . . . . . . . 321
Diagnose and Treat the Supervision. . . . . . . . . . . . . . 335
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
16 Working With Medical Students
in Psychiatric Emergency Settings . . . . . . . . . .349
Tamara Gay, M.D.
Laura Hirshbein, M.D., Ph.D.
Medical Student Orientation . . . . . . . . . . . . . . . . . . . . 350
Approaches to Integrating Medical Students
Into Psychiatric Emergency Care . . . . . . . . . . . . . . . . . 351
Intended Learning Goals and
Objectives for Medical Students . . . . . . . . . . . . . . . . . 356
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 360
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 361
17 Afterword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .363
Gregory W. Dalack, M.D.
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
List of Tables
Table 1–1 Common causes of agitation in the emergency
department setting . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Table 1–2 Common medications used in management
of agitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Table 1–3 Focused physical examination when seeking
medical clearance for psychiatric evaluation . . . . . . .18
Table 1–4 Common laboratory tests and studies
when seeking medical clearance for psychiatric
evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
Table 2–1 Guidelines for selecting a treatment setting
for patients at risk for suicide or suicidal behaviors . .47
Table 2–2 General risk management and documentation
considerations in the assessment and
management of patients at risk for suicide . . . . . . . .54
Table 4–1 Observed features of catatonia. . . . . . . . . . . . . . . . . .81
Table 4–2 Elicited signs of catatonia. . . . . . . . . . . . . . . . . . . . . . .82
Table 4–3 Laboratory findings in catatonia. . . . . . . . . . . . . . . . . .83
Table 4–4 Differential diagnosis of catatonia . . . . . . . . . . . . . . . .84
Table 4–5 Key steps to diagnosing and managing catatonia . . .86
Table 5–1 Categories of stressors to explore in patients with
abnormal mood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96
Table 5–2 Some medical disorders associated
with a depressed mood. . . . . . . . . . . . . . . . . . . . . . . .97
Table 5–3 Suggested investigations for patients
presenting with abnormal mood. . . . . . . . . . . . . . . . .98
Table 5–4 Criteria for admission in patients
with abnormal mood . . . . . . . . . . . . . . . . . . . . . . . . . .99
Table 5–5 Factors supporting emergency department
antidepressant therapy and
outpatient treatment . . . . . . . . . . . . . . . . . . . . . . . . 100
Table 5–6 Some medical disorders associated
with an elevated mood . . . . . . . . . . . . . . . . . . . . . . 104
Table 5–7 Conditions that may present with angry
or irritable mood . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Table 5–8 Irritability in depression and mania. . . . . . . . . . . . . 109
Table 6–1 Medical conditions that can present with
psychosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Table 6–2 Substances that can cause psychosis. . . . . . . . . . . 130
Table 7–1 Disorders associated with anxiety
syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Table 8–1 History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
Table 8–2 Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Table 8–3 Laboratory tests in cognitive impairment . . . . . . . . 169
Table 8–4 Causes of delirium. . . . . . . . . . . . . . . . . . . . . . . . . . 172
Table 8–5 Considerations in disposition of patients
with cognitive impairment . . . . . . . . . . . . . . . . . . . . 183
Table 8–6 Legal considerations in the management
of patients with cognitive impairment. . . . . . . . . . . 182
Table 10–1 Three spheres of functioning for child and
adolescent assessment . . . . . . . . . . . . . . . . . . . . . . 211
Table 10–2 Key laboratory studies . . . . . . . . . . . . . . . . . . . . . . . 216
Table 10–3 Elements of the suicide assessment . . . . . . . . . . . 218
Table 10–4 Commonly used psychotropic medications
for pediatric population . . . . . . . . . . . . . . . . . . . . . . 224
Table 10–5 Risk factors for child abuse . . . . . . . . . . . . . . . . . . . 226
Table 11–1 Regulations regarding seclusion and
restraint orders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
Table 11–2 Medications used to manage agitation
and aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
Table 13–1 Disposition options and indications
for dual-diagnosis patients. . . . . . . . . . . . . . . . . . . . 298
Table 14–1 Signs of escalation of agitation . . . . . . . . . . . . . . . . 307
Table 15–1 RIME model: a young woman with an acute
manic episode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
Table 15–2 One-minute preceptor model: a young woman
with an acute manic episode . . . . . . . . . . . . . . . . . 328
Table 15–3 SNAPPS model: a young woman
with an acute manic episode . . . . . . . . . . . . . . . . . 330
Table 15–4 Ten tips for effective feedback . . . . . . . . . . . . . . . . 333
Table 15–5 Questions to optimize learning climate . . . . . . . . . 341
This page intentionally left blank
List of Figures
Figure 11–1 Algorithm for decision making regarding use
of seclusion and restraint. . . . . . . . . . . . . . . . . . . . . 239
Figure 15–1 Roles of a psychiatric emergency setting
supervisor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
Figure 15–2 Centrality of diagnosis and treatment . . . . . . . . . . . 319
Figure 15–3 Spectrum of supervision . . . . . . . . . . . . . . . . . . . . . 320
Figure 15–4 Factors influencing spectrum of supervision . . . . . 322
Figure 15–5 Matching learner stages to teacher styles. . . . . . . . 342
This page intentionally left blank
xix
Contributors
James Abelson, M.D., Ph.D.
Professor, Department of Psychiatry, University of Michigan, Ann Arbor,
Michigan
Iyad Alkhouri, M.D.
Assistant Professor, Department of Psychiatry, University of Michigan Medi-
cal School, Ann Arbor, Michigan
Amin Azzam, M.D., M.A.
Department of Psychiatry, University of California—San Francisco, San
Francisco, California
James A. Bourgeois, O.D., M.D., F.A.P.M.
Professor and Vice Chair, Education, Department of Psychiatry and Behav-
ioural Neurosciences, Faculty of Health Sciences, McMaster University,
Michael G. DeGroote School of Medicine, Hamilton, Ontario, Canada
Philippe-Edouard Boursiquot, M.D.
Resident in Psychiatry, Department of Psychiatry and Behavioural Neuro-
sciences, McMaster University, Hamilton, Ontario, Canada
Jennifer S. Brasch, M.D.
Associate Professor, Department of Psychiatry and Behavioural Neuroscienc-
es, McMaster University; Medical Director, Psychiatric Emergency Service,
St. Joseph’s Healthcare Hamilton, Ontario, Canada
Kirk Brower, M.D.
Professor, Department of Psychiatry, University of Michigan Medical School,
Ann Arbor, Michigan
xx Clinical Manual of Emergency Psychiatry
Nancy Byatt, D.O., M.B.A.
Assistant Professor of Psychiatry, University of Massachusetts Medical School;
Attending Psychiatrist, Psychosomatic Medicine and Emergency Mental
Health, UMass Memorial Medical Center, Worcester, Massachusetts
M. Justin Coffey, M.D.
Chief Resident in Psychiatry, Department of Psychiatry, University of Mich-
igan, Ann Arbor, Michigan
Gregory W. Dalack, M.D.
Associate Professor and Interim Chair, Department of Psychiatry, University
of Michigan Medical School, Ann Arbor, Michigan
Tamar a Gay, M. D.
Assistant Professor, Department of Psychiatry, University of Michigan Medi-
cal School, Ann Arbor, Michigan
Patrick Gibbons, D.O., M.S.W.
Research Fellow, Department of Psychiatry, University of Michigan Medical
School, Ann Arbor, Michigan
Rachel L. Glick, M.D.
Professor, Department of Psychiatry, University of Michigan Medical School,
Ann Arbor, Michigan
Fadi Haddad, M.D.
Director of Child Psychiatric Emergency Services, Bellevue Hospital Center;
Clinical Assistant Professor of Child and Adolescent Psychiatry, NYU School
of Medicine, New York, New York
Laura Hirshbein, M.D., Ph.D.
Assistant Professor, Department of Psychiatry, University of Michigan Medi-
cal School, Ann Arbor, Michigan
Erick Hung, M.D.
Department of Psychiatry, University of California—San Francisco, San
Francisco, California
Contributors xxi
B. Harrison Levine, M.D., M.P.H.
Assistant Professor, Department of Psychiatry, University of Colorado School
of Medicine; Medical Director, Psychiatric Consultation Liaison and Emer-
gency Services, The Children’s Hospital, Aurora, Colorado
Gem Lucas, D.O.
Child and Adolescent Psychiatry Fellow, Division of Child/Adolescent Psychi-
atry, UMDNJ–Robert Wood Johnson Medical School, Piscataway, New Jersey
Kishor Malavade, M.D.
Clinical Assistant Professor, New York University School of Medicine, NYU
Langone Medical Center, New York, New York
Katherine Maloy, M.D.
Attending Psychiatrist, Comprehensive Psychiatric Emergency Program,
Bellevue Hospital; Clinical Assistant Professor, New York University School
of Medicine, NYU Langone Medical Center, New York, New York
Tracy McCarthy, M.D.
Resident in Psychiatry, Department of Psychiatry and Behavioral Sciences,
University of California, Davis Medical Center, Sacramento, California
Wanda K. Mohr, Ph.D., A.P.R.N., F.A.A.N.
Professor, Psychiatric Mental Health Nursing, University of Medicine and
Dentistry of New Jersey, New Hope, Pennsylvania
Julia E. Najara, M.D.
Private practice; formerly Assistant Clinical Professor of Psychiatry, Columbia
University; Director, Comprehensive Emergency Service, Pediatric Psychiatry
Division, Morgan Stanley Children’s Hospital of New York Presbyterian,
New York, New York
Debra A. Pinals, M.D.
Director, Forensic Education, Law and Psychiatry Program; Associate Profes-
sor, Department of Psychiatry, University of Massachusetts Medical School,
Worcester, Massachusetts
xxii Clinical Manual of Emergency Psychiatry
Ernest Poortinga, M.D.
Adjunct Clinical Assistant Professor of Psychiatry, University of Michigan
Medical School; Forensic Psychiatry and Consulting Forensic Examiner,
Center for Forensic Psychiatry, Saline, Michigan
Vasilis K. Pozios, M.D.
House Officer, Department of Psychiatry, University of Michigan, Ann Ar-
bor, Michigan
Melanie Quintero, Ph.D.
Senior Psychologist, CPEP Interim Crisis Clinic, New York, New York
Divy Ravindranath, M.D., M.S.
Psychosomatic Medicine Fellow, Department of Psychiatry, University of
Michigan, Ann Arbor, Michigan
Michelle B. Riba, M.D., M.S.
Professor and Associated Chair for Integrated Medicine and Psychiatric Servic-
es, Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
Patricia Schwartz, M.D.
Clinical Assistant Professor, Department of Psychiatry, New York University
School of Medicine, New York, New York
Zoya Simakhodskaya, Ph.D.
Clinical Instructor of Psychiatry, NYU School of Medicine, New York, New York
Patrick Smallwood, M.D.
Assistant Professor of Psychiatry, University of Massachusetts Medical School;
Medical Director, Psychosomatic Medicine and Emergency Mental Health,
UMass Memorial Medical Center, Worcester, Massachusetts
Michael Alan Taylor, M.D.
Adjunct Clinical Professor of Psychiatry, Department of Psychiatry, Universi-
ty of Michigan, Ann Arbor, Michigan
Mary Weathers, M.D.
Resident in Psychiatry, New York University School of Medicine/Bellevue
Hospital, New York, New York
Contributors xxiii
Ana Wolanin, M.S., R.N.
University of Massachusetts Medical School, Director of Psychiatric Services,
UMass Memorial Medical Center, Worcester, Massachusetts
Felicia Kuo Wong, M.D.
Resident in Psychiatry, University of Massachusetts Medical School, UMass
Memorial Medical Center, Worcester, Massachusetts
The following contributors to this book have indicated a financial interest in or
other affiliation with a commercial supporter, a manufacturer of a commercial
product, a provider of a commercial service, a nongovernmental organization,
and/or a government agency, as listed below:
Amin Azzam, M.D., M.A.—The author served as one of two primary editors
for First Aid for the Psychiatry Boards, published by the McGraw-Hill Com-
panies, Inc., Publishing Group, and receives a 10% royalty share on all do-
mestic print or electronic copies sold and a 5% royalty share on all foreign
sales, direct marketing sales, and/or specialty sales.
Kishor Malavade, M.D.—Speaker: Eli Lilly USA Lecture Bureau
The following contributors have no competing interests to report:
James Abelson, M.D., Ph.D.
Iyad Alkhouri, M.D.
James A. Bourgeois, O.D., M.D., F.A.P.M.
Philippe-Edouard Boursiquot, M.D.
Nancy Byatt, D.O., M.B.A.
M. Justin Coffey, M.D.
Gregory W. Dalack, M.D.
Tama ra Gay, M .D .
Patrick Gibbons, D.O., M.S.W.
Fadi Haddad, M.D.
Laura Hirshbein, M.D., Ph.D.
Erick Hung, M.D.
Katherine Maloy, M.D.
xxiv Clinical Manual of Emergency Psychiatry
Wanda K. Mohr, Ph.D., A.P.R.N., F.A.A.N.
Vasilis K. Pozios, M.D.
Melanie Quintero, Ph.D.
Divy Ravindranath, M.D., M.S.
Michelle B. Riba, M.D., M.S.
Patricia Schwartz, M.D.
Zoya Simakhodskaya, Ph.D.
Patrick Smallwood, M.D.
Michael Alan Taylor, M.D.
Mary Weathers, M.D.
Ana Wolanin, M.S., R.N.
Felicia Kuo Wong, M.D.
xxv
Preface
One of the most challenging clinical settings in psychiatry is the psychiatric
emergency department. Taking care of patients who are acutely ill in a timely
manner takes incredible skill and ability. Making the incorrect assessment can
have life-and-death implications. In addition, family members are very much
a part of the clinical situation and are often themselves frightened and wor-
ried. Besides facing the acuity of the clinical issues, trainees working in this
very difficult and high-stress setting at times have only backup supervision by
phone rather than in-person oversight. Busy psychiatric emergency depart-
ments where first-year and second-year psychiatry residents are trying to
quickly understand complicated clinical situations from patients who are
quite ill makes for very challenging work indeed.
In this book, we have sought to provide trainees and clinicians with an
understanding and the background of psychiatric emergency services in a for-
mat that can be easily read and highlighted. Each chapter was cowritten by a
trainee or junior faculty member as well as a senior faculty member at an ac-
ademic medical center. We chose topics that are generally the most important
and practical in any busy psychiatric emergency department. Case vignettes
are also included to contextualize the information provided and allow readers
to envision the applicable clinical scenario even if they are not actively seeing
patients in the emergency department setting. This is not meant to be a text-
book but rather a first pass at what psychiatrists often confront when working
in this type of setting. Our hope was to make this a reader-friendly and useful
clinical manual that reflects widespread practices in various academic centers
and that can be read by trainees in many different disciplines.
xxvi Clinical Manual of Emergency Psychiatry
With this in mind, we arranged many of the chapters by chief complaint
(e.g., suicidal ideation) rather than by psychiatric diagnosis (e.g., borderline
personality disorder). Many psychiatric conditions can result in the same psy-
chiatric emergency. Moreover, the emergency department is one of the few
arenas where patients do not arrive “prelabeled.” Therefore, we felt that orga-
nizing the book based on chief complaints would give the reader the greatest
opportunity to review the key points, as needed, just before seeing a patient.
This book also includes chapters on supervision and the role of medical
students and teaching in the psychiatric emergency department. These chap-
ters provide guidance both for supervisors, with regard to how to maximize
the learning potential of the emergency department, and for trainees, with regard
to what to expect from their supervisors and how to maximize the supervision
they receive. Legal and ethical issues in emergency psychiatry, disposition and re-
source options, and moving patients from the clinic to the emergency room are
also considered in separate chapters.
We hope that readers will let us know what was helpful or not in this first
edition of the clinical manual. For subsequent editions, we are open to changes
based on constructive comments. We recognize that due to the ongoing de-
velopment of newer treatments and options, future editions might also ad-
dress pharmacological and psychotherapeutic updates.
We appreciate the opportunity to have our respected colleagues partici-
pate in the writing and editing of this clinical manual. We hope that our un-
dertaking of this book will allow us to be better clinicians and teachers and
thereby provide improved service and care to our patients and their families.
Our sincere thanks and appreciation to Linda Gacioch, the administrative
manager for this clinical manual. Linda did an excellent job of organizing and
making sure that this project was done in a thoroughly professional and sys-
tematic manner.
Michelle B. Riba, M.D., M.S.
Divy Ravindranath, M.D., M.S.
xxvii
Acknowledgments
The volume editors extend their appreciation to the following faculty, resi-
dents, and fellows for their expert chapter reviews and editorial assistance:
Prachi Agarwala, M.D., Child and Adolescent Psychiatry Fellow, University
of Michigan
Sara Bobak, M.D., Child and Adolescent Psychiatry Fellow, University of
Michigan
M. Justin Coffey, M.D., Chief Resident in Psychiatry, University of Michigan
Daniel Gih, M.D., Child and Adolescent Psychiatry Fellow, University of
Michigan
Katie Hecksel, M.D., Child and Adolescent Psychiatry Fellow, Mayo Clinic
Brian Mickey, M.D., Attending Psychiatrist, University of Michigan
Richard W. Miller, M.D., Resident in Psychiatry, University of Michigan
Sara Mohiuddin, M.D., Attending Psychiatrist, University of Michigan
Christina Mueller, M.D., Child and Adolescent Psychiatry Fellow, University
of Michigan
Jennifer Seibert, M.D., Staff Psychiatrist, Salisbury NC VAMC, Charlotte
Community-Based Outpatient Clinic
Lizette Solis, M.D., Resident in Psychiatry, University of Michigan
Drs. Riba and Ravindranath also extend their sincere appreciation to
Linda Gacioch for her excellent administrative, organizational, and editorial
assistance.
This page intentionally left blank
1
1
Approach to Psychiatric
Emergencies
Katherine Maloy, M.D.
Kishor Malavade, M.D.
Although the vast majority of psychiatric practice takes place outside of the
hospital setting, the proportion of visits to emergency departments for psy-
chiatric reasons is increasing. In 2004, the 4.3 million psychiatric emergency
visits accounted for approximately 5.4% of total emergency department visits
(Hazlett et al. 2004). According to a 2008 utilization study, uninsured pa-
tients with psychiatric disorders were more likely to have multiple emergency
department visits and hospitalizations than insured patients (Baillargeon et al.
2008). As the ranks of uninsured individuals rise, psychiatric emergency ser-
vices are likely to experience an increasing demand. Many common medical
illnesses present with behavioral pathology and can cause changes in thinking
and mood, and as the population ages, the prevalence of dementia and med-
ical illnesses is escalating, further increasing demand for psychiatric emergency
2Clinical Manual of Emergency Psychiatry
services (Walsh et al. 2008). Also, patients who come to the emergency depart-
ment solely for medical reasons can present with personality traits and mal-
adaptive coping skills that may complicate their medical care.
In all these situations, the role of the mental health clinician as consultant,
liaison, educator, and detective can be crucial in facilitating appropriate care.
The mental health clinician practicing in the emergency department setting
must be adept at managing hospital systems issues, informed on medical ill-
nesses and their psychiatric manifestations, skilled in conflict resolution, eth-
ically and legally informed about responsibilities for patients’ safety, and able
to serve as a team leader who can direct staff in a crisis.
A General Approach to the Emergency
Psychiatric Patient
While hospital systems and local mental health law and policies may vary by
state or even individual hospital settings, an overall approach to the psychiat-
ric emergency patient involves an understanding of systems and a focus on pa-
tient and clinician safety.
Understanding Health Care Systems
Psychiatrists and mental health workers, including psychologists, social work-
ers, and psychiatric nurses, work in a variety of different capacities within
emergency departments. Delivery of efficient care requires that clinicians in
the emergency department know their role within the overall health care sys-
tem in which they are practicing. Issues that commonly arise include admis-
sion privileges, follow-up planning, insurance issues, safety, medical care,
available facilities at the emergency department or at affiliate hospitals, and
supervision, particularly for trainees or nonphysician consultants. Every
hospital has its own method of dividing responsibility and varying levels of
support staff. The answer to the question, “Who does what?” is primarily de-
termined by the training of the clinician within the emergency department
and the department’s overall policy for handling psychiatric cases (Brown
2005).
The settings of emergency psychiatric care delivery exist on a spectrum.
In most community hospitals, the volume of psychiatric cases is not high
Approach to Psychiatric Emergencies 3
enough to warrant dedicated psychiatric evaluation space or a comprehensive
psychiatric evaluation team. Typically, in primary care and community-based
centers, the mental health clinician acts as consultant to the emergency de-
partment. The facility may not have dedicated space for psychiatric evalua-
tion and assessment, and the nursing and support staff may be less familiar
with psychiatric issues (Woo et al. 2007). In facilities with more psychiatric
cases, particularly in hospitals with active inpatient psychiatric services, emer-
gency departments may set aside space or have more support services available
for psychiatric emergencies, as advocated by the American Psychiatric Asso-
ciation (Allen et al. 2002). A true comprehensive psychiatric emergency de-
partment is most common in large, urban settings, where a higher volume of
psychiatric cases is common. For example, dedicated social work staff, psy-
chiatrically trained nursing and support staff, a separate locked area, and the
possibility of extended observation (up to 72 hours) are features of the Com-
prehensive Psychiatric Emergency Program in New York State. Variations on
this model have developed across the country. Although a comprehensive
psychiatric emergency department can be a stressful work environment, the
role of each clinician working in such a setting is clearer and more support is
available.
Regardless of the system in which the clinician works, the same basic prin-
ciples apply. The patient should receive as comprehensive an evaluation as
possible, followed by a thorough disposition plan—whether admitted or dis-
charged—in a setting that is safe and as therapeutic as possible.
Assuring Safety
Although the idea of emergency department psychiatry commonly brings to
mind wildly out-of-control patients, the reality is much more mundane. The
vast majority of psychiatric patients are not violent toward others, and self-
harm in a supervised setting is not common. However, one must still act to
assure the safety of the patient, the doctor, the staff, and other patients in the
area.
Hospital systems play a large role in how safety is achieved, so it is impor-
tant for the clinician to know the particular challenges in his or her emergency
department and have a plan in mind for ensuring patient and staff safety
when a potentially dangerous situation arises. If contingency plans for safety
4Clinical Manual of Emergency Psychiatry
are already established, the staff can execute them more easily. Emergency de-
partments should establish policies regarding searching patients for weapons
and specifying when and how to call for backup support if a patient becomes
violent. Ideally, all patients should be searched prior to the interview. If a
search is not performed routinely, the clinician should request a search or at
least request that the patient change into hospital gowns or pajamas prior to
the interview, thereby making it harder to conceal weapons. At the start of a
shift, consultants—particularly those who work only occasionally in the
emergency department—should introduce themselves to security staff so staff
know whom to contact if backup support is needed. Although some facilities
have security cameras or panic buttons, it is also helpful to notify staff prior
to meeting with a patient so they can be ready to respond if a crisis situation
arises.
Approaching Agitated or Violent Patients
Asking staff how the patient has been behaving prior to the clinician’s arrival
can help the clinician tailor an initial approach. If the patient has been calm
and cooperative, then the clinician may elect to interview the patient follow-
ing the hospital’s standard safety protocol. However, if the patient has been
agitated, then additional precautions may be warranted prior to interviewing
the patient.
Prior to initiating an encounter with an agitated patient, the clinician should
first determine some key points about the patient, both through the clinician’s
own observation and by asking the staff for their input. Who is the patient,
including his or her basic physical characteristics and presenting complaint?
Is the patient upset about a specific issue or psychotic and disorganized? What
is the patient’s behavior? Is he or she yelling? Throwing things? Making any
specific threats? Finally, are there any indicators as to the etiology of the agi-
tation, such as appearing ill, smell of alcohol on the patient’s breath, or obvi-
ous head trauma?
Once the nature of the situation is clear, the clinician can determine the
environment in which to further assess the patient. For example, the degree
of agitation may warrant interviewing the patient in a more public area than
usual so that other staff members can monitor the interaction directly. Addi-
tionally, the clinician may request that security staff be present on standby in
Approach to Psychiatric Emergencies 5
the emergency department to provide assistance rapidly if needed. Finally, the
clinician may elect to begin the interaction with the patient by addressing the
agitation directly rather than trying to determine the chief complaint, the his-
tory of the presenting illness, and so forth. For example, the clinician may start
by pointing out the level of agitation to the patient and then offering to help.
This may include an offer of a medication to calm the patient. Given that sit-
uations may not always be as they appear, the clinician should always err on
the side of caution and containment of the patient in the least restrictive method
possible.
Maintaining a calm demeanor goes a long way toward preventing escala-
tion of agitation to violence. Many patients will resonate with the nonverbal
communication of the clinician, and a clinician who is becoming more agi-
tated may cause the patient to become more agitated as well (Flannery 2007).
The clinician should be vigilant for signs of escalating tension, such as clench-
ing fists, increased respiratory rate, threatening postures, or restlessness, and
be ready to terminate an interview or interaction before a situation escalates,
even if little information has been obtained.
General Rules for Approaching Agitated Patients
When encountering an agitated patient, the following general principles are
helpful in maintaining safety and perhaps deescalating the situation.
1. Take charge and make a plan. Staff members or other patients, meaning
well, may try to intervene in various ways. This is confusing to the patient
and can escalate the situation. The team leader should identify himself or
herself as such and ask staff to follow his or her directions.
2. Keep a safe distance. Crowding someone who is already upset is not gener-
ally a soothing tactic, and keeping a safe distance lowers the risk of inad-
vertent injury by a flailing or agitated patient.
3. Ask for backup. Whether security should be present depends on the nature
of the situation at hand. If the clinician is concerned that the patient may
require a medication or restraints, he or she should ask someone to be pre-
paring those ahead of time.
4. Provide an easy out. People who are upset and confused generally want a
way to resolve the issue rather than escalating it further. Providing a quick
and safe alternative to further escalation allows the patient a way out. For
6Clinical Manual of Emergency Psychiatry
example, the clinician might say, “I can see you are very upset. Would you
be willing to sit down with me and we can figure out a way to resolve this
situation?”
5. Give clear instructions. Specifically asking the patient to sit down in a cer-
tain place, lower his or her voice, put down the chair, and so on, is much
more likely to yield a result than general directives to “calm down,” “relax,”
or “take it easy.”
Dealing With Escalation
If a patient escalates to violence during an interview, the clinician’s priority
should always be his or her own safety. Escape is the first priority, followed by
alerting other staff and then containment of the patient. A clinician who is
injured or incapacitated should leave the situation and get help, because the
immediate fear and pain will make being an effective team leader difficult.
Particularly for trainees, who may feel that they are letting other staff down
or appearing cowardly if they protect themselves, violent situations can pro-
voke intense feelings of guilt or self-blame. Clinicians who are injured may feel
that they provoked the attack or feel intense anger that is unfamiliar and dif-
ficult to reconcile with their values and ideals of what constitutes good patient
care. Clinicians need to remember that they are also human beings, who
exhibit a full range of normal human emotions in response to trauma. Clini-
cians are advised to seek support from friends, colleagues, or a mental health pro-
fessional after a frightening incident. There is no one right answer regarding
whether the clinician should press charges against an assaulting patient; that
decision is best left to the discretion of the clinician.
Etiologies of Agitation
After safety has been assured, the overriding principle in addressing agitation
is to rule out life-threatening medical causes. The assumption that a patient
is suffering from a psychotic break as the result of schizophrenia could be fatal
for a belligerent patient with hypoglycemia and diabetes or a patient experi-
encing delirium tremens. Table 1–1 covers common causes of agitation and
basic approaches to their treatment. Delirium and intoxication/withdrawal
syndromes are covered in more detail in later chapters (see Chapter 8, “The
Cognitively Impaired Patient,” and Chapter 9, “Substance-Related Psychiat-
ric Emergencies”).
Approach to Psychiatric Emergencies 7
Treatment
A general progression of options for dealing with agitation starts with verbal/
behavioral interventions, then consideration and application of medications,
with seclusion/restraints as a final option.
Verbal/Behavioral Interventions
As mentioned previously, speaking with a patient in a calm and rational man-
ner, addressing his or her needs to the extent possible, and giving specific di-
rections for the patient to change behavior may be all that a patient needs to
calm down. In a crowded emergency department, moving the patient to a
more secluded or quiet area may be helpful. Instituting one-to-one supervi-
sion may help by giving the patient someone to talk to, showing that the staff
feels that the patient requires supervision, preventing elopement, and provid-
ing an early alert for other staff if behavior escalates again. Whenever possible,
providing patients with information about how their evaluation is proceed-
ing, why they are at the emergency department, and how long they should
expect to remain can prevent further disruption.
Medications
Operating on the principle of using the least restrictive alternative for treatment,
offering oral medication to an agitated patient is usually the first option. Most
oral medications take effect within 20–30 minutes. Dissolving tablets allevi-
ate the necessity of swallowing but do not take effect any faster than regular
oral medications. Dissolving tablets and liquid medication are more difficult
to “cheek” or conceal without swallowing. In circumstances where 1) the pa-
tient refuses oral medication and safety is a concern, 2) safety is such a concern
that oral medication would act too slowly, or 3) the patient might lack the air-
way control to swallow medication, intramuscular medication is the next best
option. The most common protocol is a benzodiazepine plus a neuroleptic
(Wilhelm et al. 2008). Table 1–2 lists medications commonly used for agita-
tion, typical dosing ranges for oral and intramuscular routes, and notable
benefits and risks of each.
8Clinical Manual of Emergency Psychiatry
Table 1–1.
Common causes of agitation in the emergency department setting
Cause Clinical presentation Treatment approach
Acute cocaine/
stimulant
intoxication
Tachycardia, dilated pupils, irritability with or
without psychosis, which can present as almost
entirely similar to schizophrenia-like symptoms.
Cocaine effects usually time limited, as opposed
to PCP or amphetamine psychosis, which can
persist longer.
Use benzodiazepines for sedation; hold beta-blockers.
Benzodiazepine/
barbiturate
withdrawal
Similar to alcohol withdrawal, but may not show
vital sign changes, and may present solely as a
delirium with or without tremor. High risk of
seizure.
Taper benzodiazepine.
Delirium Waxing and waning level of consciousness,
fluctuation in vital signs, confusion. Can be
irritable or passive and detached. More common
in the elderly or medically frail patient.
Assure safety of the patient, treat the underlying cause, use
low-dose neuroleptics to calm the patient so that medical
treatment can proceed, provide reorientation cues when
possible.
Delirium tremens All signs of delirium, with or without tremors, with
or without hallucinations; intense fluctuation in
vital signs. Last drink of alcohol 24–72 hours
prior.
If patient has intact airway, aggressively sedate with
parenteral benzodiazepines to the point of drowsiness,
if possible. Provide ICU-level monitoring, if needed.
Hypoglycemia Altered mental status with sweating, tachycardia,
and weakness.
If patient has patent airway, use oral glucose; otherwise, use
dextrose 50% iv.
Approach to Psychiatric Emergencies 9
Postictal states Altered level of consciousness, confusion, ataxia.
May have Todd paralysis or other residual
neurological signs, such as slurred speech. May
have evidence of tongue biting or incontinence
from prior seizure.
Assure patient safety, observe for further seizure activity.
If agitation requires treatment, use benzodiazepines over
neuroleptics because latter may lower seizure threshold.
Determine cause of seizure.
Psychosis/mania/
primary psychiatric
disorder
Not usually associated with disorientation,
no waxing and waning level of consciousness,
no vital sign changes. Look for other signs of
psychiatric illness or history of same.
Assure safety; offer oral medications or intramuscular
medications; or consider restraints if necessary.
Structural brain
abnormality
Varies by lesion, but altered mental status with
headache, meningeal signs, focal neurological
deficit (e.g., agitated patient who wants to leave
but cannot walk), or progressive neurological
deterioration.
Assure patent airway; use emergent CT scan or other
imaging modality.
Toxicologic
emergency
Varies by substance, but ingestion of toxic
substances can lead to mental status changes.
Watch for pupillary changes, sweating, vital sign
changes, or other signs of medical illness.
Attempt to identify toxin and contact poison control.
Note. CT = computed tomographic; ICU =intensive care unit; PCP =phencyclidine.
Source. Adapted from Moore and Jefferson 2004.
Table 1–1.
Common causes of agitation in the emergency department setting (continued)
Cause Clinical presentation Treatment approach
10 Clinical Manual of Emergency Psychiatry
Table 1–2.
Common medications used in management of agitation
Medication Dosing Benefits Risks
Aripiprazole Only intramuscular
administration effective for
agitation
9.75 mg im, up to 30 mg/day
Less risk of EPS or dystonia
Less sedating
Not in use for long, less experience
Akathisia
More expensive
Chlorpromazine 25–100 mg po
25–50 mg im
Very s edating
Lower risk of EPS/dystonia than other
typicals
High risk of orthostatic hypotension
Diazepam 5–10 mg po or im No EPS or dystonia
Also used to treat alcohol or
benzodiazepine withdrawal
Respiratory depression
Active metabolite resulting in very
long half-life and therefore
problematic if impaired liver
function
Diphenhydramine 25–50 mg po or im When used with typical antipsychotics,
prevents/treats EPS and dystonia
Very s edating
Anticholinergic delirium at higher
doses or in elderly
Paradoxical activating reaction
Fluphenazine 5–10 mg po or im Sedating
Anecdotally less dystonia than
haloperidol
EPS
Dystonia
Haloperidol 1–5 mg po (liquid or pill) or im;
can repeat up to 10–15 mg
Sedating
Rapid onset
Inexpensive
Dystonic reaction
EPS
Lower seizure threshold
Approach to Psychiatric Emergencies 11
Lorazepam 1–4 mg po or im No EPS or dystonia
Also used to treat alcohol or
benzodiazepine withdrawal
Good for patients with impaired
liver function
Paradoxical disinhibition and
agitation
Respiratory depression
Olanzapine 5–10 mg po (tablet or dissolving
wafer)
5–10 mg im, up to 20 mg total/
day
Less risk of EPS or dystonia reported
Less sedating
Wafers excellent for patients with
impaired swallowing
Maximum dosing achieved quickly
Expensive
Ziprasidone Only intramuscular
administration effective for
agitation
10 mg im, maximum 40 mg/day
Less risk of EPS or dystonia reported
Less sedating
More expensive
Effectiveness unknown
Note. EPS=extrapyramidal symptoms.
Source. Marco and Vaughan 2005; Physicans’ Desk Reference 2008; Rocca et al. 2006; Villari et al. 2008.
Table 1–2.
Common medications used in management of agitation (continued)
Medication Dosing Benefits Risks
12 Clinical Manual of Emergency Psychiatry
Seclusion
If available, the option of placing a patient in locked seclusion may be a
slightly less restrictive alternative than restraint. Seclusion is safe, however,
only if the room is properly designed and the patient is supervised appropri-
ately during the seclusion. Many general emergency departments do not have
seclusion rooms.
Restraint
Physical restraint is a last option for assuring safety of an agitated patient and
requires training to execute. Careful documentation of the time the patient
was restrained, the type of restraint used, and the reasoning behind the deci-
sion is essential. Once restrained, the patient should be on one-to-one obser-
vation until released, and vital signs should be checked frequently.
More detailed information on restraint and seclusion techniques can be
found in Chapter 11, “Seclusion and Restraint in Emergency Settings,” but cer-
tain principles are important to emphasize here. Restraint or seclusion should
always be a last resort and may lead to patient and staff injury. They should
never be used punitively and should be used only to contain behavior so un-
safe that it cannot be controlled in any other way (Downey et al. 2007; Herzog
et al. 2003).
The Emergency Psychiatric Interview
The psychiatric interview of a patient in an emergency setting is unique. Com-
pared with a typical psychiatric interview, the emergency interview is usually
shorter and frequently less private, and its primary goals are to assess the pa-
tient’s safety and determine the appropriate disposition. It can be complicated
by the fact that the patient may be unwilling to cooperate and may not have
been the person who decided that psychiatric intervention was indicated. De-
spite the compelling need to uncover complicating medical conditions and
sources of collateral information, the interview need not be formulaic. Given
that the clinician is trying to establish rapport and ask about intimate issues af-
ter only a brief interaction, the clinician should always be flexible enough to
switch the topic when necessary, follow the patient’s train of thought if indi-
cated, and adapt to the patient’s personality style (Manley 2004).
Approach to Psychiatric Emergencies 13
An important part of the assessment occurs before the clinician even en-
ters the room with the patient. Before initiating contact with the patient, the
clinician should always find out 1) the reason for seeing the patient, 2) basic
available demographic information, and 3) the patient’s behavior prior to the
clinician’s arrival. If possible, brief covert observation of the patient’s behavior
can also be extremely useful because it may uncover attempts at malingering
or reveal behavior that the patient will attempt to hide during the interview
itself. Clinicians should always begin an interview by clearly introducing them-
selves, making the patient aware that they are conducting a psychiatric evalu-
ation, and establishing a safe seating arrangement. It is also helpful to remind
the patient that the purpose of the assessment is to figure out how best to help
him or her in the given situation.
Components of the Interview
The components of an emergency psychiatric interview (Vergare et al. 2006) are
similar to those of a more comprehensive diagnostic interview, but necessarily
focus more on immediate medical and safety risk factors and on the events im-
mediately preceding the patient’s arrival to the emergency department.
Patient Identification
The clinician first determines who the patient is and how he or she got to the
emergency department. A brief sketch of the patient’s demographics contex-
tualizes the patient for the rest of the assessment. How the patient arrived
(i.e., on his or her own, with family, with police) is helpful for understanding
the patient’s attitude toward treatment.
Chief Complaint
The clinician should then determine what the patient sees as the presenting
problem.
History of Present Illness
A patient who is agitated, intoxicated, or psychotic may have difficulty clearly
reconstructing how events unfolded before arriving at the emergency depart-
ment. The patient may require specific redirection as to times, dates, events,
and the chronology of symptoms, and the clinician may require data from
collateral informants.
14 Clinical Manual of Emergency Psychiatry
Past Psychiatric History
Information sought about the patient’s past psychiatric history should include
1) prior hospitalizations, last hospitalization, and age at first hospitalization;
2) prior suicide attempts or self-harming behaviors; 3) prior episodes of vio-
lence or agitation; 4) prior trials of medications or therapies; and 5) history of
arrests or incarceration.
Substance Use History
In questioning a patient about his or her history of substance use, the clinician
should start by asking about tobacco, which is generally the most socially ac-
ceptable. For each substance, a complete history should include the patient’s
1) prior use or experimentation, 2) highest level of use, 3) longest sober pe-
riod, and 4) current level of use. In addition to questioning about alcohol,
marijuana, cocaine, and opiates, the clinician should ask about hallucinogens,
inhalants, club drugs, and prescription drugs. The clinician should also screen
for history of withdrawal symptoms (e.g., delirium tremens and seizures) and
prior treatment history (e.g., rehabilitation, outpatient programs, Alcoholics
Anonymous).
Medical History
The medical history should include questions about the patient’s history of
cardiac disease, hypertension, diabetes, epilepsy, head injury, hepatitis, cancer,
and surgeries. A general reproductive history for women can also be helpful,
specifically asking if the woman is menstruating regularly, is perimenopausal
or postmenopausal, might be pregnant, or has undergone any reproductive
surgeries. Because the Centers for Disease Control and Prevention (2006) has
recommended that all adults be tested for HIV as a routine part of health
maintenance, the clinician should routinely ask about HIV status in at-risk
individuals. In at-risk populations, history of a positive PPD (purified protein
derivative) or tuberculosis diagnosis or treatment is also important in deter-
mining whether further evaluation by chest X ray or even respiratory isolation
will be necessary.
Social Circumstances
In emergency presentations, instead of taking a detailed developmental his-
tory, the clinician should focus on painting a picture of the patient’s current
Approach to Psychiatric Emergencies 15
social circumstances. The following information is helpful for making dispo-
sition determinations: living situation, financial support, employment history,
relocation history, social situation and supports, educational background, im-
portant developmental events, and legal/immigration status.
Mental Status Examination
The mental status examination in the emergency psychiatric interview is sim-
ilar to any other mental status examination, except that particular attention
must be paid to documenting 1) active psychotic symptoms, 2) thoughts of
self-injury or suicide and thoughts of harming others or homicide, 3) evidence
of drug or alcohol intoxication, and 4) cognitive functioning.
Safety Alerts
Certain safety-related situations that may present during the emergency psy-
chiatric interview should trigger more immediate action. These include the
following:
• Children in the home or other persons for whom the patient is the primary
caregiver (The interviewer should ascertain where these individuals are
and who is caring for them, document this information carefully, and send
authorities to retrieve anyone who is unsupervised while the patient is in
the emergency department.)
• Medical conditions requiring immediate treatment
• Active alcohol or benzodiazepine intoxication and withdrawal
• Active suicidal ideation with intent and plan
• Active violent ideation with intent and plan
Collateral Information
Collateral information can be helpful in forming a clear assessment in an
emergency situation, and taking steps to obtain this information can be con-
sidered a standard of care in certain circumstances. If possible, the clinician
should obtain the patient’s consent to talk to collateral informants. However,
in an emergency situation, the clinician is permitted, even with existing
Health Insurance Portability and Accountability Act (HIPAA) regulations, to
contact collateral sources of information if demanded by the patient’s emer-
gency circumstances. Even though the clinician may obtain collateral infor-
16 Clinical Manual of Emergency Psychiatry
mation, the physician is still not permitted to unnecessarily share information
about the patient without the patient’s consent. (This point is discussed fur-
ther in Chapter 12, “Legal and Ethical Issues in Emergency Psychiatry.”) All
attempts to gain information via contacting collateral sources should be care-
fully documented, including why it was deemed necessary to contact the source
and whether the contact was made with or without the patient’s consent (U.S.
Department of Health and Human Services 2003b).
Medical Clearance
The term medical clearance has entered into the medical parlance without a
consensus about its definition. There is no way to rule out every possible
medical illness a patient may have prior to admission to a psychiatric unit
(Zun 2005). As such, the goal of the emergency room physician and/or men-
tal health clinician should be to make a reasonable investigation into the pos-
sibility that the patient has an illness 1) that would be better treated in a medical
setting (e.g., an infection requiring intravenous antibiotics, a stroke, myocar-
dial infarction); 2) that will cause the acute decompensation of the patient in
the next few hours and thus require a higher level of care (e.g., active alcohol
withdrawal that is not responding to oral medication or a smoldering gas-
trointestinal bleed); 3) that is causing the behavioral symptoms that brought
the patient to the hospital in the first place and should be treated by some-
thing other than psychiatric medication (e.g., delirium due to an underlying
infection or intracranial hemorrhage); or 4) is worsening the psychiatric pro-
cess (e.g., untreated pain that is causing agitation). This investigation is
accomplished through a careful diagnostic interview, a careful physical exam-
ination, and a combination of screening lab tests and imaging studies.
The more that emergency department psychiatrists are able to retain fa-
miliarity with routine medical issues and communicate effectively with other
services as needed, the more service they will be to their patients. Clinicians
without medical training who are working in an emergency department will
need to rely more heavily on the emergency department physician to assist
with the differentiation of medical and psychiatric issues. However, a famil-
iarity with common medical comorbidities, the medical complications of
substance withdrawal, and the differences between delirium and psychiatri-
cally caused psychosis are crucial to a thorough evaluation.
Approach to Psychiatric Emergencies 17
Many hospital systems require that the psychiatrist admitting the patient
to a psychiatric unit perform his or her own physical examination as part of
the assessment. This examination can be particularly difficult with a patient
who is agitated or psychotic, but it may reveal important information that can
contribute to treatment decisions. Table 1–3 details the contents of a focused
physical examination when seeking medical clearance for psychiatric evalua-
tion, and Table 1–4 details relevant laboratory tests and studies that may be
considered.
In summary, the examination of a psychiatric patient in the emergency
department should be targeted toward finding occult medical processes that
require treatment in a nonpsychiatric setting, are imminently life threatening,
or are contributing to the psychiatric process (Guze and Love 2004).
Substance Abuse and Withdrawal Syndromes
Substance abuse accounts for many emergency department visits. Mental health
clinicians are frequently called to evaluate patients who are acutely intoxicated
or in withdrawal, both to assess their safety and to assist in determining a dis-
position.
The emergency assessment of substance abuse problems should focus on
the immediate issues of safety, which include protecting the acutely intoxi-
cated or withdrawing patient from harming self or others and making a deci-
sion about when the patient is safe to leave. Consults can also be called to assess
a patient’s capacity to refuse medical care when a patient is acutely intoxicated
or in withdrawal.
Negative countertransferential feelings may interfere with the appropriate
assessment of the substance-abusing patient. Clinicians may be inclined to
consider patients who are intoxicated as less deserving of time or attention be-
cause they seemingly have brought the problem on themselves. In addition,
if these patients are abusive or belligerent and being held against their will,
providing appropriate care becomes even more difficult. Despite the difficul-
ties and annoyance that these patients can cause, they require close monitor-
ing and are at greatly increased immediate risk of intentional or unintentional
harm to themselves. (For more details on substance abuse in the psychiatric
emergency setting, see Chapter 9, “Substance-Related Psychiatric Emergen-
cies,” this volume.)
18 Clinical Manual of Emergency Psychiatry
Table 1–3.
Focused physical examination when seeking medical clearance for psychiatric
evaluation
Area examined What to look at What to look for
General appearance Weight, stature, grooming, level of distress,
skin
Cachexia—suspicion of tuberculosis, cancer, HIV,
malnutrition
Obvious respiratory distress
Obvious physical distress or agitation
Grossly disheveled or malodorous patient
Rashes—allergic or infectious illnesses
Head, ears, eyes, nose, throat Mucous membranes, conjunctiva, pupils and
eye movements, any discharge or lesions,
evidence of trauma, dentition
Dry mucous membranes—dehydration
Pupils and eye movements—focal neurological
deficits, evidence of drug intoxication or withdrawal
Scleral icterus—jaundice
Proptosis—hyperthyroidism
Bruises, lacerations—evidence of head or facial trauma
Poor dentition—nutritional status, occult abscesses
Neck Thyroid size, neck mobility Thyromegaly—goiter, hyperthyroidism
Neck rigidity—meningitis, encephalitis
Chest Breath sounds, accessory muscle use, any
evidence of trauma
Rales—congestive heart failure
Rhonchi—pneumonia
Chest trauma—emergent need for treatment of a
wound; risk of future pneumonia from decreased
chest expansion
Cardiovascular Heart sounds, peripheral pulses Rate, rhythm, regularity of heartbeat
Any absent peripheral pulses—vascular disease
Approach to Psychiatric Emergencies 19
Abdomen Any palpable masses, liver size, scars, areas of
tenderness
Hepatomegaly—undiagnosed liver disease
Surgical scars
Acute tenderness—acute pathology that needs to be
addressed in emergency department
Back and spine CVA tenderness, spinal curvature Curvature—scoliosis or osteoporosis
CVA tenderness—kidney infection or stones
Extremities Movement, strength, range of motion Any deficits, limps, or pain that might indicate occult
neurological illness
Neurological Cranial nerves, strength, sensation, gait,
reflexes
Any focal deficits indicating stroke or occult mass
Festinating gait, rigidity—parkinsonism
Tremors—parkinsonism, EPS
Evidence of tardive dyskinesia
Broad-based gait—hydrocephalus, tertiary syphilis
Note. CVA=cerebrovascular accident; EPS=extrapyramidal symptoms.
Table 1–3.
Focused physical examination when seeking medical clearance for psychiatric
evaluation (continued)
Area examined What to look at What to look for
20 Clinical Manual of Emergency Psychiatry
Table 1–4.
Common laboratory tests and studies when seeking
medical clearance for psychiatric evaluation
Test Abnormal results and their psychiatric implications
CBC Macrocytic anemia—vitamin B12/folate deficiency, alcohol
abuse
Microcytic anemia—iron deficiency
Normocytic—acute bleeding or chronic inflammatory disease
Leukocytosis—acute infection
Leukopenia—advanced HIV disease, immune suppression,
leukemia, carbamazepine
Low platelets—side effect of valproate or carbamazepine,
autoimmune thrombocytopenia
Basic metabolic Elevated creatinine—renal failure
Hyponatremia—can be caused by SSRIs, particularly in
elderly
Hypernatremia—dehydration, renal failure
Low potassium—risk for arrhythmia; may be due to diuretic
use, bulimia, diarrhea
High potassium—risk for arrhythmia; may be due to renal
failure
Low bicarbonate—acidosis; aspirin ingestion
Liver enzymes Elevated ALT:AST ratio—alcohol abuse
Elevated ALT and AST—liver failure due to multiple causes
(e.g., drugs, acetaminophen ingestion, hepatitis)
Urinalysis Urinary tract infection in elderly or sick patient can lead to
severe delirium
Urine drug screen Positive—detection of some common drugs of abuse
TSH Elevated—hypothyroidism leading to depression, cognitive
changes
Low—hyperthyroidism leading to manic-like symptoms,
agitation
Vitamin B12/folate Low B12—neurological changes, memory problems
Low folate—evidence of general malnutrition; may be
associated with depression, thromboembolic events
RPR Latent syphilis—can lead to dementia, mood changes,
neurological deficits
Chest X ray Considered for all homeless patients, any patients with risk
factors for tuberculosis, and elderly patients—look for
evidence of tuberculosis, occult masses, pneumonia
Approach to Psychiatric Emergencies 21
Documentation
Whenever a patient is hospitalized or released, either voluntarily or involuntarily,
one of the clinician’s most important jobs is to provide clear and thorough
documentation. The purpose of emergency department documentation is
twofold. First, the report may communicate details to other interested clini-
cians, such as the patient’s outpatient psychiatrist or therapist, admitting doc-
tor, and primary care doctor, when the treating clinician is not available to
communicate with them. Second, the report will be used as evidence of what
happened and what contributed to the assessment of the patient both by in-
surance companies and other organizations involved in utilization review ac-
tivities and by courts if the patient is involved in a legal case (e.g., currently
incarcerated, possibly raped) or if a malpractice case is brought against the
treating clinician. Clinicians need to be aware not only of the liability involved
in releasing a patient who may turn out to be dangerous, but also of the fact
that lawsuits have been filed charging doctors with false imprisonment and
deprivation of civil rights by patients who feel they were unjustly committed
against their will. Therefore, documentation should be thorough regardless of
disposition.
Head CT Occasionally used for screening for gross masses or bleeding
in patients with altered mental status or new-onset psychosis
Less sensitive than MRI but less expensive, more accessible,
and faster
EEG If available acutely, can be used to look for nonconvulsive
status epilepticus, evidence of metabolic encephalopathy
(delirium)
Lumbar puncture Indicated for any patient with new mental status changes,
fever, and/or meningeal signs
Look for evidence of viral or bacterial meningitis, encephalitis,
bleeding, cryptococcal infection
Note. ALT=alanine aminotransferase; AST=aspartate aminotransferase; CBC = complete
blood count; CT=computed tomography; EEG=electroencephalography; MRI=
magnetic resonance imaging; RPR=rapid plasma reagin; SSRI=selective serotonin re-
uptake inhibitor; TSH=thyroid-stimulating hormone.
Table 1–4.
Common laboratory tests and studies when seeking
medical clearance for psychiatric evaluation (continued)
Test Abnormal results and their psychiatric implications
22 Clinical Manual of Emergency Psychiatry
Components of Documentation
Documentation for every psychiatric admission or release should include the
following:
• The facts on which an assessment is based, including the sources of these
facts, such as the patient, collateral informants, and laboratory tests and
studies
• A risk assessment of the patient’s chronic and immediate risk of danger to
self and others (Jacobs et al. 2003)
• A reasoned argument for the decision that was made and against the alter-
native disposition
• In the case of admission, clear documentation of all evidence that proves
the patient’s dangerousness or inability to care for self and the manner in
which this will be addressed by psychiatric admission
• In the case of discharge, clear documentation of the lack of imminent dan-
gerousness (A follow-up plan of some kind—even if it is merely a listing
of information given to the patient for use on his or her own—is always
warranted.)
It is absolutely essential that the risk assessment be documented in a clear
and coherent manner that justifies the decision regarding admission and
treatment that has been made by the treating psychiatrist. Readers of the as-
sessment should not be left to deduce or infer the clinician’s thought process.
Examples of Documentation
Ms. A is a 34-year-old single white woman, employed, domiciled, and re-
cently divorced, with a history of alcohol dependence and depressive epi-
sodes. She was brought to the emergency department by emergency medical
services after she called 911 reporting that she had taken an overdose of alco-
hol, diazepam, and painkillers. After medical stabilization, she was referred
for psychiatric evaluation. Ms. A currently denies that she was intending to
harm herself and maintains that she accidentally ingested these medications.
She does not recall calling 911 for help and denies any current depressive
symptoms. Collateral information from her ex-husband reveals that their di-
vorce has resulted in the loss of custody of her children and that she has been
absent from work and drinking more heavily since. Despite Ms. A’s assertions
Approach to Psychiatric Emergencies 23
of her safety, it is evident that she is at high risk for harming herself in the near
future, given the potential lethality of her ingestion, her lack of insight into
the dangerousness of her behavior, and reports of her decreasing ability to
function. In addition, losing custody of her children is likely to have increased
her risk of suicidal behavior due to feelings of guilt. She has no support in the
community and no current psychiatric care. Due to these risks, she will be ad-
mitted for 72-hour observation for improvement in her mood with support-
ive and group psychotherapy, and plans for aftercare will be made before her
release.
Mr. B is a 55-year-old single white man with no formal psychiatric history
who was recently released from a brief jail stay for domestic violence. He pre-
sented to the emergency room after his mother called 911 stating that he was
“acting crazy” and smashing items in her home. The patient was agitated on
arrival but has maintained behavioral control since then and has shown no ev-
idence of aggression or agitation. He admits to “having problems with my
temper” and using cocaine earlier in the day. He is currently staying with his
mother since his arrest for domestic violence. He admits to having angry feel-
ings toward his ex-girlfriend who filed charges, and states that if he knew
where she was staying, he would probably “knock some sense into her.” How-
ever, he evidences no symptoms of mental illness and has a clear and coherent
thought process. He is fully aware of the legal implications and risks of assault-
ing his ex-girlfriend. He declined referral to substance abuse treatment. Despite
Mr. B’s assertions of violent ideation, he does not demonstrate symptoms of
a mental illness at this time and does not warrant psychiatric hospitalization.
Prior to his release, the precinct in his ex-girlfriend’s neighborhood was warned
of his impending release. She has not been notified, according to her family,
because she has entered a domestic violence shelter and they do not know her
location. In addition, staff spoke with the patient’s mother and advised her to
call police if her son’s behavior escalated and to take steps to assure her own
safety.
Special Situations
Telephone Emergencies
Emergency departments frequently receive calls from people in the commu-
nity seeking medical advice. When these calls are of a psychiatric nature, they
may be directed to the consulting mental health clinician or routed to the psy-
chiatric emergency department. Calls cover a wide range of questions, includ-
ing issues of medications, side effects, and drug use. The clinician should try
24 Clinical Manual of Emergency Psychiatry
to help to the degree that he or she can. Patients should always be assured that
they can come to the emergency department for further evaluation of their
complaint and encouraged to contact their personal physician or mental health
clinician for further assistance. When phone calls involve threats of violence
or self-harm, the clinician should attempt to remain on the line with the pa-
tient, be supportive, and try to obtain as much information as possible about
the patient’s location. If the patient refuses to reveal his or her identity or lo-
cation, the clinician should notify other emergency department staff to con-
tact the police so that they can attempt to trace the call, although in the age
of cellular phones, tracing can be difficult. If a clinician is concerned about the
safety of the caller, notifying police and asking them to visit the caller to check
on him or her is the safest option.
Rape
Although many rape victims never seek treatment, some victims may request
a psychiatric consultation, emergency department staff may request a psychi-
atric consultation if they are concerned that a rape victim may be suicidal or
otherwise psychiatrically compromised by the event, or a patient may reveal
an assault while being evaluated for another psychiatric issue. Clinicians
should ensure that all appropriate medical, legal, and counseling services are
made available to the patient. The hospital’s social work department can be
helpful for finding victims services available in the area. Patients who have
experienced rape or sexual traumatization should be offered and encouraged
to have a full physical examination by a nurse or physician trained in evidence
collection, even if they do not want to press charges at that time. Women
should be offered prophylactic contraception to prevent pregnancy, and all
patients should be counseled about and offered prophylaxis for sexually trans-
mitted diseases and HIV. Patients may not wish to report the incident, but
should be offered the opportunity to do so, and whenever possible they
should be assisted by a rape crisis counselor or victim’s advocate during this
process. Patients who are considered “mentally ill” may experience more dif-
ficulty in reporting assaults because of the significant stigma attached to psy-
chiatric diagnosis. The mental health clinician may have to assume more of
an advocacy role in assisting the patient in making a report if the patient
wishes to do so.
Approach to Psychiatric Emergencies 25
Chapter 7, “The Anxious Patient,” provides further information about
preventing psychiatric sequelae in victims of trauma.
Domestic Violence
As in cases of rape, the psychiatrist may be a part of the evaluation of a patient
reporting domestic violence. Counseling or advocacy services, legal services,
physical exams if indicated, and psychiatric follow-up should be made avail-
able to patients affected by domestic violence. An adult reporting domestic
violence is not required to report the events to the police. However, if children
in the home are at risk as a result of the violence, the clinician may be man-
dated by state law to report suspected child abuse. The clinician should avoid
giving patients any pamphlets or fliers that are obviously about domestic vi-
olence, because these materials can lead to escalation if discovered. Leaving
the abuser is not always immediately possible or indicated for victims; how-
ever, victims should be encouraged to make a “safety plan” for how to leave
the home safely when they are ready. Victims sometimes require multiple tries
before they successfully leave a violent situation. Once again, social work ser-
vices should also be involved.
If the clinician suspects that a patient is unable to make a reasoned deci-
sion about his or her own safety due to mental illness, the clinician can ar-
range for psychiatric admission or make a report to adult protective services.
For example, a patient with severe psychosis may not be able to organize her-
self to get out of an abusive situation and therefore may be deemed unable to
care for herself.
Child Abuse
In most states, physicians are mandated to report child abuse. If a clinician
has a reasonable suspicion that a child is being abused, neglected, or mis-
treated by a caregiver, the clinician should inform the appropriate agency of
the suspicion. Child abuse can range from obvious episodes of physical abuse
and torture, to sexual abuse or exploitation, to neglect of food, shelter, cloth-
ing, or even appropriate educational services. In the emergency department
setting, suspicion of child abuse or neglect should be triggered when children
1) appear afraid of their parents or unwilling to speak in front of them, 2) have
unexplained physical injuries, 3) have evidence of malnutrition or poor hy-
giene, or 4) are found to have excessive truancy from school. If a patient with
26 Clinical Manual of Emergency Psychiatry
dependent children is to be admitted to the hospital, efforts should be made
to contact someone who can care for the children during the hospitalization
to avoid referral to child protective services.
Elder Abuse
The aging of the population has led to a rise in the number of elderly adults
in need of various levels of care. This care frequently falls to their adult chil-
dren or spouses, who may lack the resources to adequately care for them.
Nonjudgmental questioning of caregivers by the clinician is the best route to-
ward discovering information. For example, saying, “It seems like your mom’s
care can be quite overwhelming. Do you ever feel like you can’t handle it?” is
more likely than an accusation of maltreatment to elicit a relieved request for
assistance. Report of elder abuse is not mandated, but suspicion should in-
crease when certain situations arise, including elderly patients who are dirty,
unkempt, or malnourished; who have unexplained injuries; or who repeat-
edly present to the emergency department with no clear medical pathology or
with medical conditions that are a result of noncompliance with treatment
that is supposed to be monitored or administered by family members.
The Patient in Legal Custody
Patients in legal custody are brought for psychiatric evaluation to an emer-
gency setting for a variety of reasons, including evaluation for suicidality, be-
havioral problems, treatment or prevention of withdrawal, or the need for a
recommendation for psychiatric observation or treatment while in custody.
Prior to interviewing the patient, the clinician should consider several key
points that will determine what kind of interview takes place, whether any as-
sessment is even indicated, and what question is being asked by those who are
bringing the patient for evaluation. Most important, the clinician needs to re-
member that patients do not surrender their right to doctor-patient confidential-
ity simply because they are under arrest or serving a jail or prison term (U.S.
Department of Health and Human Services 2003a). The clinician should ask
the officers escorting the patient to delineate the patient’s current legal status;
to state the charges against the patient, so that the clinician can determine if
the patient understands the charges; and to explain why the patient is being
brought for evaluation. If the patient is released from the emergency depart-
ment, the officers should know where the patient will go next—that is, to
Approach to Psychiatric Emergencies 27
court, to jail, or to the community. They can also provide information about
the patient’s behavior while he or she was in custody. The patient should be
interviewed without the police present, but should remain handcuffed to en-
sure safety.
The nature of the evaluation is determined by the question being asked,
but the following general points are helpful when interviewing any patient in
custody.
• Clarify to the patient at the outset what the nature of the interview is, what
information will be held confidential, and what information, if any, will
be disclosed to officers.
• Clarify the evaluator’s role and the parameters of the evaluation. Patients
in legal custody may be under the impression that the mental health clini-
cian can arrange for charges to be dropped or for provisions to be made for
what sort of housing they will have while incarcerated.
• Inform the patient not to make statements during the interview about his
or her guilt or innocence regarding the charges because the medical record
could be subpoenaed.
• Document the interview thoroughly in the medical record, particularly an
assessment of the patient’s risk for injury to self or others while in custody
and any recommendations to the officers or the court for special precau-
tions while in custody.
The Patient Who Does Not Speak English or
Who Requires Sign Language Interpretation
All hospitals are required to make accommodations for patients who do not
speak English or who are deaf or hard of hearing. Although the ideal is to pro-
vide a trained medical interpreter, this is not always possible. For language in-
terpretation, the best available option may be use of phone interpreter
services, which can offer the widest range of languages. If emergency depart-
ment staff speak the patient’s language, they can also be useful, but they
should be asked to provide direct translation of what the doctor and patient
are saying and to not interject their own opinions or questions. It is never ac-
ceptable to rely entirely on a family member or friend who is accompanying
the patient, because this practice violates patient confidentiality and may pro-
hibit the patient from making a full and honest accounting of his or her situ-
28 Clinical Manual of Emergency Psychiatry
ation. If absolutely no other option is available, then it is better to at least get
some information from the friend or family member, but more appropriate
alternatives should be sought. Hospitals have been and can be sued for not
providing appropriate language interpretation services or interpreter services
for people who are deaf and hard of hearing.
The Pregnant Patient
Pregnancy should be suspected in women of reproductive age until proven
otherwise by laboratory testing. The range of what is considered reproductive
age is vast, so liberal use of beta-HCG (human chorionic gonadotropin) test-
ing is advised to avoid missing a pregnancy.
Safety data on the use of psychiatric medication in pregnant patients are
limited to case reports and population surveillance, so more data are available
about older medications (Menon 2008). According to the American College
of Obstetricians and Gynecologists (ACOG Committee on Practice Bulletins—
Obstetrics 2008), it is better practice to treat pregnant women for their psy-
chiatric problems with medication if indicated, because the risk of teratoge-
nicity due to psychiatric medication is smaller than the known risk of low birth
weight and other complications from having an untreated psychiatric illness
during pregnancy. In the emergency department, discovery of a pregnancy
can influence multiple areas of the patient’s psychiatric care but should not
preclude appropriate treatment, including treatment of agitation if indicated
(Ladavac et al. 2007).
For many women, discovery of a pregnancy may be an unexpected or un-
pleasant surprise and thus may complicate whatever crisis brought them into
the emergency department in the first place. The following are considerations
for the pregnant emergency psychiatric patient:
•Disposition planning. Concerns include providing obstetric gynecological
care as part of discharge planning, increased risk of suicide after discovery
of an unplanned pregnancy, and referral to appropriate services.
•Pharmacotherapy. The clinician should make an informed choice of psy-
chotropic medication based on risks and benefits and clearly document
the thought process involved in either prescribing or refraining from pre-
scribing medication.
Approach to Psychiatric Emergencies 29
•Restraint. Safe restraint becomes more complicated as a pregnancy pro-
gresses and should be avoided if possible. Patients in advanced stages of
pregnancy should not be restrained on their back due to compromised
blood flow through the vena cava.
The legal and ethical issues surrounding pregnancy in psychiatric patients
are complicated. Patients with psychosis or severe psychiatric illness do not
automatically surrender their right to reproductive choices, including choos-
ing to terminate or continue a pregnancy, choosing to use or not use contra-
ception, and so forth. The most appropriate option for dealing with preg-
nancy in the psychiatric patient is to treat the patient first, because optimizing
her physical and psychiatric health is the best way to optimize the health of
her fetus, and to put her in the best position to make decisions regarding her
pregnancy and overall health.
Conclusion
Emergency psychiatry is a developing field, providing an opportunity for ex-
posure to a vast array of patients and situations. Clinicians in this practice need
to have skills in consultation-liaison psychiatry, crisis management, brief psy-
chotherapy, and risk assessment, as well as a broad knowledge of medicine,
hospital and health care systems, and general psychiatry. To best direct the care
of patients, the mental health clinician working in the emergency department
must view patients as individuals, as part of their social environment, and as
part of the health care system.
Key Clinical Points
• Clinicians should consider their personal safety first. Clinicians should
be aware of the protocols in the emergency department in which they
are working, the environment in which they will be seeing patients, and
patient factors that may lead to violent escalation.
• Assessment should focus on the patient’s safety. Critical questions to
consider are whether the patient’s presentation is due to a medical
30 Clinical Manual of Emergency Psychiatry
condition better treated by a different clinician and whether the patient
can adequately maintain his or her safety and the safety of others in
the current outpatient setting.
• All emergency department encounters should be documented in the
medical record, with sufficient detail that the reader of the documen-
tation can understand the factors that went into the assessment and
disposition of the patient.
References
ACOG Committee on Practice Bulletins—Obstetrics: ACOG practice bulletin: clin-
ical management guidelines for obstetrician-gynecologists number 92, April 2008
(replaces practice bulletin number 87, November 2007). Use of psychiatric med-
ications during pregnancy and lactation. Obstet Gynecol 111:1001–1020, 2008
Allen MA, Forster P, Zealberg J, et al; American Psychiatric Association Task Force on
Psychiatric Emergency Services: Report and recommendations regarding psychi-
atric emergency and crisis services: a review and model program descriptions.
August 2002. Available at: http://archive.psych.org/edu/other_res/lib_archives/
archives/tfr/tfr200201.pdf. Accessed September 19, 2009.
Baillargeon J, Thomas CR, Williams B, et al: Medical emergency department utilization
patterns among uninsured patients with psychiatric disorders. Psychiatr Serv
7:808–811, 2008
Brown JF: Emergency department psychiatric consultation arrangements. Health Care
Manage Rev 30:251–261, 2005
Centers for Disease Control and Prevention: Revised Recommendations for HIV Test-
ing of Adults, Adolescents, and Pregnant Women in Health-Care Settings.
MMWR Morbidity and Mortality Weekly Report Recommendations and Reports
(Vol 55, No RR14), September 26, 2006. Available at: http://www.cdc.gov/
mmwr/PDF/rr/rr5514.pdf. Accessed January 20, 2009.
Downey LV, Zun LS, Gonzales SJ: Frequency of alternative to restraints and seclusion
and uses of agitation reduction techniques in the emergency department. Gen
Hosp Psychiatry 29:470–474, 2007
Flannery RB Jr: Precipitants to psychiatric patient assaults: review of findings, 2004–
2006, with implications for EMS and other health care providers. Int J Emerg
Ment Health 9:5–11, 2007
Guze BH, Love MJ: Medical assessment and laboratory testing in psychiatry, in Kaplan
and Sadock’s Comprehensive Textbook of Psychiatry. Edited by Sadock BJ, Sadock
VA. Philadelphia, PA, Lippincott Williams & Wilkins, 2004, pp 916–928
Approach to Psychiatric Emergencies 31
Hazlett SB, McCarthy ML, Londner MS, et al: Epidemiology of adult psychiatric visits
to U.S. emergency departments. Acad Emerg Med 11:193–195, 2004
Herzog A, Shore MF, Beale RR, et al: Patient safety and psychiatry: recommendations
to the Board of Trustees of the American Psychiatric Association from the APA
Task Force on Patient Safety. January 2003. Available at: http://archive.psych.org/
edu/other_res/lib_archives/archives/tfr/tfr200301.pdf. Accessed September 19,
2009.
Jacobs DG, Baldessarini RJ, Conwell Y, et al; American Psychiatric Association Work
Group on Suicidal Behaviors. Practice guideline for the assessment and treatment
of patients with suicidal behaviors. Washington, DC, American Psychiatric As-
sociation, 2003
Ladavac AS, Dubin WR, Ning A, et al: Emergency management of agitation in preg-
nancy. Gen Hosp Psychiatry 29:39–41, 2007
Manley M: Interviewing techniques with the difficult patient, in Kaplan and Sadock’s
Comprehensive Textbook of Psychiatry. Edited by Sadock BJ, Sadock VA. Phil-
adelphia, PA, Lippincott Williams & Wilkins, 2004, pp 904–907
Marco CA, Vaughan J: Emergency management of agitation in schizophrenia. Am J
Emerg Med 23:767–776, 2005
Menon SJ: Psychotropic medication during pregnancy and lactation. Arch Gynecol
Obstet 277:1–13, 2008
Moore DP, Jefferson JW: Handbook of Medical Psychiatry, 2nd Edition. Philadelphia,
PA, Mosby, 2004, Section XVII, Chapters 155–156, pp 281–286
Physicians’ Desk Reference, 62nd Edition. Montvale, NJ, Thomson Healthcare, 2008
Rocca P, Villari V, Bogetto F: Managing the aggressive and violent patient in the psy-
chiatric emergency. Prog Neuropsychopharmacol Biol Psychiatry 30:586–598,
2006
U.S. Department of Health and Human Services: Health information privacy: disclo-
sure for law enforcement purposes. May 2003a. Available at: http://www.hhs.gov/
ocr/privacy/hipaa/faq/permitted/law/505.html. Accessed September 19, 2009.
U.S. Department of Health and Human Services: Summary of the HIPAA privacy
rule, May 2003b. Available at: http://www.hhs.gov/ocr/privacy/hipaa/under-
standing/summary/privacysummary.pdf. Accessed November 24, 2009.
Vergare M, Binder R, Cook I, et al; Work Group on Psychiatric Evaluation: Practice
guideline for the psychiatric evaluation of adults, 2nd edition. June 2006. Available
at: http://www.psychiatryonline.com/pracGuide/loadGuidelinePdf.as-
px?file=PsychEval2ePG_04-28-06. Accessed September 19, 2009.
Villari V, Rocca P, Fonzo V, et al: Oral risperidone, olanzapine and quetiapine versus
haloperidol in psychotic agitation. Prog Neuropsychopharmacol Biol Psychiatry
32:405–413, 2008
32 Clinical Manual of Emergency Psychiatry
Walsh PG, Currier G, Shah MN, et al: Psychiatric emergency services for the U.S.
elderly: 2008 and beyond. Am J Geriatr Psychiatry 16:706–717, 2008
Wilhelm S, Schacht A, Wagner T: Use of antipsychotics and benzodiazepines in patients
with psychiatric emergencies: results of an observational trial. BMC Psychiatry
8:61, 2008
Woo BK, Chan VT, Ghobrial N, et al: Comparison of two models for delivery of
services in psychiatric emergencies. Gen Hosp Psychiatry 29:489–491, 2007
Zun LS: Evidence-based evaluation of psychiatric patients. J Emerg Med 28:35–39,
2005
Suggested Readings
Allen MA, Forster P, Zealberg J, et al; American Psychiatric Association Task Force on
Psychiatric Emergency Services: Report and recommendations regarding psychi-
atric emergency and crisis services: a review and model program descriptions.
August 2002. Available at: http://archive.psych.org/edu/other_res/lib_archives/
archives/tfr/tfr200201.pdf. Accessed September 19, 2009.
Dubin WR, Lion JR (eds): Clinician Safety (APA Task Force Report 33). Washington,
DC, American Psychiatric Association, 1993
Manley M: Interviewing techniques with the difficult patient, in Kaplan and Sadock’s
Comprehensive Textbook of Psychiatry. Edited by Sadock BJ, Sadock VA. Phil-
adelphia, PA, Lippincott Williams & Wilkins, 2004, pp 904–907
33
2
The Suicidal Patient
Felicia Kuo Wong, M.D.
Ana Wolanin, M.S., R.N.
Patrick Smallwood, M.D.
Case Example
Mr. J is an 18-year-old single white male who was referred to emergency men-
tal health services (EMHS) by his outpatient provider after Mr. J made threats
to kill his coach for cutting him from the basketball team. In addition, he had
threatened violence toward his mother and made statements of planning to
hang himself. When he presented to the emergency department, he was ex-
tremely agitated and upset.
Suicide is a major health problem and one of the most common reasons why
people present to psychiatric emergency rooms in crisis. In 2006, it was the
eleventh leading cause of death in the United States for all age groups (Na-
tional Institute of Mental Health [NIMH] 2009). The overall rate for suicide
34 Clinical Manual of Emergency Psychiatry
in the United States in 2006 was 11 per 100,000 (Centers for Disease Control
and Prevention [CDC] 2009a). More than 33,000 completed suicides occur
in the United States each year, which is equivalent to 91 suicides per day or
one suicide every 16 minutes (CDC 2009a). It is estimated that there are
8–25 suicide attempts for every completed suicide (Moscicki 2001; NIMH
2009). Although only a small minority of suicide attempts result in death,
each attempt increases the risk of death, serious long-term physical injury, and
psychological suffering (Borges et al. 2006).
Demographics
Age
The prevalence and lethality of suicide differ across age groups. For example,
although suicide attempts are more common for persons ages 15–34 years, the
lethality is much higher in the elderly population. Among young adults ages
15–24, suicide is the third leading cause of death, accounting for 12% of all
deaths in this group annually, and it is the second leading cause of deaths for
adults ages 25–34 years (CDC 2009a). In young adults, there is one suicide for
every 100–200 attempts, whereas in the elderly population ages 65 and older,
there is one suicide for every four attempts (Goldsmith et al. 2002). The rate
of suicide for elderly adults is estimated at 14 per 100,000 (Goldsmith et al.
2002).
Although the teen suicide rate has declined by over 25% since the early
1990s, it still remains a major problem. Adolescence is a difficult and turbu-
lent time for teenagers as they attempt to navigate through a vast array of new
experiences, including new relationships, decisions about their future, and
physical changes that are taking place in their bodies due to hormonal influ-
ences. These changes can affect their mood and ability to adapt and cope,
which may lead to an increased risk for suicide (American Psychiatric Associ-
ation 2005).
The strongest risk factors for attempted suicide in the youth population
are the presence of depression, alcohol or drug abuse, aggressive or disruptive
behaviors, and a previous suicide attempt (American Psychiatric Association
2005). Other risk factors include frequent episodes of running away, incarcer-
ation, family loss or instability, significant problems with parents, expressions
The Suicidal Patient 35
of suicidal thoughts or talk of death or the afterlife during moments of sad-
ness or boredom, withdrawal from friends and family, difficulty dealing with
sexual orientation, diminished interest in enjoyable activities, and unplanned
pregnancy. The presence of depression results in a 14-fold increase in the risk
of a first suicide attempt. Over half of the youth who have depression will at-
tempt suicide at least once, and more than 7% will be successful (American
Psychiatric Association 2005). Substance abuse or dependence also plays a sig-
nificant role in youth suicide; 53% of young people who commit suicide have
a known history of substance abuse. Firearms, the most common method of
suicide completion in this age group, are used in over half of all youth suicides
(American Psychiatric Association 2005).
Older Americans are disproportionately likely to die by suicide and have
the highest suicide rates of any age group. In 2005, individuals ages 65 years
and older accounted for 12.4% of the population but represented 16.6% of
all suicide deaths. In 2004 in the United States, 14.3 per 100,000 people ages
65 and older committed suicide, compared with 10.9 per 100,000 in the gen-
eral population. Among elderly individuals, an average of one suicide occurs
every 90 minutes (National Strategy for Suicide Prevention [NSSP] 2009). The
rates of suicide in the elderly population generally increase according to age:
13.1 per 100,000 for those ages 65–69 years, 15.2 per 100,000 for those ages
70–74 years, and 21.0 per 100,000 for those ages 85 years and older (NSSP
2009).
Risk factors for suicide among persons older than age 65 years differ from
those of the rest of the population. In addition to having a higher prevalence
of depression, older persons tend to be more socially isolated, make fewer at-
tempts per completed suicide, and use more lethal methods (Goldsmith et al.
2002; NSSP 2009). The most common methods for suicide by older adults
include firearms (71%), overdose (11%), and suffocation (11%) (Goldsmith
et al. 2002). Because elderly persons have a higher burden of physical ill-
nesses, they most often visit a health care provider before their suicide. It is
estimated that prior to committing suicide, 20% of elderly persons had vis-
ited a physician within the preceding 24 hours, 41% within the previous
week, and 75% within the previous month (NSSP 2009). Those who are di-
vorced or widowed have the highest suicide rates, and men account for ap-
proximately 84% of suicides in this age group (NSSP 2009).
36 Clinical Manual of Emergency Psychiatry
Gender
Suicide manifests differently in men and women. In 2004, suicide was the
eighth leading cause of death for males and the sixteenth leading cause of
death for females. Although women attempt suicide almost two to three times
more often than men during their lifetime (Krug et al. 2002), almost four
times as many males as females die from completed suicide (NIMH 2009).
Males represented 78% of all suicides in the United States in 2005 (NIMH
2009). Although firearms, suffocation, and poisoning are the three most com-
mon methods of suicide for both males and females, males most often use
firearms (56%), followed by suffocation (23%) and poisoning (13%),
whereas females most often use poisoning (40%), followed by firearms (31%)
and suffocation (19%) (NIMH 2009).
Race and Ethnicity
Data show different patterns or rates of suicide across various racial and ethnic
groups in the United States. According to the CDC (2009a), for Native Amer-
icans ages 15–34 years, suicide is the second leading cause of death, with a rate
of 19.7 per 100,000, which is 1.8 times higher than the national average for that
age group. A study by Eaton et al. (2006) demonstrated that Hispanic female
high school students in grades 9–12 reported a higher percentage of suicide
attempts (14.9%) than their non-Hispanic white (9.3%) or non-Hispanic
black (9.8%) counterparts. Caucasians have a substantially higher rate of sui-
cide completion than African Americans, Hispanics, or Asians. For example, of
every 100,000 people, the highest rates of death by suicide occurred in non-
Hispanic whites (12.9) and Native Americans (12.4), whereas the lowest rates
were among the non-Hispanic blacks (5.3), Asian Pacific Islanders (5.8), and
Hispanics (5.9) (NIMH 2009).
Risk Factors
Research has clearly identified several risk factors related to suicide. The cli-
nician needs to weigh the complex interaction of these factors when assessing
a patient’s risk for suicide and not simply consider each factor individually,
because the cumulative effects of these factors place a patient at greater risk
(Moscicki 1999). For example, the acute or immediate risk of suicide in a pa-
The Suicidal Patient 37
tient who is experiencing major depression and who may also be struggling
with an impending loss increases considerably if he or she also has an alcohol
abuse or dependence disorder, because alcohol may increase the patient’s
impulsivity and behavioral disinhibition (American Psychiatric Association
2003).
Demographics
The major demographic features that are linked to increased risk for suicide
are marital status, age, gender, sexual orientation, and race. Men and women
who are unmarried (never married, divorced, or widowed) have higher suicide
rates than people who are married (American Psychiatric Association 2003).
Cutright and Fernquist (2007) found that marital status has a greater protec-
tive effect on men than on women. The effect of age on suicide risk should
be assessed in conjunction with race and gender. Caucasian males have a
higher rate of suicide in late life (over age 65) (American Psychiatric Associa-
tion 2003; U.S. Public Health Service 1999). Asian females have a dramati-
cally high rate of suicide after age 80 and have the highest suicide rate among
all women (American Psychiatric Association 2003; U.S. Public Health Ser-
vice 1999). Native American males experience higher rates of suicide in ado-
lescence and young adulthood compared with the national average for those
age groups (CDC 2009a). Among all youth, 30% of attempted and com-
pleted suicides are related to sexual identity issues, especially among gay males
(American Psychiatric Association 2003; U.S. Public Health Service 1999).
Overall, men have the highest rate of completed suicides, whereas women
have the highest lifetime rate of suicide attempts (Moscicki 1997).
Psychiatric History
Approximately 90% of people who have completed suicide have been diag-
nosed with a major psychiatric disorder (American Psychiatric Association
2003; Arsenault-Lapierre et al. 2004; Harris and Barraclough 1997). People
with mood disorders, substance-related disorders, psychotic disorders, and
personality disorders were found to have the highest risk for suicide (Ar-
senault-Lapierre et al. 2004; Moscicki 1999). The majority of completed sui-
cides were by people with mood disorders, especially in the depressive phase.
However, suicide risk is increased in those with bipolar disorder experiencing
38 Clinical Manual of Emergency Psychiatry
mixed episodes (American Psychiatric Association 2003). For people with mood
disorders, the risk of suicide increases in those with comorbid alcohol abuse,
anxiety and panic attacks, and symptoms of global insomnia and hopelessness
(American Psychiatric Association 2003). People with schizophrenia and
schizoaffective disorder also have high rates of suicide attempts, with risk in-
creased in those with schizophrenia who had higher premorbid functioning
(American Psychiatric Association 2003). The period of time immediately af-
ter hospitalization has been shown to increase the risk of suicide for patients
with schizophrenia and schizoaffective disorders (American Psychiatric Asso-
ciation 2003). Importantly, suicide attempts by people with schizophrenia and
schizoaffective disorder tend to be of greater lethality compared with attempts
made by the general population and produce higher mortality and morbidity
(American Psychiatric Association 2003).
Psychiatric comorbidity has also been found to increase a person’s risk for
suicide. Arsenault-Lapierre et al. (2004) found that on average suicide com-
pleters had 2.36 diagnoses. Studies show that 70%–80% of completed suicides
have been by people with comorbid disorders and that the most important di-
agnostic comorbidities in increasing a person’s risk for suicide are mood dis-
orders combined with substance abuse disorders and personality disorders
(American Psychiatric Association 2003).
In people diagnosed with a personality disorder (especially borderline per-
sonality disorder and antisocial personality disorder), the incidence of sub-
stance abuse and past history of suicide attempts are high, and when these
patients have depressive states or experience a particular interpersonal loss,
their risk for suicide is augmented (American Psychiatric Association 2003).
The premise for increased suicide risk in people with substance abuse disor-
ders and personality disorders is that they have a higher predisposition to ag-
gression and impulsivity (Mann et al. 1999).
Psychological and Cognitive Dimensions
Psychological factors that have been found to potentiate suicide risk are anx-
iety and hopelessness (Fawcett 1999; Jacobs et al. 1999). Fawcett (1999) de-
fined anxiety in the presence of depression as unremitting psychic pain.
Hopelessness has been suggested as the culminating factor that explains why
some depressed patients choose suicide whereas other depressed patients do
The Suicidal Patient 39
not (Jacobs et al. 1999). Shame, worthlessness, and poor self-esteem in vul-
nerable individuals can lead to narcissistic injury that can be intolerable and
increase the person’s suicidal intent (American Psychiatric Association 2003).
People who exhibit thought constriction and polarized thinking are unable to
consider options when faced with stressful situations and are at higher risk for
suicide (American Psychiatric Association 2003).
Psychosocial Dimensions
An important factor to establish when assessing patients for suicide risk is
their access to firearms. The availability of firearms in combination with a
mood disorder and intoxication is an acutely lethal profile (Moscicki 1999).
Stressful life events can also significantly increase suicide risk. Stressors that
have been identified as proximal risk factors include interpersonal loss, rela-
tionship conflicts, rejection, legal issues (e.g., incarceration), economic diffi-
culties, and lack of social supports (American Psychiatric Association 2003;
Moscicki 1999).
Childhood Trauma
Patients with a history of childhood trauma (physical and sexual abuse) may
develop complex and incapacitating disorders as adults. These disorders in-
clude dissociative disorders, personality disorders, eating disorders, substance
abuse disorders, and posttraumatic stress disorder (Chu 1999). In addition,
these patients may express symptoms of severe impulsivity, mood lability, and
self-injurious behaviors (Mann et al. 1999). The combination of these disabling
disorders and complex traits places these patients at significant risk for suicide
(American Psychiatric Association 2003; Chu 1999).
Family History
Both environmental and genetic factors have been identified as contributing
to the increased risk of suicide. Although specific genetic factors involved in
the transmission of suicidal behavior have yet to be identified, the clinician
should make an effort to determine if the patient has a family history of sui-
cide, particularly among any first-degree relatives, because this history has
been shown to increase the patient’s risk for suicide (American Psychiatric As-
sociation 2003; Mann et al. 1999). Environmental factors that are most likely
40 Clinical Manual of Emergency Psychiatry
to be associated with suicide risk are parental separation or divorce, parental
legal problems, child abuse and neglect, and a family history of mental illness
and/or substance abuse (Jacobs et al. 1999).
Physical Illness
The following physical illnesses and conditions are associated with an in-
creased risk of suicide: malignant neoplasms, ulcer, lung disorders (especially
asthma and chronic obstructive pulmonary disease), HIV/AIDS, Hunting-
ton’s disease, brain injury, multiple sclerosis, lupus erythematosus, renal he-
modialysis, and seizure disorders (Harris and Barraclough 1997; Jacobs et al.
1999). These illnesses have been found to increase suicide risk due to their as-
sociation with chronic pain, impaired functioning, debilitation, and chronic-
ity (American Psychiatric Association 2003; Jacobs et al. 1999). Likewise, the
treatment of these illnesses may precipitate or exacerbate underlying mental
illness (American Psychiatric Association 2003; Jacobs et al. 1999).
Assessment
The depth and breadth of information obtained from a psychiatric evaluation
will vary with the setting, the patient’s ability or willingness to provide infor-
mation, and the availability of information from collateral sources. In some
emergency mental health (EMH) settings, the psychiatrist may work with a
team of professionals to gather all pertinent clinical information. In this in-
stance, the psychiatrist should take on the leadership role of ensuring that all
necessary information is obtained and then integrated into a final assessment
and treatment plan. Because the patient may minimize the severity or even the
existence of his or her difficulties, other individuals may serve as valuable re-
sources for the psychiatrist in providing information about the patient’s current
mental state, activities, and psychosocial stressors. Sources of collateral infor-
mation that may be helpful include the patient’s family members and friends,
physicians, other medical or mental health professionals, teachers or school
personnel, colleagues or coworkers, and staff from supervised housing pro-
grams where the patient may reside (American Psychiatric Association 2003).
A thorough psychiatric evaluation is essential to the suicide assessment
process. Information regarding the patient’s psychiatric and medical history,
The Suicidal Patient 41
current circumstances, and mental state must be obtained during this evalua-
tion and used by the clinician to a) identify specific factors and features that
may increase or decrease the risk of suicide or suicidal behaviors and that may
be amenable to acute and ongoing interventions, b) address the patient’s imme-
diate safety and determine the most appropriate treatment setting, and c) develop
a multiaxial differential diagnosis that can help guide the next step of treat-
ment (Jacobs et al. 2003).
Psychiatric Signs and Symptoms
When evaluating a suicidal patient, the clinician should attempt to identify
specific psychiatric signs and symptoms that have been correlated with an in-
creased risk of suicide or other suicidal behaviors by asking the patient directly
or through collateral information if available. These include aggression and
violence toward others, impulsiveness, hopelessness, agitation, anxiety, anhe-
donia, global insomnia, and panic attacks (Fawcett 2001). Other psychiatric
signs and symptoms, such as psychosis or depression, can help inform the cli-
nician as to whether the patient has a psychiatric syndrome that should be ad-
dressed in treatment.
Past Suicidal Behavior
One of the most significant risk factors for suicide is a past history of suicide
attempts (Moscicki 1997). Because suicide risk can be further increased by
more serious, frequent, or recent attempts, the psychiatrist needs to explore in
depth any past suicide attempts, aborted suicide attempts, and self-destructive
behaviors. Details surrounding the attempts should be elicited, including in-
formation about the precipitants, timing, intent, consequences, and medical
severity. If the patient was intoxicated with alcohol and/or drugs prior to the
attempt, this should be noted, because intoxication can facilitate suicide at-
tempts, as well as be part of a more serious suicide plan. Any interpersonal
issues involved in the attempt should also be documented. The patient’s
thoughts about the attempts, including his or her perception of the lethality,
ambivalence toward living, visualization of death, degree of premeditation,
persistence of suicidal ideation, and reaction to attempt should be explored.
Finally, information about prior self-injurious behaviors, including risk-taking
behaviors such as unsafe sexual practices and reckless driving, may be relevant
(Jacobs et al. 2003).
42 Clinical Manual of Emergency Psychiatry
Past Psychiatric and Medical History
A patient’s past psychiatric treatment history can provide information on co-
morbid diagnoses, prior psychiatric hospitalizations, current suicidal ide-
ation, and any previous suicide attempts. Information regarding a history of
medical treatment can also help to identify medically serious suicide attempts,
as well as any medical conditions that may be associated with increased suicide
risk. A study by Druss and Pincus (2000) found that in models controlling
for major depression, depressive symptoms, alcohol use, and demographic char-
acteristics, the presence of a general medical condition predicted a 1.3 times
greater likelihood of suicidal ideation. They also found that pulmonary diseases
(e.g., asthma, bronchitis) were associated with a two-thirds increase in the
odds of lifetime suicidal ideation, and cancer and asthma were associated with
a more than fourfold increase in the likelihood of a suicide attempt (Druss
and Pincus 2000).
Many patients who present with suicidality or after a suicide attempt are
already in treatment, either with psychiatrists, mental health professionals, or
primary care physicians. Collateral information from these caregivers can pro-
vide important insight that may be useful in determining a treatment plan
and setting. The strength and stability of the therapeutic alliance should be
gauged, because a positive therapeutic alliance is considered protective against
suicidal behaviors, whereas a less reliable therapeutic alliance may represent
an increased risk of suicide (Jacobs et al. 2003).
Family Psychiatric History
Because a family history of completed suicide and psychiatric illness signifi-
cantly and independently increases the risk of suicide, the clinician must in-
vestigate the family’s history of psychiatric hospitalizations, mental illness,
substance use, and completed suicides or suicide attempts (Qin et al. 2002).
Other information regarding the patient’s childhood and current family mi-
lieu may also be relevant, because many aspects of family dysfunction, such
as a history of family conflict, parental legal trouble, family substance use,
domestic violence, and physical and/or sexual abuse, can be linked to self-
destructive or suicidal behavior (Moscicki 1997).
The Suicidal Patient 43
Current Psychosocial Stressors and Function
Acute psychosocial crises or chronic psychosocial stressors may augment sui-
cide risk and should be thoroughly assessed. Significant precipitants may in-
clude perceived losses or recent or impending humiliation. Understanding
the patient’s psychosocial situation is essential in helping the patient to mobi-
lize external supports and can also have a protective influence on suicide risk
(Jacobs et al. 2003).
Psychological Strengths and Vulnerabilities
A patient’s psychological strengths and vulnerabilities should be considered
when evaluating suicide risk and formulating a treatment plan. These strengths
and vulnerabilities may include coping skills, personality traits, and thinking
style, as well as developmental and psychological needs. Determining the pa-
tient’s tendency to engage in risk-taking behaviors as well as past responses to
stress, including capacity for reality testing and ability to tolerate rejection,
subjective loneliness, or psychological pain when his or her unique psycho-
logical needs are not met, may give clues to the patient’s suicide risk (Ameri-
can Psychiatric Association 2003). Factors such as thought constriction or
polarized (“either-or”) thinking, closed-mindedness, or perfectionism with
excessively high self-expectations have also been noted in clinical practice to
be possible contributors to suicide risk (American Psychiatric Association
2003).
Suicide Inquiry
Two important predictors of suicide are current suicidal ideation and a history
of suicide attempts (American Psychiatric Association 2003; Mann 2002).
Careful inquiry into the patient’s current and past thinking and behavior in re-
lation to suicide are extremely important in determining proximal risk (Amer-
ican Psychiatric Association 2003; Mann 2002). The essential features of a
suicide inquiry are assessment of suicidal ideation, suicidal intent, suicide plan,
suicidal behavior, and suicide history.
Suicidal Ideation and Suicidal Intent
When interviewing a suicidal patient, the clinician needs to explore the fre-
quency and intensity of current and recent suicidal ideation as a means of de-
44 Clinical Manual of Emergency Psychiatry
termining the severity. Clinicians must also ask specifically when the thoughts
began, how frequently they occur, and whether the patient can control the
thoughts or the thoughts are obsessive (Jacobs et al. 1999). Also, clinicians
must determine if the patient’s thoughts are passive (i.e., a wish to be dead)
or if the patient is actively planning to kill himself or herself, because suicidal
ideation with a clear, detailed, and well-conceived plan increases proximal risk
(American Psychiatric Association 2003; Jacobs et al. 1999). It is also impor-
tant to determine what patients believe they will accomplish by killing them-
selves, because such motivations as a wish to reunite with a dead loved one,
ending intense psychological pain, escaping shame, and perceiving death as
peaceful all increase the severity of intent and proximal risk of suicide (Amer-
ican Psychiatric Association 2003). Not all patients will admit to suicidal ide-
ation, but the clinician can elicit thoughts of suicide by asking the patient to
talk about his or her future (American Psychiatric Association 2003).
Suicide Plan and Suicidal Behavior
It is important to determine if a patient has a plan and the lethality of that plan.
Plans with high lethality that are irreversible, such as the use of firearms, jump-
ing, hanging, and suicide via motor vehicles, place the patient at higher risk
(American Psychiatric Association 2003). The clinician should also investi-
gate if the patient has rehearsed the plan or made preparations, because re-
hearsal and preparations, such as completing a will or purchasing the means
to accomplish the plan, indicate an increased wish to die (American Psychiat-
ric Association 2003). Even if the plan is not one that will likely result in
death from an objective medical standpoint, the clinician should still consider
the patient’s expectation, because the patient’s belief that the plan will culmi-
nate in death places the patient’s risk as high (American Psychiatric Associa-
tion 2003).
Suicide History
Clinicians should assess the patient’s history of suicide attempts and assess the
lethality of previous attempts as a means of defining the patient’s current risk
(American Psychiatric Association 2003; Jacobs et al. 1999; Mann 2002). At-
tempts that resulted in medical or intensive care unit admission, loss of con-
sciousness, or extensive tissue or organ damage are considered high-risk
attempts (Jacobs et al. 1999). Attempts made with low potential for rescue,
The Suicidal Patient 45
such as attempts made in locations and at times with low probability of dis-
covery or in locations with poor accessibility for rescue, are also attempts of
high lethality (Jacobs et al. 1999).
Estimated Suicide Risk
No body of scientific literature is available to inform the clinician on how to
assign suicide risk to a patient. The clinician must integrate the clinical data
gathered, evaluate the data in light of the severity and acuity of the patient’s
symptoms and psychosocial stressors, and apply clinical judgment to formu-
late risk. Risk factors should be considered cumulative and synergistic and
should be weighed against the patient’s protective factors, which can attenu-
ate risk (American Psychiatric Association 2003). Protective factors or factors
that mitigate risk include a) a positive therapeutic relationship; b) psychoso-
cial supports, such as family and friends; c) evidence of coping skills, such as
the ability to tolerate rejection, loss, and humiliation; d) flexibility; e) a sense
of responsibility to family; f) children (except in cases of postpartum depres-
sion); g) religious prohibition; h) pregnancy; i) full-time employment (espe-
cially in persons with substance abuse disorders); and j) the ability to cite
reasons for living and optimism (American Psychiatric Association 2003). Fi-
nally, the patient’s access to means must be determined and restricted if
possible. Table 2–1 provides guidelines for determining whether hospital ad-
mission is indicated based on a patient’s risk factors and psychopathology.
Case Example (continued)
Mr. J had just learned that he did not make the varsity basketball team 2 days
prior to his referral to EMHS. He reported active suicidal ideation with the
aforementioned plan but denied intent to the EMHS clinician. He denied
any homicidal ideation but endorsed being “upset” and “frustrated.” He had
no previous history of psychiatric hospitalizations, suicide attempts, or ag-
gression. He denied any history of trauma or abuse. His family psychiatric
history was significant only for schizophrenia. He had been seeing his outpa-
tient psychiatrist for treatment of bipolar disorder and attention-deficit/
hyperactivity disorder since age 15. He was clear that he did not like his pro-
vider, stating, “I don’t think he has helped me at all.” Upon medical clearance
in EMHS, the toxicology screen was positive for cannabis, which he reported
using three times a week. In addition, he acknowledged occasional use of al-
cohol on the weekends but denied blackouts or alcohol withdrawal symp-
46 Clinical Manual of Emergency Psychiatry
toms. He described his main support system to be his girlfriend of 2 years and
various close friends. He did not get along with his mother but reported a
close relationship with his father and grandmother. He was a high school stu-
dent with a B/C average who enjoyed hanging out with his friends and “play-
ing ball.”
Psychiatric Management of Suicidal Behaviors
The management of suicidal patients who present to the emergency depart-
ment or an EMH unit includes a broad array of therapeutic interventions tar-
geting the suicidal behavior, as well as any comorbid major mental illnesses,
personality disorders, psychosocial issues, and interpersonal difficulties that
may be present. According to the “Practice Guideline for the Assessment and
Treatment of Patients With Suicidal Behaviors” (American Psychiatric Associ-
ation 2003), “Psychiatric management includes establishing and maintaining a
therapeutic alliance; attending to the patient’s safety; and determining the pa-
tient’s psychiatric status, level of functioning, and clinical needs to arrive at a plan
and setting for treatment” (p. 29). Once the initial evaluation is complete and
the treatment plan has been determined, additional goals of psychiatric man-
agement may be applied in the emergency setting; these include crisis interven-
tion, facilitating treatment adherence, and providing education to the patient
and family members.
Establishing Therapeutic Alliance
When a suicidal patient presents to an EMH unit, he or she may never have
had an encounter with a mental health professional. During this initial en-
counter, the psychiatrist must work to buil</