Enhancing Clinician Safety and Managing Psychiatric Emergencies

As with all medical emergencies, psychiatric emergencies are among the most clinically challenging situations. In our training, we learn how to assess for suicidality, homocidality, and other aspects of dangerousness to self and others. Psychiatric residents have required training in emergency department settings, under close supervision, to prepare them for this important aspect of clinical care. We train our students to think about potential risk factors, such as substance abuse; obtaining a good history of violence; assessment of weapons; and demographic information, such as gender, age, race, psychiatric diagnosis, comorbid medical conditions, pain, and recent loss.

By practice, experience, and didactics, we drill how to recognize danger in our patients; clinical situations in which violence may be acute, such as agitated depression, mood lability, or psychosis with command hallucinations; and certain situations that lend themselves, by their very nature, to potential violence or emergencies, such as suicidal ideation, intent, or plan. In addition, there are medical settings, such as psychiatric and medical emergency departments and inpatient psychiatric units, and certain high-risk patient populations, such as the elderly and those with comorbid medical conditions, in which the risks of emergencies may be greater.

Yet, prediction of violence is difficult and complex. Taking care of patients who may be aggressive, homicidal, or suicidal, requires incredible skill and ability. Making the wrong decision regarding hospitalization or discharge, not obtaining information from family or other sources, and not taking enough time to obtain a careful history all can have life-or-death consequences. How to best enhance clinician safety and manage psychiatric emergencies as well as anticipate potential violence and aggression are key themes in this Special Report.