Emergency Psychiatry

Agitated patients who display “excessive verbal and/or motor behavior”-can be loud, disruptive, hostile, sarcastic, threatening, hyperactive, and even combative. This article discusses new best practices and guidelines for agitation.

He wasn’t the first person I met days before I was to start my psychiatric residency, but as I walked about in my new city, he caught my attention much more than most. As psychiatrists, we typically assume that we will hear the inside stories, even if in bits and pieces, that will help us better understand and help patients. But perhaps we are too expectant . . .

Here we present how to assess safely patients who become oppositional or menacing in a clinic or office.

Here we address some of these problems of meaningless phrasing, empty shells, and template-distorted recording in an attempt to improve clinical documentation for both clinical care and risk management.

Every case of patient violence against clinicians provides lessons to be learned in safety management. Here: some key points that can enhance physician safety and help minimize the risks.

The psychiatric emergency room (ER) is an intense, stressful work environment where psychiatrists must perform rapid assessments and make swift treatment decisions.

A shortage of inpatient beds and staff at mental health facilities may mean that a patient presenting to an emergency department may be there for an extended period of time.

Violence by patients towards staff members is an inherently complex matter for the physically and/or psychologically injured person. An expert in the field of forensic psychiatry answers a reader's question about what clinicians can do in the aftermath of an assault.

Which treatment was found to be detrimental to patients with PTSD? What is the Brøset Violence Checklist used for? These questions and more in this week's quiz.

It is not surprising that one of the most complicated aspects of collaboration with faculty and staff in the ED setting is the professional or social contract.

A funny thing happened to me on the way back from the New Hampshire Governor’s Statewide Conference on Domestic & Sexual Violence. I don’t mean funny in a comedic sense, but rather in an unexpected, shocking sense.

What routine screening for alcohol abuse is recommended to avoid alcohol-related psychiatric emergencies in older adults? How will the presence of additional staff members affect an agitated patient in a psychiatric emergency? These and more in this week's quiz.

What Every Psychiatrist Needs to Know to Be Prepared

Decreasing the Clinician’s Risk

Keys to diagnosis, assessment, and management.

As with all medical emergencies, psychiatric emergencies are among the most clinically challenging situations.

Domestic violence emerges from a host of causes and motivations, and that each case deserves individual attention and solutions.

Since the time of Homer, warriors have returned from battle with wounds both physical and psychological, and healers from priests to physicians have tried to relieve the pain of injured bodies and tormented minds.1 The soldier’s heartache of the American Civil War and the shell shock of World War I both describe the human toll of combat that since Vietnam has been clinically recognized as posttraumatic stress disorder (PTSD).2 The veterans of Operation Iraqi Freedom (OIF) and of Operation Enduring Freedom (OEF) share with their brothers and sisters in arms the high cost of war. As of August 2009, there have been 4333 confirmed deaths of US service men and women and 31,156 wounded in Iraq. As of this writing, 796 US soldiers have died in the fighting in Afghanistan.3

Many refugees have been victims of severe violence that has profoundly affected their physical, psychological, and spiritual lives.

The foreword to the Textbook of Vio­lence Assessment and Management promptly reminds readers that the mental health system has been invested in the prediction and prevention of violence since its inception. In a field dedicated to promoting wellness via the management of cognition, emotion, and behavior, violent thoughts, feelings, and actions are of primary concern. When psychiatric illness or psychological distress manifests as violence, the costs in terms of human suffering are extreme, wreaking havoc in the lives of patients, clinicians, and society at large-often with irrevers­ible consequences.

Racial/ethnic and sexual orientation minorities and women historically have been relegated to social, legal, and economic disadvantage in the United States.

Emergency medicine provides care to a vast number of patients each year. In 2005, 115.3 million people visited emergency departments (EDs).

The term “domestic violence” emerged in the United States with the rise of the women’s movement in the 1970s. Before that, violence between partners was considered a private matter. A specific type of domestic violence, intimate partner violence, refers to violence between intimate partners. Public awareness campaigns help us identify one type of intimate partner violence in which one partner, typically the male partner, is the aggressor, and the other partner, typically the female, is the victim.

Agitation in older adults is frequently associated with multiple psychiatric and medical conditions and comorbidities. It commonly occurs in patients with anxiety, affective illness, psychosis, dementia, stroke, brain injury, delirium, or pain.

On a hypothetical morning, you've arrived early at your office to answer e-mails and respond to prescription requests without interruptions. The following voice mail, left for you much earlier that day, awaits your attention: "Doctor, I need to discuss my mother's behavior with you. The medications she's taking might be calming her down during the days, but she's not okay at night."

When a suicidal patient in crisis calls the psychiatrist and hears the recorded message, "If you have a 'true' emergency, go to your nearest emergency room or call 911," the patient's risk of suicide may increase.

A Public Health Approach to Intervening With Youth in Schools

Almost 3 years after the FDA warned of increased mortality in elderly patients who received atypical antipsychotics off-label for neuropsychiatric syndromes of dementia, no medication has been approved as safe and effective for this increasingly challenging problem. Recent publications, however, including a white paper from the American College of Neuropsychopharmacology (ACNP), indicate that clinical investigators are wrestling with the dilemma and considering potential alternatives to antipsychotics.

I was very pleased to read Robert Langs' letter ("Violence Against Mental Health Professionals," Psychiatric Times, July 2007), in the wake of Dr Fenton's death.

Part 1 of this article, discussed a general approach to treating psychiatric emergencies in patients with bipolar and related disorders, as well as the assessment and management of agitation and impulsive aggression. Part 2 focuses on psychosis, suicidality, and specific treatments relevant to patients in emergency settings who are agitated or have bipolar disorder.