Immediate management and disposition
Agitated patient. When an agitated patient has been identified (Table 1), determine the area in which and the manner by which that person will be engaged. The site of evaluation should be free of potential weapons, such as lamps, cords, or chairs that can be easily lifted. Clear exits for both the clinician and patient are needed. The clinician may need to flee if the agitation escalates, but the patient may also relax if he does not feel involuntarily confined.
Finally, the presence of other staff members in a “show of force” often dissuades the agitated patient from actually becoming combative. The examiner should not hesitate to have this assistance on hand or on call when interviewing an agitated patient.2 Of course, if a patient becomes agitated very rapidly, there is little time to plan and perform an evaluation. This heightens the importance of designing the environment with safety in mind and having a pre-practiced plan for managing emergencies.
Engagement of the agitated individual begins with verbal interventions. Pointing out the patient’s restlessness or loud voice encourages him to recognize and modulate his behavior and opens a dialogue about what troubles him. This should be done as respectfully as possible while refraining from being provocative. The clinician can offer choices to address the patient’s needs while setting supportive limits regarding unreasonable requests. This can result in better communication, stronger rapport, and progress toward resolution of the acute crisis.3 Formal training in verbal de-escalation, such as that offered by the Crisis Prevention Institute,4 can further enhance the clinician’s ability to address agitation.
Pharmacological interventions for agitation have a smaller role in the clinic than in the ED or inpatient settings, simply because they are less likely to be available. However, the patient may have brought his own medications. Oral benzodiazepines and antipsychotic medications effectively reduce agitation.5
If the agitated individual does not respond to these interventions, further evaluation and management in the ED may be warranted. However, the clinician may be safer if he or she allows an agitated individual to flee the clinic; the clinician can then provide information to police or security to retrieve the patient. If the patient is calm enough, he may be able to wait until transport to an ED is available. Because agitated patients may pose a risk to emergency medical services personnel, consider having police transport the patient.6
Suicidal patients. Patients who are suicidal but not agitated typically present less of an immediate challenge, although they represent just as much of a psychiatric emergency as an agitated patient. The patient should be kept in a quiet area but closely observed. It is important to maintain strong rapport with the patient so that he is comfortable discussing any distressing thoughts.
When a patient reveals suicidal ideation, questioning should be aimed at determining the acute risk. Important factors include frequency of suicidal thoughts and ability to redirect these thoughts. Furthermore, the presence of a considered plan, rehearsal of the plan, and lethality of the intended means are important considerations. Inquire about number and severity of previous suicide attempts if this information is not already known. A family history of suicide is another risk factor. Protective factors such as social support and moral opposition to suicide are also important to establish (Table 2). To the extent possible, key elements of the recent and remote history should be confirmed with collateral sources.
Outpatient management of some patients with suicidal ideation is possible. For instance, a patient with support at home and without prior suicide attempts who describes only vague, passive suicidal ideation may be a candidate for discharge with close clinical follow-up. Patients with acute-on-chronic suicidal ideation who participate in dialectical behavioral therapy (DBT) may best be served by a DBT approach to their current crisis. DBT encourages the use of learned skills in self-management and may prevent hospitalization.7 However, even for DBT patients, referral to a psychiatric ED is advised if the clinician has any concerns about the patient’s safety. In general, patients at higher risk for suicide should be transferred to a local ED for further evaluation and possible hospitalization.
The manner in which a patient is transported to the ED depends on his mental status. Family members may be able to transport a patient who poses a danger only to himself. However, severely suicidal patients may convince family members to take them home instead. Moreover, the medical stability of patients who have made a suicide attempt before presenting to the clinic cannot be guaranteed until a medical evaluation is performed. Many patients warrant transportation by emergency medical services.