The document defines psychiatric emergencies, highlighting the risk factors for violence and suicide associated with mental illness and substance abuse. It outlines assessment techniques, de-escalation strategies, pharmacological interventions, and necessary precautions when treating agitated patients, alongside addressing suicidal ideation and risk assessment. Furthermore, it emphasizes the importance of supportive environments and the role of mental health services in preventing suicide and managing crises.

1. Emergency psychiatric
conditions

2. Definition
A psychiatric emergency is any unusual behaviour, mood, or thought, which if not
rapidly attended to may result in harm to a patient or others.

3. Psychiatric emergencies arise in the context of
1. Chronic psychiatric illness
2. Consequence of medical illness that presents with psychiatric
symptoms
3. Adverse drug reaction
4. Intoxication
5. Drug-drug interaction.
6. When a patient is the victim of severe physical or emotional
trauma, and is unable to respond adequately without
professional intervention.

4. Assessing the risk of violence
Circumstances of violence and characteristics of people involved are
important.
Mental illness carries a 9X greater risk than the general population
particularly paranoid schizophrenia and confused states related to medical
problems.
Substance dependence or abuse carries a 30X increase risk than the
general population!!
Antisocial personality disorder with comorbid substance abuse or
dependence carries greater than 100X the risk compared to the general
population.
Immediate past, recent past and more distant history of violence is the
best predictor of future violence.

5. Behavioral Predictors of violence
Angry words
Loud language
Abuse language
Physical agitation such as making fists, pacing and akasthisia

6. Violence Signs predicting assault:
 Threats
 Anger
 Demanding immediate attention
 Loud voice
 Excitement
 Staring eyes
 Flared nostrils
 Hands clenched or gripping
 Pacing about in the room
 Possessing weapons
 Pushing furniture
 Uncooperativeness and suspiciousness
 Slamming objects
 Sudden movements

7. Keep an eye on your immediate surroundings
Look for potential weapons such as things that can be thrown
Look for objects that the patient could use for self harm
Give yourself and the patient equal access to the door

8. How to de-escalate a patient
Use a calm voice
Sit down with the patient
Maintain adequate physical distance of at least 6 feet
Attempt to establish rapport
Listen to the patient’s concerns

9. Maintain personal space
The comfort zone for most people is hand shaking distance.
The comfort zone for paranoid or agitated patients may be
2-3 X the usual distance.
Remember the patients’ history when you are in their
personal space. When you do a physical exam and you
invade their space they may react defensively.

10. When verbal de-escalation is not enough:
When there is risk of imminent harm and verbal de-escalation has been ineffective
either pharmacologic supports or physical restraints may be needed.

11. Physical restraints
Have restraints, stretcher and restraint keys ready
Use a show of force with 5 or more trained staff who may need
to physically lay hands on the patient. Sometimes gathering
that many clinicians will persuade the patient to comply.
Try to talk the patient into lying on the stretcher

12. If the patient will not comply the team will put the patient in restraints.
Remember people can bite and spit so one of the team will control the
head during the restraining procedure
A minimum of two points ( one arm and one leg)
Risk of infection is high during the process of treating agitated and
aggressive patients.

13. Once the patient is in restraints:
Search the patient for potentially harmful objects such as
lighters, knives
Perform a brief survey for any physical injuries to the patient
including head injury and observe movement in all 4 limbs
Check the head and eyes including eye movements and
pupillary response

14. Pharmacologic Support: Benzodiazepines
Lorazepam is one of the most useful meds in the emergency
setting. In the first 24 hours agitation is as effectively addressed
with lorazepam as antipsychotics even if psychosis is present.
Lorazepam is best absorbed IM. Diazepam and
chlordiazepoxide have erratic absorption. PO or IV
administration of diazepam is effective and actually has a more
rapid absorption than PO lorazepam.

15. Lorazepam is available in PO, IM and liquid forms.
The primary reason not to use a benzodiazapine is its sedative
hypnotic effect which can be additive with other such agents
(ex. Alcohol) resulting in excessive sedation and respiratory
depression.
Patients can have a paradoxical reaction and actually become
more agitated. This is seen in about 5% of the population

16. Pharmacologic support: Antipsychotics
Antipsychotics can be quite effective in reducing agitation.
There are options in the following forms:
PO
IM
Quick dissolving tabs

17. PO antipsychotics
Risperidone (Risperdal) 1-2 mg po upto 6mg/24 hours. Also comes in a rapid
melting tab called Risperdal M-tab.
Olanzapine 10-20mg po upto 20mg/24 hours. Also comes in a rapid melting tab
called Zydis.
Haloperidol 1-5mg po q 1-2 hours upto 30mg/24 hours

18. Extrapyramidal symptoms
Haldol is the most likely to cause extrapyramidal symptoms (eps) followed by
risperidone with the other atypicals having less eps risk.
EPS is most likely to occur in young males and older women.
EPS is usually noted as muscle tightness in limbs, tongue thickness and neck
tightness. More rarely laryngeal and pharyngeal spasm and a sense of choking.

19. NEUROLEPTIC MALIGNANT
SYNDROME(NMS)

20. Idiosyncratic reaction
Prevalence: 0.02-2.4%

21. Causes
Use of neuroleptic drugs
Dopmine depleting drugs
Rapid withdrawal of dopamine agonist drugs
neuroleptic malignant-like syndrome or parkinsonism
hyperpyrexia syndrome

22. Risk factors
The first seven days, 28 days with depot
High starting dose/rapid upward titration
Psychotropic polypharmacy
Concurrent systemic disease

23. Other risk factors
Organic syndromes
Bilateral frontal lesions
Affective disorders
Dehydration
Agitation, exhaustion, and rapid or parentral administration of antipsychotics

24. Evolves rapidly within 24 to 72 hours
 As early as within 24 hours of the first dose
 Average onset: 48-72 hours
It lasts up to 10 to 14 days

25. Diagnosis
Three of the following
•Hyperthermia
•Marked extrapyramidal side effects
•Autonomic dysfunction

26. Hyperthermia
>38
 Resetting of thermostat (caused by dopamine blockade in
hypothalamus causing temperature dysregulation and
profuse sweating)+heat production secondary to muscle
activity
95% of the cases

27.  marked extrapyramidal side effects:
 At least two of the following:
 Marked muscular rigidity
 Cogwheeling
 Occulogyric crisis
 Trismus
 Opisthotonus
 Sialorrhea
 Retrocollis
 Choreathetoid movements
 Tremulousness
 Dysphagia

28. Autonomic dysfunction:
At least two of the following:
Tachycardia
Hypertension
Lability of blood pressure
Urinary incontinence
Marked diaphoresis

29. Two of the above +at least one of the following:
Fluctuating consciousness
Agitated, stuporous, delirious or comatose
97% of the cases
Serum creatinine kinase >1000IU/ml
Over 95% of the cases
Leucocytosis
As a response to stress or tissue damage

30. Other signs
Abnormal liver function tests
Electrolyte imbalances
Hyperkalemia, hyponatremia, hypocalcemia, hypomagnesiumia
As a result of diaphoresis, urinary incontinence, dehydration and renal failure
Rhabdomyolysis
• Myoglobinuria may lead to renal damage.
• Can lead to elevation of lactic acid, aldolase and transaminase.
Metabolic acidosis
• 75% of the cases

31. Diffuse slowing of EEG
Dehydration
Proteinuria

32. Complications
Rhabdomyolysis , myonecrosis, myoglobinuria and renal
failure.
Seizure
Hyperthermia
Myocardial infarction, pulmonary edema, aspiration
pneumonia, arrythmia, cardiac arrest, DIC, and death.

33. Management
Medical emergency
Airway protection, preventing hypoxia, supporting systemic
perfusion, preventing systemic organ failure, restoring the
dopaminergic balance in CNS.
ICU management
Antipsychotics should be stopped.

34. Bromocriptine
• Levodopa and amantidine can also be used.
• Reverse antidopaminergic effects
Dantrolene
• To relieve muscle spasm
• Inhibits excess calcium release
BZD
• Controversial
• Stimulates GABA receptors and may indirectly increase dopaminergic activity and leading to
muscle relaxation.
• It can cause respiratory depression.

35. Supportive measures
Tracheal intubation may be required to establish and
protect the airway.
Mechanical ventilation also may become necessary.
Continuous cardiac monitoring is recommended.
Intravenous therapy should be implemented to correct any
fluid or electrolyte imbalances.

36. Medication Rechallenge
Two weeks “washout” period (Bottoni (2002)
Under strict clinical supervision
Low dose, low potency neuroleptics or atypicals

37. Prevention
Good nutrition
Adequate hydration
Avoid repeated parentral medications
Use of BZDs for agitation
Routine exercises

38. Suicide
Mental disorder, acute emotional distress and hopelessness are common in
emergency settings.
Such problems may lead to suicide or acts of self-harm
Approximately 1/3 of people who kill themselves tell their doctors. More tell family
members about their thoughts therefore getting collateral information from family
members is important.
People who talk about suicide do kill themselves

39. Suicide statistics
The rate of suicide in the general population is 12/100,000.
Suicide is the 2nd
or 3rd
most frequent cause of death in adolescents and young
adults.
Men attempt less often but use more lethal means than women (shooting, hanging,
jumping).
Ethiopia: suicide attempt 0.9-3.2%(risk of
suicide attempt-1,200,000)
completed suicide 7.7/100,000/year(suicide
per year-3,160)

40. Risk factors for suicide
Mental illness including mood disorders, psychotic disorders,
borderline personality disorder, anxiety disorders, substance issues.
Older men (>65) particularly those who have lost a partner
Caucasian
Chronic illness and/or intractable pain
Hopelessness

41. Suicide in the mentally ill
The first year after psychiatric hospitalization for major
depression carries the highest risk.
People with a history of psychiatric hospitalization for major
depression or bipolar disorder have a lifetime suicide risk of
10-20%.
Schizophrenics who have had a psychiatric hospitalization have
about a 10% lifetime risk of suicide.
Substance abuse and dependence also increases the risk.

42. 7 or more needs admission

43. Is there an imminent risk of suicide or self-harm?
» Ask the person and/or carers about:
Thoughts or plans of suicide (currently or in
◆
past month)
Acts of self-harm in the past year
◆
Access to means of suicide (e.g. pesticides,
◆
rope, weapons, knives, prescribed medications
and drugs).
» Look for:
Severely emotional distress or hopelessness
◆
Violent behaviour or extreme agitation
◆
Withdrawal or unwillingness to
◆
communicate.
» The person is considered at imminent
risk of suicide or self-harm if either of
the following is present:
◆ Current thoughts, plans or acts of
suicide
◆ History of thoughts or plans of
self-harm in the past month or acts of
self-harm in the past year in a person
who is now extremely agitated, violent,
distressed or uncommunicative

44. Are there concurrent conditions associated with suicide or
self-harm?
» Assess and manage possible concurrent conditions:
◆ Chronic pain or disability (e.g. due to recent injuries incurred during the
humanitarian emergency)
Moderate-severe depressive disorder
◆
Psychosis
◆
Harmful alcohol or drug use
◆
Post-traumatic stress disorder
◆
Acute emotional distress
◆

45. How to talk about suicide or self-harm
1. Create a safe and private atmosphere for the person to
share thoughts.
Assessment question
1: Has the person recently attempted suicide or self-harm?
» Do not judge the person for being suicidal. » Offer to talk
with the person alone or with other people of their choice.
2. Use a series of questions where any answer naturally
leads to another question. For example:
» [Start with the present] How do you feel?
» [Acknowledge the person’s feelings] You look sad/ upset. I
want to ask you a few questions about it.
» How do you see your future? What are your hopes for the
future?
» Some people with similar problems have told me that they
felt life was not worth living. Do you go to sleep wishing that
you might not wake up in the morning?
» Do you think about hurting yourself?
» Have you made any plans to end your life?
» If so, how are you planning to do it?
» Do you have the means to end your life?
» Have you considered when to do it?
» Have you ever attempted suicide?
3. If the person has expressed suicidal ideas:
» Maintain a calm and supportive attitude » Do not make false
promises

46. Having the patient contract to not kill themselves has little support in research or
practice in preventing suicide; however, if a person cannot agree that he/she will be
safe there is an indication of more risk.
The strength of the contract may depend on a long term meaningful relationship and
strong connection with the provider rather than short term rapport.
talking about suicide often reduces the person’s anxiety around suicidal thoughts,
helps the person feel understood and opens opportunities to discuss the problem
further

47. Suicides are often seen by the patient as problem solving behavior.
Understanding which problems are perceived to be solved can allow for alternative
options to be introduced.
Similarly understanding the rewards in the suicide attempt can help in changing the
contingencies.

48. Prevention
Mental health services and individual providers Government
Mental illness Deliver care in different ways (eg, digital modalities)
develop support for health-care staff affected by adverse
exposures (eg,multiple traumatic deaths)
ensure frontline staff are adequately supported, given breaks
and protective equipment, and can access additional support
Adequate resourcing
for interventions
Experience
ofsuicidal crisis
Clear assessment and care pathways
train expanded workforce
evidence-based online interventions and applications
Crisis helplines
Adequate resourcing
for interventions

49. Government Communi
ties
Friends and
family
Mental
health
services
media
Financial stressors Provide financial safety nets
ensure longer-term measures
Domestic violence access to support and can leave
home
Alcohol consumption monitoring alcohol intake and
reminders about safe drinking
Isolation,entrapment,lon
eliness, And
bereavement
Provide
support
Check in
regularly
Ensure
easily
accessible
help
Access to means restricting access to commonly used
and highly lethal suicide method
Irresponsible media
reporting
Moderate
reporting

50. Suicide prevention cont.
Develop plans for management of symptoms such as anxiety and akathisia.
Develop plans for management of cravings to use drugs.
When appropriate choose meds that decrease the risk of suicide. These include
Lithium for bipolar patients and Clozapine for psychotic patients.
Antidepressants have not been shown to decrease suicide risk in terms of long term
risk.

51. Manage suicidal person
Monitor the person:
Create a safe and supportive environment for the person.
Remove all possible means of self-harm/ suicide and, if possible, offer
a separate, quiet room. However, do not leave the person alone.
Have carers or staff stay with the person at all times.
Regardless of the location, ensure that the person
is monitored 24 hours a day until they are no longer
at imminent risk of suicide.

52. Offer psychosocial support:
◆ DO NOT start by offering potential solutions to the
person’s problems. Instead, try to instill hope. For example:
▸ Many people who have been in similar situations
– feeling hopeless, wishing they were dead – have then discovered that there is hope, and their
feelings have improved with time.
Help the person to identify reasons to stay alive.
◆
Search together for solutions to the problems.
◆
Mobilize carers, friends, other trusted individuals
◆
◆ Providing a positive experience for the patients while on the unit.
◆ A study on inpatient medicine floor found in patients post SA who perceived being treated
kindly has reduced frequency of subsequent suicide attempts