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INTRODUCTION

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Psychiatric emergencies are acute changes in thought processes and behaviors potentially impairing a patient’s ability to function in his or her environment. Patients are in a state of crisis in which their baseline coping mechanisms have been overwhelmed by real or perceived circumstances. The most common place for them to be seen is in the emergency department (ED) where providers need to address potential medical issues creating psychiatric manifestations or control the aggression for safe placement. The issue of psychiatric patients boarding in the ED has become an increasing issue within the majority of departments across the nation. Therefore, we have begun to see the importance of the emergency medicine providers understanding psychiatric emergencies, especially suicidal ideation, psychosis, and agitation with the intention to begin treatment just as one would with chest pain, respiratory distress, or abdominal pain. Not all patients with mental illness need to be seen by a mental health provider, just as not all chest pain patients need to be seen by a cardiologist. With limited availability of mental health services, this has become an essential part of emergency medicine. This chapter is designed to help the ED provider to understand psychiatric illnesses, assess suicidality, and begin treatment for psychosis and/or agitation while maintaining personal, staff, and patient safety.

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This chapter is a revision of the chapter by Eric Brown, MD and Lori Whelan, MD from the 7th edition.

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Zeller  S, Calma  N, Stone  A. Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments. West J Emerg Med. 2014;15(1):1–6
[PubMed: 24578760]
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Zeller  S, Mao  RJ. Mental healing: emergency psychiatry options improve care and reduce ED psychiatric patient boarding. ACEP Now. 2016;35(7):14.

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APPROACH TO COMMON PSYCHIATRIC DISORDERS AND SYMPTOMS

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DEPRESSION

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Although the primary complaint of depression represented the chief complaint in only a small amount (0.6%) of ED visits nationwide, the reality may be about one in five emergency department patients may be experiencing depression. There is significant evidence that either generalized psychological distress or a formal diagnosis of depression may increase medical, including ED, utilization.

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Symptoms of a major depressive episode are highly variable in expression or severity and may be confounded by comorbid medical conditions or medications. In addition to determining the time course of symptoms, evaluation for depression should include specific questions about mood, apathy, changes in appetite or sleep, fatigue, hopelessness, and thoughts of death and suicide. Diagnosis of a major depressive episode includes five or more of the above symptoms present during a 2-week time period in addition to a change in functioning and change in mood or apathy.

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Differential diagnosis of depression can be quite broad (Table 49–1) and includes a number of potential medical conditions. A focused review of systems may help ...

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