Emergency psychiatry is the clinical application

of psychiatry in emergency settings.[1][2] Conditions requiring

psychiatric interventions may include attempted suicide,substance
abuse, depression, psychosis, violence or other rapid changes in
behavior. Psychiatric emergency services are rendered by
professionals in the fields ofmedicine, nursing, psychology and social
work.[2] The demand for emergency psychiatric services has rapidly
increased throughout the world since the 1960s, especially in urban
areas.[3][4] Care for patients in situations involving emergency
psychiatry is complex.[3]

Individuals may arrive in psychiatric emergency service settings

through their own voluntary request, a referral from another health
professional, or through involuntary commitment. Care of patients
requiring psychiatric intervention usually encompasses crisis
stabilization of many serious and potentially life-threatening conditions
which could include acute or chronic mental disorders or symptoms
similar to those conditions.[2]

Definition

Symptoms and conditions behind psychiatric emergencies may

include attempted suicide, substance dependence, alcohol
intoxication, acute depression, presence ofdelusions, violence, panic
attacks, and significant, rapid changes in behavior.[5] Emergency
psychiatry exists to identify and/or treat these symptoms and
psychiatric conditions. In addition, several rapidly lethal medical
conditions present themselves with common psychiatric symptoms.
A physician's or a nurse's ability to identify and intervene with these
and other medical conditions is critical.[1]

[edit]Delivery of services

The place where emergency psychiatric services are delivered are

most commonly referred to as Psychiatric Emergency Services,
Psychiatric Emergency Care Centers, or Comprehensive Psychiatric
Emergency Programs. Mental health professionals from a wide area
of disciplines, including medicine, nursing, psychology, and social
work work in these settings alongside psychiatrists and
emergency physicians.[2] The facilities, sometimes housed in
a psychiatric hospital, psychiatric ward, oremergency room, provide
immediate treatment to both voluntary and involuntary patients 24
hours a day, 7 days a week.[6][7] Within a protected environment,
psychiatric emergency services exist to provide brief stay of two or
three days to gain a diagnostic clarity, find appropriate alternatives to
psychiatric hospitalization for the patient, and to treat those patients
whose symptoms can be improved within that brief period of time.
[8]
Even precise psychiatric diagnoses are a secondary priority
compared with interventions in a crisis setting.[2] The functions of
psychiatric emergency services are to assess patients' problems,
implement a short-term treatment consisting of no more than ten
meetings with the patient, procure a 24-hour holding area, mobilize
teams to carry out interventions at patients' residences, utilize
emergency management services to prevent further crises, be aware
of inpatient and outpatient psychiatric resources, and provide
24/7 telephone counseling.[9]

[edit]History

This section
requires expansion.

Since the 1960s the demand for emergency psychiatric services has
endured a rapid growth due to deinstitutionalization both
in Europe and the United States, increases in the number of medical
specialties, and the multiplication of transitory treatment options, such
as psychiatric medication.[3][4][10] The actual number of psychiatric
emergencies has also increased significantly, especially in psychiatric
emergency service settings located in urban areas.[5] Psychiatric
emergency services attracted unemployed, homeless and other
disenfranchised populations due to its characteristics of accessibility,
convenience, and anonymity policies.[3] While many of the patients
who used psychiatric emergency services shared common
sociological and demographic characteristics, the symptoms and
needs expressed did not conform to any single psychiatric profile.
[11]
The individualized care needed for patients utilizing psychiatric
emergency services is evolving, requiring an always changing and
sometimes complex treatment approach.[3]
[edit]Scope

Suicide attempts and suicidal thought

As of 2000, the World Health Organization estimated one million

suicides in the world each year .[12] There are countless more suicide
attempts. Psychiatric emergency service settings exist to treat the
mental disorders associated with an increased risk of completed
suicide or suicide attempts. Mental health professionals in these
settings are expected to predict acts of violence patients may commit
against themselves (or others), even though the complex factors
leading to a suicide stem from so many sources, including
psychosocial, biological, interpersonal, anthropological and religious.
These mental health professionals will use any resources available to
them to determine risk factors, make an overall assessment, and
decide on any necessary treatment.[2]

[edit]Violent behavior

Aggression can be the result of both internal and external factors that
create a measurable activation in the autonomic nervous system. This
activation can become evident through symptoms such as the
clenching of fists or jaw, pacing, slamming doors, hitting palms of
hands with fists, or being easily startled. It is estimated that 17% of
visits to psychiatric emergency service settings are homicidal in origin
and an additional 5% involve both suicide and homicide.[13] Violence is
also associated with many conditions such as acute intoxication,
acute psychosis paranoid personality disorder, antisocial personality
disorder, narcissistic personality disorder, and borderline personality
disorder. Additional risk factors have also been identified which may
lead to violent behavior. Such risk factors may include prior arrests,
presence of hallucinations, delusions, or other neurological
impairment, being uneducated, unmarried etc..[2] Mental health
professionals complete violence risk assessments to determine both
security measures and treatments for the patient.[2]

[edit]Psychosis

Patients with psychotic symptoms are common in psychiatric

emergency service settings. The determination of the source of the
psychosis can be difficult.[2] Sometimes patients brought into the
setting in a psychotic state have been disconnected from their
previous treatment plan. While the psychiatric emergency service
setting will not be able to provide long term care for these types of
patients, it can exist to provide a brief respite and reconnect the
patient to their case manager and/or reintroduce necessary
psychiatric medication. A visit to a crisis unit by a patient suffering
from a chronic mental disorder may also indicate the existence of an
undiscovered precipitant, such as change in the lifestyle of the
individual, or a shifting medical condition. These considerations can
play a part in an improvement to an existing treatment plan.[2]

An individual could also be suffering from an acute onset of psychosis.

Such conditions can be prepared for diagnosis by obtaining a medical
or psychopathological history of a patient, performing a mental status
examination, conducting psychological testing,
obtaining neuroimages, and obtaining other neurophysiologic
measurements. Following this, the mental health professional can
perform a differential diagnosis and prepare the patient for treatment.
As with other patient care considerations, the origins of acute
psychosis can be difficult to determine because of the mental state of
the patient. However, acute psychosis is classified as a medical
emergency requiring immediate and complete attention. The lack of
identification and treatment can result in suicide, homicide, or other
violence.[3]

[edit]Substance dependence, abuse and intoxication

Psychoactive drugs.

Another common cause of psychotic symptoms is substance

intoxication. These acute symptoms may resolve after a period of
observation or limited psychopharmacological treatment. However the
underlying issues, such as substance dependence or abuse, is
difficult to treat in the emergency room.[citation needed] Both acute alcohol
intoxication as well as other forms of substance abuse can require
psychiatric interventions.[2][3] Acting as adepressant of the central
nervous system, the early effects of alcohol are usually desired for
and characterized by increased talkativeness, giddiness, and a
loosening of social inhibitions. Besides considerations of impaired
concentration, verbal and motor performance, insight, judgment and
short term memory loss which could result in behavioral
change causing injury or death, levels of alcohol below 60 milligrams
per deciliter of blood are usually considered non-lethal. However,
individuals at 200 milligrams per deciliter of blood are considered
grossly intoxicated and concentration levels at 400 milligrams per
deciliter of blood are lethal, causing complete anesthesia of
the respiratory system. Beyond the dangerous behavioral changes
that occur after the consumption of certain amounts of alcohol,
idioyncratic intoxication could occur in some individuals even after the
consumption of relatively small amounts of alcohol. Episodes of this
impairment usually consist of confusion, disorientation, delusions and
visual hallucinations, increased aggressiveness, rage, agitation and
violence. Chronic alcoholics may also suffer from alcoholic
hallucinosis, wherein the cessation of prolonged drinking may trigger
auditory hallucinations. Such episodes can last for a few hours or an
entire week. Antipsychotics are often used to treat these symptoms.[3]

Patients may also be treated for substance abuse following

the administration of psychoactive substances
containing amphetamine, caffeine,tetrahydrocannabinol, cocaine, phe
ncyclidines, or
other inhalants, opioids, sedatives, hypnotics, anxiolytics, psychedelic
s, dissociatives and deliriants. Clinicians assessing and treating
substance abusers must establish therapeutic rapport to
counter denial and other negative attitudes directed towards
treatment. In addition, the clinician must determine substances used,
the route of administration, dosage, and time of last use to determine
the necessary short and long term treatments. An appropriate choice
of treatment setting must also be determined. These settings may
include outpatient facilities, partial hospitals, residential treatment
centers, or hospitals. Both the immediate and long term treatment and
setting is determined by the severity of dependency and seriousness
of physiological complications arising from the abuse.[2]
[edit]Hazardous drug reactions and interactions

Overdoses, drug interactions, and dangerous reactions from

psychiatric medications, especially antipsychotics, are considered
psychiatric emergencies. Neuroleptic malignant syndrome is a
potentially lethal complication of first or second generation
antipsychotics.[10] If untreated, neuroleptic malignant syndrome can
result in fever, muscle rigidity, confusion, unstable vital signs, or even
death.[10] Serotonin syndrome can result when selective serotonin
reuptake inhibitors or monoamine oxidase inhibitors mix
with buspirone.[2] Severe symptoms of serotonin syndrome
includehyperthermia, delirium, and tachycardia that may lead to
shock. Often patients with severe general medical symptoms, such as
unstable vital signs, will be transferred to a general medical
emergency room or medicine service for increased monitoring.[citation
needed]

[edit]Personality disorders

Disorders manifesting dysfunction in areas related

to cognition, affectivity, interpersonal functioning and impulse control
can be considered personality disorders.[14] Patients suffering from a
personality disorder will usually not complain about symptoms
resulting from their disorder. Patients suffering an emergency phase of
a personality disorder may showcase combative or suspicious
behavior, suffer from brief psychotic episodes, or be delusional.
Compared with outpatient settings and the general population, the
prevalence of individuals suffering from personality disorders in
inpatient psychiatric settings is usually 725% higher. Clinicians
working with such patients attempt to stabilize the individual to their
baseline level of function.[2]

[edit]Anxiety

Patients suffering from an extreme case of anxiety may seek

treatment when all support systems have been exhausted and they
are unable to bear the anxiety. Feelings of anxiety may present in
different ways from an underlying medical illness or psychiatric
disorder, a secondary functional disturbance from another psychiatric
disorder, from a primary psychiatric disorder such as panic
disorder or generalized anxiety disorder, or as a result of stress from
such conditions as adjustment disorder or post-traumatic stress
disorder. Clinicians usually attempt to first provide a "safe harbor" for
the patient so that assessment processes and treatments can be
adequately facilitated.[3] The initiation of treatments for mood and
anxiety disorders are important as patients suffering from anxiety
disorders have a higher risk of premature death.[2]

[edit]Disasters

Natural disasters and man-made hazards can cause severe

psychological stress in victims surrounding the event. Emergency
management often includes psychiatric emergency services designed
to help victims cope with the situation. The impact of disasters can
cause people to feel shocked, overwhelmed, immobilized, panic-
stricken, or confused. Hours, days, months and even years after a
disaster, individuals can experience tormenting memories, vivid
nightmares, develop apathy, withdrawal, memory lapses, fatigue, loss
of appetite, insomnia, depression, irritability, panic attacks, or
dysphoria. Due to the typically disorganized and hazardous
environment following a disaster, mental health professionals typically
assess and treat patients as rapidly as possible. Unless a condition is
threatening life of the patient, or others around the patient, other
medical and basic survival considerations are managed first. Soon
after a disaster clinicians may make themselves available to allow
individuals to ventilate to relieve feelings of isolation, helplessness
and vulnerability. Dependent upon the scale of the disaster, many
victims may suffer from both chronic or acute post-traumatic stress
disorder. Patients suffering severely from this disorder often are
admitted to psychiatric hospitals to stabilize the individual.[3]

[edit]Abuse

Incidents of physical abuse, sexual abuse or rape can result in

dangerous outcomes to the victim of the criminal act. Victims may
suffer from extreme anxiety, fear, helplessness, confusion, eating or
sleeping disorders, hostility, guilt and shame. Managing the response
usually encompasses coordinating psychological, medical and legal
considerations. Dependent upon legal requirements in the region,
mental health professionals may be required to report criminal activity
to a police force. Mental health professionals will usually gather
identifying data during the initial assessment and refer the patient, if
necessary, to receive medical treatment. Medical treatment may
include a physical examination, collection of medicolegal evidence,
and determination of the risk of pregnancy, if applicable.[3]

[edit]Treatment

Treatments in psychiatric emergency service settings are typically

transitory in nature and only exist to provide dispositional solutions
and/or to stabilize life-threatening conditions.[3] Once stabilized,
patients suffering chronic conditions may be transferred to a setting
which can provide long term psychiatric rehabilitation.[3] Prescribed
treatments within the emergency service setting vary dependent upon
the patient's condition.[15] Different forms of psychiatric
medication, psychotherapy, or electroconvulsive therapy may be used
in the emergency setting.[15][16][17] The introduction and efficacy of
psychiatric medication as a treatment option in psychiatry has
reduced the utilization of physical restraints in emergency settings, by
reducing dangerous symptoms resulting from acute exacerbation of
mental illness or substance intoxication.[16]

[edit]Medications

With time as a critical aspect of emergency psychiatry, the rapidity of

effect is an important consideration.[16] Pharmacokinetics is the
movement of drugs through the body with time and is at least partially
reliant upon the route of
administration, absorption, distribution and metabolism of the
medication.[10][18] A common route of administration is oral
administration, however if this method is to work the drug must be
able to get to the stomach and stay there.[10] In cases of vomiting and
nausea this method of administration is not an
option. Suppositories can, in some situations, be administered
instead.[10] Medication can also be administered through intramuscular
injection, or through intravenous injection.[10] The amount of time
required for absorption varies dependent upon many factors including
drug solubility, gastrointestinal motility and pH.[10] If a medication is
administered orally the amount of food in the stomach may also affect
the rate of absorption.[10] Once absorbed medications must be
distributed throughout the body, or usually with the case of psychiatric
medication, past the blood-brain barrier to the brain.[10] With all of
these factors affecting the rapidity of effect, the time until the effects
are evident varies. Generally, though, the timing with medications is
relatively fast and can occur within several minutes. As an example,
physicians usually expect to see a remission of symptoms thirty
minutes after haloperidol, an antipsychotic, is administered
intramuscularly.[16]

[edit]Psychotherapy

Other treatment methods may be used in psychiatric emergency

service settings. Brief psychotherapy can be used to treat acute
conditions or immediate problems as long as the patient understands
his or her issues are psychological, the patient trusts the physician,
the physician can encourage hope for change, the patient has
motivation to change, the physician is aware of the
psychopathological history of the patient, and the patient understands
that their confidentiality will be respected.[16] The process of brief
therapy under emergency psychiatric conditions includes the
establishment of a primary complaint from the patient, realizing
psychosocial factors, formulating an accurate representation of the
problem, coming up with ways to solve the problem, and setting
specific goals.[16] The information gathering aspect of brief
psychotherapy is therapeutic because it helps the patient place his or
her problem in the proper perspective.[16] If the physician determines
that deeper psychotherapy sessions are required, he or she can
transition the patient out of the emergency setting and into an
appropriate clinic or center.[16]

[edit]ECT

Electroconvulsive therapy is a controversial form of treatment

which cannot be involuntarily applied in psychiatric emergency service
settings.[16][17] Instances wherein a patient is depressed to such a
severe degree that the patient cannot be stopped from hurting himself
or herself or when a patient refuses to swallow, eat or drink
medication, electroconvulsive therapy could be suggested as a
therapeutic alternative.[16] While preliminary research suggests that
electroconvulsive therapy may be an effective treatment for
depression, it usually requires a course of six to twelve sessions of
convulsions lasting at least 20 seconds for those antidepressant
effects to occur.[10]

[edit]Hospital admission

The emergency care process.

The staff will need to determine if the patient needs to be admitted to

a psychiatric inpatient facility or if they can be safely discharged to the
community after a period of observation and/or brief treatment.[citation
needed]
Initial emergency psychiatric evaluations usually involve patients
who are acutely agitated, paranoid, or who are suicidal. Initial
evaluations to determine admission and interventions are designed to
be as therapeutic as possible.[2]
[edit]Involuntary commitment

Involuntary commitment, or sectioning, refers to situations

where police officers, health officers, or health professionals classify
an individual as dangerous to themselves, others, gravely disabled, or
mentally ill according to the applicable government law for the region.
After an individual is transported to a psychiatric emergency service
setting, a preliminary professional assessment is completed which
may or may not result in involuntary treatment.[2] Some patients may
be discharged shortly after being brought to psychiatric emergency
services while others will require longer observation and the need for
continued involuntary commitment will exist. While some patients may
initially come voluntarily, it may be realized that they pose a risk to
themselves or others and involuntary commitment may be initiated at
that point.[citation needed]
[edit]Referrals and voluntary hospitalization

Voluntary hospitalizations are outnumbered by involuntary

commitments partly due to the fact insurance companies tend not to
pay for hospitalization unless an imminent danger exists to the
individual or community. In addition, psychiatric emergency service
settings admit approximately one third of patients from assertive
community treatmentcenters.[2]

[edit]See also

Emergency medicine

Mental health first aid

Psychiatry

Psychiatric hospital

[edit]References

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Economic. (1999). San Francisco: Jossey-Bass Publishers.

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McGraw-Hill.

3. ^ a b c d e f g h i j k l m Bassuk, E.L. & Birk, A.W. (1984). Emergency Psychiatry: Concepts,

Methods, and Practices. New York: Plenum Press.

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 8. ^ Allen, M.H. (1995). The Growth and Specialization of Emergency Psychiatry. San Francisco:

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14. ^ American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental

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15. ^ a b Walker, J.I. (1983) Psychiatric Emergencies. Philadelphia: J.B. Lippincott.

16. ^ a b c d e f g h i j Rund, D.A., & Hutzler, J.C. (1983). Emergency Psychiatry. St. Louis: The C.V.

Mosby Company.

17. ^ a b Potter, M. (2007, May 31). Setting the Standards: Human Rights and Health - Mental

Health. Northern Ireland Human Rights Commission.

18. ^ Holford N.H.G., Sheiner L.B. (1981). "Pharmacokinetic and pharmacodynamic modeling in

vivo". CRC Critical Reviews in Bioengineering 5: 273322.

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Otong-Antai, D. (2001). Psychiatric Emergencies. Eau Claire:

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41 http://www.primarypsychiatry.com/aspx/articledetail.aspx?
articleid=2675