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.
Owens D, Horrocks J, House A. Fatal and non-fatal repetition of self-harm: Systematic review. Br J Psychiatry. 2002;181:193-199. doi:10.1192/bjp.181.3.193.
National Institute of Mental Health. Frequently Asked Questions About Suicide. Accessed January 10, 2025. https://www.nimh.nih.gov/health/publications/suicide-faq.
Ernst CL, Goldberg JF. Antisuicide Properties of Psychotropic Drugs: A Critical Review. Harv Rev Psychiatry. 2004;12(1):14-41. doi:10.1080/10673220490425924.

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 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.

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References

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Reviewed and Edited By

Arif Alper Cevik, MD, FEMAT, FIFEM

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.