Approach to Acutely Confused Patient (2025)

January 20, 2025January 20, 2025 ~ iEM Education Project Team ~ Leave a comment

by Mehnaz Zafar Ali

You Have New Patients!

Patient 1

You meet a 40-year-old man in the ED, held by three security staff, looking diaphoretic and agitated, having tachycardia, and pointing vaguely in a direction as if interacting with imaginary people. When you try to assess him, he appears to be confused and disoriented and smells of alcohol. Over 6 hours, the patient has tremulousness, gets easily frightened, and gets further uncooperative for examination.

Patient 2

You evaluate an 80-year-old woman in the ICU. She has a history of diabetes mellitus, hypertension, depression, and a stroke two years ago. She was admitted due to increased sleepiness, urinary and fecal incontinence for one week, and difficulty recognizing people. Before her admission, she was active and independent, had a reasonably good memory, and could manage household responsibilities. On physical examination, her eyes remain spontaneously closed but open with audible stimuli, and she is disoriented to time, place, and person.

Introduction

Delirium is a rapidly developing clinical syndrome characterized by alterations in attention, consciousness, and awareness, with a reduced ability to focus, sustain, or shift attention. It commonly occurs in the elderly, with an incidence reported in 10% to 30% of patients hospitalized for medical illnesses and up to 50% following high-risk procedures [1].

This condition is also referred to as acute organic brain syndrome, characterized by rapid onset, diurnal fluctuations, and a duration of less than six months. Its behavioral presentation can vary, with the following manifestations.

Hyperactive Delirium: Patients present with increased agitation and heightened sympathetic activity. They may exhibit hallucinations, delusions, and combative or uncooperative behavior.
Hypoactive Delirium: Patients display increased somnolence and reduced arousal. The diagnosis is often overlooked due to its subtle clinical manifestations, which are frequently mistaken for fatigue or depression. This subtype is associated with higher rates of morbidity and mortality.
Mixed Presentation: Patients fluctuate between hyperactive and hypoactive delirium.

Delirium tremens (DT) is the most severe form of alcohol withdrawal syndrome and can be fatal. It typically occurs within 2 to 4 days following complete or significant abstinence from heavy alcohol consumption in approximately 5% of patients, with mortality rates as high as 50%. Alcohol functions as a depressant, similar to benzodiazepines and barbiturates, and affects serotonin and gamma-aminobutyric acid type A (GABA A) receptors, leading to tolerance and habituation.

Delirium is a dangerous and often preventable condition, associated with significant costs and increased morbidity and mortality. Among delirium patients presenting to the emergency department, there is a 70% increased risk of death within six months. In the ICU, delirium is linked to a 2- to 4-fold increased risk of overall mortality. Prevention, early diagnosis, and treatment of the underlying cause, along with well-coordinated care, are essential to improve patient outcomes.

General Approach

The diagnosis of delirium is primarily clinical and relies on careful history-taking, mental status examination, and detailed cognitive assessment. While laboratory and diagnostic tests may assist in identifying the underlying etiology, the initial evaluation should focus on addressing reversible causes. Life-threatening conditions must be promptly recognized, requiring rapid intervention and stabilization.

Differential Diagnoses

Delirium can present with symptoms that may be easily mistaken for mental illness, such as acute aggression, irritability, restlessness, and visual hallucinations [1]. Delirium mimics may include psychosis or mood disorders in the case of hyperactive delirium, and depression in the case of hypoactive delirium.

According to the International Classification of Diseases (ICD-10) guidelines [2], a definite diagnosis of delirium requires the presence of symptoms (mild or severe) in each of the five described areas. These include: impairment of consciousness and attention (ranging from clouding to coma, with a reduced ability to direct, focus, sustain, and shift attention), global disturbance of cognition, psychomotor disturbances, disturbance of the sleep-wake cycle, and emotional disturbances.

Delirium

Delirium typically presents with an acute onset and progresses rapidly. It often resolves completely with treatment of the underlying cause. Clinically, it is characterized by fluctuating levels of consciousness, inattention, disorientation, worsening symptoms in the evening (a phenomenon known as sundowning), and transient visual hallucinations. Delirium carries significant risks, including high mortality due to the underlying medical condition, as well as increased risk of falls, injuries, exhaustion, or aggression.

Dementia

Dementia has an insidious onset and follows a chronic, progressive course marked by continuous deterioration over time. Key clinical features include memory disturbances, changes in personality or behavior, apathy, and apraxia. Individuals with dementia are at risk of falls, neglect, abuse, agitation, and wandering away from their safe environments.

Depression

Depression typically has a slow onset and an episodic course, with periods of remission and recurrence. Symptoms include a persistently depressed mood, loss of interest or pleasure in activities, reduced energy, feelings of hopelessness, disturbances in sleep and appetite, difficulties with concentration, and pervasive negative thoughts, often accompanied by guilt. The associated risks include suicide, deliberate self-harm, neglect, and agitation.

Psychosis

Psychosis usually begins insidiously and follows a progressive course punctuated by episodes of exacerbation. Clinical features include delusions, auditory hallucinations, disorganized thoughts, social withdrawal, apathy, avolition (lack of motivation), and impaired reality testing. Psychosis poses risks such as aggression, harm to others, and non-adherence to treatment, which can exacerbate the condition further.

History and Physical Examination Hints

It is of paramount importance to obtain a detailed corroborative history regarding the onset, course, and progression of the illness, along with performing a thorough physical and neurological examination of the patient. A biopsychosocial formulation must identify the predisposing, precipitating, and perpetuating causes of delirium [1].

The mnemonic “I WATCH DEATH,” developed by Dr. M.G. Wise in 1986, is a valuable tool for clinicians to screen for possible causes of delirium [3].

I – Infections: Infections are a common cause and can include conditions such as sepsis, urinary tract infections, encephalitis, and meningitis.
W – Withdrawal: Sudden withdrawal from substances such as alcohol, sedatives, or drugs can lead to significant medical complications.
A – Acute Metabolic Disturbances: Issues such as electrolyte imbalances (e.g., hyponatremia) and organ failure, such as hepatic or renal failure, can significantly disrupt normal physiological functions.
T – Trauma: Physical injuries, including head trauma and falls, are notable causes that may lead to further complications like bleeding or swelling.
C – CNS Pathology: Central nervous system disorders such as stroke, hemorrhage, seizures, or the presence of space-occupying lesions like tumors can have profound impacts on a patient’s condition.
H – Hypoxia: A lack of adequate oxygen supply, often due to anemia or hypotension, can result in significant systemic effects.
D – Deficiencies: Nutritional deficiencies, particularly a lack of essential vitamins and minerals like thiamine, can result in various clinical symptoms.
E – Endocrine Disorders: Hormonal imbalances, including thyroid storm and hyperglycemia, can disrupt metabolic processes and cause severe systemic effects.
A – Acute Vascular Events: Sudden vascular events, such as subarachnoid hemorrhage, require prompt identification and management due to their life-threatening nature.
T – Toxins or Drugs: Exposure to industrial poisons, carbon monoxide, or drugs with anticholinergic properties can have toxic effects on the body.
H – Heavy Metal Poisoning: Exposure to heavy metals such as lead and mercury can lead to chronic toxicity and require specific interventions.

Several factors increase the likelihood of developing delirium, especially in vulnerable populations:

Age: Both elderly individuals and young children are at heightened risk due to their increased susceptibility to physiological and cognitive changes.
Recent Hospitalizations: Hospital stays, particularly those involving medical illnesses or surgical procedures, can act as significant stressors and predispose individuals to delirium.
Pre-existing Brain Conditions: Conditions like brain damage or dementia further increase the risk, as they impair cognitive resilience.
Chronic Medical Disorders: Long-term health conditions often contribute to a state of chronic physiological stress, increasing the likelihood of delirium.
Sensory Deprivation: Impairments in vision or hearing can lead to sensory deprivation, which may exacerbate confusion and disorientation.
Substance Use Disorders: Alcohol or drug use disorders are major contributors to the onset of delirium, particularly during withdrawal periods or intoxication.
Medications: The use of psychotropic medicines and polypharmacy (simultaneous use of multiple medications) heightens the risk of delirium due to potential drug interactions and side effects.
History of Delirium: Individuals with a previous history of delirium are more likely to experience recurrent episodes, particularly if the underlying risk factors persist.
Malnutrition: Poor nutritional status can exacerbate vulnerability to delirium by impairing metabolic and neurological functions.
Burns: Severe burns create systemic inflammation and stress, which can predispose individuals to delirium.

Screening tools for delirium, such as the Mini-Mental Status Examination (MMSE) [4] and the Confusion Assessment Method (CAM) [5], are valuable for early identification and intervention. These tools can also be used to monitor clinical improvement when performed repeatedly during the course of the illness.

The Confusion Assessment Method (CAM) includes four key features to identify delirium. A diagnosis of delirium requires the presence of Features 1 and 2 and either Feature 3 or Feature 4:

Feature 1 – Acute Onset and Fluctuating Course: There is evidence of an acute change in mental status from the patient’s baseline.
The abnormal behavior fluctuates throughout the day, tending to come and go or change in severity.

Feature 2 – Inattention: The patient has difficulty focusing attention, is easily distractible, or cannot keep track of what is being said.

Feature 3 – Disorganized Thinking: The patient demonstrates disorganized or incoherent thinking, such as rambling or irrelevant conversation, illogical flow of ideas, or unpredictable switching between subjects.

Feature 4 – Altered Level of Consciousness: The patient’s consciousness level deviates from “alert.” It may range from hyperalert (vigilant) to lethargy, stupor, or coma.

The CAM is a widely used, reliable tool with high sensitivity (94–100%) and specificity (90–95%). It enables quick and accurate identification of delirium, facilitating early intervention to manage underlying causes and improve patient outcomes.

Confusion Assessment Method (CAM) Instrument:

Acute Onset:
- This involves an abrupt change in the patient’s mental status, which is evident when comparing their current state to their baseline cognitive function. This change may be noticed by family members, caregivers, or clinicians and is typically indicative of an acute underlying medical issue or condition.
Inattention:
- 2A: The patient has difficulty concentrating or paying attention. This may manifest as being easily distracted, unable to follow conversations, or losing track of what is being discussed.
- 2B: If inattention is present, the behavior often fluctuates over time, meaning it can improve or worsen during an assessment or throughout the day.
Disorganized Thinking:
- The patient’s thought process appears chaotic or incoherent. They may exhibit rambling, irrelevant speech, an illogical sequence of ideas, or rapid, unpredictable topic changes during a conversation. This suggests a loss of organized, goal-directed thinking.
Altered Level of Consciousness:
- The patient’s alertness deviates from normal. This can range from:
  - Alert (normal): Fully awake and responsive.
  - Vigilant (hyperalert): Overly sensitive to stimuli, easily startled, or hypervigilant.
  - Lethargic: Drowsy but easily aroused.
  - Stupor: Difficult to arouse, with limited responsiveness to stimuli.
  - Coma: Unarousable and non-responsive.
Disorientation:
- The patient is confused about time, place, or identity. They may incorrectly believe they are in a different location, misjudge the time of day, or demonstrate an inability to recognize familiar surroundings or people.
Memory Impairment:
- Memory issues are evident when the patient cannot recall recent events, forgets instructions, or struggles to remember details of their hospital stay or interactions.
Perceptual Disturbances:
- The patient may experience hallucinations (e.g., seeing or hearing things that aren’t present), illusions (misinterpreting real stimuli, such as mistaking a shadow for an object), or misinterpretations (believing something benign, such as a coat rack, is threatening).
Psychomotor Disturbances:
- 8A (Agitation): The patient may exhibit increased motor activity, such as restlessness, repeatedly picking at bedclothes, tapping their fingers, or making frequent, sudden movements.
- 8B (Retardation): Alternatively, the patient may show decreased motor activity, appearing sluggish, staring into space, staying in the same position for extended periods, or moving very slowly.
Altered Sleep-Wake Cycle:
- Disturbances in the patient’s sleep pattern are evident. They may experience excessive daytime sleepiness coupled with difficulty sleeping at night, or their sleep-wake rhythm may become reversed.

Associated Features

Certain medical conditions can present with a range of distressing symptoms and features:

Hallucinations and Illusions: Patients may experience vivid and often frightening visual or auditory hallucinations. Additionally, tactile hallucinations, such as the sensation of insects crawling on the body, can occur, adding to their distress.
Autonomic Disturbances: Marked autonomic instability is common and may include symptoms such as tachycardia, fever, hypertension, sweating, and pupillary dilation.
Psychomotor and Coordination Issues: Psychomotor agitation and ataxia (lack of muscle coordination) are frequently observed, contributing to physical instability and difficulty performing tasks.
Sleep Disturbances: Insomnia is a notable feature, often accompanied by a reversal of the sleep-wake cycle, further exacerbating cognitive and physical impairments.

It is crucial to obtain a detailed history of the patient’s premorbid personality, as this helps establish their baseline cognitive state and allows the clinician to determine the magnitude of cognitive deterioration. Patients with fluctuating levels of consciousness may experience rapid shifts in their activity levels, ranging from extreme psychomotor excitement to sleepiness during an interview [1].

The Mental State Examination (MSE) should include an assessment of mood (e.g., apathy, blunted affect, emotional lability), behavior (e.g., withdrawn, agitated), activity levels, thoughts (e.g., delusions), and perceptions (e.g., hallucinations, illusions). A brief cognitive assessment may utilize the COMA framework, which evaluates Concentration, Orientation, Memory, and Attention.

Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar)

The CIWA-R is a tool designed to standardize the assessment of withdrawal severity in patients experiencing alcohol withdrawal. This instrument is particularly useful for guiding treatment decisions and ensuring appropriate management of symptoms.

Alcohol withdrawal delirium progresses through distinct stages, including:

Tremulousness or Jitteriness: Occurs within 6–8 hours of cessation or reduction in alcohol use.
Psychosis and Perceptual Symptoms: Develops between 8–12 hours, marked by hallucinations and disorganized thinking.
Seizures: Typically occur within 12–24 hours of withdrawal.
Delirium Tremens: The most severe stage, manifesting within 24–72 hours and potentially lasting up to one week. This phase is characterized by confusion, autonomic instability, and significant risk of complications.

The CIWA-R plays a critical role in monitoring these stages and ensuring timely interventions to mitigate risks associated with alcohol withdrawal.

Click here to download full CIWA-R evaluation form.

Diagnostic Tests and Interpretation

Relevant laboratory tests and diagnostic imaging are recommended to assess the underlying etiology of delirium. Routine workups for electrolytes, kidney and liver function, and pregnancy tests for women are advised. Blood tests can help identify medical conditions that may mimic delirium, such as hypoglycemia and diabetic ketoacidosis (via blood sugar levels) or thyrotoxicosis (via thyroid profile). Test results indicative of long-term heavy alcohol use, such as evidence of cirrhosis or liver failure on ultrasound, macrocytic anemia, and elevated liver transaminase levels—particularly gamma-glutamyl transpeptidase—can aid in reaching the correct diagnosis [6].

Positron emission tomographic (PET) studies have suggested a globally low rate of metabolic activity, particularly in the left parietal and right frontal areas, in otherwise healthy individuals withdrawing from alcohol. Diffuse slowing of the background rhythm has been observed on electroencephalography (EEG) in patients suffering from acute delirium, except in cases of alcohol-related delirium tremens, which typically exhibit fast activity [1].

Management

Delirium is a medical emergency requiring immediate hospitalization to correct the underlying causes while minimizing risks associated with behavioral symptoms, aggression, dehydration, falls, and injury. High-potency antipsychotics in low doses are recommended for managing aggression and behavioral symptoms. Haloperidol (Haldol) has been extensively studied for reducing agitation due to delirium [7]. Evidence also supports the use of other atypical antipsychotics such as risperidone. Aripiprazole has demonstrated significant benefit in the complete resolution of hypoactive delirium [8].

The use of benzodiazepines should be restricted to cases of delirium caused by alcohol withdrawal. If liver function is not impaired, a long-acting benzodiazepine, such as chlordiazepoxide or diazepam, is preferred and can be administered orally or intravenously. In cases of reduced liver function, lorazepam may be given orally or parenterally as needed to stabilize vital signs and sedate the patient. These medications should then be tapered gradually over several days with close monitoring of vital signs. Anticonvulsants like carbamazepine and valproic acid are also effective in managing alcohol withdrawal. However, antipsychotics should be avoided in such cases due to their potential to lower the seizure threshold. Chronic alcoholics are at high risk of vitamin B1 (thiamine) deficiency, which can predispose them to Wernicke-Korsakoff syndrome (characterized by memory problems, confabulation, and apathy), cerebellar degeneration, and cardiovascular dysfunction. To mitigate this risk, such patients should receive 100 mg of thiamine intravenously before glucose administration.

Environmental modification strategies are particularly useful for managing delirious patients. These include providing well-illuminated rooms with good ventilation and reorientation cues such as calendars and alarm clocks. Assigning patients to a room near the nursing station allows for closer monitoring, ideally with the presence of a family member or close friend. In severe cases with agitation or injury risk, one-on-one supervision is advisable to ensure patient safety [1]. Both under-stimulation and overstimulation should be avoided. The use of physical restraints should be considered a last resort, with frequent monitoring and discontinuation as soon as possible. Psychoeducation for family members and caregivers is crucial to manage expectations and improve their involvement in the patient’s care [2].

Special Patient Groups and Other Considerations

Elderly patients are at high risk of altered mental status, and studies have recommended advanced age as an independent risk factor warranting screening of this vulnerable group through structured mental state assessments. It is important to recognize that behavioral manifestations of this magnitude should not be regarded as a normal part of the aging process. Dementia must be carefully differentiated from delirium in the geriatric population, as dementia typically presents with an insidious onset and a progressive course [3].

Other risk factors in the elderly that require attention include underlying neurological causes, multiple medical comorbidities, polypharmacy, poor drug metabolism, and sensory limitations [9]. Medications for elderly patients should be initiated at lower doses, and potential drug interactions must be considered whenever new medications are introduced.

The pediatric age group may present with nonspecific symptoms of acute onset, necessitating a detailed history and physical examination to rule out causes such as fever, injury, or foreign objects. Pregnancy, meanwhile, may predispose healthy women to medical conditions such as diabetes, venous thromboembolism, strokes, and eclampsia [9].

When To Admit This Patient

Admission decisions for confused patients or those undergoing alcohol withdrawal require a multifaceted approach that prioritizes accurate diagnosis, evidence-based treatment, and legal considerations. These decisions should aim to address the immediate medical needs while planning for long-term recovery and safety.

Admitting a confused patient requires careful evaluation of the underlying causes, as confusion can result from various conditions such as dementia, delirium, or depression, each requiring distinct management strategies [10]. Delirium, an acute confusional state, is particularly prevalent in older adults and often develops rapidly with fluctuating severity [11]. It is essential to determine whether the confusion is acute, chronic, or a combination of both, as this distinction guides the initial management plan [11].

Risk factors for acute confusion include admission from non-home settings, lower cognitive scores, restricted activity levels, infections, and abnormal laboratory values. These indicators suggest frailty and may also point to underlying chronic undernutrition or dehydration [12]. Early recognition and appropriate management are crucial to reducing morbidity and mortality, as confusion is often misdiagnosed or undertreated in hospital settings [10].

Furthermore, legal and ethical challenges, such as evaluating a patient’s decision-making capacity and ensuring that any necessary restraints are lawful and ethical, must be addressed to avoid infringing on the patient’s rights [13]. A comprehensive assessment of cognitive and physical status, coupled with an understanding of legal considerations, is essential for developing a management plan that effectively addresses the specific causes and risks associated with confusion [11-13].

Disposition decisions for confused patients, including those undergoing alcohol withdrawal, require a comprehensive and systematic approach that integrates accurate diagnosis, appropriate treatment, and continuous monitoring. Alcohol withdrawal can result in severe complications, such as seizures and delirium tremens, with mortality rates ranging from 1% to 30%, depending on the quality of treatment provided [14]. Prompt identification and management are critical, often involving benzodiazepines like diazepam to alleviate symptoms and prevent progression to life-threatening conditions [15]. Management becomes particularly challenging in critically ill patients, as incomplete alcohol consumption histories and the need for adjunctive medications beyond benzodiazepines complicate care during severe withdrawal or delirium tremens [16].

Emergency departments frequently encounter substance use disorders; however, less than half of alcohol-related issues are identified, highlighting the importance of comprehensive assessments and evidence-based interventions. Effective disposition decisions rely on early identification, tailored treatment strategies, and ongoing evaluations to ensure patient safety and recovery.

Clinical Pearls

Alcohol Withdrawal Characteristics: Alcohol withdrawal can begin within hours to days following heavy and prolonged alcohol use. A key feature of alcohol withdrawal is autonomic hyperactivity, which may present as increased heart rate, sweating, tremors, and other signs of sympathetic nervous system overactivity.
Overlap with Sedative-Hypnotic Withdrawal: The diagnostic criteria and symptoms for alcohol withdrawal are identical to those for sedative-hypnotic withdrawal. This similarity highlights the importance of carefully assessing a patient’s history of substance use to guide appropriate management.
Treatment Approaches:
- Delirium Due to General Medical Conditions: The preferred treatment is low doses of high-potency antipsychotics, which help manage symptoms without excessive sedation or complications.
- Alcohol Withdrawal: Benzodiazepines remain the first-line treatment to alleviate withdrawal symptoms and prevent complications such as seizures or delirium tremens. In cases where hepatotoxicity is a concern, short-acting benzodiazepines like lorazepam are preferred due to their safer profile in patients with compromised liver function.
Hallucinations and Diagnosis: Visual hallucinations are more characteristic of delirium than of primary psychiatric disorders. This distinction is critical in differentiating between medical and psychiatric causes of altered mental status.

Revisiting Your Patient

Patient 1

The patient presents with the smell of alcohol and clinical features consistent with delirium tremens, a severe manifestation of alcohol withdrawal.

Further Management: The patient should be treated promptly with a benzodiazepine, starting with high doses and tapering as recovery progresses. Chronic alcohol users are commonly deficient in vitamin B1 (thiamine), which can result in dementia and cognitive impairments. Thiamine replacement should be administered prior to glucose to prevent the development of Wernicke-Korsakoff syndrome [17].

Patient 2

The patient is unresponsive to stimuli, disoriented, and has multiple medical conditions, which is suggestive of delirium due to a general medical condition, hypoactive type.

Further Management: Immediate steps should include ensuring 24-hour supervision, investigating the underlying cause, and implementing reorientation strategies. Low-dose antipsychotics have been recommended, with studies reporting complete resolution of symptoms with the use of aripiprazole and other atypical antipsychotics [18].

Author

Mehnaz Zafar Ali

Consultant Psychiatrist, Al Amal Psychiatry Hospital, Emirates Health Services, Dubai, United Arab Emirates

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References

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Gower LE, Gatewood MO, Kang CS. Emergency department management of delirium in the elderly. West J Emerg Med. 2012;13(2):194-201. doi:10.5811/westjem.2011.10.6654.
Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189-198. doi:10.1016/0022-3956(75)90026-6.
Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941-948. doi:10.7326/0003-4819-113-12-941.
Chan M, Moukaddam N, Tucci V. Stabilization and management of the acutely agitated or psychotic patient. In: Cevik AA, Quek LS, Noureldin A, Cakal ED, eds. International Emergency Medicine Education Project. 1st ed. iEM Education Project; 2018:452-457.
Smit L, Slooter AJ, Devlin JW, et al. Efficacy of haloperidol to decrease the burden of delirium in adult critically ill patients: the EuRIDICE randomized clinical trial. Crit Care. 2023;27(1):413. doi:10.1186/s13054-023-04692-3.
Lodewijckx E, Debain A, Lieten S, et al. Pharmacologic treatment for hypoactive delirium in adult patients: a brief report of the literature. J Am Med Dir Assoc. 2021;22(6):1313-1316.e2. doi:10.1016/j.jamda.2020.12.037.
Cetin M, Oktem B, Canakci ME. Altered mental status. In: Cevik AA, Quek LS, Noureldin A, Cakal ED, eds. International Emergency Medicine Education Project. 1st ed. iEM Education Project; 2018:111-121.
Winstanley L, Glew S, Harwood RH. A foundation doctor’s guide to clerking the confused older patient. Br J Hosp Med (Lond). 2010;71(5):M78-M81. doi:10.12968/hmed.2010.71.Sup5.47934.
Andrews H, Clarke A, Parmar S, et al. You’ve been bleeped: the confused patient. BMJ. 2015;351:h3266. doi:10.1136/sbmj.h3266.
Wakefield BJ. Risk for acute confusion on hospital admission. Clin Nurs Res. 2002;11(2):153-172. doi:10.1177/105477380201100205.
Lyons D. The confused patient in the acute hospital: legal and ethical challenges for clinicians in Scotland. J R Coll Physicians Edinb. 2013;43(1):61-67. doi:10.4997/jrcpe.2013.114.
Thanyanuwat R. Patients who suffer from alcohol withdrawal and disorientation. J Med Assoc Thai. 2013;96(2):78-83.
Thompson WL. Management of alcohol withdrawal syndromes. Arch Intern Med. 1978;138(2):278-283. doi:10.1001/archinte.1978.03630260068019.
Sutton LJ, Jutel A. Alcohol withdrawal syndrome in critically ill patients: identification, assessment, and management. Crit Care Nurse. 2016;36(1):28-40. doi:10.4037/ccn2016420.
Toy EC, Klamen DL. Alcohol withdrawal. In: Case Files: Psychiatry. 6th ed. McGraw-Hill Education; 2020:400-405.
Lodewijckx E, Debain A, Lieten S, et al. Pharmacologic treatment for hypoactive delirium in adult patients: a brief report of the literature. J Am Med Dir Assoc. 2021;22(6):1313-1316.e2. doi:10.1016/j.jamda.2020.12.037.

Reviewed and Edited By

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Approach to Suicidal Patient (2025)

January 12, 2025January 20, 2025 ~ iEM Education Project Team ~ Leave a comment

by Faisal A. Nawaz

You Have A New Patient!

A 19-year-old male was brought to the emergency room (ER) by his family with the assistance of an ambulance. The patient was discovered unconscious in his car, surrounded by leftover pills of an unknown medication. Upon arrival at the ER, he was assessed by the medical team and found to have regained consciousness, with a Glasgow Coma Scale (GCS) score of 12 and stable vital signs.

Introduction

Suicide is one of the top ten causes of death worldwide, with increasing rates of occurrence and mortality observed across various countries and patient populations in recent years [1]. It is the second most common cause of death among individuals aged 10-14 and 20-34 years [1]. Suicide is defined as “an act with a fatal outcome, that is deliberately initiated and performed by the person in knowledge or expectation of its fatal outcome.”

Durkheim classifies suicide into four types: egoistic suicide, altruistic suicide, anomic suicide, and fatalistic suicide [2]. The act of suicide can be completed using various methods, with risks influenced by factors such as gender, age, family history of suicide, comorbid mental and physical disorders, and social and psychological stressors (e.g., poor financial stability, unemployment, divorce, isolation).

It is well established that females have higher rates of suicide attempts, while males have higher rates of completed suicide. The most common method of suicide among men is hanging, whereas women most often use drug overdose as a method of suicide [3,4].

Notable psychiatric risk factors predisposing individuals to suicide include depressive disorders, alcohol dependence or abuse, schizophrenic disorders, and personality disorders. Medical risk factors include chronic physical illnesses and epilepsy. Despite advancements in suicide prevention, the most significant risk factor remains a past history of suicide attempts or deliberate self-harm [5].

General Approach

When approaching a patient with suicidal thoughts or behaviors, it is essential to provide empathetic and patient-centered care to ensure their safety and well-being. Key steps include implementing safety precautions, such as placing the patient in a private, secure environment without access to dangerous objects and ensuring continuous observation or restraints when necessary [6]. A focused medical assessment should be conducted, emphasizing the evaluation of cognitive and emotional status, drug ingestion, or other medical conditions that may influence the patient’s mental state. This targeted approach is preferable to routine “medical clearance,” as it avoids the misconception that standard diagnostic testing is always required [6,7].

In cases of an active suicidal attempt, immediate stabilization is paramount, with a focus on addressing any abnormalities in airway, breathing, or circulation. Initial interventions include checking vital signs, obtaining a rapid blood glucose level, initiating cardiac monitoring and pulse oximetry, and establishing IV access. Oxygen administration and IV fluids may also be warranted depending on the patient’s condition [7]. Physical signs such as pupillary changes (indicating drug intoxication), altered consciousness (assessed by the Glasgow Coma Scale), respiratory distress or depression, and self-harm injuries should be carefully evaluated [2]. Comprehensive vital assessments, laboratory investigations (e.g., electrolytes, liver and renal function tests), and ECGs may provide further insight into the patient’s medical condition and guide interventions.

The cornerstone of management is a comprehensive suicide risk assessment, which involves evaluating the patient’s personal and psychiatric history, current mental state, and specific suicidal thoughts or behaviors. This assessment should explore the presence of a suicide plan, prior attempts, mental illness, substance abuse, and agitation. For low-risk patients, management by the emergency department provider and discharge home may be appropriate. However, most patients require a thorough risk evaluation, which can be aided by tools like the Suicide Assessment Five-step Evaluation and Triage (SAFE-T) if mental health specialists are unavailable [6]. Establishing rapport with the patient through a sympathetic yet direct approach is crucial for obtaining reliable information, including details about suicidal ideation, and collateral sources such as family or friends can provide additional context [6].

Once medically stabilized, a mental status examination is necessary to evaluate the patient’s affect, attention, orientation, memory, and behavior, with particular attention to changes in cognition and alertness [7]. If the patient is deemed to pose a high risk of harm to themselves or others, inpatient admission is often warranted to provide intensive monitoring and care. Conversely, if the patient demonstrates insight, judgment, and stability, outpatient follow-up with close monitoring may suffice. Obtaining collateral history from family or other reliable sources is a critical component of the psychiatric evaluation, providing context for the patient’s condition and ensuring a comprehensive risk assessment. It is essential to remember that asking about suicidal thoughts does not incite suicidal behavior, and most suicidal crises are transient, underscoring the importance of timely and appropriate intervention [6].

Physical Examination

A thorough physical examination is an essential component of evaluating patients with psychiatric complaints and should be conducted with the same diligence as in patients presenting with medical conditions. Along with the patient’s history and mental status examination (MSE), the physical exam helps to distinguish between functional (psychiatric) and organic (medical) causes of the symptoms. A complete and systematic approach ensures that critical diagnoses are not missed, as studies have highlighted that incomplete evaluations often result in missed medical conditions and potentially dangerous outcomes [7].

Key Aspects of the Physical Examination

The general appearance of the patient should be carefully observed for signs of anxiety, distress, or other physical manifestations of their condition. For example, in one case study, the patient appeared anxious, which provided an important clue to their mental and physical state [7].

Vital signs are a critical starting point. These include heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature. Abnormalities in vital signs should be promptly evaluated and managed. However, studies indicate that vital signs are not consistently documented, with complete sets recorded in only 52% of cases. This underscores the importance of thorough documentation during assessments [7].

The cardiovascular examination involves assessing the pulse for rate and regularity. For instance, in a referenced case, the patient presented with an irregular pulse, which necessitated further evaluation with an electrocardiogram (EKG) to assess for potential arrhythmias [7].

In the respiratory system, clinicians should observe the patient for signs of tachypnea or respiratory distress and auscultate the lungs for abnormal sounds like crackles. In the same case study, the patient exhibited tachypnea and crackles at the lung bases, prompting the need for a chest x-ray to investigate potential causes such as pneumonia or heart failure [7].

The extremities should be examined for signs of edema or dryness, as these can provide clues about systemic or localized medical conditions. Similarly, the abdomen should be assessed for tenderness and abnormalities, ensuring it is soft and non-tender [7].

The neurological examination plays a pivotal role in identifying focal deficits, meningeal signs, or changes in alertness, cognition, and behavior. Basic neurological assessments can provide insight into potential underlying causes of psychiatric complaints, such as an organic brain disorder [7].

Skin and hair changes should also be noted, as they may indicate systemic illnesses. Additionally, other physical complaints such as cough, fever, heat intolerance, headache, neck pain, or stiffness should be carefully documented and investigated [7].

Integrating Findings with Further Testing

The findings from the physical exam, combined with the history and MSE, should guide laboratory investigations and imaging studies. For example, abnormal vital signs may warrant blood tests or imaging such as chest x-rays or EKGs. Missed diagnoses often stem from inadequate physical evaluations, reinforcing the need for comprehensive assessments to ensure patient safety and optimal outcomes.

Risk Assessment

Through History

During the history-taking component of the assessment, the most critical indicator of high suicide risk is a direct statement indicating intent for suicide. Research shows that many patients verbalize their suicidal intent to close contacts prior to an attempt and may have also visited their general practitioner or psychiatrist before the suicide attempt. History-taking should incorporate questions addressing potential risk factors for suicide, such as:

Previous history of suicide attempts
Marked hopelessness
Social isolation
Depressive disorder
Alcohol dependence
Current death wishes
Current suicidal intent
Auditory hallucinations of a commanding or derogatory nature

The SAD PERSONS mnemonic is a helpful tool in assessing suicidality in patients by highlighting common risk factors that can be identified during history-taking [8].

Risk Factor	Description
Sex	Male gender has an increased risk of suicide
Age	Age <19 or >45 years
Depression	Including bipolar depression
Previous Attempt	Previous suicide attempt
Excess Alcohol	Alcohol or substance use
Rational Thinking Loss	Poor judgment in different situations
Social Support	Lacks social support
Organized Plan	Use of death notes or wills
No Partner	Unmarried, divorced
Sickness or Stress	Chronic illnesses or stressful life events

The SAD PERSONS scale, widely used for assessing suicide risk, categorizes individuals into three risk levels based on cumulative scores: low risk (0–4 points), moderate risk (5–6 points), and high risk (7–10 points). Despite its popularity, the scale has faced significant criticism regarding its clinical utility. A key concern is its low sensitivity. Another major critique is its oversimplification of complex individual risk factors. The scale’s binary scoring system may overlook the nuanced aspects of a patient’s mental health, potentially leading to inadequate risk assessment.

Given these limitations, clinicians are encouraged to consider alternative or supplementary assessment instruments:

Columbia-Suicide Severity Rating Scale (C-SSRS): This tool evaluates the severity of suicidal ideation and behavior, offering a more nuanced risk assessment.
Beck Scale for Suicide Ideation (BSI): A widely used instrument that assesses the intensity of an individual’s suicidal intentions.
Suicide Behaviors Questionnaire-Revised (SBQ-R): A self-report measure that evaluates various dimensions of suicidality, including ideation, attempts, and future risk.

Continuous assessment during initial presentations, inpatient or outpatient encounters, and post-discharge follow-ups is essential to ensure the long-term safety of patients at risk for suicide. It is noteworthy that the first two weeks of inpatient stay and the first week post-discharge are high-risk periods for suicidal attempts among individuals with mental illness [9]. The presence of a strong social support system can significantly enhance care and reduce risk after discharge.

It is also important to assess abnormal personality traits that may increase suicide risk. Borderline personality disorder and traits such as anxiety, impulsivity, aggression, or obsessive tendencies are associated with elevated suicide risk [10].

In cases of active or past suicide attempts, history-taking should focus on the method and intent of the attempt, preparations made beforehand, the presence of a death note, and any overt communication regarding the act. These factors strongly suggest increased suicidal intent. The intent of suicide may also help differentiate between “deliberate self-harm” (also known as parasuicide) and an unsuccessful suicide attempt.

Deliberate self-harm is described as an “episode of intentional self-harm that did not lead to death and may or may not have been motivated by a desire to die.” Reasons for deliberate self-harm include the need to escape unbearable stressors, seek relief, or, in some cases, as a call for help. It is important to note that deliberate self-harm significantly increases the risk of suicide in the future [11].

In this case, the use of drug overdose as a suicide attempt is a relatively common presentation. The type and quantity of medication or drug used during the attempt are critical in determining appropriate antidotes for overdose reversal, as well as in understanding potential physical complications to organ systems caused by drug toxicity.

Helpful Interview Questions [12] for Assessing Suicide Risk:

Suicidal Ideation: With increased stress, have you had any thoughts of hurting or killing yourself?
Suicidal Intent: How likely are you to try to kill yourself today or in the near future?
Suicidal Plan: Do you have a plan for how you would like to kill yourself or end your life?

Protective Factors:

Assessing protective factors is crucial to determining suicide risk. For example:

Is there anything or anyone that stops you from attempting suicide?

Mental Status Examination

A Mental Status Examination (MSE) is a critical component of evaluating patients with psychiatric complaints. It systematically assesses seven key areas: affect, attention, language, orientation, memory, visual-spatial ability, and conceptualization [7]. The MSE provides insights into changes in alertness, cognition, and behavior, helping clinicians differentiate between conditions such as delirium, dementia, and psychiatric illnesses, which have distinct management strategies and prognoses. Delirium, for example, is associated with decreased survival when encountered in emergency settings [7]. Alternatives to the traditional MSE, like the Quick Confusion Scale, offer a structured and easily interpretable tool for assessing mental status [7].

The MSE should be conducted in an organized and focused manner, aiming to identify whether a patient’s complaints stem from functional or organic etiologies. It is crucial to note sudden changes in behavior, mood, or thought in patients, as these may indicate underlying medical conditions. Additionally, a thorough evaluation should include an assessment of substance use, medication adherence, and medical comorbidities, alongside a careful review of physical findings such as trauma, fever, or abnormal vitals [7]. These components play a pivotal role in identifying patients whose altered mental status might otherwise be misattributed to psychiatric causes. In a review of psychiatric ward admissions, it was found that many patients with medical diagnoses had not received appropriate medical screenings, underscoring the importance of thorough medical evaluations [7].

The MSE also holds particular significance in assessing suicide risk, as it offers a snapshot of the patient’s current mental state, which may fluctuate over time. This makes it a valuable tool for monitoring recovery and ensuring the patient’s safety. The appearance of suicidal patients can vary widely, from restlessness and agitation during heightened suicidality to expressions of guilt or disappointment after a failed suicide attempt. In some cases, outward signs of suicidal risk may be absent, emphasizing the need for a thorough evaluation of the patient’s mood, current suicidal ideations, intent, and plan. Homicidal ideations may also occasionally accompany suicidal thoughts, reflecting a patient’s belief that their actions might “relieve” loved ones from perceived burdens.

Evaluating a patient’s insight into suicidal behaviors, recognition of the need for treatment, and judgment in managing future crises provides valuable guidance for clinical decision-making during risk assessment. The MSE serves as both a diagnostic and monitoring tool, helping clinicians evaluate and address the complex interplay of medical, psychological, and social factors that influence mental health.

Differential Diagnoses

When evaluating patients with psychiatric complaints, it is essential to adopt a systematic approach that encompasses a broad range of differential diagnoses, addressing both psychiatric and medical conditions. Medical conditions such as sepsis, diabetic ketoacidosis, pneumonia, pulmonary embolism, meningitis, encephalitis, hyperthyroidism/thyroid storm, intoxication, withdrawal syndromes, overdose, and trauma can mimic or exacerbate psychiatric symptoms. These conditions may also include infectious, pulmonary, thyroid, diabetic, hematopoietic, hepatic, or CNS disorders and require prompt recognition to avoid misdiagnosis [7].

Psychiatric conditions, including schizophrenia, bipolar disorder, psychosis, mood disorders, anxiety disorders, delirium, and dementia, often present with overlapping features. Differentiating between functional (psychiatric) and organic (medical) causes is particularly important in patients with sudden changes in behavior, mood, or cognition or in those with a deteriorating chronic disorder [7]. Additional considerations, such as substance abuse, alcohol withdrawal, medication effects, or salicylate ingestion, can further complicate the clinical presentation. In particular, intoxicated patients may struggle to provide a reliable history, adding complexity to the diagnostic process [7].

Risk Factors and Diagnostic Approach

Certain groups are at an increased risk of medical causes for psychiatric symptoms, including the elderly, individuals with substance abuse histories, those without prior psychiatric diagnoses, and patients with new or pre-existing medical complaints. A comprehensive history, physical examination, and mental status examination (MSE) are critical for identifying the underlying etiology of psychiatric complaints. Gathering collateral information from family or caregivers helps ensure the accuracy of the history, as missed medical diagnoses have been shown to result from insufficient history-taking or physical examination [6,7].

Diagnostic testing should be tailored to the patient’s presentation. Common evaluations include laboratory studies (e.g., CBC, metabolic panel, thyroid function tests, alcohol level, urine drug screen, acetaminophen and salicylate levels), imaging studies (e.g., chest x-ray, CT scan of the brain), cardiac assessments (e.g., ECG, troponin, BNP), and infectious workups (e.g., urinalysis, urine culture, blood cultures, lumbar puncture). These tools help distinguish between psychiatric and medical conditions and guide appropriate management [7].

Differential Diagnoses for Suicide Attempts

When addressing a suicide attempt, specific psychiatric diagnoses must be considered, including Major Depressive Disorder, Bipolar Disorder, Psychotic Disorders, Substance-Induced Mood or Psychotic Disorders, and Cluster B Personality Disorders. Each condition requires a tailored treatment approach based on the underlying diagnosis [1].

For Major Depressive Disorder, first-line treatment often involves antidepressants, while Bipolar Disorder may require antipsychotics or a combination of antipsychotics with mood stabilizers. Psychotic Disorders are typically managed with antipsychotics, whereas substance-induced mood or psychotic disorders may necessitate antidepressants, mood stabilizers, or antipsychotics, depending on the clinical presentation. Cluster B Personality Disorders benefit from a detailed personality assessment and psychotherapy approaches such as Cognitive Behavioral Therapy (CBT) or Dialectical Behavior Therapy (DBT) [1].

Management

Emergency Treatment and Interventions

Effective emergency treatment for patients presenting with psychiatric or medical emergencies involves a combination of medical stabilization and supportive interventions. Medical stabilization is the first priority and focuses on addressing any identified medical issues. This may include administering supplemental oxygen, managing acute conditions such as hyperthyroidism or thyroid storm, and providing appropriate medications or therapies based on the patient’s needs [7].

For patients who are medically stable and being discharged, brief interventions are essential to ensure safety and continuity of care. These interventions often include patient education, personalized safety planning, and counseling to reduce access to lethal means [6]. Safety plans should identify warning signs, coping strategies, and emergency contacts, tailored to the individual’s circumstances. Lethal means counseling involves discussing strategies for the safe storage of firearms and toxic medications to mitigate risk [6].

Rapid referral for outpatient follow-up care is a critical component of post-discharge planning. Efforts should be made to arrange follow-up appointments within 24 hours and no later than 7 days. Providing patients with specific appointments and addressing potential barriers to follow-up care, such as transportation or availability, ensures better adherence to treatment plans [6].

Another important intervention includes caring contacts after discharge, such as brief communications via telephone calls, text messages, emails, or mail [6]. These contacts serve to maintain connection with the patient, encourage treatment adherence, and demonstrate ongoing support during their recovery process. By combining these strategies, emergency treatment not only addresses immediate medical needs but also promotes long-term safety and mental health stability.

When To Admit This Patient

The disposition of patients presenting with psychiatric crises, particularly those at risk for suicide, should be guided by their assessed level of risk and the availability of supportive resources [6]. Psychiatric hospitalization is appropriate for patients in acute crisis with moderate to high suicide risk. When feasible, voluntary admission is preferred to foster patient cooperation and engagement in treatment. For patients assessed to have a low risk of imminent suicide, outpatient management may be appropriate if they have a stable living environment, supportive relationships, and restricted access to lethal means [6]. Additionally, all patients should be provided with the National Suicide Prevention Hotline, if available, as an immediate resource for crisis support and suicide prevention, ensuring they have access to help when needed. This tailored approach to disposition ensures both immediate safety and continuity of care.

Additional ED Considerations

Proper management of patients presenting with psychiatric crises requires attention to several important considerations. Thorough documentation is essential to ensure a clear record of the patient’s history, physical examination, mental status evaluation, risk assessment, and any interventions or treatments administered [7]. Comprehensive documentation not only supports continuity of care but also provides a medico-legal record of the clinical reasoning and decisions made during the encounter.

Emergency departments (EDs) should have a written policy outlining the care of suicidal patients. Such policies help clarify care pathways, standardize procedures, and support provider actions, ensuring consistent and effective care delivery for this vulnerable population [6].

Collaboration with mental health professionals, including psychiatrists, psychologists, and social workers, is critical for delivering comprehensive care [6]. This interdisciplinary approach allows for a more holistic understanding of the patient’s needs and facilitates the development of individualized treatment plans that address both immediate and long-term concerns.

Further Management Considerations

Inpatient Management

If inpatient admission is required, the patient should be assessed for any underlying diagnoses that may have contributed to the suicide attempt. Medications tailored to the underlying diagnosis should be prescribed, with the patient under close observation during their stay. Inpatient staff must ensure the safety of the environment by removing sharp objects or any potential items that could be used for self-harm. Psychotherapy sessions may be initiated during this time. Upon discharge, safety netting is crucial to ensure the patient is aware of early warning signs and available support systems to help manage future crises.

Outpatient Management

For outpatient treatment, the patient must maintain regular follow-up appointments to monitor symptoms and assess ongoing suicide risk. Appropriate medications and psychotherapy sessions should be provided as needed. Depending on the treatment regimen, regular follow-up laboratory tests may be required to monitor for potential side effects. Psychotherapy sessions should also continue during this period.

Community Management

Community management involves collaboration with social services to support the patient in transitioning back to professional and personal life activities after discharge. Family support and adherence to the treatment plan are vital to maintaining the patient’s stability and preventing future crises.

Clinical Pearls

Discharge Medications:

For patients with a history of suicide attempts or an increased risk of future suicide, medications should be prescribed cautiously upon discharge. It is important to avoid providing large quantities of medications, as these may be misused in potential future suicide attempts.

Anti-Suicide Medications:

Certain medications have been shown to effectively reduce the risk of suicide:

Lithium: Proven to be effective in the management of mood disorders.
Clozapine: Demonstrated efficacy in reducing suicide risk in patients with schizophrenia [13].

Revisiting Your Patient

The findings in our case suggest that the patient is currently medically stable but requires close observation for any potential changes. Further psychiatric evaluation is essential to assess underlying mental health issues and suicide risk factors. A definitive diagnosis cannot be established at this stage and will depend on the outcomes of additional assessments.

Author

Faisal A. Nawaz

Dr. Faisal Nawaz is a Psychiatry Resident Doctor at Al Amal Psychiatric Hospital in Dubai. Dr. Nawaz’s research expertise extends across health, global health, digital health, and medical education with over 60 peer-reviewed publications in the field. Beyond his clinical pursuits, Dr. Nawaz serves as the Co-founder of the Global Remote Research Scholars Program.

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References

Harrison PJ, Cowen P, Burns T, Fazel M. Shorter Oxford Textbook of Psychiatry. 7th ed. Oxford University Press; 2018.
Durkheim E. Suicide: A Study in Sociology. Translated by JA Spaulding and G Simpson. Free Press; 1951.
Shenava M, Hitching R, Dunn LB. Suicide in the Geriatric Population: Risk Factors, Identification, and Management. In: Bhattacharya R, Agarwal V, Chaturvedi SK, eds. Clinical Geriatric Psychopharmacology. Springer; 2019:153-167. doi:10.1007/978-3-030-10401-6_8.
Centers for Disease Control and Prevention. Multiple Cause of Death, 2018-2020, Single Race Request. Accessed January 10, 2025. https://wonder.cdc.gov/mcd-icd10-expanded.html.
Kirkcaldy BD, Siefen RG, Urkin J, Merrick J. Risk factors for suicidal behavior in adolescents. Minerva Pediatr. 2006;58(5):443-450.
Betz ME, Boudreaux ED. Managing Suicidal Patients in the Emergency Department. Ann Emerg Med. 2016;67(2):276-282. doi:10.1016/j.annemergmed.2015.09.001.
Siever K, Tucci V. Medical Clearance – Suicidal Thought/Ideation. International Emergency Medicine Education Project. Accessed January 10, 2025. https://iem-student.org/medical-clearance-suicidal-thought-ideation/.
Patterson WM, Dohn HH, Bird J, Patterson GA. Evaluation of suicidal patients: The SAD PERSONS scale. Psychosomatics. 1983;24(4):343-349. doi:10.1016/S0033-3182(83)73213-5.
Bickley H, Hunt IM, Windfuhr K, Shaw J, Appleby L, Kapur N. Suicide Within Two Weeks of Discharge From Psychiatric Inpatient Care: A Case-Control Study. Psychiatr Serv. 2013;64(7):653-659. doi:10.1176/appi.ps.201200026.
Paris J. Suicidality in Borderline Personality Disorder. Medicina (Kaunas). 2019;55(6):223. doi:10.3390/medicina55060223.
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Reviewed and Edited By

Arif Alper Cevik, MD, FEMAT, FIFEM

Approach To Acutely Agitated Patient (2025)

January 10, 2025January 12, 2025 ~ iEM Education Project Team ~ Leave a comment

by Mazin A Mukhtar

You Have A New Patient!

A 35-year-old male was brought to the emergency department by police due to violent behavior, including damaging vehicles and threatening individuals in a public area. On initial assessment, he was highly agitated, hostile, and uncooperative, exhibiting signs of psychomotor agitation characterized by verbal outbursts, exaggerated hand gestures, and shouting phrases such as “Leave me!”

He demonstrated persecutory delusions, expressing a belief that law enforcement and medical personnel were conspiring to harm him by damaging his brain, which necessitated his transport to the hospital.

Despite stable vital signs, his aggressive and uncooperative behavior made a complete physical examination impractical. Efforts at verbal de-escalation and pharmacologic intervention with rapid tranquilization were ineffective. Given the severity of his agitation and the potential risk to himself and others, physical restraints were applied to ensure safety. Following stabilization, the patient was initiated on an oral antipsychotic regimen, which resulted in a gradual return to baseline functioning within three weeks.

Introduction

Psychosis is one of the most common presentations in hospital emergencies and can sometimes pose significant challenges for physicians. The main challenges in managing psychosis include the uncooperativeness of patients during the acute phase and the unavailability of collateral resources, particularly when the patient is brought in from the street [1]. Physicians must remain vigilant to avoid overlooking organic disorders that present with behavioral disturbances. Approximately three out of 100 people will experience at least one episode of psychosis during their lifetimes.

During psychosis, patients’ thoughts and perceptions are distorted, leading to difficulty in distinguishing what is real from what is unreal, which can result in violent behavior.

The symptoms of psychosis can be categorized into two dimensions [2]:

Positive symptoms: These involve the acquisition of new symptoms, including delusions, hallucinations, disorganized speech, and disorganized behavior.
Negative symptoms: These involve the loss of abilities or functions, such as alogia, avolition, flattening of affect (reduced facial expression), self-neglect, or social withdrawal.

Psychosis can occur in various psychiatric disorders, such as schizophrenia spectrum disorders, bipolar disorder, and major depressive disorder. It can also manifest as a result of substance use or other medical conditions [3].

General Approach and History Taking

Always ensure the safety of yourself and your staff. Be mindful of both verbal and nonverbal communication. Listen actively to your patient and demonstrate genuine interest in their story. Use open-ended questions to encourage the patient to express what’s on their mind. Maintain a neutral stance and avoid showing approval or disapproval unless absolutely necessary. Be honest and sincere to build a trusting relationship.

Remember, when there is a risk to the patient or others, confidentiality may need to be overridden. Ensure that you gather the highest-quality information to inform your decisions. Perform a thorough physical examination and order the necessary investigations. Always consider potential organic causes of psychiatric manifestations.

Document your assessment and decisions clearly and comprehensively. Do not hesitate to act immediately if the situation demands urgent intervention [4].

Evaluating an acutely agitated patient presents unique challenges, as obtaining a thorough history is often difficult [5,6]. Despite these limitations, gathering as much information as possible is critical, and collateral information from family, emergency personnel, or police can be invaluable. Key elements to obtain include the patient’s past medical and psychiatric history, including any current or past psychotropic medications and known allergies. A detailed review of home medications and social history—such as alcohol use, substance abuse, living situation, and caregiving arrangements—can provide important context. Recent health changes, such as headaches, which might suggest an intracranial process, or dysuria in elderly patients, which could indicate urosepsis, should also be explored. Establishing the patient’s baseline mental status is vital to differentiate acute changes from pre-existing conditions. While history is often a cornerstone of diagnosis, in cases of acute agitation, a thorough physical examination becomes even more essential due to the frequent limitations of the patient’s ability to provide accurate information.

Differential Diagnoses

When evaluating a patient presenting with acute agitation or psychosis, it is essential to consider a broad differential diagnosis encompassing both organic (medical) and inorganic (psychiatric) causes. Organic causes are often rooted in medical conditions such as hypercalcemia, hypercapnia, hypoxia, and infections like encephalitis, meningitis, or sepsis. Substance-related causes, including the use of alcohol, hallucinogens, steroids, stimulants, or synthetic marijuana, must also be considered. Other organic disorders, such as delirium, hypoglycemia, stroke, carbon dioxide poisoning, neurosyphilis, Wilson’s disease, AIDS, vitamin B12 deficiency, and drug overdose, should be ruled out early in the evaluation. Drug-related problems, including intoxication, withdrawal, or complications like Wernicke’s encephalopathy, also warrant investigation [5,6].

In contrast, inorganic causes are primarily psychiatric and include schizophrenia spectrum disorders, bipolar disorder, posttraumatic stress disorder (PTSD), psychotic depression, and mood disorders with psychotic features, such as major depressive disorder or bipolar affective disorder. Other psychiatric considerations include malingering, factitious disorders, personality disorders (e.g., schizoid, schizotypal, or borderline personality disorders), and autistic spectrum disorders [5,6].

Differentiating between organic and inorganic causes is critical, particularly in cases of acute, undifferentiated agitation where limited history and physical examination findings may complicate the assessment. Organic causes often present with abnormal vital signs, disorientation, fluctuating symptoms, or signs of trauma, indicating an underlying medical condition. In contrast, inorganic causes typically lack these features, suggesting a primary psychiatric etiology. A thorough evaluation of symptoms and key clinical features is essential to guide diagnosis and management effectively [5,6].

Physical Examination

In cases of acute agitation, a thorough physical examination is critical due to the typically limited history and review of systems. The examination should include a comprehensive neurologic evaluation and a head-to-toe inspection for signs of trauma or injury. Although a full neurologic examination may not always be feasible during the initial assessment, it should be completed as soon as possible and before final disposition [6].

The first priority in the physical examination is to assess and ensure the patient’s airway, breathing, and circulation (ABCs) are intact. This process begins with a focus on safety, as the patient may pose an immediate threat to themselves or medical staff. Factors such as the patient’s age, psychiatric history, suspected or known substance abuse, and the severity of their agitation should be considered when determining the need for intervention, including medication. The patient should be placed on monitors, and a complete set of vital signs, including temperature, should be obtained [6].

The primary survey of the patient can be guided by the mnemonic “ABCDE” [6]. A stands for airway, assessing its patency to ensure there are no obstructions. B involves evaluating respiratory effort and adequacy. C focuses on circulation, ensuring adequate perfusion and ruling out hypotension or arrhythmias. D addresses disability by assessing the patient’s level of consciousness and screening for reversible causes of altered mental status, such as hypoglycemia, hypoxemia, or abnormal pupil responses. Finally, E involves exposing the patient fully by changing them into a hospital gown to facilitate a rapid visual assessment for trauma or concealed items such as weapons.

A full neurologic examination should be performed as soon as possible to evaluate for underlying neurologic conditions contributing to the agitation [6]. Additionally, a head-to-toe inspection is essential to identify any signs of trauma or physical injury that may explain the presentation [6]. In cases of acute undifferentiated agitation, the examination findings can help differentiate between organic and inorganic causes. Organic causes are often associated with abnormal vital signs, disorientation, fluctuating symptoms, or signs of trauma. In contrast, inorganic causes, such as primary psychiatric conditions, typically lack these features. A systematic and detailed physical examination is crucial for identifying the underlying cause and guiding appropriate management.

A thorough physical examination is also important, as individuals with psychiatric disorders have a mortality rate 2-4 times higher than that of the general population. Deviations in vital signs may signal infections, while abnormalities in pupil size (constriction or dilation) can indicate substance use or withdrawal. Signs such as optic neuritis, neuropathy, and muscle weakness should prompt consideration of multiple sclerosis. A bull’s-eye rash suggests Lyme disease, while a malar rash may indicate systemic lupus erythematosus (SLE).

Dermatitis, particularly on exposed skin, may point to pellagra (vitamin B3 deficiency), and choreiform movements raise suspicion for Huntington’s disease. Findings such as a pill-rolling tremor and bradykinesia are characteristic of Parkinson’s disease, whereas tremor, dysarthria, and gait disturbances may suggest Wilson’s disease. Cognitive assessments revealing memory impairment and disorientation are consistent with dementia, while deficits in attention and orientation often indicate delirium [7].

Diagnostic Testing

The investigation of psychosis should be guided by findings from the physical examination, ensuring that potential underlying medical causes of behavioral disturbances are identified and addressed. A series of common tests are routinely performed to evaluate possible contributing factors.

Hematology screening is conducted to rule out anemia, which can impact mental and physical health. Urea and creatinine levels are measured to assess for uremia, a condition associated with kidney dysfunction that may present with altered mental status. Similarly, glucose levels are checked to exclude hypoglycemia or hyperglycemia, both of which can lead to behavioral disturbances or psychosis.

Urine screening plays a pivotal role in identifying substance abuse, a common and reversible cause of psychotic symptoms [8]. Additionally, urine analysis is performed to detect urinary tract infections or alterations in pH, which could indicate tampering, such as dilution with water, in cases of drug screening.

Inflammatory and autoimmune causes are considered through tests like ESR (erythrocyte sedimentation rate), which helps identify systemic inflammatory processes, and antinuclear antibodies (ANA), used to rule out autoimmune diseases that may present with neuropsychiatric symptoms. Screening for infectious diseases is crucial, particularly for conditions like HIV, hepatitis B and C, and neurosyphilis, which are known to affect the central nervous system and contribute to psychosis.

For suspected metabolic or genetic causes, ceruloplasmin levels may be assessed to rule out Wilson’s disease, a rare disorder that can lead to neuropsychiatric symptoms. CT scans are considered in specific circumstances, such as cases of late-onset psychosis, to identify structural brain abnormalities or other intracranial pathologies [9].

These investigations provide a systematic approach to diagnosing psychosis by addressing potential medical, infectious, metabolic, and autoimmune causes, ensuring comprehensive and accurate patient evaluation.

Management

The management of psychosis, particularly in acute cases, requires a holistic approach grounded in the biopsychosocial model, addressing biological, social, and psychological factors to ensure comprehensive care. The primary goals are to recognize the issue early, intervene before behavior escalates, stabilize life-threatening conditions, and ensure the safety of both the individual and others [6]. A systematic approach combining non-pharmacological and pharmacological interventions is critical for achieving these objectives while addressing the underlying causes of agitation or psychosis [10].

A thorough risk assessment is an essential first step for patients presenting with acute psychosis or agitation in the emergency department. Tools such as the unstructured interview, HCR-20, and DASSA scales can help determine the appropriate level of observation and the patient’s disposition [11]. When verbal de-escalation or medication fails to control aggression, physical or mechanical restraints may be necessary. Before applying restraints, the physician should clearly explain the rationale to the patient, and staff should remain nearby to provide reassurance, alleviate fear, and release the patient as soon as they are calm. This integrated approach ensures patient safety while promoting stabilization and recovery.

The first step in managing an acutely agitated or psychotic patient is to assess and ensure that the patient’s airway, breathing, and circulation (ABCs) are intact. If the patient poses an immediate threat to themselves or medical staff, factors such as age, psychiatric history, substance use, and severity of agitation should guide the intervention. Patients should be placed on monitors, and a complete set of vital signs, including temperature, should be obtained. A primary survey using the ABCDE mnemonic is critical (details are given in the physical examination section):

A: Assess airway patency.
B: Evaluate respiratory effort and adequacy.
C: Ensure adequate circulation, ruling out hypotension or arrhythmias.
D: Assess consciousness, check pupils, and measure blood glucose.
E: Fully expose the patient to identify signs of trauma or concealed weapons.

The management of psychosis is best approached through a biopsychosocial model, which addresses biological, social, and psychological factors across three stages: immediate, intermediate, and long-term management. This structured approach combines non-pharmacological and pharmacological strategies, creating a comprehensive framework to ensure patient safety, stabilization, and recovery while preventing future episodes [6].

Biological management focuses on medication to address the symptoms of psychosis. In the immediate phase, oral antipsychotics should be offered, with injectable options used if the patient refuses. Pharmacological interventions typically involve the use of antipsychotics and benzodiazepines [6], administered intramuscularly or intravenously for rapid tranquilization. Haloperidol, an antipsychotic, is effective for patients with a known history or high suspicion of psychosis [6]. Lorazepam, a benzodiazepine, is preferred for undifferentiated agitation or psychosis due to its anxiolytic properties and efficacy in cases of substance-related psychosis, such as PCP intoxication or alcohol withdrawal [6]. During the intermediate phase, medication dosages should be adjusted, and side effects closely monitored. In the long-term phase, maintaining a stable medication regimen helps prevent relapse and ensures sustained symptom control.

Social management emphasizes the importance of stabilizing the patient’s environment and facilitating reintegration. Immediate interventions may include hospital admission to relieve family burdens and ensure patient safety. In the intermediate phase, a social study can identify stressors contributing to the psychosis, while long-term support focuses on helping the patient return to work or prior activities to promote social reintegration.

Psychological management addresses both the patient’s and family’s understanding and adaptation to the condition. In the immediate phase, family education provides insight into the condition and support mechanisms. Non-pharmacological strategies are essential for creating a safe and calming environment [6]. These include environmental modifications such as screening for weapons, minimizing noise, and dimming lights to reduce sensory overstimulation. De-escalation techniques, such as establishing rapport, addressing basic needs (e.g., safety, hunger, and comfort), and maintaining a calm, respectful demeanor, can effectively reduce agitation [6]. Acknowledging the patient’s feelings, respecting personal space, and avoiding confrontational behavior further enhance the effectiveness of these strategies. When non-pharmacological approaches fail, mechanical restraints or seclusion may be used as a last resort, though these measures carry risks and should be applied cautiously. During the intermediate phase, psychometric tools like the Positive and Negative Syndrome Scale (PANSS) can assess symptom severity and progression. The long-term phase emphasizes ongoing psychological support to prevent relapse, enhance insight, and promote well-being.

Medications

The pharmacological management of agitated patients involves the use of various drug categories, each tailored to the severity of agitation and underlying clinical conditions. Below is an overview of the commonly used pharmacological agents, their dosages, onset times, and important considerations [1].

First-Generation Antipsychotics

Haloperidol (Haldol)
Haloperidol is commonly used for agitation across mild, moderate, and severe cases. The dosage varies depending on the severity: 2.5 mg orally for mild cases, 5 mg orally for moderate agitation, and 5 mg intramuscularly for severe agitation. The time of onset is approximately 30 minutes for all routes. However, haloperidol carries a high risk of extrapyramidal symptoms (EPS). Co-administration with agents such as benztropine, diphenhydramine, lorazepam, or promethazine can help reduce this risk. Care should be taken to avoid combining three of these medications simultaneously. Intravenous use is associated with an increased risk of QTc prolongation, and the medication may lower the seizure threshold. The maximum daily dose is 30 mg, and repeat dosing is allowed every 0.5–4 hours as needed.
Droperidol (Inapsine)
Droperidol is primarily used in severe agitation, with a dose of 5 mg administered intramuscularly or intravenously. The onset of action is faster than haloperidol, typically around 15 minutes. It shares a similar risk profile for EPS and QTc prolongation. Combining droperidol with midazolam (5 mg) is recommended to optimize efficacy. The maximum daily dose ranges between 10–20 mg.

Second-Generation Antipsychotics

Olanzapine (Zyprexa)
Olanzapine is effective for agitation and can be administered as 5 mg orally disintegrating tablets (ODT) for mild cases, 5–10 mg ODT for moderate cases, and 10 mg intramuscularly for severe agitation. The onset of action is approximately 15–60 minutes depending on the route of administration. Concomitant use with benzodiazepines should be avoided within one hour. The maximum daily dose is 20 mg.
Risperidone (Risperdal)
Risperidone is used at 1 mg ODT for mild agitation and 2 mg ODT for moderate agitation, with an onset time of approximately 60 minutes. It is particularly effective for undifferentiated or substance-related agitation but should not be used in cases of CNS depressant intoxication. Risperidone carries the highest risk of EPS among second-generation antipsychotics and may cause orthostatic hypotension. Repeat dosing is allowed every 4–6 hours, but caution is advised for doses exceeding 10 mg per day.
Ziprasidone (Geodon)
Ziprasidone is typically reserved for severe agitation, with doses of 10–20 mg intramuscularly and an onset time of 15–30 minutes. It has a high risk of QTc prolongation, exceeding even that of haloperidol, making it unsuitable for patients with cardiac disease or pre-existing QTc prolongation. The medication requires reconstitution before administration, and the maximum daily dose is 40 mg.

Benzodiazepines

Lorazepam (Ativan)
Lorazepam is a versatile benzodiazepine used for mild agitation (2 mg orally), moderate agitation (5 mg intramuscularly or 2.5 mg intravenously), and severe agitation (10 mg intramuscularly or 5 mg intravenously). The onset of action is 20–30 minutes for oral administration and faster for intramuscular or intravenous routes. While effective for undifferentiated agitation, caution is required in patients with CNS depression (e.g., ethanol intoxication).
Midazolam (Versed)
Midazolam, administered as 5 mg intramuscularly or intravenously, has a faster onset time of 5–15 minutes depending on the route. It is often used in combination with haloperidol or droperidol for severe agitation. Care must be taken due to its sedative effects.

Dissociative Anesthetic

Ketamine (Ketalar)
Ketamine is a dissociative anesthetic used for severely agitated patients, such as those experiencing excited delirium. Doses range from 1–2 mg/kg intravenously or up to 5 mg/kg intramuscularly, with an onset time of 1–2 minutes (IV) or 3 minutes (IM). Ketamine can cause emergence reactions, bronchorrhea, and, rarely, laryngospasm, and may increase the need for intubation. It is known to elevate heart rate, cardiac output, and blood pressure, making it suitable for patients requiring rapid sedation.

When To Admit This Patient

Disposition decisions for acutely agitated or psychotic patients should be guided by the underlying cause of the agitation, once the patient has been stabilized [6]. For cases involving organic causes, such as sepsis, acute intracranial hemorrhage, or severe metabolic disturbances, hospitalization is necessary until the underlying condition is adequately treated and stabilized. Patients with substance-induced psychosis may be eligible for discharge if they are no longer clinically intoxicated and have returned to their baseline mental status. However, if a thorough medical evaluation reveals no medical cause for the agitation or psychosis, the patient should undergo a psychiatric assessment [6]. Psychiatric admission is typically indicated for patients with acute psychosis due to an underlying psychiatric disorder if they pose a high risk of harm to themselves or others. Additionally, admission is strongly recommended for first episodes of psychosis attributed to psychiatric causes to ensure appropriate evaluation and management [6].

Clinical Pearls

Patients with a brief psychotic disorder experience psychotic symptoms that last at least one day but not more than one month, with gradual recovery. If symptoms persist beyond one month but less than six months, the condition is termed schizophreniform disorder. If symptoms extend beyond six months, it is classified as schizophrenia [12].
Children and elderly patients should generally be dosed at the lower end of the dosing spectrum to account for their increased sensitivity to medications.
Neuroleptic malignant syndrome can develop at any time during treatment. Physicians should remain vigilant for clinical symptoms, which include hyperthermia, muscle rigidity, altered mental status, and autonomic dysregulation.

Revisiting Your Patient

This patient presented with prominent symptoms of grossly disorganized behavior, auditory hallucinations, and paranoid delusions, followed by a rapid return to baseline mental state, consistent with a diagnosis of Brief Psychotic Disorder (BPD) [12]. This diagnosis includes two specifiers: with marked stressors or without marked stressors, previously classified under the term Brief Reactive Psychosis.

When a patient is admitted with an unclear duration of psychotic symptoms, they are often initially diagnosed with Unspecified Psychotic Disorder. However, if symptoms resolve within one month, the diagnosis is revised to Brief Psychotic Disorder. Antipsychotic treatment has been shown to reduce the duration of symptoms in BPD, facilitating quicker recovery. If symptoms persist beyond one month, the diagnosis transitions to Schizophreniform Disorder; persistence beyond six months supports a diagnosis of Schizophrenia.

Positive symptoms, such as hallucinations and delusions, are generally associated with a better prognosis than negative symptoms due to their typically acute onset and favorable response to treatment. It is critical to exclude organic etiologies, medication side effects, or substance-induced psychosis through a comprehensive physical examination and targeted investigations based on clinical findings. In this case, all relevant investigations were unremarkable, supporting a primary psychotic diagnosis.

Author

Mazin A Mukhtar

Dr. Mazin Mukhtar is a psychiatrist with over 15 years of experience, currently practicing at Amal Hospital in Dubai. Before moving to Dubai, Dr. Mukhtar served as an Assistant Professor of Psychiatry at the University of Bahri, where he was appointed as Head of the Department in 2015. In addition to his qualifications in psychiatry, Dr. Mukhtar has a strong interest in leadership and holds a Professional Diploma in Clinical Leadership from the Royal College of Surgeons of Ireland. He also possesses a Clinical Diploma in Cognitive Behavioural Therapy (CBT) from Notting Hill College.

Listen to the chapter

References

Roppolo LP, Morris DW, Khan F, et al. Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA (Best Practices in the Evaluation and Treatment of Agitation). J Am Coll Emerg Physicians Open. 2020;1(5):898-907. doi:10.1002/emp2.12138.
Psych Central. What Are the Symptoms of Psychosis? Updated May 28, 2021. Accessed January 10, 2025. https://psychcentral.com/lib/symptoms-of-psychosis#signs-and-symptoms.
National Institute of Mental Health. Understanding Psychosis. Updated 2023. Accessed January 10, 2025. https://www.nimh.nih.gov/health/publications/understanding-psychosis.
Harrison PJ, Cowen P, Burns T, Fazel M. Shorter Oxford Textbook of Psychiatry. 7th ed. Oxford University Press; 2018.
Sadock BJ, Sadock VA, Ruiz P. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 11th ed. Wolters Kluwer; 2015.
Chan M, Moukaddam N, Tucci V. Stabilization and Management of the Acutely Agitated or Psychotic Patient. International Emergency Medicine Education Project. Accessed January 10, 2025. https://iem-student.org/stabilization-and-management-of-the-acutely-agitated-or-psychotic-patient/.
Vyas CM, Petriceks AH, Paudel S, Donovan AL, Stern TA. Acute Psychosis. Prim Care Companion CNS Disord. 2023;25(2). doi:10.4088/pcc.22f03338.
Reidy L, Junquera P, Van Dijck K, Steele BW, Nemeroff CB. Underestimation of substance abuse in psychiatric patients by conventional hospital screening. J Psychiatr Res. 2014;59:206-212. doi:10.1016/j.jpsychires.2014.08.020.
Khandanpour N, Hoggard N, Connolly DJA. The role of MRI and CT of the brain in first episodes of psychosis. Clin Radiol. 2013;68(3):245-250. doi:10.1016/j.crad.2012.07.010.
Schleifer JJ. Management of acute agitation in psychosis: an evidence-based approach in the USA. Adv Psychiatr Treat. 2011;17(2):91-100. doi:10.1192/apt.bp.109.007310.
Frick PJ, Barry CT, Kamphaus RW. Structured Diagnostic Interviews. In: Clinical Assessment of Child and Adolescent Personality and Behavior. 3rd ed. Springer; 2010:253-270. doi:10.1007/978-1-4419-0641-0_11.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. American Psychiatric Publishing; 2013.

Reviewed and Edited By

Arif Alper Cevik, MD, FEMAT, FIFEM

Tired before the long journey

May 5, 2021April 30, 2021 ~ Carmina Shrestha, Nepal ~ Leave a comment

Most articles related to rural health bombard us with problems, the solutions to which are often out of reach. We can classify most of the issues into large and sometimes intersecting domains; logistics, workforce, finance, and education. Also, most reports on medical education boast its universality. We can build the two arguments; 1) There is an apparent lack of a well-trained workforce in the rural and 2) We should solve this problem by incentivizing urban trained physicians to work in the rural. The second part of that argument doesn’t always hold; a discussion for other times.

A solution many governments, including that of Nepal, implement in solving the apparent lack of physicians is to produce more paramedics. I have before, and I continue to argue that paramedics have a significant role in rural health. Certain aspects of rural health deserve a bit more robust education and training. One such aspect is mental health.

A 67 years female visited a rural PHC. The endless excuse of a road through the forest, down the hill, and across the river brought her to a very dedicated health assistant. She complained of fatigue. “Do you have any abdominal pain?” asked the concerned provider. “No,” replied the old lady spontaneously. Almost as if she knew where this discussion is headed. “Are you bleeding from anywhere?” “No.” “Fever? Headache? Nausea? Vomiting? Diarrhea? Anything?” The old lady kept nodding no as the list of symptoms, as long as the road that brought her to the PHC continued. A multivitamin was prescribed before calling up the next patient. That week I talked about depression with my paramedics.

Mental health is an essential yet ignored aspect of health. As universal as that is, my two years in Beltar made me acutely aware of mental-health-related ignorance that prevails among the providers in the rural.
Paramedics we produce are not equipped enough to deal with a lot of mental health issues. After being a boss, a colleague, and a friend to many hardworking and dedicated paramedics in rural Nepal, I can confidently tell that they seek to understand more. The lack certainly is on the delivery side. We need to figure out ways to train our rural providers to better manage mental health issues.

While some rural health issues are extensive and require significant effort to solve, others are easy to address yet equally important. I sometimes wonder if we should incentivize physicians who serve in the rural for a limited time to train the paramedics who stay there longer. Being in the same room as the patient who could not articulate her symptoms of depression and the paramedics who, while being very attentive, wasn’t adequately trained to identify subtle signs of depression can be a good incentive. But I strongly argue that is not a good kind of incentive.

An update to the curriculum, refresher training and provision of adequate resources to learn about mental health can help the providers of rural help many of these patients who are “tired” before their long journey to the PHC.

[cite]

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Suicide – An Emergency Priority of Public Health Care

October 19, 2020October 23, 2020 ~ Leah Sarah Peer, Canada ~ Leave a comment

A significant number of emergency department visits annually arise as a result of intentional self-harm. Although no accurate description explains what leads to suicide or what comes after, it is a multifaceted phenomenon of public health urgency during a global health crisis. In the United States alone, suicide is the 10th leading cause of death and worldwide claims up to 800,000 lives each year. The international community must unite to come up with solutions to prevent the loss of life, as every single life lost is one too many.

With the COVID-19 pandemic, such an emergency naturally affects both individuals’ health and well-being and the communities in which they live. Unprecedented times unleash various emotional reactions from isolation, grief and trauma to other unhealthy behaviours, noncompliance with public health guidelines and the exacerbation of mental health conditions. While those who’ve been emotionally, sexually or physically abused in the past are more vulnerable to the psychosocial effects of a crisis, supportive interventions such as the Zero Suicide program and Cognitive Behavioural Therapy designed to promote wellness and enhance coping should be implemented [1].

In honour of World Suicide Prevention Week, and World Suicide Prevention Day held on the 10th of September every year, it is important to raise attention to the global importance of suicide prevention. Suicide impacts all people and particularly the world’s most marginalized and discriminated groups. It is a huge problem in developed countries and just as serious in low-and middle income countries where resources and access to healthcare professionals are scarce. In many regions of the world, the taboo and stigma surrounding suicide persist, causing people in need of help to be left alone.

Suicide prevention with awareness campaigns ought to be prioritized on the global health and public policy agendas as a major public health issue. Routine screening for suicidal ideation by health care professionals providing care should identify and assess suicide risk among populations. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), risk factors of suicide include mental illness, substance use diagnoses, trauma or conflict, loss, family history of suicide, and previous suicide attempts [2].

Effectively implementing suicide prevention strategies at the populational, sub-populational and individual level requires ensuring patients’ lethal means are restricted, reduced, and that all accesss to weapons of self-harm are removed from the nearby environments. Healthcare providers should keep up to date with new developments, research, and technologies screening for suicidal ideation, allowing them to effectively serve patients beyond their clinics’ walls. Key to prevention are strong physician patient relationships that help ensure care transitions allow for physicians to act as supportive contacts reaching out with calls, texts, letters and visits to their patients particularly when services are interrupted. With access to technology the role of psychiatrists, and psychologists may continue uninterrupted as telemedicine serves as an effective platform providing patients with access to care, even during lockdowns. Besides these objectives, greater awareness and education into the community means encouraging the responsible portrayal of suicide in mainstream media. A sensitive issue of this magnitude ought to be communicated responsibly placing special attention to not trigger susceptible individuals. With school based interventions, professionals may act sooner before worsened prognosis’ effectively ensuring that access to peer support services is available.

Suicide prevention is a responsibility of healthcare systems, medical professionals and communities. All countries must stand in solidarity and unify in collaboration to battle this common threat as preventing the tragic loss of life to suicide is of utmost importance.

References & Further Reading

In Health and Behavioral Healthcare. (n.d.). Retrieved September 14, 2020, from http://zerosuicide.edc.org/toolkit/treat/interventions-suicide-risk
Psychiatry Online: DSM Library. (n.d.). Retrieved September 15, 2020, from https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596

[cite]

Mindsores

October 12, 2020October 3, 2020 ~ Sajan Acharya, Nepal ~ Leave a comment

The patient said he did not care about his stage IV ulcers. He refused antibiotics for chronic osteomyelitis until we gave him opiates. He denied all other non-opiate alternatives. “The patient has an opiate use disorder but also has pain,” said the pain and palliative doctor. In medicine, we try our best to explain all that a patient is experiencing with one diagnosis. A patient suffering from two different diseases as a diagnosis is frowned upon. But here was a seasoned doctor, speaking with his years of precious experience reflected in his white beard and even whiter apron, telling me that the patient I have barely started to present to him, had two diagnoses.

I had taken care of this patient for some days now. In my head, I would associate all the requests he makes, everything he says, and every single complaint he has, to his addiction. “I do not have an opiate use disorder, I have a pain problem!” said the patient as soon as “addiction” was mentioned. The doctor said, “I know you don’t think you have opiate use disorder.” I thought that was clearly mentioned to calm the patient down. Later I would be surprised to know that the doctor actually meant it.

He gave me an ‘overly simplistic heuristic’ that had helped him remember what patients with substance use disorder are going through. “The first time a patient takes a substance, he feels the intended high. The effect remains for a couple times more. As the effect due to the same dose decreases with subsequent exposure, the patient increases the dose to get the intended effect. This seemingly linear relationship is a tricky one. Soon the patient will depend on the substance only to feel okay. Which, let us remind ourselves, the patient felt before starting to take any substance. Hence, many patients with substance use disorder, claiming they do not do it for the high, they do it because they cannot tolerate “normal” without it. Substance use disorder is a complex topic and one that deserves much more effort and attention than is the scope of this conversation but I hope this ignited an enthusiasm to learn more, in you” That night I read some papers on opiate use disorder.

I sometimes wonder if I am not as sensitive to suffering as my patients are. I wonder if what they taught me about signal transduction in my first year of medical school holds true for day-to-day emotions like it held true for addiction’s pathophysiology. The more we are exposed, the more we desensitize. “Being emotional is understandable but unnecessary and unhelpful”, says Sherlock Holmes in one of his many palimpsests. Maybe I was trying to objectively look at this patient of mine. So much so that it did not occur to me that the patient had stage IV ulcers. All I heard was a cry for the high, which, mistake not, was there. But there was something more, something that was hidden to my objective eyes. In focusing my attention on the patient’s mindsores, I was ignoring his very physical and painful bedsores. I dare say Sherlock was wrong. Only emotions can drive passion. People who are so passionate about the pathways and mechanisms of addiction and people who are emotional about the patients’ problems are the ones who we rely upon to solve this tangled problem of pain and addiction. I appeal to you to acknowledge that this is a complex issue. That is the sole intention of this article. And that is the first step in trying to understand and hopefully help patients with multiple sores.

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A Study in Yellow

September 30, 2019October 4, 2019 ~ Arthur Martins, Brasil ~ 1 Comment

In Brazil and many other countries around the world, we got used to know September as the suicide prevention month, represented by the yellow ribbon, with September 10th being the World Suicide Prevention Day. As said by Sherlock Holmes in “A Study in Scarlet,” “There is a scarlet thread of murder running through the colorless skein of life, and our duty is to unravel it, and isolate it, and expose every inch of it.” Despite the dramatic content of Holmes’s words, it is possible to draw a parallel with the current situation related to suicide in society. There is a visible red stain in front of us, and we need to unravel it, understand it, deal with it. Moreover, everything should start somewhere…

If we think about the role of the emergency department (ED) and the emergency physician in the suicide prevention and response, we will see that it is of indispensable importance, as many patients at risk of attempting suicide are sent to the ED in order to be evaluated and to stay in a “24h safe environment.” Also, many actual suicide attempts arrive at the ED requiring immediate care – for the patient and for the family. However, World Health Organization estimate that for every death by suicide, there are 20 suicide attempts, making us to questioning our capability to give extended care for those patients. Besides, if we look to the big picture, which has suicide one of the major preventable causes of death worldwide, we can ask ourselves how many patients with suicidal thoughts are seen at the ED every week due to other health problems and go unnoticed. The ED, along with the primary care in the communities, is the main entry door to the health care system and like no other, act as a nexus between outpatient and inpatient care. Gairin et al. have found that approximately 40% of people who died by suicide have visited an ED in the year before, one third of them because of self-harm injuries. (1) If we look to the last attendance before death, those who have presented with self-harm injuries presented less than two months before ending their lives.

With all of this in mind, what strategies we can use to assess suicidal thoughts and behavior at the ED? Which reliable tools are available for emergency physicians to recognize and classify these patients? Let’s take a look at the last American College of Emergency Physicians (ACEP) recommendations.

ICAR2E

IDENTIFY

IDENTIFY suicide risk – actively ask about suicidal ideation.

Evidence shows that as many as 10% of suicidal patients may not disclose ideation unless asked (1)
In the other hand, none of the standardized questionnaires and methods currently available have strong evidence supporting its use as a universal screening tool at the ED.
As there is no universally accepted standard reference for suicidal ideation, the sensitivity and specificity of these methods are unknown.
The authors’ conclusion is that suicidal ideation should be screened in the ED, as recommended for other authorities (2,3).

COMMUNICATE

COMMUNICATE with the patient.

Actively ask maybe not enough when we talk about mental health problems with patients and make them feel comfortable is the first step to improve the communication
The ED is not what we can call a “cozy” or “receptive” environment for most of the patients, so the authors recommend providers try to make it an emotionally-safe place, using methods to improve physical and mental comfort of the patient (i.e giving blankets if its cold, providing food, do not stigmatize)
Ask open questions as “what’s that been like for you?” and be clear on what you are asking when necessary – prefer “are you thinking about ending your life?” over “are you gonna be ok?”.

ASSESS

ASSESS for (medical) life-threats and ensure (environmental) safety.

The authors did not find ED-based studies assessing this topic specifically, but a consensus emerges when we think on the best practice for this step of evaluation: A complete history, a good physical exam, mental status assessment and laboratory testing as needed.
Regarding the environment, besides the strategies commented before (communicate), the best practice and the common sense tell us to keep the environment as safe as possible and free any kind of weapons and other objects that could be used for self-harm (sharp objects, loose wires, medications, etc.).
Continuous monitoring should be done in all patients with suicidal ideation, as no ED-based studies are addressing whether all patients should be observed continuously or not.

RISK assessment

This step assumes that, regardless of how the patient was identified (first step), there is suspicion of potential suicide risk.
Even though there is no reliable and easy to use tool to predict which patients will try to commit suicide in the near future, there are lots of evidence establishing risk and protective factors for a suicide attempt.
- Risk factors: previous suicide attempt, access to lethal means, current impaired mental status or psychiatric illness (psychosis, depression, mood changes, anxiety crisis), substance abuse, external stressors such death of loved one, financial crisis, divorce.
- Protective factors: family and friends support, established mental care, with patient’s good adhesion, cultural and/or spiritual beliefs
The authors do not recommend any specific risk assessment scale. The evidence for that comes from a meta-analysis from Carter et al.(4) that investigates the predictive validity of risk scales in determining the level of risk. According to the data from this study, the currently available tools have low accuracy, so the authors recommend not to use one scale alone to determine if the patient can be discharged home or not.
With this in mind, the recommendation is that all patients identified as being at potential risk of attempt suicide should go under one standardized tool for risk assessment, using this as a complementary tool, along with mental status examination, history taking and evaluation of risk and protective factors.

Some scales and risk assessment tools to know

Columbia Protocol – link
Patient Safety Screener and Tip Sheet (PSS-3) – link
Secondary screener from ED-SAFE – link

REDUCE the risk

Safety Planning Intervention is a collaborative process in which patient and provider develop a plan on what to do if the symptoms worsen. It usually involves contact with trusted individuals, lethal means counseling, hotlines, and local resources in the community.
The adherence of ED on this practice is very low, although some evidence shows that safety planning could reduce future suicide attempts (5).
Hospitalization is a complicated topic in this scenario. As seen on recommendations above, it is difficult to formally classify a patient as a “high-risk” for suicide in the near future. Knowing that the authors recommend hospitalization for those patients who “felt to be likely to attempt suicide after the discharge,” and voluntary admission should be preferred over involuntary.

EXTENDED CARE beyond the ED visit

There is good evidence that follow-up contact after the ED can help reduce the risk of subsequent suicidal behaviors.
The follow-up contact can be made by letters, phone calls, postcards and even in-person visits.
Of course, a follow-up with a mental health professional is key to good care of these patients.

How about us?

Despite all the fame and social prestige traditionally linked to doctors, it is well documented that physicians, residents and medical students experience one of the highest rates of depression and suicidal behaviors among all professions. More than that, physicians can have a risk of suicide from twice to even six times higher than the general population depending on the country (6,7). And it starts early: almost 50% of medical students experience burnout before residency (8). High rates of depression, sleep deprivation, substance abuse, stressful work environment, burnout, easy access to and wide knowledge of lethal means, all of these contribute to killing our colleagues, professors, students, and friends. Four hundred physicians per year in the US (6,7) – more than once per day. Speaking specifically of emergency physicians and residents, the specialty had always reached the top 5 in the burnout rankings (8) and less than one third will seek for help, according to a Medscape survey. We have been trained to save lives, but sometimes we also need to be saved – from ourselves.

If you are in crisis, experiencing burnout symptoms, feeling sad or suicidal, or know a friend who is, please seek for help as soon as you can.

References

Gairin, I., House, A., & Owens, D. (2003). Attendance at the accident and emergency department in the year before suicide: Retrospective study. British Journal of Psychiatry, 183(01), 28–33. doi:10.1192/bjp.183.1.28
Suicide Prevention Resource Center. Caring for adult patients with suicide risk: A consensus guide for emergency departments. 2015; http://www.sprc.org/sites/default/files/EDGuide_full.pdf. Accessed May 30, 2018.
Detecting and treating suicide ideation in all settings. Sentinel Event Alert. 2016;56:1-7.
Carter G, Milner A, McGill K, Pirkis J, Kapur N, Spittal MJ. Predicting suicidal behaviours using clinical instruments: systematic review and meta-analysis of positive predictive values for risk scales. Br J Psychiatry. 2017;210(6):387-395.
Miller IW, Camargo CA, Jr., Arias SA, et al. Suicide Prevention in an Emergency Department Population: The ED-SAFE Study. JAMA Psychiatry. 2017;74(6):563-570.
Stehman CR, Testo Z, Gershaw RS, Kellogg AR. Burnout, Drop Out, Suicide: Physician Loss in Emergency Medicine, Part I. West J Emerg Med. 2019;20(3):485–494. doi:10.5811/westjem.2019.4.40970
Kishore S, Dandurand DE, Mathew A, et al. Breaking the culture of silence on physician suicide. National Academy of Medicine. 2016. Available at: https://nam.edu/breaking-the-culture-of-silence-on-physician-suicide/Accessed March 15, 2019.
Burnout in medical students before residency: A systematic review and meta-analysis Frajerman, Ariel et al. European Psychiatry, Volume 55, 36 – 42

[cite]

Managing Psychosis In The ED

July 11, 2018July 11, 2018 ~ iEM Education Project Team ~ Leave a comment

Case 1. It is a quiet Wednesday night in the emergency department when you suddenly hear someone coming down the hall continuously spouting out a string of profanities. You leave the comfort of your chair to see what the commotion is all about only to find a 37-year-old female brought in by police for altered mental status. She is acutely agitated on presentation, spouting obscenities non-stop, refusing to answer questions and uncooperative with a physical exam.

Case 2. As you are pondering your next step, you see the paramedics wheeled an older gentleman past you and into the next room. You step into the next room to get a report. The family is at the bedside and states the patient is an 82-year-old male with a history of hypertension and BPH who has been increasingly confused and aggressive over the past two days. You note that he is mildly tachycardic when you hear the PA system announce, “Security is needed in the critical care hallway.”

Case 3. A nurse pops her head into the room and requests your immediate assistance. You follow him down the hall and see your charge nurse along with three security officers trying to hold down a male patient. The patient, who appears to be in his late twenties, is actively kicking and trying to bite and spit at the medical staff. He appears flushed and diaphoretic.

You Have New Patients!

Patient 1

Patient 2

Introduction

General Approach

Differential Diagnoses

Delirium

Dementia

Depression

Psychosis

History and Physical Examination Hints

Associated Features

Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar)

Diagnostic Tests and Interpretation

Management

Special Patient Groups and Other Considerations

When To Admit This Patient

Clinical Pearls

Revisiting Your Patient

Patient 1

Patient 2

Author

Mehnaz Zafar Ali

Listen to the chapter

References

Reviewed and Edited By

Arif Alper Cevik, MD, FEMAT, FIFEM

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Like this:

You Have A New Patient!

Introduction

General Approach

Physical Examination

Key Aspects of the Physical Examination

Integrating Findings with Further Testing

Risk Assessment

Through History

Helpful Interview Questions [12] for Assessing Suicide Risk:

Protective Factors:

Mental Status Examination

Differential Diagnoses

Risk Factors and Diagnostic Approach

Differential Diagnoses for Suicide Attempts

Management

When To Admit This Patient

Further Management Considerations

Inpatient Management

Outpatient Management

Community Management

Clinical Pearls

Discharge Medications:

Anti-Suicide Medications:

Revisiting Your Patient

Author

Faisal A. Nawaz

Listen to the chapter

References

Reviewed and Edited By

Arif Alper Cevik, MD, FEMAT, FIFEM

Sharing is caring

Like this:

You Have A New Patient!

Introduction

General Approach and History Taking

Differential Diagnoses

Physical Examination

Diagnostic Testing

Management

Medications

First-Generation Antipsychotics

Second-Generation Antipsychotics

Benzodiazepines

Dissociative Anesthetic

When To Admit This Patient

Clinical Pearls

Revisiting Your Patient

Author

Mazin A Mukhtar

Listen to the chapter

References