Approach to Emergency Psychiatric Evaluation

The purpose of this book is to provide an organized overview of the knowledge and problem-solving approaches relevant to the most common emergencies that arise in the course of providing psychiatric care. Psychiatric providers inevitably face unexpected emergencies in outpatient offices, inpatient units, emergency department (ED) wards, and consult services. In all environments the management of psychiatric emergencies starts with safety. Triage, formulation, and disposition follow, keeping in mind that the true nature of the emergency may not be plain to see. An informed, systematic approach is a prerequisite to life-saving emergency psychiatric care. This chapter discusses an overall approach to evaluating a psychiatric emergency.

By definition, a psychiatric emergency involves dangerousness on the part of a patient to himself or herself or to others. Acute agitation is the most obvious emergency and can incorporate both danger to self and others—for example, a delirious postoperative patient pulling out his intravenous (IV) lines and swinging them at others. Often less obvious, but no less dangerous, are suicidal ideation, inability to care for self, and homicidal ideation. All of these emergencies are discussed in detail in their respective chapters; here we provide an overview of the general principles and steps involved in psychiatric emergency response.

One principle that is difficult to describe—and probably difficult to accept for scientific-minded physicians—is instinct. Although we often make much of the unconscious verbal clues that patients provide us when formulating their personality structures or drives, clinicians may tend to overlook their own countertransference or instincts in emergency settings. However, if a patient makes you uncomfortable, pay attention! A clinician’s “gut” feelings are likely the result of an assimilation of subtle and key unconscious or subconscious information and experiences that do not translate verbally into the language of risk assessment but are no less vital to safety.

Logistically, safety can be maximized by following practices common to emergency or inpatient psychiatric settings. Patients should be searched and interviews conducted in a room free of potential weapons, such as intravenous poles, sharps, or glass. Clinicians should allow the patient to enter the room first, and then sit closest to, but not blocking, the door, so that the clinician can easily escape or be assisted by other providers or security if necessary. If the patient is too agitated or menacing to be seen in a closed room, find a relatively private space within a larger setting where you will not become trapped with the patient. Clinicians should not hesitate to terminate the interview to get security backup if they feel uncomfortable. It may be appropriate to have staff prepare medication and restraints based on your phone triage of the consult. A one-to-one watch may be required until more stable arrangements can be made if there is any chance of immediate self-harm, elopement, or violent behavior. Finally, clinicians should remember that the safest thing to do may be to defer the interview and return for further assessment after the patient’s level of acute agitation has subsided.