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In the wake of the coronavirus pandemic 2019, physicians and trainees are facing new types of stressors. In a profession where burnout and depression are already commonplace, these additional stressors and traumas can prove overwhelming. Many physicians may need and want to seek psychiatric care but feel unable to do so due to fear of professional repercussions.

The consequences are tragic. The story of 

, MD, the New York City physician who died by suicide at the start of the pandemic is, lamentably, not unique.

 Only a month into 2021, there are already multiple reports of physicians and medical students dying by suicide. Approximately 300 to 400 physicians die by suicide each year, 

Suicide is largely associated with untreated or undertreated psychiatric illness.

, treatment for psychiatric disorders is generally low due to various barriers to care, including inadequate access, self-denial of symptoms, and stigma.

 Physician populations seeking treatment face additional barriers to care. Fear of the 

 if they are known to be receiving psychiatric care can play a major role in their avoidance of care.

Although stigma toward psychiatric conditions in medicine has decreased, it remains a real problem. A recent 

 confirms the fears of those who worry about revealing their illnesses.

 When residency applications disclosed a common psychiatric illness (major depressive disorder), they were at a notable disadvantage when compared to applicants who disclosed non-psychiatric illness (diabetes mellitus type 1). This is just a single example of the many systems within medicine that still perpetuate stigma surrounding psychiatric disorders. Given the very real, often punitive impacts to receiving psychiatric care, it is not surprising that so many physicians chose to stay silent, which can have dire consequences.

 do not ask about mental health conditions, or only ask about current impairment.

 But other states inquire into applicants’ psychiatric history, asking questions related to current functioning and 

 about diagnoses or treatments in the past.

 Furthermore, disclosure of treatable and common conditions such as anxiety or depression may result in a 

 Physicians working in states with more in-depth questions about psychiatric diagnoses are 20% less likely to seek treatment.

 This silence can lead to deadly consequences, quite literally putting the physicians’ life in jeopardy.

 despite current attempts to improve trainee wellness.

 now make explicit efforts to ensure mental wellbeing of their students.

 When students enter medical school the administration does its due diligence by providing links to resources for 

 and advising students to seek help when needed.

 Regrettably, even now after all of these positive changes, 

medical students are still 3 times more likely than their peers to die by suicide

 report having suicidal thoughts in the past 2 weeks.

The process of seeking help for a psychiatric issue can be daunting for anyone. For potential patients, there are often guides online providing step-by-step information about what the process of seeking help looks like. Unfortunately, this process can be different for those in the medical profession. They learn about psychiatric care through rumors or whisper networks. Fear motivates most to stay quiet, and this silence continues after medical school. 

 of physicians have found that almost 50% believe they met DSM criteria for a psychiatric diagnosis but refuse to seek treatment, largely due to concerns relating to stigma and repercussions of licensing boards.

 released in October 2020 showed that many physicians still do not feel comfortable seeking mental health treatment, even in light of the additional stress of COVID-19. More than half (57%) reported concerns for their jobs if they were to seek help, and 73% believed that there was still significant stigma in the workplace towards those with psychiatric disorders, stating that this stigma played a role in their avoidance of the care they believed they needed.

It is clear that the current system leads physicians and trainees to avoid 

 While the system may prevent some from seeking care, the benefits from seeking treatment do outweigh these risks in a majority of cases. Last year, hundreds of physicians spoke out on social media about their own pathways to treatment, many stating that they wished they had sought treatment earlier.

 These testimonials prove that although seeking treatment for a psychiatric condition may be more professionally burdensome than it should be, it does not end careers—for most. In fact, by seeking treatment many of these physicians stated that it improved their ability as physicians.

Physicians should never be penalized for seeking help. Nonetheless, while we work to further improve the system it is important that medical training also includes education about how and when to get treatment. Both trainees and their supervisors should understand this process. Physicians who do not need to seek psychiatric help are often not aware of these processes and their implications; however, trainees are all taught about the importance of reporting physicians who appeared impaired. Providing clear information on how to seek treatment and demystifying concerns surrounding the professional impacts of treatment allows individuals to seek help early, rather than creating a situation where we must wait to catch our colleagues at their lowest points before they submit to treatment.

There is no doubt that more physicians would seek psychiatric care if non-punitive, non-stigmatizing policies were in place. Fortunately, 

many are already working towards policy improvements

 The medical licensing board questionnaires remain 

 found there have been changes in questions related to mental health, especially after it was evident that many of these intrusive questions violated the ADA.

 Additionally, the Dr Lorna Breen Health Care Provider Protection Act (

) has been introduced in the House and the Senate and is supported by 

Even if we cannot remove all aspects of these problems today, we can advocate for systemic change that supports physicians and trainees, such as the Dr Lorna Breen Act, by contacting our 

 to show our support. Through awareness of the process, those who need help will feel able to regain some control of their situation; this knowledge can empower physicians and trainees to feel comfortable to seek treatment as soon as they realize they need it.

currently pursuing an MD/PhD in Neuroscience at Wayne State University

is a third-year medical student at Wayne State University School of Medicine.

1. Knoll C, Watkins A, Rothfeld M. ‘I couldn’t do anything’: the virus and an ER doctor’s suicide. 

https://www.nytimes.com/2020/07/11/nyregion/lorna-breen-suicide-coronavirus.html

2. Anderson P. Physicians experience highest suicide rate of any profession. 

https://www.medscape.com/viewarticle/896257?src=soc_fb_share#vp_1

3. Dong M, Zhou F, Xu S, et al. Prevalence of suicide‐related behaviors among physicians: A systematic review and meta‐analysis. 

4. National Institute of Mental Health. Mental Illness. Accessed February 1, 2021. 

https://www.nimh.nih.gov/health/statistics/mental-illness.shtml

5. Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: a consensus statement. 

6. Pheister M, Peters RM, Wrzosek MI. The impact of mental illness disclosure in applying for residency. 

7. Dyrbye LN, West CP, Sinsky CA, et al. Medical licensure questions and physician reluctance to seek care for mental health conditions. 

8. Gold J. It is time to stop stigmatizing mental health among healthcare workers. 

https://www.forbes.com/sites/jessicagold/2020/07/13/it-is-time-to-stop-stigmatizing-mental-health-among-healthcare-workers/?__twitter_impression=true&sh=1314f1997709

9. Gold KJ, Andrew LB, Goldman EB, Schwenk TL. “I would never want to have a mental health diagnosis on my record”: A survey of female physicians on mental health diagnosis, treatment, and reporting. 

10. Mehta SS, Edwards ML. Suffering in silence: mental health stigma and physicians’ licensing fears. 

11. Association of American Medical Colleges. Recommendations regarding health services for medical students. Accessed February 1, 2021. 

https://www.aamc.org/professional-development/affinity-groups/gsa/health-services-recommendations

12. Batra M, McPhillips H, Shugerman R. Improving resident use of mental health resources: it’s time for an opt-out strategy to address physician burnout and depression (commentary). 

13. Staff News Writer. Medical school burnout: How to take care of yourself. 

https://www.ama-assn.org/residents-students/resident-student-health/medical-school-burnout-how-take-care-yourself

14. Goebert D, Thompson D, Takeshita J, et al. Depressive symptoms in medical students and residents: A multischool study. 

15. Paturel A. Healing the very youngest healers. 

https://www.aamc.org/news-insights/healing-very-youngest-healers

16. American College of Emergency Physicians. Poll: Workplace stigma, fear of professional consequences prevent emergency physicians from seeking mental health care. 

https://www.emergencyphysicians.org/article/mental-health/poll-workplace-stigma-fear-of-professional-consequences-prevent-emergency-physicians-from-seeking-mental-health-care

17. Berg S. 5 reasons physicians are less likely to seek support. 

https://www.ama-assn.org/practice-management/physician-health/5-reasons-physicians-are-less-likely-seek-support

18. Jones JTR, North CS, Vogel-Scibilia S, et al. Medical licensure questions about mental illness and compliance with the americans with disabilities act. 

19. O’Reilly KB. Federal legislation’s message to doctors: It’s OK to ask for help. 

https://www.ama-assn.org/practice-management/physician-health/federal-legislation-s-message-doctors-it-s-ok-ask-help

20. Dr Lorna Breen Heroes Foundation. The Legislation: The Dr Lorna BreeHealth Care Provider Protection Act. Accessed February 1, 2021. 

https://drlornabreen.org/about-the-legislation/

More than half of physicians believe that seeking psychiatric care would jeopardize their employment. What can be done? 

Stigma in Healthcare: Empowering Physicians and Trainees to Seek Help

When the email from “Sam” arrived asking about adding a natural weight loss product to his more mainstream prescription medications, I was not surprised. Binge eating was his bête noire. A onetime college athlete who lost his scholarship because of an ankle injury, he had since sat around eating while watching sports on TV and lamenting his lost career. He desperately wanted to shed unwanted weight, but treatments that control bingeing do not guarantee weight loss. He had tried 

 with no success. So, when he heard about a new natural weight loss concoction, he was understandably excited yet skeptical because he knew of the government’s crackdown on hoodia.

Sam forwarded me a laundry list of ingredients without hoodia but with 

 (Pausinystalia yohimbe). Years had passed since I had seen that word in print.

“Was it safe?” was all he wanted to know. Whether it worked seemed to be a secondary concern. My short answer was no, and I promised a longer explanation at his next appointment. In the interim, flashbacks of another patient from long ago popped up. Although psychopharmacology has quickly evolved in the decades since the 

, that related case was too dramatic to forget.

I remember the frantic call from the ED staff, begging me to see their patient posthaste.

“Maybe you can prescribe lithium or haloperidol or something like that. We cannot contain him here, but we have nowhere to send him,” said the pressured voice on the phone. “He saw a psychiatrist, but that is all we know.”

It was Sunday midmorning, late summer, when many Manhattanites escape town leaving side streets empty and opening tables at New York City’s unending array of eateries. Uninterrupted by impatient New Yorkers demanding seats, out-of-towners could enjoy unhurried brunches, fussed over by glamorous waitstaff who were patiently anticipating their Broadway debuts. The tidy townhouses lined side by side behind the hospital conveyed an extra sense of calm that contrasted with rowdy Saturday nights.

 which was nearly abandoned. I peered through the window of the make-do quiet room and could see that the doctor who called the consult was not exaggerating. A tanned, middle-aged man stood a few feet behind the door. He looked to be 50-something, but he jumped and hopped like a child, in sync to the beat of an invisible drum. His thinning silver hair swung wildly. Most strikingly, his suit jacket was draped around his waist, hiding his backside and little else. Empty sleeves looped across the front, dangling like a loincloth, albeit one with a shiny—probably pricey—silk lining. Where he left his pants, shoes, socks, and shirt was anyone’s guess. All I knew is that he wore nothing else.

Per protocol, I checked the chart before walking into the room, not just for safety’s sake but to

 by skimming the demographics. He was, in fact, middle-aged, married, and, in hindsight, possibly a vestige of the 

 had not aired yet. For that matter, sildenafil had not been invented, nor had the now-ubiquitous second-generation antipsychotics that are often used to treat bipolar disorder. Per the intake sheet, “Mr Smith” was a senior vice president at a name-brand advertising firm, even if his present posture suggested otherwise.

The history mentioned that his private psychiatrist, who had retreated to the Hamptons for the summer, referred all emergencies to the hospital, as per his answering machine message. Before leaving, said psychiatrist started him on lithium, then carbamazepine, maybe even 

, but now everything spiraled out of control. Experience told me that advertising executives with bipolar disorder tendencies are not uncommon, because advertising takes high energy, unabashed enthusiasm, and lots of chutzpah, which are abundant in 

. Yet it was also unlikely that someone with uncontrolled bipolar disorder could rise so high through the corporate ranks, even if his prescriptions screamed bipolar. It was also unlikely that this behavior represented garden-variety bipolar disorder, because the nurse noted that he was disoriented to time and place, distracted, and responding to unseen stimuli. His rapid, jerky movements put me on high alert for impending seizures, even though a cursory 

I scrolled through the medication list, checked the charted vital signs, scanned all labs listed, and looked for clues to explain this seemingly sudden deterioration. Even the toxicology screens were negative. The medications included several antihypertensives, which opened the possibility of a recent cerebrovascular accident secondary to hypertension, but he was moving all 4 limbs without restrictions, and his frenetic, dancelike activity functioned as a makeshift 

 stress test, making it unlikely (but not impossible) that his strange symptoms followed hypoperfusion. There was only 1 odd entry, a little, nearly illegible word: Yocon.

In those days, we checked prescription pharmaceuticals through big, bulky Physicians’ Desk Reference editions with thin pages and small print. And that was where I found the culprit: that little word was the trade name for 

, a reputed (but disputed) aphrodisiac used in fertility rituals in Cameroon, Central Africa, according to a memorable medical school ethnopharmacology lecture. I called the man’s internist, who had hospital privileges and even made rounds on weekends. The internist checked his chart and confirmed that a urologist had started the man on prescription yohimbine a few weeks earlier. The doctor noted that he added more antihypertensive medications soon after, which made sense, given that this herb can increase blood pressure and interfere with the efficacy of blood pressure medications.

The nurses crowded outside the room, eager for an explanation, and appreciative of the colorful story behind this mystery. Yohimbine was an α1-adrenergic agonist, a product of an East African tree with a similar name. It was marketed as an 

 and subsequently approved for this purpose, despite equivocal evidence. Whether yohimbine helped in this regard was unclear, but its psychoactive properties were apparent. I wondered whether prescriptive yohimbine (or nonmedicinal yohimbe bark) directly increased libido as advertised, or whether it simply induced 

 in susceptible individuals, with the attendant hypersexuality of mania.

That theory was within the realm of possibility, especially because recent reports confirm that the stimulant especially affects individuals who are predisposed to bipolar disorder, as well as schizophrenia, panic disorder, and 

. Even popular online consumer medical websites warn against its use in cases of depression because it can precipitate manic reactions.

 The National Institute of Health’s National Center for Complementary and Alternative Medicine, now the National Center for Complementary and Integrative Health, has since taken a 

, warning against its use in individuals with any psychiatric history.

Over time, we learned much about yohimbine and its positive and negative effects. Although it fell into disuse after the invention of the much more predictable 

 indicated for erectile dysfunction, online marketers still promote it for a wide range of problems, including appetite suppression and obesity. Yohimbine gained greatest use as a veterinary antidote to animal tranquilizers. It has been misused by some humans, as was the case with ketamine, a onetime animal tranquilizer turned club drug that has recently been repurposed as a treatment for depression. No comparable success stories have been reported for yohimbine, although bodybuilders cite anecdotal evidence that the herb enhances exercise endurance. In contrast, forensic medicine journals 

 and note that yohimbine can cause delirium, hallucinosis, seizures, and sometimes deaths. An 

article in American Journal of Psychiatry

confirms that it can switch depression into mania.

Importantly, dangerous interactions can occur with 

—so it was fortunate that the patient quieted down with a dark, soundless room and intravenous diazepam, prescribed by the neurologist to stop seizures should they occur. Aided by the tincture of time, and a short stay upstairs once a bed opened, he reportedly returned to baseline. When I checked on him a few days later, he did not recall this episode.

In hindsight, our mystery man escaped easily. Who knows what tragedies could have occurred had strong psychotropics been added to his medication mix without stopping the clandestine culprit? At worst, lethal medication interactions could have followed. And, at best, he would have been condemned to a lifetime’s treatment for a condition that might not have emerged without this botanical boost.

, and we must consider the big picture, without reflexive and thoughtless prescriptions for psychotropics—even if the general public, as well as other medical professionals, assume that is all we do. As for Sam, I expect him to appreciate this warning story about yohimbine, even if the negative studies about its efficacy for weight loss disappoint him.

is assistant clinical professor of psychiatry and behavioral sciences at Icahn School of Medicine at Mount Sinai, New York, NY.

Three cases of manic symptoms following yohimbine administration

2. Yohimbe. National Center for Complementary and Integrative Health. Updated November 2020. Accessed December 21, 2020. 

3. Anderson C, Anderson D, Harre N, Wade N. 

Case study: two fatal case reports of acute yohimbine intoxication.

As physicians first, psychiatrists must consider the big picture, without reflexive and thoughtless prescriptions for psychotropics—even if many, including medical professionals, assume that is all we do.

Never Forget the Fine Print: From Fertility Rites to “Miracle Med”

On any given day, a psychiatrist working in an emergency department may face any or all of the scenarios listed here, one after another or concurrently.

The Promise and Potential of Emergency Psychiatry

The Field as a Master Class in Interviewing

CAHOOTS: A Model for Prehospital Mental Health Crisis Intervention

10 Most Common Presentations in Emergency Psychiatry

Infographic: Never a Dull Moment in Emergency Psychiatry

Emergency Psychiatry: The Intertwining of Physical and Mental Health

Psychiatric emergencies occur when a patient is a danger to self, to others, or is so psychiatrically impaired the patient cannot meet their own basic needs. How do such emergencies manifest?

Happy 40th birthday to emergency psychiatry! Many in our field point to a 

 by Samuel Gerson, PhD, and Ellen Bassuk, MD, in the 

 as first truly defining the subspecialty of emergency psychiatry. Since those days, we have seen impressive growth, scholarship, diversification, and impact throughout our area of care, and we can confidently state that at 40 years young our subspecialty has never been stronger.

Emergency psychiatry was preceded by the rise of emergency medicine, which became a distinct specialty in the late 1960s, and although a few years behind, emergency psychiatry has paralleled emergency medicine’s long-term development in many ways. Indeed, with overlaps in our patient populations, the fields often intersect and can be complementary. Recognizing this, the practitioners of emergency medicine may be some of emergency psychiatry’s biggest advocates. An emergency medicine physician has even served as the president of the 

American Association for Emergency Psychiatry

In addition to the AAEP, emergency psychiatry also boasts a major annual conference dedicated to the field, the 

National Update on Behavioral Emergencies

 (NUBE). There are emergency psychiatry fellowships offered at multiple medical teaching institutions. Research efforts around the facets of the subspecialty abound, including labs with professors focused solely on behavioral emergencies, and there are numerous textbooks available covering all aspects. And it is now quite common to see young psychiatrists pursuing a career in emergency psychiatry.

Meanwhile, emergency psychiatry programs in all sizes and shapes are now found across the nation and in many foreign countries. They help to improve the care, timeliness, and access to more therapeutic environments, along with trained personnel, for patients that traditionally were held in medical emergency departments (EDs) for long hours waiting for a psychiatric inpatient bed. With the number of behavioral emergency chief complaints now estimated to be 1 in every 7 patients presenting to US EDs, the demand for these programs cannot be understated. Although Emergency psychiatry facilities go by many names, including CPEP (Comprehensive Psychiatric Emergency Program), PES (Psychiatric Emergency Services), EmPATH (Emergency Psychiatry Assessment, Treatment and Healing unit), they have 

 the ability to safely stabilize and discharge in less than 24 hours 75% or more of patients previously thought to need inpatient admission.

 These sites can provide immediate, compassionate, and effective care for many individuals, while also preserving the limited psychiatric inpatient beds for those who truly have no alternative.

Over the last year, we have seen enormous behavioral health impacts not only from the pandemic itself, but also from the stress of lockdowns, isolation, job insecurity, family dynamics, and loss of support networks. Last summer, the Centers for Disease Control (CDC) 

 substantial increases in suicidal thoughts and substance abuse throughout the country. Shockingly, 11% of the CDC survey respondents reported suicidal ideation in the previous month, and for young adults aged 18 to 24 years, the number considering suicide jumped to an alarming 25%.

 Meanwhile, 2020 also opened many eyes to 

 with behavioral crisis intervention, suggesting mental health professionals might be better suited for these tasks. Clearly, emergency psychiatry as a discipline will need to climb to even higher levels to assist in these considerable and impactful issues.

However, the road to positive change is not without its obstacles. Despite constituting such a large percentage of their trainees’ future patients, only about 25% of emergency medicine residencies 

 formal instruction in acute psychiatric management.

 Many psychiatry residencies provide only minimal emergency psychiatry experience and education. Still, in too many hospitals, the default treatment for acute patients with acute psychiatric disordes remains little more than heavy sedation and physical restraints.

Given these challenges, how do we leverage the 40 years of advancement in emergency psychiatry to meet the myriad and growing demands of today, and continue to rise to the next level? Here are a few suggestions:

 Begin the process of making emergency psychiatry an accredited, boarded subspecialty under the Accreditation Council for Graduate Medical Education (ACGME). Emergency psychiatry now meets the same standards and requirements for a psychiatry subspecialty as did consultation-liaison psychiatry, when it was formally recognized in 2005. An accredited subspecialty will be much more formidable in promoting appropriate care, and its tenets more difficult to overlook, even in peripheral training programs and outmoded hospitals.

 Emergency psychiatry must further deepen its integration with emergency medicine and other adjacent specialties.Behavioral emergencies are encountered in all types of clinical settings by many different types of practitioners, and we must raise awareness with all health care professionals about our capabilities and innovative solutions.

 We must educate our acute care health systems about the financial benefits of our programs and interventions. For example, a 

 demonstrated that a psychiatric emergency unit dramatically increased revenue for the affiliated medical ED, while providing better and more prompt care for behavioral emergency patients.

 Recognize that according to federal law, psychiatric emergencies are legally equivalent to medical emergencies, with the requirement of hospitals providing the same level of assessments and stabilizing efforts for patients as they would for those with chest pain or having experienced a car accident. We must stop thinking of a false dichotomy between the brain and the rest of the body. Mental health and physical health are completely intertwined, and should not be divided up and treated separately.

 We need to promote a culture that eliminates the 

, while understanding that the symptoms of acute psychiatric illness can be just as painful and debilitating as broken bones and bleeding cuts. Patients who experience auditory hallucinations commanding them to hurt themselves or others are in extreme distress, as are those who are despondent and suicidal. Thus, they should not be rated as a low priority in emergency settings. We must send the message that psychiatric emergencies are as random as any other emergency; people do not plan to become suicidal any more than they would schedule themselves to have a heart attack. Life events are almost always unpredictable, so suggestions that we should plan services to try to catch a psychiatric emergency days before it happens will be about as successful as guessing tomorrow’s lotto numbers. Instead, we should be better prepared for all emergencies, and realize they will not cease any time soon, despite any bureaucrats’ assertion to the contrary.

Emergency psychiatry as its own field holds incredible promise, on top of an already remarkable short history. In the special articles of this month’s 

, I trust you will see some of that for yourself.

is vice president for acute psychiatry with the physician partnership Vituity and assistant clinical professor of psychiatry, University of California, Riverside. He is an Editorial Board Member of 

Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments

3. Czeisler MÉ, Lane RI, Petrosky E, et al. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic — United States, June 24–30, 2020. 

Tabatabai RR, et al. Training in the management of psychobehavioral conditions: a needs assessment survey of emergency medicine residents

5. Stamy C, Shane DM, Kannedy L, Van Heukelom P, et al. 

Economic evaluation of the emergency department after implementation of an emergency psychiatric assessment, treatment, and healing unit

September 1, 2020. Epub ahead of print. ❒

As a discipline, emergency psychiatry has widened its role, especially following the enormous mental health fallout from the pandemic and the shift of police and first-responder interventions.

“It is a capital mistake to theorize before one has data. Insensibly one begins to twist facts to suit theories, instead of theories to suit facts.”


—Arthur Conan Doyle, “A Scandal in Bohemia”

As the fictional detective Sherlock Holmes notes, the pursuit of truth and facts is not one to be taken lightly. In the field of medicine, the topic of diagnostics is perpetually under pressure to evolve and surpass past performances.

In psychiatry, the idea of diagnostics, assessment, and prognosis has a 

 that many have categorized, debated, and (to this day) reviewed.

 However, unlike our peers in other medical specialties, we do not have the luxury of the full use of computed tomography or tissue biopsy. Instead, our best analogue to laboratory studies and invasive procedures is the psychiatric interview. Honing one’s skills in this regard is akin to optimizing the act of auscultation or laparoscopic investigation.

Like other methods of diagnosis, the psychiatric interview can not only uncover an etiology but also serve as a form of treatment. Nowhere is this exemplified so regularly and explicitly as in psychiatric emergency services and crisis intervention. Let us examine how an assessment as an emergency psychiatrist truly can be perceived as a master class in the psychiatric interview.

Several conflicting factors must first be noted and resolved: ethical tensions, autonomy vs beneficence; legal components, civil rights vs police power; and clinical decisions needing completion and ownership, medical decision-making vs public interest and scope of patient-centered processes. In examining all this, it is obvious how emergency psychiatry provides a master class in the medical skill of interviewing.

“Life is infinitely stranger than anything which the mind of man could invent. We would not dare to conceive the things which are really mere commonplaces of existence.” 

—Arthur Conan Doyle, “The Adventure of the Bruce-Partington Plans”

In emergency psychiatry, one must conduct an interview while managing efficiency, acuity, and extensive medical complications. As such, it is an area where maintaining a broad medical proficiency is paramount, and this it goes far beyond the 

 of medical stabilization processes (ie, medical clearance).

 Once an individual has been cleared for further psychiatric care, many items pertaining to the patient’s chief complaint and ongoing medical comorbidities are a focus during the emergency interview.

 How a physician uncovers those items plays a primary role in the successful of the psychiatric intervention.

The emergency psychiatrist must not only maintain a broad medical understanding, but also be skilled and comfortable with a wide degree of risk tolerance and mitigation strategies. The most familiar risks often pertain to suicide and homicide; however, there are a plethora of 

 that must be addressed in every crisis interview. A nonexhaustive list is in the 

The third leg of the tripartite successful psychiatric interview includes multitasking and time management (

). Unlike in other interview milieus, these assessments cannot usually be deferred, delayed, or done in a preliminary fashion.

These interviews are often performed in contexts that are complex in terms of acuity, physical plant, and medicolegal stakes. The emergency psychiatrist’s decisions do not occur in a vacuum nor do they go unwitnessed, unnoticed, or without scrutiny. There are many shareholders, and, as such, the psychiatric interview is of great complexity when noting the relationships considered. Rather than viewing this through a patient-physician scope, the emergency psychiatry interview requires broadening that aperture to a patient-physician-family-advocate-guardian-law enforcement-case worker-community individual-probate court lens.

Now, noting that the emergency interview requires sophistication in medical care, risk management, and timeliness, it is also worthwhile to remark how this master class in interviewing attends not only to diagnostics, but also to therapeutics and treatment.

“The world is full of obvious things which nobody by any chance ever observes.”

 —Arthur Conan Doyle, “The Hound of the Baskervilles”

A skilled psychiatric interview can function as both treatment and assessment,

 especially in an emergency psychiatric situation. The clinician must establish immediateand effective rapport, master service recovery, and appreciate the finer points of psychodynamics in the interview process.

One of the greatest challenges of a complex emergency psychiatric interview is that it may be the psychiatrist’s only chance to ever interact with the patient. As such, the stakes are higher, the room for error diminished, and the overall emotional valence to patient and loved ones quite accentuated. The most gifted emergency department interviewers are able to establish rapport in a sincere, direct manner that can reach those in crisis on their darkest days. Not only will this rapport help in lessening a patient’s agitation, but the intervention leads to an enhanced accuracy of whatever information is obtained, as well as to patient satisfaction.9 A successful emergency interview, consequently, will have tenets of trauma-informed care, patient-centered processing, and autonomous medical decision as core competencies.

Occasionally, when you are dealing with patients during their most difficult times, they will be upset regardless of your intentions. Consequently, the emergency psychiatric interviewer must be aware of and accept advanced service 

 A patient’s recovery may actually be due to something that occurred in your setting or, more commonly, to events that preceded their arrival. This would include patients who were conveyed to your setting involuntarily and/or those not engaging in the interview as the primary requestor of services.

In the overall field of crisis services, success also highlights the importance of redressing grievances or concerns in the moment. Redressing grievances will assist not only with patient satisfaction, but also with patient loyalty and trust over time.

 Marketing data indicate that users of a service are often more impressed when a provider deals with an issue successfully,

 as opposed to when an issue never presents itself.

Although the acuity and speed of the psychiatric emergency settings tend to focus on the biological components of medical research, there are many important aspects to the psychiatric interview rooted in psychodynamic theory. Aside from the rapport, the physician has to fully contextualize the transference and countertransference to successfully engage the patient in a way that benefits both patient and examiner. Additionally, the 

 noted in a crisis are of priceless significance when trying to navigate items that are lacking in possible maturity but also varying degrees of neuroticism.

 Once the clinician has moved into the deeper stages of the interview, using techniques pertaining to neutrality, observation, clarification, and confrontation is also beneficial.


—Arthur Conan Doyle, “The Sign of the Four”

Imagine working with a young patient showing signs of psychosis for the past 6 weeks. Your initial assessment appears to rule out medical- or substance-induced etiologies, yet symptoms persist. What's a psychiatrist to do?

Psychiatric Emergencies