Over the last two decades, the rate of ED mental health–related visits increased 38%, from 17.1 to 23.6 per 1000 U.S. population.¹ Mental health and/or substance abuse accounts for about one of every eight ED visits in the United States, and covert mental health problems may be present in over 40% of all ED patients.² ED visit increases are especially noTable for older persons and those living in urban areas, and with visits related to mood and anxiety disorders, suicide attempts, and substance abuse. Behavioral disorders in children account for at least 1.6% of ED pediatric visits, of which nearly 20% are admitted. ED visits in children are often related to substance use, anxiety and attention deficit disorders, disruptive behavior, and psychosis.³

Because there are about 4000 general hospital EDs in the United States but <200 psychiatric EDs, the vast majority of acute behavioral problems are assessed and treated in general hospital EDs.^4,5 Patients with behavioral health problems often provide vague and nonspecific symptoms, and obtaining collateral information as part of the assessment is difficult and time-consuming.

ED disposition decisions can be especially challenging for homeless patients and for those with repeated ED visits. Given the complexities of assessment, diagnosis, and disposition, it is important to maintain a positive and nonjudgmental attitude toward patients with mental health disorders.

A decision strategy for emergency assessment of patients with mental health disorders should follow the sequence of actions in Table 286-1.

This chapter presents an overview of the care of adult patients with mental health disorders from ED entry to departure—triage, patient and staff safety, medical and psychiatric evaluation, admission and disposition decisions, and the care of patients with prolonged ED stays. Diagnostic criteria of the psychiatric disorders are summarized. Behavioral and psychiatric disorders in children are discussed in chapter 147, “Behavioral Disorders in Children.”

Paramedics or police often provide advance notice to the ED, especially of the severely agitated patient, so preparations can be made for patient arrival. The best preparation includes assembly of an ED “psychiatric code” team, designation of an appropriate room, and having medications on hand. Team members may consist of an ED physician and nurse, hospital nurse manager, psychiatric clinical nurse, and security staff who can respond to threats of harm to others, patients with altered mental status, and patients trying to leave against medical advice.⁶

In most Western countries, psychiatric patients are triaged in the same manner as medical patients using the Emergency Severity Index, Canadian Triage Acuity Scale, Manchester Triage System, or Australasian Triage Scale/National Triage Scale. These triage tools were originally designed for medical patients. For psychiatric patients, behavior descriptors determine acuity. The most acute behaviors are actively dangerous (e.g., violent, possession of a weapon), with decreasing acuity as the likelihood of dangerousness to self or others declines.

THE PRECAUTIONARY PRINCIPLE

Agitated or distressed patients, those expressing suicidal or homicidal ideation, or patients who raise concern about harm to self or others should not be allowed to leave the ED before medical or psychiatric evaluation is completed, even if departure is formalized as “against medical advice.”⁷ Many institutions have a formal process to make sure staff are aware that the patient cannot leave. Processes include the writing of an order (e.g., “sitter with patient,” “precautionary hold,” “suicide precautions”), but while the process varies by institution, the goal is to ensure patient and staff safety during the time-consuming process of evaluation. The foundation of such action is called the “Precautionary Principle,” which is the need to prevent or minimize harm before it occurs.⁸

Fragmented mental health care and mass deinstitutionalization of the severely mentally ill have ensured that many psychotic, violent, and chronically mentally unwell patients now visit the ED on a regular basis. Mental health emergencies include situations in which patients are highly distressed, suicidal, and/or homicidal. Patients with suicidal or homicidal ideation, suicide or violence plans, or suicide or homicide attempts require measures to minimize the possibility of harm to themselves or others. Mental health disorders coexisting with substance abuse are also a recipe for violence.⁹ In one study of psychiatric patients in a veteran’s hospital, about one third of patients who committed violence during hospitalization did so in the ED. Violent incidents have been associated with dementia, court-ordered admission, and mood disorder.¹⁰ Violent and aggressive behavior frequently demands immediate chemical or physical restraint to protect the patient, other patients, staff, and visitors.¹¹

Although hospital security forces and police are often available to subdue violent patients and reduce risks of staff or patient injury, ED staff must be educated and equipped with a range of skills to protect themselves. These skills include enhanced awareness of risk factors and warning signs of violent behavior, verbal de-escalation techniques, quick access to rapidly tranquilizing or neuroleptic medications, and emergency strategies for getting help quickly in explosive circumstances.

Approach patients with potentially dangerous behavior cautiously and with a nonthreatening attitude, with adequate security nearby. If necessary, isolate and restrain threatening patients before they are disrobed, gowned, and searched for weapons. Medical and nursing staff should stay distant from the patient; avoid excessive eye contact; maintain a calm, controlled posture and tone of voice; and stand in a location that neither threatens the patient nor blocks the exit of the healthcare worker from the room.

A number of techniques can help de-escalate aggressive patient behaviors. Allow patients to verbally ventilate feelings. Provide an environment that decreases stimulation. Place the patient alone in a room designed for patient safety, but with close monitoring by staff. Offer food or drink. Set limits on accepTable behavior and respond with neutral comments. Adequate force nearby should be visible to the patient, and tell the patient that uncontrolled behavior will result in restraint.

EXAMINATION ROOMS AND SECLUSION

Waiting rooms and examination rooms need to be designed to ensure safety. Steps that promote safety include security staff, metal detectors, rooms with doors that permit rapid and easy exit, panic buttons, and the removal of any objects that could be used in violent attacks or suicide attempts (including neckties of both staff and patient, large earrings, patient belts or belt buckles, shoes, shoelaces, stethoscopes, blood pressure cuffs, and cutting instruments).

Seclusion rooms may be used to protect patients and staff. Remove or carefully secure any objects that could be used for self-injury or against staff. Austere seclusion rooms may be useful for some agitated patients by providing relief from external stimuli. Search patients before entry, and remove potentially dangerous objects, clothing, or weapons. Make sure staff are aware of the location of exits and of panic buttons. Initially, leave the door open, but if the patient remains agitated, lock the door. Keep the patient advised of each action and the expected duration, and explain the consequences of violent behavior. Monitor the patient in a seclusion room with a personal guard or nurse-monitor, by closed–circuit television, or by individual checks about every 10 minutes. Give the patient opportunities to comply with staff demands for accepTable behavior that can lead to release from seclusion. If violent behavior persists, physical restraint is justified. Document all steps in the use of seclusion and medical and physical restraints.

CHEMICAL RESTRAINT

Pharmacologic/chemical restraint of violent or agitated patients is discussed in detail in chapter 287, “Acute Agitation.” The Sedation Assessment Tool score (SATS) is one method of grading behavior and assessing medication options.¹² Treatment options can be selected based on behavior (Table 286-2).

Ketamine has been used for acute agitation or depression, but concerns about hypoxia or oversedation, and lack of large clinical ED studies, limit its use in the ED at the present time.^13,14,15

PHYSICAL RESTRAINTS

In many cases, there is no substitute for the application of physical limb restraints. Restraints should be applied rapidly and safely by individuals trained and skilled in their use. A team of five staff members is recommended: one team leader and one person for each limb. Sometimes, the show of force and the presence of many staff may in itself be sufficient to subdue the patient without recourse to restraints. The team leader oversees and orchestrates the procedure. The patient and any family members present should be provided with clear, ongoing explanations of all procedures. Place the patient on a bed or stretcher, and secure all four limbs with leather restraints. Be careful to avoid injury. Elevate the patient’s head, if possible, to minimize risk of aspiration. Once the patient is restrained, offer medications, and if refused, administer medications involuntarily.¹¹

Hospital policies dictate the frequency and type of observation (e.g., vital signs, pulses, range of motion, skin integrity, toileting) with written orders that limit the time in restraint and require renewal as needed. Once the patient is calm and compliant, restraints can be removed one at a time, while staff carefully monitor the patient to ensure the safety of all concerned.

The initial steps include simultaneous medical and psychiatric evaluation while maintaining patient and staff safety.¹⁶ Obtain vital signs including pulse oximetry, and perform point-of-care blood glucose determination. Simultaneously assess the patient’s potential for dangerous behavior, such as harming self or others or leaving the ED without medical advice; stabilize the behavior; and evaluate the chief complaint. Then, obtain a focused history; perform physical examination and mental status/-neurologic testing to identify comorbid or primary medical issues; and assess the need for hospitalization. Formulating a specific diagnosis is not as important as determining whether the patient is harmful to self or others or is unable to take care of self and needs hospitalization. Determining that an individual is suicidal and in need of protection and hospitalization, for instance, is more important than deciding whether that person has schizophrenia or psychotic depression.

The medical evaluation of patients with apparent psychiatric symptoms should be the same as for those with medical conditions¹⁷ (Table 286-3). The findings of the history and physical examination should guide laboratory testing and diagnostic inquiry. The combined findings from history, physical examination, laboratory testing, and diagnostic inquiry form the basis of the medical description of the patient.

The evaluation of the patient with psychiatric symptoms in the ED is commonly termed “medical clearance.” This term is a misnomer because many patients have medical problems and the term does not really mean that the patient’s medical problems have been “cleared.” Rather, this process identifies medical problems and their relationship to the patient’s presentation. One alternative to the term “medically clear” is a discharge note that includes key features of the history, physical examination, and mental status and neurologic examination; laboratory results; discharge instructions; and follow-up plans.¹⁸ Alternatively, the term “medically stable” could be used if a specific term is required.

The medical evaluation is used to determine whether the patient has a medical condition that causes or exacerbates the psychiatric illness. The medical evaluation process is also used to identify medical illnesses or injuries that are coincident to the psychiatric illness and that need to be identified and treated prior to a psychiatric admission. The determination of a medical versus psychiatric cause for psychiatric illness or behavioral change is difficult because many psychiatric patients have medical comorbidities and some with medical illness have undiagnosed psychiatric disorders. The most frequent medical comorbidities include diabetes, cardiovascular disease, and pulmonary disease.¹⁷ If the patient with medical comorbidities needs hospitalization, be sure the psychiatric facility can provide care for concurrent medical illnesses.

MEDICAL AND BEHAVIORAL HISTORY

Medical comorbidities may produce changes in behavior. Ask specifically about fever, head trauma, immunocompetence (including malignancies and risk factors for human immunodeficiency virus infection), diabetes, pulmonary diseases, and toxic ingestions or overdose.

Obtain information about recent changes in behavior from the patient, as well as from caregivers and family members. Obtain the history of previous psychiatric illness and treatment to identify patterns of relapse. Family and social history may identify stressors in the patient’s environment that are a direct cause of changes in behavior or that accentuate any responses to underlying disease. Whenever possible, corroborate all history provided by the patient, with information from family members, care providers, or law enforcement. Compare direct observations of the patient’s behavior with reports from the patient’s family and caregivers. This is especially important for institutionalized or group home patients whose baseline mental capacity is often unclear to ED staff.

MEDICATION/DRUG HISTORY

Mental health disorders and substance abuse disorders frequently coexist.¹⁹ The syndromes associated with alcohol and substance abuse that can result in altered behavior include intoxication, withdrawal, delirium, hallucinosis, paranoid behavior, and dementia. Identify any initiation of substance abuse, changes in the patterns of abuse, and medication compliance.

Behavioral changes may be due to prescription or over-the-counter drugs, especially sedatives-hypnotics, stimulants, psychotropic agents, anticonvulsants, anticholinergic agents, angiotensin-converting enzyme inhibitors, β-blockers, corticosteroids, fluoroquinolone antibiotics, histamine-2 receptor blockers, opioids, salicylates, selective serotonin reuptake inhibitors, thiazide diuretics, and antiparkinsonian agents.²⁰ The increasing use of serotonergic agents makes it important to check drug interactions (e.g., linezolid, tramadol) to identify serotonin syndrome as a cause of behavioral change.²¹ Over-the-counter analgesics or herbals and alternative medications containing salicylates, anticholinergics, antihistamines, or bromides may produce delirium or toxic psychosis.²⁰ Alcohol and street drugs, such as phencyclidine, lysergic acid diethylamide, mescaline, amphetamines, and cocaine, can produce a toxic psychosis. Hypnosedatives, such as barbiturates and benzodiazepines, may produce a confusional state or delirium in both intoxication and withdrawal. Ask about alcohol and substance use in psychiatric presentations, even when the odor of ethanol or evidence of substance use is absent.

Psychoactive drugs are associated with a variety of hematologic and metabolic abnormalities. Clozapine, olanzapine, phenothiazines, and carbamazepine can cause neutropenia/agranulocytosis.²² Hyponatremia (sodium level <136 mmol/L) can occur with typical and atypical antipsychotics.²³ Hepatotoxicity, manifested as transaminitis, obstruction, or hepatic failure, has been reported with norepinephrine-selective reuptake inhibitors more than with selective serotonin reuptake inhibitors, and also with tricyclics/tetracyclics, monoamine oxidase inhibitors, and typical and atypical antipsychotics.²⁴ Of the herbal medications, kava-kava can cause serious hepatotoxicity, while St. John’s wort has been indirectly associated with hepatotoxicity due to its effects on the P450 system of other medications.²⁵

PHYSICAL EXAMINATION

Perform a physical examination on every patient.^25,26,27 Measure vital signs, including temperature, and oxygen saturation by pulse oximetry. Investigate abnormal vital sign values, and do not dismiss them as due to anxiety or stress. Fever is especially important, because both local and systemic infections can cause altered mental status, as can meningitis, encephalitis, and brain abscess. Neuroleptic malignant syndrome and serotonin syndrome are causes of psychoactive drug-related fever.²⁸

Patients with abnormal vital sign values, abnormal mental status examination results, psychosis, mental retardation, or advanced age usually require a complete head-to-toe physical examination, with street clothing removed and dressed in a hospital gown. Look for signs of trauma to the head, face, and neck, and reconstruct any mechanisms of injury. In the homeless, or in those with exposure, assess for hypothermia and check the extremities for frostbite. Examine for skin rash, extremity trauma, and needle tracks. Neurologic examination typically includes an assessment of most cranial nerves, gait, mental status, and general motor function and strength. For more focused neurologic examinations, test for apraxias, agnosias, right-left disorientation, aphasias, visual field cuts, and inability to follow complex spoken and written commands. Such signs may or may not occur in association with other localizing neurologic signs, such as asymmetric reflexes, paralysis, or hemiparesis.

Table 286-4 lists signs and symptoms associated with medical causes of behavioral abnormalities. Sudden onset of major changes in behavior, mood, or thought in a previously normal patient, or definite deterioration in a patient with a chronic behavioral disorder should stimulate evaluation for an underlying medical or neurologic disorder. A sudden change in behavior, especially in a patient >45 years old, is an important indicator of a possible medical disease process. Evaluate neurologic symptoms such as fainting, dizziness, disorientation, impairment of speech, confusion, loss of consciousness, headaches, difficulty performing routine tasks, new cognitive deficits, and focal weakness.

MENTAL STATUS EXAMINATION

The mental status examination is conducted to understand the patient’s mental state and, when combined with the history and physical examination, aids the formulation of a diagnosis and disposition. A mental status examination can help identify delirium, medical disorders, and psychiatric disorders; identify patients who are dangerous to themselves or others; and help assess patient disposition (Tables 286-5 and 286-6). A great deal of the information obtained in mental status examinations becomes evident through observing the patient’s appearance, behavior, language, comprehension, and affect during the initial patient interview. However, cognitive assessment and determination of suicidal or homicidal ideation or hallucinations and delusions generally require additional questioning.

Important components of the mental status examination include ability to provide historical information, attention, speech patterns, language comprehension, affect and mood, hallucinations and delusions, level of cognitive functioning, degree of insight and capacity for introspection, and ability to establish a therapeutic relationship. Abnormal findings in any of the above components may suggest a medical basis for abnormal thought or behavior. Liability of affect, the need for simple questions to be repeated, irritability, disorientation, and lack of cooperation are some additional signs of medical dysfunction.

During the examination, the patient’s affect or outward display of emotion should be evaluated for sadness, euphoria, and anxiety, and whether such emotions are appropriate to the current situation. This may help distinguish between cognitive disturbance induced by depressive disorders and dementia due to cerebral pathology. An examiner can draw some conclusions regarding a patient’s thought processes during the patient’s telling of his or her personal history. Disordered thought processes include paranoid or grandiose delusions, fixed false beliefs, and delusional denial of illness. Such beliefs should be compared with reports from family and friends. Visual hallucinations can occur in psychiatric illnesses (schizophrenia or affective disorder) but most often result from medical disease; assume medical pathology until proven otherwise. Judgment can be gained by asking the patient to describe how he or she would deal with day-to-day problems, such as finding the way home from the hospital. Judgment may be impaired in medical disease, so ask about historical evidence of faulty judgment.

COGNITIVE ASSESSMENT

Assess cognitive impairment to identify the presence of dementia or delirium. Cognitive impairment often is not detected in ED patients, despite estimates suggesting that from 26% to 40% of older ED patients are cognitively impaired.²⁹ There are many tests of cognitive function, from simple to complex, but few have been investigated in the ED.

The Quick Confusion Scale consists of seven items and takes about 3 minutes to administer (Table 286-7; see also Table 168-3). A cut-off of ≤11 points has a sensitivity of 64% and specificity of 85% for identifying cognitive impairment.³⁰

Another self-administered screening test for cognitive function is the clock test. Give the patient a piece of paper with a circle drawn on it, and ask the patient to “place the numbers on it to make it look like a clock.” After completing this task, then ask the patient to place the hands of the clock to read a time such as “10 past 11.” Although there are various methods for scoring the clock drawing test, the easiest for ED use is the simplest: correct or not correct. Using a more complex 10-point scoring system, the sensitivity for dementia detection was reported as 76% and specificity was 81%. Clock test results do not appear to be affected by depression.³¹

The Mini-Mental State Examination is a widely used tool for assessing cognitive impairment and to follow changes in cognition over time³² but is not practical for general ED use.

LABORATORY EVALUATION

Obtain laboratory testing based on abnormalities in the history and the physical examination. There is no unanimity between specialties about the need for extensive laboratory testing for all ED psychiatric patients.^33,34 The psychiatric literature reports that 46% to 80% of psychiatric patients have undiagnosed medical illness,^35,36 whereas the emergency medicine literature supports a selective approach to laboratory testing in the ED.^37,38 Often, routine testing is a requirement of the psychiatric consultant or is part of the admission process of the psychiatric hospital.^39,40 The best approach is to collaboratively establish standards for testing on a local level.

For adults with new psychiatric complaints, obtain a through laboratory evaluation including a CBC, electrolytes, liver and renal function studies, urinalysis, and possibly chest radiograph, neuroimaging, or drug and alcohol testing depending on the patient and the circumstances.

Many institutions require drug and alcohol testing for all patients with psychiatric complaints whether the patient admits to substance abuse or not. However, specific drug and alcohol testing is not clinically necessary if the patient admits to using alcohol and drugs when asked and is awake and cooperative.⁴¹ Urine drug testing and blood alcohol concentrations do not correlate with the degree of intoxication. The patient’s cognitive abilities, rather than a specific blood alcohol level, should be the basis for assessment. On the other hand, patients with altered mental status without known cause need a complete evaluation including alcohol and drug testing.

One guide for the discretionary use of testing is provided in Table 286-8.^41,42 Documenting items in Table 286-8 can also be used as a communication tool to psychiatrists about the ED evaluation process.