Management of Psychiatric Emergencies
In psychiatric emergencies, immediately ensure safety of the patient and others, utilize existing behavioral health crisis services to avoid unnecessary ED visits when possible, perform comprehensive medical screening alongside psychiatric assessment, and maintain the least restrictive setting while providing access to urgent psychiatric consultation and appropriate disposition. 1
Immediate Safety and Triage
Safety assessment is the absolute first priority - evaluate for imminent danger to self or others, including active suicidal ideation with plan/intent, homicidal ideation, severe psychotic symptoms impairing judgment, or acute behavioral dyscontrol requiring immediate intervention 2, 3
Utilize existing behavioral health crisis services, crisis hotlines, and mobile crisis teams to divert patients from emergency departments when clinically appropriate, as these specialized services can provide more targeted psychiatric intervention 1
For patients requiring urgent evaluation, systems should include blocked provider hours for urgent referrals and dedicated crisis clinics with trained staff to ensure timely access 4
Comprehensive Medical and Psychiatric Assessment
All patients presenting with psychiatric complaints require proper medical evaluation for co-occurring conditions - use evidence-based screening algorithms to identify medical causes of behavioral changes including metabolic derangements, infections, intoxication/withdrawal, neurological emergencies, and medication effects 1, 4
Telehealth and telephonic screening by qualified, licensed professionals should be utilized for initial assessment when feasible, particularly for medical screening and psychiatric triage before in-person evaluation 1
Mental status examination must document specific findings including thought process abnormalities, mood/affect disturbance, presence of psychotic symptoms, cognitive impairment, and behavioral observations to support clinical decision-making 2, 3
Intervention Principles and De-escalation
Establish a stable, trusting relationship and attempt verbal de-escalation first - calm, patient "talk down" techniques often rapidly improve acute manifestations and should precede pharmacological or physical interventions 3, 5, 6
Control of aggressive behavior is the highest immediate priority, but preserving the physician-patient relationship is a close second and becomes the top priority for long-term outcomes 5, 6
Discourage use of physical restraints and maintain the least restrictive setting possible that corresponds to the patient's condition and presenting symptoms, as restraints increase morbidity and mortality risk 1, 4
Pharmacological Management
Oral medications, particularly concentrates, are clearly preferred when the patient can cooperate - benzodiazepines alone are first-line for 6 of 12 common emergency situations 5, 6
For suspected schizophrenia, mania, or psychotic depression with severe agitation, a combination of benzodiazepine plus antipsychotic (either high-potency conventional or atypical, particularly liquids) is preferred over either agent alone 5, 6
Lorazepam requires caution in elderly/debilitated patients (initial dose should not exceed 2 mg), patients with respiratory compromise, and those with hepatic insufficiency; resuscitative equipment must be readily available when using parenteral formulations 7, 8
High-potency conventional antipsychotics used alone never received higher expert ratings than benzodiazepines alone in behavioral emergencies 5, 6
Special Population Considerations
Systematically screen vulnerable populations - children, elderly, those with severe mental illness, intellectual/developmental disabilities, and domestic partners for signs of abuse, as social isolation and crisis situations elevate these risks 1, 4
For pediatric mental health emergencies, a multidisciplinary team approach with specialized screening tools, pediatric-trained mental health consultants, and availability of pediatric psychiatric facilities is essential 1
Adolescents can seek psychiatric care without parental involvement in many jurisdictions; maintain confidentiality unless the patient is at risk of harming themselves or others 1
Disposition and Follow-up
Patients with severe behavioral escalation, active suicidal ideation with inability to engage in safety planning, or acute psychotic decompensation impairing safety require psychiatric hospitalization for comprehensive evaluation and stabilization 4, 9
Formulate aftercare services based on existing community resources and partnerships - schedule first outpatient appointment within 48-72 hours of discharge for high-risk patients, with weekly therapy initially and medication management every 1-2 weeks 4, 9
Provide patients at suicide risk with local crisis center numbers, National Suicide Prevention Lifeline, and Crisis Text Line before discharge 1
Encourage creation of psychiatric advance directives that provide treatment guidance before symptoms worsen to the point of impaired decision-making capacity 1, 4
Critical Pitfalls to Avoid
Never rely on "no-suicide contracts" or "no-harm agreements" - these have no proven efficacy, may damage the therapeutic alliance, and provide false reassurance to clinicians 4, 9
Do not automatically approve work excusal requests without proper functional assessment, as this enables dysfunction and worsens long-term outcomes 10
Avoid the concept of "chemical restraint" - medications should be viewed as treatments for target behaviors even when underlying causes are not fully understood 5, 6
Never forward patient communications to employers or third parties without explicit written consent to maintain confidentiality 10
Staff Support and System Requirements
Ensure staff have access to adequate personal protective equipment and support education/training on psychiatric disorder treatment and best practices for behavioral health patient care 1
Promote self-care among care providers - acknowledge that maintaining individual health and wellness is essential for overall stability of patients and the care delivery system, and make staff aware of local, state, and regional support options 1, 4
Distribute urgent cases evenly among outpatient clinicians to prevent burnout, recognizing these patients require greater time and care coordination 4