Definition

A psychiatric emergency is an acute psychiatric disorder of thought, behavior, mood, or social relationships that requires immediate treatment. Acute means the complaint has just occurred or appeared suddenly. This emergency must be treated immediately to save the patient and other people from the danger that may arise due to the disorder.

Patients presenting with a psychiatric emergency typically have mania, acute psychosis, suicidal ideation, or homicidal ideation. Psychosis is when someone experiences a disturbed relationship with reality so that they cannot differentiate between what is real and what is not real.

Causes

The causes of this extreme behavioral disorder vary, such as substance use, medical conditions, mood disorders, or intense anxiety and trauma. Almost all patients with suicidal thoughts also have a previous psychiatric illness, such as major depression, substance abuse, or schizophrenia.

Approximately 50% of patients with psychiatric emergencies also have medical illnesses. Thus, medical screening is essential to assess physical conditions that may contribute to psychiatric emergencies. Screening examinations are carried out to determine if someone is at risk of developing certain diseases.

Some causes of acute psychosis and mania are delirium, infection, metabolic disorders, drugs, drug abuse/withdrawal, and brain or central nervous system disorders.

Risk Factor

For people with mental disorders, suicidal thoughts are an emergency condition that must be treated immediately. Factors that can increase the risk of suicide include:

• Male gender
• Age over 60 years
• Widowed or divorced
• White race
• Living alone
• Unemployed or having financial problems
• Victim of bullying
• History of traumatic events
• Long-term medical illness
• Psychiatric disorders such as depression, schizophrenia, panic attacks, severe anxiety disorders
• Substance abuse
• Feelings of hopelessness
• Severe anhedonia or disinterest in having fun
• Ease of access to suicide equipment
• Presence of suicidal ideation or history of attempts

Symptoms

Patients with acute psychosis and mania exhibit eccentric and excessive behavior, unusual, or disorganized thinking, paranoia, and inappropriate or dangerous behavior. Other emergency symptoms that require immediate treatment are thoughts or attempts at suicide, killing, hurting, or destroying.

Warning signs that someone may attempt suicide include:

• Frequently talks or writes about death, dying, or suicide
• Making comments about being hopeless, helpless, or worthless
• The expression of having no reason to live, no purpose in life, saying things like "it would be better if I weren't here"
• Increased alcohol and/or drug abuse
• Withdrawal from friends, family, and community
• Behaving recklessly or riskily, as if without thinking
• Dramatic mood swings
• Feeling like a burden to others

Meanwhile, signs of an emotional crisis that can develop into a psychiatric emergency include:

• Neglecting hygiene, for example not bathing
• Changes in sleeping habits, not sleeping enough or sleeping too much
• Significant weight gain or loss
• Decreased performance at work or school
• Extreme changes in mood, such as feeling more irritable, angry, anxious, or sad
• Withdrawing from activities, work, or relationships
• Other worrying symptoms include paranoia or hallucinations

Diagnosis

In psychiatric emergencies such as symptoms of acute psychosis and mania, or attempted suicide, the doctor will treat the existing emergency first and secure the situation. After the atmosphere is safe and conducive, interviews and examinations will be carried out on the patient and their family or those closest to the patient.

Usually the doctor will ask about what happened during the incident, assess the patient's mental status, daily activities, and medical history, including mental health, consumption of certain medications, and if there is a history of substance use. The interview is also accompanied by a physical examination of the patient's body.

In cases where patients have suicidal ideas, once the situation is safe and under control, the doctor will look for factors that increase or decrease the risk of suicide. Usually you will also be asked if the patient has ever attempted suicide or had suicidal ideas before. It is important to obtain detailed information about the patient so that it is easy to build a good relationship with the patient.

The assessment of patients with homicidal ideation is similar to that of suicidal patients. The risk factors for this disorder are not yet known. Risk factors that should be assessed by a doctor are a history of violence and access to weapons. When assessing these patients, there must be an exit route that can be accessed quickly and cannot be blocked by the patient in case the patient behaves dangerously in the middle of the examination.

The temporary diagnosis obtained from the examination results above will guide further examination and treatment. The doctor will also consider certain investigations to rule out general medical causes or substance use, such as:

• Urine drug test
• Blood alcohol level test
• A lumbar puncture or brain fluid examination is carried out if there is a suspicion of inflammation of the lining of the brain and bone marrow (meningitis) or inflammation of the brain (encephalitis).
• CT scans or other imaging do not add much information if there are no abnormal findings on examination, except in elderly patients

Management

Acute psychosis, mania, agitation, or homicidal ideation

The main goal of treatments is to stabilize and ensure the safety of the patient and the surrounding environment. The initial approach for patients experiencing acute agitation or restlessness is to help manage their stress, such as through behavioral therapy, medication, or both.

When a patient has a comorbid medical illness that contributed to his or her psychiatric emergency, it is important to treat the medical illness. In some cases, medical illness is the cause of a psychiatric emergency and therefore must be differentiated from a genuine psychiatric disorder.

When examining a patient with acute agitation, the clinician should help the patient feel safe by creating a non-threatening environment and speaking in a calm, low tone. This will help patients control their emotions and want to be involved in treatment. You also need to prepare a backup doctor or examiner.

If rapid treatment or sedation therapy is required, it must be given by injection. If the patient has comorbid medical conditions, medication adjustments must be made to prevent complications.

Suicidal ideation

Treatment of patients with suicidal ideation aims to reduce risk and strengthen protective factors. These factors and risks include patient safety, psychological or social stress, social support, and treatable psychiatric disorders.

When treating patients with suicidal ideation, doctors must build good relationships and include the patient and family in treatment. Doctors need to determine a safe place as a treatment location. Before occupying the treatment area, the patient must be freed from objects that could be dangerous.

In depression, psychotherapy and cognitive behavioral therapy can help. Additionally, cognitive behavioral therapy can reduce hopelessness and suicide attempts in outpatients. For patients with borderline personality disorder and suicidal ideation, psychodynamic therapy and dialectical behavioral therapy may be useful.

ECT (Electroconvulsive Therapy) or electric shock therapy has been proven to be beneficial in patients with suicidal ideation, and is even safe for pregnant women. However, such therapy is not sufficient for long-term maintenance of the patient's condition and must be combined with medication.

Complications

The complication of a psychiatric emergency is that it can endanger yourself and the environment around you. Physical injury can result, or even loss of life to yourself or others. Other complications include side effects of drugs such as benzodiazepine drugs which can cause respiratory depression, and antipsychotic drugs can cause nervous disorders.

People who are agitated or violent often come to health facilities tied up by the police. Sometimes, patients can die in restraints before or soon after arriving at the hospital. The cause is thought to be a combination of metabolic disorders and increased body temperature during a tantrum, drug use, aspiration of stomach contents into the respiratory tract, embolism due to restraint for a long time, and sometimes due to serious underlying medical disorders.

Death is more likely to occur if people are restrained with their wrists tied to their ankles behind their back. This type of restraint can cause asphyxia (a condition of lack of oxygen) and this condition should be avoided.

Prevention

It is important to know the warning signs of a suicide attempt in order to prevent and help patients. Prevention that can be done includes:

• Ask the person you are worried about if they are thinking about suicide. Even though other people are hesitant to ask this, research shows that this action is useful
• Keep them safe. Reduce patient access to suicide tools, such as weapons, sharp objects, matches, or insecticides
• Accompany and listen to what they need
• Help them get ongoing support
• Stay connected with them to monitor their progress

When to See a Doctor?

If you or someone you know has any of the psychiatric emergency symptoms above, immediately notify the people closest to you to get help. Ask to be taken to the emergency room if symptoms cannot be controlled. Immediate treatment can prevent complications that are detrimental to yourself or others.

Looking for more information about other diseases? Click here!