The American Psychiatric Association defines a psychiatric emergency as “an acute disturbance in thought, behavior, mood, or social relationship, which requires immediate intervention as described by the patient, family, or social unit.”1 The etiology of a psychiatric emergency can vary, including suicidal behaviors, agitation, psychosis, mania, substance use sequelae (intoxication or withdrawal), and anxiety/panic symptoms. Agitation, which is simply defined as excessive verbal or physical activity, can also stem from delirium, behavioral disturbances in dementia, or from volitional activity related to personality disorders. Agitation can be the primary presenting symptom of a psychiatric emergency; thus, when presented with such a situation, the physician may be mostly dealing with a general situation with no well-defined cause.
Scope of the Problem and Treatment Challenges
Where do psychiatric emergencies occur? They can occur practically anywhere, both in clinical and nonclinical settings, sometimes prompting involvement from families or police officers to bring the patient to an appropriate management setting. Most emergencies are treated in emergency departments (ED). The reported percentage of ED visits related to psychiatric etiology varies from 6% to 25 %, and about 10% of primary care visits are also due to psychiatric emergencies.2 According to one study, between 1992 and 2001 approximately 53 million ED visits were estimated to be due to a psychiatric chief complaint, an increase from 4.9% to 6.3% of all emergency department visits in a decade.2 Most visits do not translate into hospitalizations, although it is estimated that there are 2.5 million psychiatric admissions in the United States yearly.2
A specific type of psychiatric emergency, suicidal behavior, has drawn much attention. According to the US Centers for Disease Control and Prevention, there were 42,773 suicides reported in the United States in 2014 (a rate of 13.4 per 100,000 people), which represents a 24% increase since 1999.3 Suicide is the second leading cause of death for people age 25 to 34 years and people age 15 to 24 years.3 It is the 10th leading cause of death in all age groups. The cost related to suicides and suicidal attempts in 2013 was estimated to be approximately $58.6 billion.3 In a multisite retrospective chart review of psychiatric emergency patients, more than 50% of patients had some documented agitation and 55% of patients had some documented self-harm ideation.4
A well-managed psychiatric emergency can save lives—not only the life of the patient undergoing the emergency (who may be suffering from a life-threatening emergency such as delirium tremens), but also the lives of people around the patient who may hurt by inadvertent agitation. Health care workers can also be hurt in the process and are often victims of random violence in the workplace. The threads of agitation, workplace violence, substance use disorders, and mental illness are often intertwined. In the American health care system, data do not reflect kindly on patient and staff protection, and awareness of this issue has not yet yielded any satisfactory solutions. In regard to patients, a 2007 national survey of mental health and well-being showed that 50% of patients who committed suicide had visited their primary care physician within 1 month of their death, and 20% of adults who died by suicide had visited their primary care physician within 24 hours of their death.5 According to the Bureau of Justice National Crime Victimization Survey, the annual rate of violent victimization was 12.6 per 1,000 for all workers, but, the annual rate for mental health professionals was 68.2 per 1,000 workers, which is three times higher than the rest of the health care field.6 Furthermore, up to one-half (32.4%–56%) of psychiatric trainees reported being assaulted sometime during their training.7 These figures highlight the need for effective and early intervention and support for the patient as well as the staff caring for them in context of the emergency. The data also show the ineffectiveness inherent to the current system.
Clinical Perspectives on Psychiatric Emergencies
In the ED, the clinician is confronted with various types of psychiatric emergencies. The commonality of agitation and risk of harm to self and others binds all these entities together, but the etiology differentiates cases and makes them unique. In this article, we guide the reader through what constitutes a psychiatric emergency and the steps to navigate the management of these entities. Some emergencies are medical in nature (see section on medical comorbidities), so psychiatric management has to wait until the patient is medically stable (eg, after an overdose). The second class of emergencies stems from chronic disorders with psychiatric manifestations but that are not necessarily psychiatric in nature; this category includes traumatic brain injuries and behavioral emergencies related to dementia/neurocognitive disorders, seizures disorders, and encephalopathies. The third category, psychiatric emergencies due to psychiatric disorders, is notable for mania, psychosis, depression/suicidality, and violence. Substance use-related emergencies may have a dual diagnosis (ie, underlying psychiatric disorder under control) but this is often not detected until the patient has calmed down enough to provide a full history.
Steps in the Management of Psychiatric Emergencies
There are multiple challenges that can present when providing care to psychiatric patients. Depending on the presentation, there are multiple settings to provide that care. There are many types of emergency psychiatry services available, including mental health consultations, dedicated mental health units within the larger ED, or free-standing psychiatric EDs. Community outreach programs and the police are increasingly trained in mental health. These various models have the same goals and have converged to address treatment of psychiatric emergencies. The same general principles apply across settings and should be emphasized for protection of the patient and the staff. The Association of Emergency Psychiatry, in its landmark guidelines “Best Practices in Evaluation and Treatment of Agitation” (the BETA project),8 emphasizes a holistic approach in the management of agitated patients, with the global aim of decreasing medication use, seclusions, and restraints.
The first step in management starts before an emergency even occurs and includes thoughtful design of the units, such as having waiting rooms with staff in full view of patients. The ability of staff to detect early warning signs is paramount. Staff drills can enhance effectiveness and help prevent injuries.9 Staff training in recognizing early signs of agitation and developing comfort and familiarity with redirection and de-escalation techniques is essential for proper handling of emergencies. Goals of short-term management include early detection of risk factors (such as pacing, holding an object that can be used in a dangerous manner, intense/threatening glares), rapid control of the situation, and minimization of the immediate danger to the patient and others.10
Second, most emergencies present with nonspecific agitation and mostly nonspecific behaviors (except in cases of stated suicidal or homicidal ideations). Once the acute emergency is controlled and the patient and staff are safe, the next step is to determine whether the etiology is medical or psychiatric. That determination allows better triage and subsequent management and treatment. Severe alcohol withdrawal, complicated post-ictal states, delirium, and hepatic encephalopathy are examples of issues that can initially present as a psychiatric emergency but are best treated in a medical unit. Medical clearance of the psychiatric patient is beyond the scope of this article, but general principles suggest the elimination of modifiable, treatable medical causes prior to labeling a patient with a psychiatric ailment.
A successfully managed psychiatric emergency results in a solid physician-patient rapport and a concomitant improvement in the patient's symptoms, as well as improved ability to report accurate history and participate in treatment planning.
My Patient Is Agitated: Which Modality Do I Use?
Behavior modifications and pharmacological interventions have long been the staples of acute emergency management. Practices such as chemical restraints, now outdated and out of favor, have been replaced by active efforts and widespread national and institutional monitoring to avoid excessive use of force and restraints in patients. Coercive incidents should be kept to a minimum. Maintaining safety and helping stabilize patients has to be weighed against impinging on individual rights and denying patients their rights to make treatment decisions. Six core strategies are recommended: (1) enhanced staff knowledge, (2) enhanced staff skills, (3) enhanced staff attitudes, (4) development of restraint orders, (5) decision support in the electronic medical record to enable informed debriefing and tracking of events, and (6) implementation of initiatives to include service users and their families in the planning of care.11
The BETA project directs acute agitation management in three steps to minimize the early use of force, restraints, or involuntary medication: (1) maximize patient verbal engagement, (2) establish trust with patients, and (3) verbal de-escalation of the patient to bring him or her out of an agitated state12
The techniques discussed in this section may sound simple but they are helpful in de-escalating situations. Reassuring the patient, asking earnestly “what's wrong,” and providing basic facilities like food, water, and a blanket help establish rapport and actively engage the patient. If these steps fail to provide any desired result, then the next step is behavioral and environmental modifications.
Modification of Environment
Modification of environment involves removing sharp objects, removing wires a patient can use to hang themselves, and keeping a safe distance around the patient. In the teaching hospital environment where the authors work, patients with a psychiatric chief complaint deemed at risk of self-harm or acting out because of psychosis or altered mental state are clothed in a gown of a different color than patients without psychiatric complaints.
Minimizing stimulation, which is typically a major issue in the ED, can be achieved by moving patients to a slightly calmer environment such as the hallway, a bed in the corner of the room, and dimming lights and silencing alarms if feasible.
Removal or Management of Physical Issues
Issues related to pain management and to toileting can cause much agitation in individuals, possibly leading to escalation. Keeping the patient as comfortable as possible is helpful.
Level of Supervision
The level of supervision depends upon acting out or suicidal risk and it is typically decided after an initial risk assessment. Levels vary from 15-minute check-ins to group close supervision to one-to-one monitoring, which is the most intense level of supervision. Shortage of staff and lack of insurance reimbursement may be factors in staffing models that conflict with clinical decision-making. Keep in mind that no level of supervision is perfect or 100% effective. In a review of 76 inpatient suicides, 42 of these patients were on 15-mintue suicide checks and 9% were on one-on-one monitoring with the presence of a staff member at the time of suicide.13 Numbers are estimated to be even worse in ED settings, although formal data are lacking.14
Mechanical restraint is a final and last resort. It should be considered only if all other behavioral modifications modalities have failed. The use of mechanical restraint can lead to legal issues and potential patient trauma and is best used only for a short time while administering emergency medications. In the US, the use of mechanical restraints is carefully regulated, but the days of using more intense restraints such as cage beds were not that long ago.15 Mental health practitioners agree that restraining patients physically breaches human dignity and is counter-productive at times, but lack agreement on what to replace such measures with and whether discontinuing such practices would constitute increasing safety risks in already tense ED conditions.16
Pharmacological Interventions in Psychiatric Emergencies
When behavior modalities fail to de-escalate the situation, pharmacological strategies can be used. Parameters to be kept in mind when selecting an agent are discussed in the following text.
Onset of Action
Is the agent fast acting? When behavioral measures have failed and imminent harm is feared, an almost-immediate onset of action is desired. This is the rationale for polypharmacy use in most medication combinations used in emergency medicine or psychiatry, such as an antipsychotic combined with a benzodiazepine.
An agitated patient may receive medications within minutes of arriving to the ED. Because the etiology of presentation and complicating medical comorbidities are unknown at the time, medications with a short half-life are preferred. Ketamine has been gaining popularity among emergency physicians,17 but less so among psychiatrists.
Side Effects and Sedation
The aim of managing a psychiatric emergency effectively is to calm the patient down but not to sedate excessively. Increasing the length of stay in the ED can be associated with further adverse encounters with staff and more medical issues. Most patients who receive intramuscular haloperidol require re-administration of emergency medications, therefore increasing lengths of stay; however, this could be a direct result of the severity of their condition rather than medication choice.18 The advent of intramuscular second-generation antipsychotics was thought to present an attractive alternative to first-generation antipsychotics such as haloperidol, but in cases of insufficient medical data, benzodiazepines may be the class of choice for first-line treatment.19,20
This criterion is usually not considered in acute situations but is a factor in selection of items for pharmacies and formulary panels. Second-generation antipsychotics remain more expensive than older medications such as haloperidol or droperidol.21
Least or Noninvasive Measures
If patient is cooperative, it is much preferable to use an oral agent. In cases in which a conversation with the patient, however rudimentary, is possible, an oral agent can be selected in the context of a step-wise approach.
Maximize Collection of Medical Data
Relative contraindications for antipsychotic use may include a prolonged QT interval, thromboembolisms, or a heighted risk/prior history of acute dystonia. Impaired liver function may preclude the use of long-acting benzodiazepines, whereas vomiting rules out safe use of ketamine. To the greatest extent possible, knowledge of a patient's medical history is essential to navigate acute emergencies safely.
Pharmacological Options in Psychiatric Emergencies
The most common pharmacological classes for agents used in psychiatric emergencies are benzodiazepines, antipsychotic medications, and antihistamines, with an expanding use for ketamine. Mood stabilizers, beta-blockers, and selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are less frequently used, mostly because of lack of intramuscular formulations. Inhaled formulations such as loxapine have been slow to gain ground although are theoretically promising.22,23
Benzodiazepines are a class of psychoactive drugs that bind to the gamman-aminobutyric acid A receptor in the brain. This process results in sedative-hypnotic, anxiolytic, and anticonvulsant clinical effects. Short-acting agents like lorazepam and midazolam are frequently used for their immediate calming effect in the ED, often as a first-line treatment when medical data are lacking or in cases of impaired liver function,19,20 whereas longer-acting compounds such as diazepam or chlordiazepoxide are excellent for alcohol withdrawal and self-tapering given the presence of active metabolites.24
Antipsychotics are divided into typical and atypical classes. Blockade of dopamine-2, rather than 5-hydroxytryptamine receptors, differentiates typical (first-generation) antipsychotic from atypical (second-generation) antipyschotics. The latter are thought to have less extrapyramidal side effects because of serotonin and histaminergic receptor involvement. Haloperidol, olanzapine, and ziprasidone are the most used injectable antipsychotics in psychiatric emergencies. Oral disintegrating formulations are a second-line strategy that works in subacute emergencies, and choices in this category include disintegrating olanzapine, aripiprazole, and risperidone.
The combination of haloperidol, lorazepam, and diphenhydramine remains the preferred options both by evidence base25 and by survey opinions,26 although other treatment options are available; younger providers and those not specifically trained in emergency psychiatry choose chlorpromazine much less frequently (Table 1 and Table 2).
Drugs Used in Treatment of Acute Dystonias or Prophylaxis of Extrapyramidal Symptoms in the Emergency Department
Antipsychotic Drugs Used in the Treatment of Psychiatric Emergencies
Mood stabilizers such as lithium, valproic acid, carbamazepine, topiramate, and gabapentin also do not constitute a first-line treatment intervention in psychiatric emergencies. They do, with the exception of lithium, have a niche in the management of alcohol use disorder and mitigating mild-to-moderate alcohol withdrawal.27,28
SSRIs and SNRIs
SSRIs and SNRIs are the first-line treatment for depressive and anxiety disorders. They do not carry an indication for treatment of suicidality. Antidepressants work by increasing levels of serotonin (and possibly norepinephrine and dopamine) in postsynaptic neuronal spaces, but onset of action is slow; therefore, antidepressants are not a first-line treatment for psychiatric emergency management. However, with that caveat in mind, starting individuals on SSRIs as early as their ED visits, rather than waiting for the outpatient appointment, may yield a significant decrease in medical sue, emergency service use, and laboratory use in patients with panic disorder taking sertraline.29 Studies show that use of SSRIs resulted in decline of suicidal ideation, depression severity, and suicide attempts, regardless of psychotropic-combination received, but they should be used in children and adolescents with caution.30–32 Initiation of psychotropics in the ED is beyond the scope of this article but constitutes one of the tenets of emergency psychiatry.
Medical Comorbid Conditions and Psychiatric Emergencies
In addition to the challenges related to treatment from a psychiatric standpoint, there are potential comorbid medical conditions that the clinician should be diligent in evaluating for in the patient who is agitated. Early in the process of evaluating a patient who is agitated, it is important to determine if there is a medical condition that may necessitate further evaluation in a medical setting. There are multiple nonpsychiatric potential causes of agitation in psychiatric patients that should be considered, including electrolyte imbalances, seizure activity/post-ictal states, infectious process such as meningitis and encephalitis, traumatic injuries, hyperthyroidism, intoxication from substances such as cocaine, as well as possible toxic ingestions, and finally central nervous system abnormalities such as a cerebrovascular accident, malignancy, or intracranial hemorrhage. These examples are extensive but not all inclusive and speak to some potential medical etiologies of agitation and medical conditions a psychiatric provider should evaluate for in treating a patient with agitation. In addition to evaluating for possible medical conditions that might cause agitation in these patients, it is important to consider the common medical comorbidities that might complicate treatment. There are several medical conditions that are found in higher rates within patients with a significant mental illness when compared to the general public, including HIV, tuberculosis, poor dental status, chronic obstructive pulmonary disease, obstetric complications, cardiovascular diseases including coronary heart disease and cerebral vascular disease, diabetes mellitus, dyslipidemia, and obesity.31,32
Some physical health conditions that are frequently comorbid with psychiatric illness may be iatrogenic to some degree and secondary to the medications used to treat these illnesses. Some psychotropic medications can produce more emergent conditions: monoamine oxide inhibitors have been associated with hypertensive crisis as well postural hypotension;35 tertiary tricyclic antidepressants can slow cardiac conduction; clozapine at high doses has been associated with seizures; some neuroleptics can produce a dystonic reaction; and lithium intoxication can produce ataxia, seizures, and coma. Serotonin syndrome and neuroleptic malignant syndrome (NMS) can present similarly and are emergent conditions. Serotonin syndrome can present with autonomic and mental status changes as well as neurologic hyperexcitability.18 NMS can present with rigidity, altered mental status, fever, autonomic dysfunction, elevated serum creatinine, and an elevated white blood cell count. NMS is an uncommon side effect of antipsychotic medications. This is particularly relevant because from 2000 to 2004 there was an 8-fold increase in combination use of typical and atypical antipsychotics during ED visits.36 Physicians should be prudent in their use of antipsychotics because they pose a risk for QTc prolongation. There have been antipsychotic drugs that have been pulled from the market secondary to reports of torsade de pointes.37
Sensory Modulation: The Next Frontier in Emergency Management
One last consideration is the use of sensory modulation. The restrictive environment of a psychiatric ED can leave patients vulnerable to increased agitation and distress without available forms of self-soothing.38 Sensory modulation has emerged as a patient-driven intervention that promotes self-soothing or independent management of arousal and distress. Sensory-based tools and environments have the potential to engage the patient's senses to reduce agitation and hyperarousal and prevent escalation to aggression.37 Despite an absence of research assessing efficacy of this treatment technique in an ED setting, it is a highly anticipated treatment based on initial research in inpatient settings and because of national trends to decrease the use of seclusion and restraints in ED settings.39–41 The potential efficacy of this treatment modality is rooted in the same theories that explain the efficacy of dialectical behavioral therapy skills, such as grounding techniques used in the treatment of borderline personality disorder.38
Novak et al.40 concluded that access to sensory rooms in an Australian inpatient facility significantly reduced levels of distress and disruptive behavior. Seclusion and aggression rates on the unit were unaffected by use of the sensory room. A weighted blanket was noted to be the most significantly effective sensory item to decrease levels of distress and anxiety when compared to rocking chairs, scents, music, and reading. Weighted items such as blankets, vests, and lap pads may convey a sense of containment or physical hold.38 Chalmers et al.39 published similar findings of statistically significant reduction in distress and arousal using massage chairs, music, water features, and lamps. Similar to the data of Novak et al.,40 rates of seclusion and restraint were unaffected by use of sensory rooms.37 Research by Cummings et al.42 has begun to identify a patient population referred to as “high utilizers” who may not benefit from the use of sensory rooms. “High utilizer” patients are characterized by male gender, severe psychosis or personality disorder with history of violence, and traumatic brain injury or mental retardation. Analysis when this patient population data are omitted showed a statistically significant decline in rates and duration of seclusion and restraint with use of a sensory room. Items cataloged in other “sensory rooms” with similar effects on reduction of arousal and distress include massage chairs, rocking chairs, beanbags, faux-fur blankets, weighted blankets, weighted soft toys, “stress balls,” portable audio and DVD players with relaxing sounds and visual scenes, posters of nature scenes, aromatic oils and diffusers, scented hand creams, adjustable ambient lighting, bubble lamps, music, self-help books, and magazines.38–41
Sensory modulation for treatment of distress, anxiety, and agitation is not necessarily a new concept in the field of mental health. Occupational therapists and nursing staff are likely familiar with these concepts, and much of existing research comes from these foci of mental health care.38–40 The intervention is valued for its trauma-centered care of mentally ill patients who, in general, experience trauma more often than patients without mental illness.38,43 Providing sensory modulation opportunities in the ED setting can be a supportive approach to avoid re-traumatization and escalation to agitation and aggression.44
Little research exists regarding the efficacy of sensory tools to manage distress and agitation outside designated “sensory rooms.” Much of what is known about aromatherapy in the treatment of agitation comes from research in patients with dementia, and the results have been mixed.45,46 Researchers maintain that aromatherapy remains a potentially effective treatment worthy of further investigation because aromatherapy has been a well-tolerated and acceptable form of intervention among patients.46,47 The most proximal research to sensory modulation in the ED setting was the use of music versus aromatherapy to reduce anxiety in parents of pediatric patients in the ED.48 This research suggests that music played at a tempo of 60 to 70 beats per minute, similar to the average adult human heart rate, reduced anxiety rates whereas aromatherapy did not.48
Based on preliminary research in psychiatric inpatient settings, sensory modulation is potentially an effective means to treat agitation and distress and possibly to reduce seclusion and restraint use. Researchers appreciate sensory modulation as a tool to promote patient-driven and trauma-centered care.
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Drugs Used in Treatment of Acute Dystonias or Prophylaxis of Extrapyramidal Symptoms in the Emergency Department
||Mechanisms of Action
||Method of Administration
Antihistamine: acetylcholine and histamine receptor antagonism
||Oral or intramuscular
||Antihistamine: histamine-1 receptor antagonism
||Oral/syrup or intramuscular
||M1 muscarinic acetylcholine receptor antagonism
Antipsychotic Drugs Used in the Treatment of Psychiatric Emergencies
||Mechanism of Action
||Dose per Administration (mg)
||Antagonist of dopamine-2 receptor
||Oral or intramuscular (intravenous not approved by FDA)
||Antagonist of dopamine-2 receptor
||Intravenous (black box warning for QTc prolongation)
||Partial antagonist of dopamine-2 receptor and serotonin receptors
||Oral or intramuscular
Risk of QTc prolongation
||Partial antagonist of dopamine-2 receptor and histamine receptors
||Oral, dissolvable, or intramuscular
Sedation is a common side effect
||Antagonist of dopamine-2 receptor
||Oral or intramuscular
Sedation is a common side effect
||Dopamine-2 receptors and 5-hydroxytryptamine 2A receptors
||Oral and dissolvable
||Partial agonist at dopamine-2 receptors
||Oral and dissolvable