Emergency Psychiatry: Identifying the Need for Immediate Mental Health Services

At 2 a.m., a family came to the emergency room with their 34 year old son. Their son hadn’t slept in four days. At that point, he would talk very quickly about all of the things he wanted to accomplish; he had made grandiose plans. Additionally, he had spent money impulsively from his bank account and could not provide an explanation for why he did so. His mother apologized repeatedly saying “We’re sorry we are unsure if this qualifies as an emergency. We didn’t want to panic.”

That wasn’t panicking. That was arriving at the exact time needed for him.

This is probably the most frequent thing we hear in emergency psychiatry: families hesitate before seeking help in an emergency situation because they aren’t certain whether what they witnessed constitutes a mental health crisis. While there’s certainly some basis for hesitancy — after all, mental health crises may not resemble medical or physical emergencies — the potential consequences of delaying treatment can be equivalent and often greater than those seen with medical/physical emergencies.

This article has been prepared for use by patients, families and caregivers interested in learning about emergency psychiatry, including how to identify your need for immediate services and what to expect when you arrive at the hospital.

What is emergency psychiatry? 
Why are psychiatric emergencies often misperceived?

Psychiatrists define emergency psychiatry as the discipline for providing treatment to patients experiencing severe acute psychiatric emergencies. An individual’s mental condition may present an immediate threat to either themselves (or) someone else; or the nature of their acute psychological distress requires an urgent assessment and/or treatment intervention.

As clearly defined, emergency psychiatric assessments are among the least understood medical assessments. A number of misconceptions contribute to this misunderstanding.

1. "They're just stressed out -- they'll be okay."
Severe acute psychiatric symptomatology are not indicative of an individual's lack of will power, or an indication that these symptoms represent a phase or aspect of their personality. These are medical occurrences requiring medical attention.

2. "If I go to a psychiatric emergency room, they’ll lock me up."
This misconception causes many individuals from seeking assistance when needed. As previously noted, a psychiatric emergency evaluation represents a structured and compassionate clinical experience; it is not punitive.

3. "We should take care of this at home by ourselves."
While the support provided by families is one of the greatest assets for all forms of treatment; there are times when a crisis exceeds the capacity of a family to provide safe management without professional assistance. Identifying such boundaries represents acts of love rather than failures.

Common psychiatric emergencies: Understanding the situation for swift action

Knowing the criteria for determining a psychiatric emergency will allow you to take action quickly, rather than wondering what you should have done. Below are some examples of common ways we see families presenting to our hospitals.

Suicidal thoughts/behaviors

You must take serious any thought about suicide, whether expressed directly ("I am going to kill myself") or indirectly ("better off without me"). Any evidence of recently inflicted harm on one's body, regardless of how minimal it may seem, must be assessed as potentially indicative of suicidal ideation.
The literature clearly supports the notion that the time immediately after a person has made a suicide attempt is considered to be "high-risk" for another attempt. Thus, early response during this critical time frame will save lives!

Acute psychotic episode

An acute psychotic episode is characterized by a loss of contact with reality — such as hearing voices other people cannot hear, seeing objects/things that do not exist, believing in fixed false ideas/delusions, having disorganized and/or grossly illogical thoughts and/or behaviors. Acute psychosis can develop in several mental illnesses including schizophrenia, bipolar illness, major depressive illness, or secondary to the effects of a medication/toxins.

Psychotic episodes can be frightening for both those experiencing them and their family. Those who are experiencing a psychotic episode are frequently frightened by what they are perceiving and the rest of us are usually unclear as to how to react so that we do not make the situation worse. As stated earlier, prompt treatment results in improved outcome while delayed treatment can contribute to prolonged and arduous recovery processes.

Manic episode

A manic episode is characterized by excessive feelings of elation/exhilaration and decreased need for sleep. A manic episode can progress from feeling very good/better than normal/invincible and behaving recklessly/aggressively/paranoid/psychotically. Manic Episodes can also lead to financial disaster, impulsive/reckless decision-making, damaged interpersonal relationships, etc. 

Because individuals who experience mania frequently report feeling better than usual, it can sometimes be difficult for families to recognize the onset of mania until unsafe behavior occurs which can indicate that the individual's manic episode is now severe.

Major depressive illness with inability to care for oneself

There are several forms of depression which require hospitalization — e.g., inability to eat or move out of bed, inability to perform essential daily activities (e.g., bathing); co-existing symptoms of psychosis; or a degree of hopelessness where the risk of harming oneself is present.

Drug/alcohol intoxication/substance withdrawal syndrome/induced psychosis

All three of these crises require an immediate medical and psychiatric evaluation. They are complex cases since both the substance(s) being used and the underlying mental health issue usually need simultaneous assessment/treatment.

Danger to others/self

When an individual places themselves at danger to themselves or others, due to their psychiatric condition, then they is considered to be in a psychiatric emergency. Examples include: when a person experiences psychosis; severe mania; certain personality disorders in extreme distress; or an organic brain syndrome.

Warning Signs Families Should Not Ignore 

If you’re taking care of somebody with an established psychiatric disorder – or if you think you might be able to help some one that needs it, then look out for these warning signs that indicate you should get the family member evaluated as soon as possible. Don’t wait to see if things will resolve on their own. 

• Talking about dying, committing suicide, or disappearing. Even casual talk (or passing mentions) can be a warning sign. 
• Giving away valued belongings, for no apparent reason. 
• Sudden extreme behavioral changes (suddenly becoming withdrawn, agitated, aggressive, etc.) in a relatively short time span. 
• Not sleeping for many consecutive days while feeling extremely high/ elated or having excessive racing thoughts. 
• Refusal to eat, drink, or take necessary medications for a prolonged amount of time. 
• Becoming disoriented from reality. This includes talking to people that aren’t present and stating things that are clearly untrue but they believe them with all their heart. 
• Threatening/acting aggressively towards yourself or other people. 
• A sudden calm after a period of great emotional turmoil. This is often indicative of someone making the decision to do self-harm.

When in doubt – go see a professional. It’s always better to have a clinician tell you that your crisis isn’t as bad as you thought than to have waited too long.

What to expect during an emergency psychiatry evaluation?

Most families hesitate to bring a family member for a psychiatric emergency evaluation due to uncertainty. Here is what happens during a typical psychiatric emergency evaluation.

Initial Assessment and Triage. Upon arriving, the clinical team will evaluate the acuity of the situation and make sure the individual is physically safe. They check vital signs and collect a brief synopsis of the presenting issue - usually from both the individual and the accompanying family member.

• Psychiatric Interview. The psychiatrist will conduct a psychiatric interview with the individual to determine symptoms, mental status, past experiences and current stresses. This is a clinical conversation and not an interrogation. The purpose of this interview is to understand and not to judge.

• Risk Assessment. The psychiatrist will assess the potential risks to both the individual and other individuals. This assessment will help determine what type of treatment and care is required.

• Medical Evaluation. Many times, there are medical reasons for psychiatric symptoms (medication side effects, thyroid disorders, etc.) so a general medical examination may accompany the psychiatric evaluation.

• Treatment Planning. Once all assessments are completed, the team will create a treatment plan. Depending on the results of the evaluations, the recommended course of action could include adjusting medications, recommending a short stay in an in-patient psychiatric facility or recommending outpatient follow-up appointments.

At Adayu, we strive to maintain dignity and compassion throughout the entire evaluation process. All patients/families are treated like equal partners in their care - informed, respected and supported throughout each phase of their care.

Out-Patient Treatment vs. Admitting Family Members to In-Patient Psychiatric Facilities

Frequently asked questions by family members are: "Is our loved one really going to have to admit?" Out-Patient care is indicated if your family member is currently stable and does not pose a threat to him/herself or others; they can attend scheduled therapy/medication management sessions; and have adequate support in their living environment.

Admission to an in-patient psychiatric hospital becomes necessary when:

-Your family member poses an immediate threat to themselves or others;
- Their symptoms are extreme and cause them to lose ability to function normally;
- New or changed medication needs constant supervision;
- Their home environment cannot meet their needs while experiencing these extreme symptoms;
- A full diagnostic evaluation is required in order to obtain a complete diagnosis; and/or
- A more controlled environment such as an in-patient hospital provides better support for a successful recovery.

An in-patient hospital admission is not a sign of failure, but rather indicates additional support through hospitalization. Much like you would want to take a family member who has developed pneumonia into the hospital for treatment, even if they were able to manage at home before developing pneumonia, hospital admission is sometimes required for an individual experiencing a severe psychiatric episode to stabilize and provide them with the highest level of medical support available.

The Approach to Psychiatric Emergency at Adayu 

Adayu has created its in-patient psychiatric hospital based on an assumption which seems obvious but is rarely followed: all individuals suffering from a mental health issue should receive the same quality of compassionate, clinically-excellent and respectful treatment as anyone else experiencing any type of medical emergency. 

Our psychiatric emergency service team includes experienced psychiatrists, psychiatric nurses, and psychologists working together to treat each individual  with both kindness and clinical expertise.

It can be difficult to reach out. Families may have immense feelings of guilt, uncertainty and exhaustion when they finally do seek help. We see you; we will provide support to the entire family-not only the patient.

The Adayu model focuses on:

• Rapid Assessment - Time is critical during a psychiatric emergency.
• Family Communication - Open communication through the duration of the process.
• Each Patient receives a Customized Care Plan - This plan takes into account the individual's complete picture, including: past experiences, relationships, culture, etc. as well as their future aspirations.
• Bridge to Ongoing Treatment - Stabilization is merely the initial step in the recovery process.

If you are uncertain if your situation requires an immediate response/evaluation, please contact us. Talking with a professional does not obligate you to admit your loved one to an in-patient program- this conversation allows you to make the most informed decision for your loved one.

Recovery from psychiatric emergencies is always possible - and often only one Decision away

Psychiatric emergencies can be treated. People can recover from psychosis, suicidal crises, severe manic states, and debilitating depressive states. Although recovery may not always be straightforward or quick, it occurs daily - for individuals receiving timely, adequate medical care.

When families react swiftly - when they overcome their fears and uncertainties and bring their family members into the medical system for assistance - they are offering their loved ones the greatest opportunity for recovery.

If you are reading this article and feel as though something is amiss, heed that feeling. You do not need to be positive of anything; you do not need to wait until things become even worse. Seek the advice of a healthcare professional today.

We are here at Adayu. Our team is ready to assist you, evaluate your situation and provide insight regarding which level of care would be the most beneficial. Nobody should ever experience a psychiatric emergency without having access to quality and experienced professionals.

Frequently asked questions regarding emergency psychiatry

1. How will I know whether a mental health issue is a 'true' emergency?

An individual experiencing suicidal thoughts, hallucinations/delusions indicative of psychosis, behavior posing a danger to themselves or others or failure to engage in basic functions such as eating, sleeping or communicating, indicates a psychiatric emergency. Should you remain uncertain, contact a mental health professional or visit the nearest psychiatric emergency unit. It is always safer to err on the side of caution and seek aid rather than delaying treatment.

2. What is the distinction between a psychiatric emergency and a mental health crisis?

While these two terms are frequently utilized synonymously, a psychiatric emergency represents a specific event necessitating immediate clinical involvement -- generally indicating an impending risk to safety. A mental health crisis is significantly broader and includes acute emotional distress that could potentially be managed within either a community or outpatient environment. Consultation by a qualified professional will assist in determining the optimal level of care.

3. Will my family member be required to be held against their will if I admit them?

Involuntary commitment is a legally binding and clinically based decision made under extraordinary circumstances -- primarily where an individual poses an imminent threat and/or is incapable of providing informed consent to accept treatment. Typically, evaluations begin in a voluntary manner, and the multidisciplinary team collaborates with both the patient and their family to utilize the least restrictive form of care necessary to protect all parties involved.

4. What should I do if someone is currently threatening to commit suicide?

Do not leave the individual unattended. Remove any potential tools of self-harm (medication, etc.) if doing so will not pose additional risk. Immediately call emergency services or transport the individual to the closest psychiatric emergency department. Remain calm and attempt to maintain communication with the individual. Your presence is paramount; you do not require possessing the correct words to effectively communicate with someone experiencing extreme desperation.

5. Does inpatient psychiatric hospitalization indicate that a person has been diagnosed with a chronic and incurable disease?

Absolutely not! Individuals are admitted into inpatient psychiatric facilities for the purpose of treating acute episodes of their disorder(s). Such admissions may represent singular events in the course of their life or components of a treatable condition. Admissions to an inpatient psychiatric unit in no way defines the remainder of an individual's future. Many individuals undergo a single hospitalization for a mental health-related episode during their lifetimes, receive sufficient treatment, and continue to lead productive, healthy lives. Appropriate early interventions correlate positively with improved long-term outcomes.