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 282-1.
Table 282-1 Emergency Psychiatric Assessment Steps |Favorite Table|Download (.pdf)
Table 282-1 Emergency Psychiatric Assessment Steps
Safety and stabilization
Contain violent and dangerously psychotic persons to provide a safe environment for staff, patients, family, and visitors while simultaneously attending to airway, breathing, and circulation.
Identification of homicidal, suicidal, or other dangerous behavior
Determine whether the patient needs to be forcibly detained for emergency evaluation.
Determine the presence of any serious organic medical conditions that might cause or contribute to abnormal behavior or thought processes (e.g., hypoglycemia, meningitis, drug withdrawal, or other causes of delirium).
Psychiatric diagnosis and severity assessment
If the behavior change is not due to an underlying medical condition, it is primarily psychiatric or functional, requiring a psychiatric diagnosis and assessment of the severity of the primary psychiatric problems.
Determine the need for immediate psychiatric consultation.
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 142.
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 ...