Making the decision to hospitalize a patient with a psychiatric disorder can be a daunting task. Inpatient hospitalization occurs when outpatient management is not adequate to maintain the imminent safety of the patient and/or the community. It is the role of the emergency department (ED) psychiatrist to weigh both the risk and the protective factors to determine when inpatient hospitalization is necessary. ED psychiatrists must consider the unique clinical histories and current symptomatology, and also perform real-time risk assessments of each emergent patient. In addition to the clinical presentation, information about triggers for acuity, such as medication noncompliance, recent illness, or substance use, as well as accessibility of social resources through family, caregivers, case managers, or drug and alcohol counselors, can help the physician decide whether inpatient hospitalization is appropriate. The goal of the ED psychiatrist is to optimally assess the clinical presentation and use available resources so that inpatient hospitalization is reserved for situations with high imminence of danger to the patient or others.
Although sometimes patients are hospitalized to monitor for adverse effects of psychiatric medications, this article addresses the need for imminent hospitalization in two common scenarios: self-harm and agitation.
Self-harm can take many forms: suicidality, nonsuicidal self-injury (NSSI), inability to care for one's daily needs, or other high-risk behaviors.
Each year, there are 903,400 visits to EDs in the United States for suicidal ideation.1 Suicide is one of the 10 leading causes of death in all age groups.2 It is the role of the ED psychiatrist to assess for level of imminence to determine the final outcome, which may include hospitalization for a higher level of care and stabilization, observation in the ED for mental status stabilization, and resolution of suicidal ideation or outpatient management. To appreciate these various outcomes, one must first have an understanding of the common presentation for suicidal ideation in the ED and then be able to identify risk and protective factors unique to each patient, obtain collateral data if indicated, and identify key findings in the documentation that may point toward one outcome more than another.
The patient who is suicidal has a wide potential spectrum of presentations. Patients may be sent directly to the ED from the psychiatry clinic for verbalizing suicidal ideation, as studies have shown that almost all people who commit suicide have had a recent health care visit.3 Other patients may present directly to the ED themselves voicing a chief complaint of suicidal ideation, or patients may be brought in by family or police or emergency medical service personnel after either the patient or someone else has reported that the patient is suicidal. The role of the ED psychiatrist always begins with stabilization of the patient and maintaining the safety of the patient and the ED. Evaluation of all suicidal patients must include a comprehensive evaluation of suicidal thoughts and increased suicidal behavior.
The purpose of the suicide risk assessment is to identify high-risk and protective factors (Table 1). The best predictor of completed suicide is a history of previous attempts, and patients (primarily those with psychosis) who attempted to kill themselves by hanging, drowning, shooting, or jumping are at extremely high risk for completed suicide.4 Major risk factors include a previous suicide attempt, chronic illnesses, access to weapons, family history of suicide, and psychiatric history. A direct link between physical illness and risk of suicide has been established, with particular risk attributed to hypertension, back pain, epilepsy, HIV, and sleep disorders.5 Past psychiatric history and prior suicide attempts amplify the risk for suicide attempts, as up to two-thirds of those with suicidal ideation have had a history of mental illness.6 Anxiety disorders, mood disorders, substance use disorders, and impulse control disorders all increase the likelihood of suicide attempts, with bipolar disorder carrying the highest risk.6
Suicide Risk Factors
Given the high cost of suicide, it is critical to obtain an accurate suicide risk assessment. The patient's response to the assessments as well as the collateral information plays a crucial role. Warning signs such as visiting friends and family members, posting or sharing suicidal thoughts on the social media, giving away personal possessions, and making a will all hint at the possible suicidal actions of the patient in the near future. The spectrum of suicide risk can be viewed along a timeline of imminent, near-term, and long-term risk.7 The ED psychiatrists must screen for patients who are at imminent risk for suicide by detecting which clinically actionable risk is present. All risk assessments must be carefully documented, including even lower-risk behaviors such as superficially cutting oneself or low-acuity overdose on medications. Recognition of or insight into bad decision-making and future orientation have also been listed as lower-risk situations.7 Suicide protective factors (Table 2) must be assessed along with risk factors to more accurately determine the patient's actual suicide risk. Collateral information from family, friends, health care workers, or law enforcement can be important in helping guide the clinician in determining imminence.
Suicide Protective Factors
Patients who are of high imminent danger to themselves require admission to a psychiatric hospital. The risk and protective factors mentioned above contribute to the decision-making process, as all must be weighed against the patient's presentation and history. If there is a concern that the patient is a danger to themselves, admission is warranted. If there are protective factors and therapeutic engagement that would allow a patient to maintain safety after brief ED interventions are employed, such as medication management and supportive therapy, a patient may be managed safely in the ED with close observation for 24 hours with regular re-assessments and a coordinated outpatient care plan.
Involuntary commitment of the patient may be required for actively suicidal patients. Discharge of a suicidal patient may be appropriate if they are deemed low risk for self-harm. In these instances, collateral information is extremely important. Strong family support and use of outpatient psychiatric management support within a reasonable time frame points toward possible discharge from the ED.
Separate yet similar to suicidal ideation is NSSI, a new diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition.8 NSSI can be defined as the intentional damage to one's own body without the intent to die that achieves a specific psychological outcome.9 Many methods are used to engage in NSSI with the most common being cutting and then scratching, burning, hitting, and banging10 (Table 3).
Common Methods of Nonsuicidal Self-Injury
The lifetime prevalence of NSSI ranges between 13% and 32% for adolescents and young adults.11 Often there is no suicidal intent and the behavior seems to decrease a distressing affect, be a way to engage in self-punishment, or signal personal distress to others.12 However, NSSI is associated with negative physical and psychological sequelae and is a risk factor for suicide attempts. Given the trajectory on which NSSI lies, it is of extreme importance that the ED psychiatrist performs an adequate safety assessment to determine risk for further decompensation against ongoing NSSI behaviors.
The ED presentation of NSSI is variable. As these behaviors are not socially acceptable and quite concerning to others, a patient may present with a concerned relative, friend, clinician, or casual observer. Other times, a patient may present on their own accord if their behavior resulted in a medical emergency, such as a severe burn or deep laceration. Frequently, these patients may have a history of personality psychopathology, usually borderline personality disorder. Impulsivity, substance use, aggression, and comorbidity with other personality disorders are risk factors in those patients with underlying borderline traits who go on to attempt suicide. Similar to NSSI, patients with severe personality disorders with chronic suicidality and poor impulse control do not necessarily warrant hospitalization. Some patients have chronic NSSI and chronic suicidal ideation, which may need to be treated differently than acute suicidal ideation. It has also been suggested that attempts at acute management, such as hospitalization, have not proven to be beneficial in this group.13 A more recent study conducted to assess if hospitalization of borderline personality disorder patients who are suicidal could be related to another suicidal episode within 6 months showed no increase in suicide attempts if those patients are hospitalized.14 NSSI patients may be managed in outpatient settings if available. It is important to assess this chronicity and severity of the injuries to determine whether the patterns are escalating due to psychological distress in the patient, and collateral information from a family member or an outpatient provider can be essential in evaluating the need for hospitalization.
Other patients who may engage in self-injury without intent to harm themselves may be patients with a developmental, neurocognitive, or intellectual disorder. A large-scale, longitudinal study found there to be a 5% prevalence of self-injurious behavior in patients with intellectual disability.15 Common examples would be self-hitting, self-biting, or pulling one's own hair in response to an emotional trigger. A common ED presentation is a man with severe intellectual disorder purposefully banging his head against a wall after being told that he could not participate in a desired activity at his care home. Given a patient's level of daily functioning, ability to take advantage of the inpatient milieu, and the lack of tangible benefit from medication adjustments, some patients may benefit more from structured supervision at home or in a day program setting compared to a psychiatric hospital. Patients can be assessed and observed in the ED for other causes of distress prior to discharge, and caregivers may be provided with additional social and community resources for appropriate outpatient management.
In addition to suicidal ideation and NSSI leading to self-harm, psychosis places one at risk for decompensation and inability to care for one's most basic needs. There are several conditions that may cause a person to present with psychosis, including schizotypal personality disorder, delusional disorder, brief psychotic disorder, schizophreniform disorder, schizophrenia, bipolar I disorder, depression with psychotic features, schizoaffective disorder, prescription or illicit drug use or withdrawal, or underlying medical disorders (Table 4). These conditions may have overlapping symptoms such as delusions, hallucinations, impaired thought process, movement disorders, or manifestations of negative symptoms (scarcity of emotions and meaningful activities).8
Common Causes of Psychotic Episodes
Common presentations to the ED for psychosis include acute onset of psychosis, worsening in nature, frequency or intensity of psychosis, desire to act out specific harmful command hallucinations, or inability to care for oneself given the level of psychosis. Postpartum psychosis is another condition that could require hospitalization, and studies have shown that up to 10% of women who are hospitalized before the delivery for psychiatric illnesses go on to develop postpartum psychosis.16 A mother with severe decompensation who has lost touch with reality due to psychosis or who has thoughts of harming herself or children is an alarming symptom that requires the ED psychiatrist to do all that is possible to ensure safety for the mother and the family. She requires evaluation and treatment, which often leads to hospitalization due to the severity and high acuity of these symptoms, but assessment of risk factors, protective factors, history, and collateral information remain key. Similar to patients with NSSI, a concerned relative, friend, or clinician may present with the patient or the patient may have had insight into their psychosis and presented willingly to the ED.
Symptoms during a psychotic episode. Hallucinations experienced are mostly auditory but could also affect senses of sight, touch, taste, and position. Patients could be paranoid, believing that their thoughts have been invaded and controlled by the others. Somatic delusions could be another cause for presentation to the ED. There could be behavioral inappropriateness such as awkward conversations and attire. Agitation and aggression are the most troubling behavioral presentation for patients with psychosis. Agitated patients with psychosis could demonstrate pacing, unusual pose and gait, hypersexuality, and loud volume when speaking.17
An acute psychotic episode in a patient with preexisting psychotic illnesses needs investigation for an inciting cause such as substance abuse, stress, or medication noncompliance as well as other precipitating medical conditions.18 Collateral information is crucial to analyze the symptoms and for further management.
Sometimes, psychosis is severe enough to limit a patient's ability to care for his or herself. Clear examples include a patient with a delusion of being poisoned by his caretaker who refuses to eat or drink any items at home, a patient in the early stages of catatonia who is not communicating, or a patient who believes the voice of God is telling him to cut off his hand. Each of these patients would warrant an inpatient admission, particularly if there was not a trusted network capable of maintaining the physical needs and medication administration of the patient. It bears reminding, however, that patients in psychiatric hospitals must operate with some level of independence to perform activities of daily living; therefore, a patient with dementia or with significant medical decomposition may be excluded from admission.
Although all acute psychoses warrant thorough medical testing, not all psychotic patients require inpatient hospitalizations. A patient may have a delusion about being spied on by her neighbors despite constant reassurance by loved ones and lack of proof. However, if this woman is otherwise lucid and functioning generally well in other aspects of her life, the delusion is not in itself a reason to be hospitalized. Similarly, a patient brought in by the police for talking to himself in public and alarming bystanders does not necessarily warrant hospitalization. If, after a period of observation and administration of antipsychotic in the ED, the patient requests discharge and is organized enough to participate in safe discharge planning, the patient may not be admitted despite still endorsing auditory hallucinations. Such patients who are able to care for themselves and not at high imminent risk of harming themselves do not meet criteria for involuntary hospitalization in most states.
Agitation in the ED setting can be defined as verbally or physically threatening behavior that may lead to harm of the afflicted person, other patients, or hospital staff. There are several reasons why a patient might be behaviorally aggressive, including both medical and psychiatric causes, such as substance intoxication or withdrawal, delirium, medical conditions, and numerous underlying psychiatric conditions19 (Table 5).
Common Causes of Agitation
The first role of the ED psychiatrist is to ensure the safety of the patient and others, followed by initiation of comprehensive medical testing to determine the etiology of agitation so that proper treatment can be initiated. The assessment and documentation of the level of agitation can be done with tools such as the Behavioral Activity Rating Scale (BARS), which can further aid in determining appropriate management,20 although collateral information should be obtained when possible. If verbal de-escalation is not effective, use of chemical or physical restraints is the appropriate next step, followed by serial evaluations to determine ongoing imminence for danger to self or others.
Patients with acute mania or substance intoxication can present with behaviors that are imminently dangerous. Acutely manic patients may have agitation evidenced by constant movement, pacing and intruding into the physical and emotional space of others, and/or hypersexuality notable for frequent disrobing, public masturbation, or openly unwanted sexual advances. Patients may also present with irritability and feelings of invincibility, leading to altercations and belligerence with staff or other patients. If verbal de-escalation is not effective, use of rapid tranquilization pharmacotherapy or physical restraints in the acute ED setting is the appropriate next step, followed by serial evaluations to determine ongoing imminence for danger to self or others. Such patients that have required multiple medication doses and/or restraints most likely would require admission to stabilize their symptoms over the course of days to weeks.
Intoxicated patients, on the other hand, may be monitored and treated in the ER until symptoms resolve over the course of several hours, thereby avoiding the need for inpatient treatment. Substances such as synthetic marijuana, amphetamines, and phencyclidine can present with protracted courses of intoxication marked by psychosis, delusions, and physical violence of more than a day. If an intoxicated patient requires emergent restraints and does not appear to be improving, inpatient hospitalization may be necessary.
Patients with psychosis may be dangerous to others due to delusions or command auditory hallucinations. Patients who have specific intent and plan to hurt others may present to the ED through emergency medical services, police, or through referral from a clinician or loved one more frequently than presenting by themselves. Like other types of patients with agitation, patients with psychosis may require emergent medications and restraints due to their behavior. It is important to assess for psychiatric history, legal history, antisocial traits, and imminence and means of harm. It is also necessary to obtain collateral information from family and former providers if available and to document observable psychotic symptoms such as self-talk or hypervigilance when hospitalizing high-risk patients.
As with self-harmful behaviors, patients with neurocognitive and intellectual disorders may also act out in ways that are harmful to others, whether intentional or not. Common ED presentations would include a patient with dementia being brought in by nursing home staff after striking an aide. In these scenarios, ruling out the biological causes for agitation listed in Table 5 is necessary, as well as thoroughly investigating the social and psychological health of the patient. Presence of depression, poor frustration tolerance, paranoid ideation, and negative caregiver interactions must be evaluated, and imminent safety must be addressed. Although these types of altercations can cause immediate alarm, an inpatient hospital may not provide much benefit in reducing the behaviors associated with a neurocognitive disorder. In such circumstances, ED physician liaison with social and case managers for home or facility-based care may lead to more practical management of such behaviors.
Sometimes a patient might present to the ED with exaggerated or feigned symptoms of a psychiatric disorder to obtain an external benefit. ED psychiatrists may grapple with this condition, most commonly known as malingering or secondary gain, when inpatient hospitalization is viewed as a means to stable, if not temporary, housing. As stated earlier, ED psychiatrists want to deliver appropriate care and allocate limited resources, including inpatient psychiatric beds, responsibly. Although there are some reported symptoms that are more commonly feigned (eg, hallucinations occurring in one sensory modality only, visual hallucinations in black or white only, and stilted or implausible language),21 there are no validated tools to screen for malingering in the ED setting. Therefore, when evaluating patients with mood or psychotic symptoms, physicians must explore the expressed complaints in comparison to the observed findings and review clinical history, obtain collateral information, and collaborate with other members of the treatment team to determine the imminent need for hospitalization of each presenting patient.