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The National Suicide Prevention Lifeline is getting an upgrade. On July 16, 2022, the Lifeline will change from its previous number (800-273-8255) to just 3 digits: 988. Although the old number will remain available for calls, individuals may call, text, or chat 988, where they will be connected with trained counselors.

Additionally, if functioning as intended, operators will be able to counsel callers 24 hours a day and dispatch specially trained responders, hopefully reducing armed law enforcement interventions and emergency department (ED) visits.

“Having a 3-digit number sends the message that mental health emergencies are as important and require the same level of response as other types of health emergencies, and it makes it easier for clinicians to counsel their patients on how to access emergency mental health care,” 

, chief of quality and clinical innovation at Connections Health Solutions and associate professor of psychiatry at the University of Arizona, told 

Currently, when individuals call the Lifeline, they hear a greeting and then a list of options: “Press 1 to connect to the Veterans Crisis Line” and “Press 2 (“Oprima dos”) for the Spanish subnetwork.” Callers who do not choose either of these options are routed to a local Lifeline crisis center based on their area code. If the local center is unable to take their call, they are rerouted to another center within the network.

The Lifeline’s network has more than 200 crisis centers in place. From its inception in 2005 through 2020, the Lifeline has received 20,478,698 calls.

 After the past few years of crisis, 988’s introduction may prove an opportunity for restructuring 

“Far more than just a rebrand of the National Suicide Prevention Lifeline, the implementation of 988 provides an opportunity to reform and improve our nation’s crisis response system,” 

, chief medical officer of the American Foundation for Suicide Prevention, told 

™. She added that 988 “is an opportunity to reimagine crisis response and increase the involvement of trained mental health professionals who are equipped to address the needs of a person in crisis.”

Right now, the lifeline receives approximately 4 million calls or texts per year. In 2020, of more than 940,000 total callers, 22.57% had suicidal thoughts within the past 24 hours, 4.03% were believed to be at imminent risk of suicide, and 0.90% were in the midst of a suicide attempt during the call.

 About 24.60% of callers required emergency services to be dispatched to their location.

 All these calls, in addition to calls from local crisis centers and certain 911 calls, will be redirected to 988.

Use of the Lifeline is expected to grow exponentially in coming years, potentially attracting more than 10 million individuals, according to some estimates.

 By 2026, volume could reach up to 24 million callers or texters per year.

 This has led to increasing questions and concerns over whether the hotline will be able to meet the already vast demand. According to

 data analysts, approximately 17% of the 2 million calls in 2021 were abandoned before the caller could receive help.

 This may be a result of long hold times and limited staffing in call centers.

Among many goals, 988 hopes to answer 95% of all incoming calls within 20 seconds.

 “The infrastructure of local crisis call centers must be strengthened to address the needs of millions of people in distress every year. Building capacity at the state level is critical so calls do not go unanswered, wait times do not increase, and people get the help they desperately need. These centers must be adequately staffed to respond to the projected increase in call volume and ensure training is provided for crisis center staff and volunteers,” Moutier shared with 

Since the Lifeline’s launch, the national network and the network administrator have been funded through the Substance Abuse and Mental Health Services Administration (SAMHSA), whereas local Lifeline crisis centers have received funding through varied federal, state, local, and private sources. SAMHSA has significantly increased federal funding resources for the national network and local crisis call centers to help ensure a smooth transition to 988.

 The current crisis system has been historically underfunded and undervalued, but new funding developments may help meet the growing need.

“If we are going to do this, then we must fund mental health at the level we fund law enforcement and paramedics. There is a massive discrepancy—multitudes of salaries’ discrepancy—there. We must pay people to be on call 24/7. It is going to take a pretty significant financial dedication,” 

, president of the American Association for Emergency Psychiatry and medical director of crisis services in the Milwaukee County Behavioral Health Division in Wisconsin, told 

In 2022, planned federal funding is $282 million. Of that, $177 million will go toward strengthening network operations including expanding paid and trained staffing for backup, specialized services, and chat and text centers; building up data and telephony infrastructure; strengthening standards, training, and quality improvement; and ensuring evaluation and oversight. The remaining $105 million will go to local crisis centers for expanding capacity to increase response rates, providing follow-up so individuals are effectively engaged with local behavioral health crisis services, staff are sufficiently paid, and staff/volunteers are adequately trained to provide evidence-based interventions even in high-risk populations.

Nonprofit Lifeline administrator Vibrant Emotional Health is also providing funding through grants to 49 states and US territories through the Lifeline’s 988 State Planning Grant Initiative. The funds will be used to develop coordination, capacity, and communications surrounding the launch of 988.

The National Suicide Hotline Designation Act (S.2661) allows states to collect revenue to sustain and expand local crisis services. Fees will be collected on both land and cell phone bills to provide ongoing financial support for crisis call centers. The Biden administration recently announced it will allot an additional $700 million to local crisis centers in its fiscal year 2023 budget, but each state will need to maintain its sustainable revenue stream and infrastructure for 988. States that fail to do so face increased risk of individuals in crisis not getting the support they need.

Despite this increased funding, as of May 2022, at least 13 states—Alabama, Colorado, Idaho, Indiana, Kentucky, Minnesota, Nebraska, Nevada, New York, Oregon, Texas, Virginia, and Washington—have passed 988 implementation laws that include fee measures to pay for the expected increase in calls.

 At least 11 states—California, Florida, Idaho, Kansas, Massachusetts, Michigan, New Jersey, New York, Ohio, Vermont, and Washington—have introduced new or additional legislation.

 Without significant supplemental state funding and staffing, the Lifeline may have difficulties delivering on goals. The focus will be on these states to iron out the details of how 988 will function in practice.

“Like any big undertaking, the devil is in the details—and 988 is a huge undertaking. You are taking a network of 200 or so suicide hotlines and trying to create a uniform system, which is hard enough,” said Balfour. “Opening up access without a crisis system in place could potentially make problems like ED boarding worse. We need to build that 

, and that will take time. There is legislation in Congress to start laying the foundation for that—creation of national standards, funding for planning and infrastructure, and parity coverage by health insurance. Although 988 has the potential to catalyze a huge transformation of crisis services, that will be a stepwise process that will happen over years.”

Thrasher agrees. “You are asking mental health to be fire, [emergency medical services (EMS)], and law enforcement. Mental health can be like that, but then you have to fund and staff it appropriately.”

Despite these concerns, the conversion to 988 is “not optional,” according to SAMHSA.

 To increase staffing, SAMHSA has put out a call online, encouraging individuals to apply: “These centers are looking to bring on new volunteers and paid employees. You will receive training, so if you are a caring person who wants to help those in crisis, apply today.”

To best gauge how the rollout of 988 may proceed, it might be time to look to the past, specifically to 911. The first 911 call was made in February 1968.

 The National Academy of Sciences had published a report emphasizing the epidemic rates of accidental deaths and injuries in 1966.

 The report suggested the need for a single, nationwide telephone number to call for assistance.

It took almost 20 years to create the National 911 Program. Established in 2004, the program supports state efforts to improve 911 services by creating resources and disseminating grant funding for 911 technology and operations. If that is any indication, it could take 20 years before the 988 program is fully functional.

Even now, 911 is not a perfect system. According to a 2002 study of 911 response times, mortality rates in medical emergencies rose if response time increased beyond 5 minutes.

 For dispatchers, dealing with traumatic or verbally abusive calls is correlated with lower organizational commitment, a higher desire to leave the job, and greater emotional exhaustion.

 Trauma exposure also affects ambulance operatives, with some reporting angry outbursts, trouble sleeping, nightmares, flashbacks, and increased alcohol consumption.

Training initiatives for 988 dispatchers may need to keep this in mind. According to SAMHSA, current training is primarily determined by each individual crisis center based on its organizational needs. However, the Lifeline Core Clinical Training is in development, and will consist of self-paced online courses covering essential skills for crisis counselors who answer calls/chats/texts within the Lifeline network. Further training to address the specific needs of populations at higher 

Approximately 1 in 10 individuals with mental health disorders have interactions with 

 and up to 10% of police calls are for mental health emergencies.

 Individuals with serious mental illness account for 17% of use-of-force cases and 20.2% of suspects injured in police interaction.

 Furthermore, injury, death, and other adverse outcomes are 10.7 times more likely for individuals with mental health disorders.

 Negative outcomes are also disproportionately experienced by people of color.

 The 988 hotline will provide an option beyond 911 for patients, caregivers, and witnesses to call during a mental health emergency.

According to a 2022 poll commissioned by The Trevor Project, 36% of adults do not trust police officers to be the first responders in a mental health crisis. In contrast, at least 7 in 10 adults trust social workers, psychologists, and EMS.

“A law enforcement response to mental health crises only perpetuates the myth and association some people may have between mental illness and criminality,” Moutier shared with 

™. However, the elimination of law enforcement from mental health crisis response may not be plausible, particularly if there are firearms involved. Thus, Thrasher suggested a combined model of mental health team and police: “If we get called for a suicidal individual who is at home with a gun, I won’t let my team go in there—it’s a safety concern. We have to have law enforcement or some ability to safely clear and handle people that are using firearms before we can speak to them.”

According to a national poll, 46% of adults have never heard of 988.

 With nearly half of adults unfamiliar with 988, will this resource help clinicians and their patients? 

-Do you think this will impact your practice?

Approximately 63% of respondents said they believed the implementation of 988 will reduce suicide.

 However, on affecting practice, respondents were not totally convinced, with a 50/50 split. What are your thoughts on 988? We would love to hear: 

New 988 Suicide Hotline: Thoughts From the Editor in Chief

1. The lifeline and 988. National Suicide Prevention Lifeline. Accessed April 12, 2022. 

https://suicidepreventionlifeline.org/current-events/the-lifeline-and-988/

2. 988 serviceable populations and contact volume projections. Vibrant Emotional Health. December 2020. Accessed April 12, 2022. 

https://www.vibrant.org/wp-content/uploads/2020/12/Vibrant-988-Projections-Report.pdf

3. Suicide prevention by the numbers. National Suicide Prevention Lifeline. Accessed April 12, 2022. 

https://suicidepreventionlifeline.org/by-the-numbers/

4. Substance Abuse and Mental Health Administration. 988 appropriations report. December 2021. Accessed May 11, 2022. 

https://www.samhsa.gov/sites/default/files/988-appropriations-report.pdf

5. Gould MS, Lake AM, Munfakh JL, et al. 

Helping callers to the National Suicide Prevention Lifeline who are at imminent risk of suicide: evaluation of caller risk profiles and interventions implemented.

6. Eder S. As a crisis hotline grows, so do fears it won’t be ready. 

 March 13, 2022. Accessed April 5, 2022. 

https://www.nytimes.com/2022/03/13/us/suicide-hotline-mental-health-988.html?referringSource=articleShare

7. Vibrant Emotional Health to provide state grants in preparation for future 988 dialing code for the National Suicide Prevention Lifeline. News release. Vibrant Emotional Health. January 25, 2021. Accessed May 11, 2022. 

https://www.vibrant.org/wp-content/uploads/2021/01/Vibrant-988-Planning-Grant-Announcement.pdf?_ga=2.13525815.1606522482.1652114257-409111235.1652114257

8. Howard J. States prepare for summer launch of new 988 suicide prevention number. 

https://www.cnn.com/2022/05/06/health/988-suicide-prevention-number-states-prepare/index.html

9. State legislation to fund and implement ‘988’ for the National Suicide Prevention Lifeline. National Academy for State Health Policy. January 18, 2022. Accessed April 27, 2022. 

https://www.nashp.org/state-legislation-to-fund-and-implement-988-for-the-national-suicide-prevention-lifeline/

10. 988 suicide and crisis lifeline volunteer and job opportunities. Substance Abuse and Mental Health Administration. Updated May 12, 2022. Accessed May 16, 2022. 

https://www.samhsa.gov/find-help/988/jobs

11. The National 911 Program celebrates 50 years of 911. 911.gov. Accessed April 27, 2022. 

12. Committee on Trauma and Committee on Shock; Division of Medical Sciences; National Academy of Sciences; National Research Council. Accidental death and disability: the neglected disease of modern society. September 1966. Accessed April 27, 2022. 

https://www.ems.gov/pdf/1997-Reproduction-AccidentalDeathDissability.pdf

Response time effectiveness: comparison of response time and survival in an urban emergency medical services system.

Verbal abuse in the National Health Service: impressions of the prevalence, perceived reasons for and relationships with staff psychological well-being.

Living in critical times: the impact of critical incidents on frontline ambulance personnel—a qualitative perspective.

16. Adams K, Shakespeare-Finch J, Armstrong D. 

An interpretative phenomenological analysis of stress and well-being in emergency medical dispatchers.

17. 988 frequently asked questions. Substance Abuse and Mental Health Administration. Updated April 22, 2022. Accessed May 16, 2022. 

https://www.samhsa.gov/find-help/988/faqs

Contact between police and people with mental disorders: a review of rates.

Seattle Police Department and mental health crises: arrest, emergency detention, and referral to services.

Measuring disparities in police use of force and injury among persons with serious mental illness.

Racial/ethnic disparities in the use of mental health services in poverty areas.

22. Morning Consult. U.S. adults’ knowledge on suicide prevention and 988. The Trevor Project. April 2022. Accessed May 16, 2022. 

https://www.thetrevorproject.org/wp-content/uploads/2022/04/988-poll-report.pdf

23. Poll: what are your thoughts on 988? 

https://www.psychiatrictimes.com/view/poll-what-are-your-thoughts-on-988

The new suicide hotline is launching July 16. Are we ready for it? 

New 988 Suicide Hotline: Hope or Hype?

 Tales of the Clinic, The Art of Psychiatry, 

we visit a case of a young woman struggling with opioid use disorder while pregnant. This woman was lucky enough to have access to a multidisciplinary treatment clinic, including psychiatry and maternal-fetal-medicine, and to have family support. Pregnancy is often a time of renewed interest in being off drugs and trying to build a healthy mom-baby dyad, but also a time of struggle, given hormonal changes and lack of specialized treatment guidelines for this population. Cooccurring issues such as mental illness, trauma history, and negative social determinants of health often make treatment extremely challenging.

“Ms Landry” is a 25-year-old female with generalized anxiety disorder, reported history of bipolar disorder, 

 (OUD), methamphetamine use disorder, cocaine use disorder, benzodiazepine use disorder, and tobacco use disorder. She presented in September 2020 to the emergency department (ED) for management of opioid withdrawal, as she found out several weeks prior that she was 

. She wanted to be off drugs for her baby. Due to irregular menses, she was unable to state how far along she was in the pregnancy. She reported using intravenous heroin over the last 4 to 5 years, with her last use 2 days ago. She stated that she has used 1.5g per day for the past year-and-a-half, since she has been homeless.

At the time of presentation, she endorsed worsening symptoms of withdrawal, including rhinorrhea, diarrhea, nausea/vomiting, abdominal pain, flushing, and chills. After workup and imaging, she was estimated to be 8 weeks pregnant. Consult-liaison psychiatry was consulted by OB/GYN for medication-assisted treatment initiation. Ms Landry reported that she had been tried in the past on both methadone and 

. She described her primary motivation for seeking treatment as her pregnancy and the opportunity to be a mother. She explained that it is her responsibility to ensure the physical well-being of her baby and agreed to start suboxone 4mg BID (buprenorphine 4mg/naloxone 1mg).

At time of treatment initiation, Ms Landry was living at multi-site residential and outpatient substance use treatment center, which also provides care for pregnant and parenting women, along with their children. Following initiation of suboxone and resolution of withdrawal symptoms, they discussed a plan for discharge to her mother or return to the facility. Ms Landry was inpatient for a total of 4 days. On the evening of her last day, she approached the obstetrician, requesting to leave the hospital. She described frustration that her boyfriend was not able to visit with her during nonvisiting hours. After brief discussion, she agreed to stay and follow the agreed-upon treatment plan. Several hours later, she left her room with her boyfriend and did not return. Attempts to contact her were unsuccessful.

Ms Landry started drinking with her father when she was 13 years old. She explained that it was used as a “bonding activity” and something they could do “behind mom’s back.” Her father also introduced her to 

. In later years, she was estranged from him due to other mental health issues (reported 

 and suicidality) and threats of physical violence made against her mother. Her parents later divorced, and her father died from complications related to 

. Ms Landry described her mother as a consistent source of support, and she later lived with her mother, following delivery. She also has a younger brother and reported no additional substance use disorder (SUD) in her family.

Following a sexual assault between the ages of 15 and 16 years old, she began to experiment with 

. At 18 years old, she moved out of her parents’ home and into the home of friend who used methamphetamine. Shortly after, she began using methamphetamine as well, both intravenously and via smoking. She described enjoying the energy it provided and how it “unbridled” her creativity. After being caught intoxicated at school around 19 years old, she was referred to and seen by a psychiatrist. She was given the diagnosis of 

, due to “erratic behavior,” although she continued actively using substances at that time. She says she was tried on both Vraylar and Latuda, with good effect. She also described multiple suicide attempts (SAs) around this time, including cutting and intentional overdosing on substances. She denied additional SAs following this period.

Several years later, Ms Landry met the father of her baby, who she continued to have an on/off relationship with over several years, leading to the pregnancy. At times, she reported the relationship as physically abusive. She stated that he introduced her to IV heroin, which was her substance of choice, when she initially presented to the ED. She has been to inpatient substance use rehabilitation programs several times and was able to maintain sobriety for 2- to 3-month periods. However, after programs concluded, she relapsed almost immediately each time she left. Her substance use has resulted in multiple arrests and DWIs.

Ms Landry had difficulties maintaining employment due to ongoing 

. After finishing high school, she was able to complete 2 years of college. She previously worked at one of the local airports, and also had jobs as a waitress and as a dancer.

From the initial presentation through multiple clinic follow-ups, a similar pattern emerged where Ms Landry would skip follow-up for both obstetrics care and psychiatry appointments, or where she would present to the hospital with symptoms of withdrawal and leave shortly after against medical advice. During this time, she lived between her mother’s home, hotels, and the local SUD treatment facility, with intermittent periods of 

. To pay for hotels, she would steal and sell objects.

She was forthcoming regarding her continued substance use and difficulty managing cravings on suboxone.Initially she reported she was relapsing on IV heroin, but later into her pregnancy, various collected UDSs were consistent with fentanyl, cocaine, and 

. During her initial presentations, she expressed interest in resuming methadone, but due to the daily dosing, was concerned about having regular transportation to the clinic. Toward the latter portion of her pregnancy, dosage of suboxone was titrated to 16mg. After delivery, transition to methadone was discussed, given inability to adhere to buprenorphine requirements including drug screens and clinic visits.

In addition to difficulties with transportation and housing, Ms Landry frequently did not have consistent access to a phone, adding another barrier to treatment. Her mother would be unaware of her whereabouts and unable to get into contact with her. When members of the team were able to contact her, she indicated that the baby’s father was present, and it was suspected that he encouraged guardedness during these conversations.

By the end of the pregnancy, Ms Landry stated she had ended her 5-year relationship with the father of the baby, due to continued substance use and physical abuse. She delivered her baby in early March 2021 at roughly 35 weeks. She presented via EMS to the ED for preterm premature rupture of membranes, and following delivery, her baby was transferred to the neonatal intensive care unit for prematurity. Child Protective Services became involved after the baby tested positive for cocaine. She again shared her intention to return to the local SUD facility. Shortly after, she left the facility against the advice of the treatment team. Following the baby’s discharge from the hospital, Ms Landry took the baby home. It was reported that she was sober for a total of 9 days throughout the remainder of her pregnancy.

Over the next 3 months, Ms Landry missed several appointments in the obstetrics and psychiatry clinics. On a few occasions, she would call the clinic following missed appointments to reschedule or reengage in SUD treatment, but then failed to present to clinic. The last documented encounter in her chart was when she presented to the ED, endorsing worsening withdrawal symptoms from recent IV 

. When she was called from the waiting room for further examination, staff were unable to locate her.

Throughout the United States, there has been a sharp up-tick in deaths involving synthetic opioids over the last decade. This is largely thought to be due to the rapid proliferation of illicitly manufactured 

 and fentanyl analogs (eg, acetylfentanyl, carfentanil), which are highly addictive and very potent.

 These substances are sold as a standalone product (ie, tablet or powder), as an additive to increase the potency of heroin at little cost, or as a substitute ingredient for more expensive sedative-hypnotic and opioid drugs, such as alprazolam, oxycodone, and hydrocodone.

 death rate in the United States was 14.98 per 100,000, with a median of 13.88 deaths per 100,000. The highest rate of opioid overdose-related death occurred in West Virginia (40.03 per 100,000), at roughly ~169% higher than the national average. In contrast, the lowest mortality rates were found in Texas (4.93 per 100,00), at approximately 3 times lower than the national average.

 However, results of a recent study at the University of Texas at San Antonio showed that although Texas has consistently had rates of mortality significantly lower than the national average, opioid-related deaths are on the rise. The study revealed that between 1999 and 2019, opioid-related deaths among persons aged 15 to 64 increased over 402% (from 3.8 per 100,000 in 1999 to 8.2 per 100,000 in 2019).3 Women accounted for 32.9% of those reported deaths.

Between 1992 and 2012, the rate of substance use treatment admissions among pregnant women with OUD increased from 2% to 28%.

 Similar to Ms Landry, demographic characteristics reflected a predominance of younger, unmarried, white non-Hispanic women; criminal justice referrals; and those with 

 In 2018, recognizing increasing incidence of mothers with OUD, the Substance Abuse and Mental Health Services Administration (SAMHSA) responded to the unique needs of women by outlining specific clinical guidance for 

The guides highlighted the complex needs of a women-centered approach to OUD treatment. These needs included the importance of adjusting the dose of MAT to account for the increased metabolic demands during pregnancy, breastfeeding, and breastmilk to decrease neonatal abstinence syndrome (NAS) severity among opioid-exposed infants; the provision of family-planning services that include highly effective contraceptive options to decrease high rates of unintended pregnancy; and engagement with obstetric, social services, and behavioral health providers during pregnancy and after delivery.

 Evaluation of 13,000 substance abuse treatment facilities across the United States found that only 40% offered women-centered OUD, listed in the aforementioned recommendations by SAMHSA.

In 2019, the Texas Health and Human Services Commission (HHS) was awarded $750,000 in federal funding to help increase access to treatment for pregnant and postpartum women with OUDs and enrolled in Medicaid.

 Goals for the initiative include establishing a multidisciplinary clinic designed to 

, reduce barriers to prenatal care, and improve the quality of maternal care for women with SUDs. Texas was 1 of 10 states chosen to implement this model of care, with aims closely related to the clinical guidelines by SAMHSA.

Ms Landry was able to utilize similar multidisciplinary services during her treatment course. However, as seen in her case, higher rates of intimate partner violence and sexual abuse, and cooccurring psychiatric disorders among women with OUD adversely affect levels of engagement and retention.

 Studies present mixed rates of continuation into the postpartum period, with some showing high rates of continued engagement into the postpartum period and others with rates of relapse as high as 56% at 6 months postpartum.

 Other factors in Ms Landry’s case—such as significant trauma history, history of substance use in her family, and misdiagnosis of psychiatric disorder leading to delays in care—add to the complexity of her presentation. These factors are not unique to her case, and further research should be done to develop additional modalities in treating pregnant and postpartum women with OUD.

is a PGY3 psychiatry resident at Baylor College of Medicine, in Houston, TX. She is currently on the Women’s Mental Health track and has additional clinical interest in addiction psychiatry, in which she plans to complete fellowship. 

is assistant professor at the Menninger Department of Psychiatry, Baylor College of Medicine. He specializes in addiction and women’s health/reproductive psychiatry, and serves as the primary psychiatrist on the maternal perinatal addiction treatment program.

Continued increases in overdose deaths related to synthetic opioids: implications for clinical practice. 

2. Lyle Cooper R, Thompson J, Edgerton R, et al. 

Modeling dynamics of fatal opioid overdose by state and across time. 

The burden of opioid-related mortality in Texas, 1999 to 2019. 

Recent trends in treatment admissions for prescription opioid abuse during pregnancy. 

Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants

. Substance Abuse and Mental Health Services Administration; 2018.

The pregnancy recovery center: a women-centered treatment program for pregnant and postpartum women with opioid use disorder. 

7. Phillips C. Texas awarded funding to help pregnant and postpartum women affected by opioid use disorders in Houston. Texas Health and Human Services Commission. December 20, 2019. Accessed February 28, 2022. 

https://www.hhs.texas.gov/sites/default/files/documents/mom-press-release.pdf

Opioid use disorder in pregnancy: health policy and practice in the midst of an epidemic. 

Substance use disorder may prove to be a significant issue for some mothers. 

“I Want to Do This for My Baby”: The Woes of Pregnancy and Addiction 

 is a leading cause of suffering and disability worldwide, affecting about 1% of the global population, community services for those with chronic schizophrenic illness are lacking in many areas. As a result, the emergency department (ED) often becomes a primary location for care of this severe mental disorder.

With our combined experience as an emergency medicine physician with interest in the management of acute psychiatric presentations (Furiato) and a psychotherapist with interest in the psychotherapy of schizophrenia (Ruffalo), we believe a psychologically (and psychodynamically) informed guide to the management of schizophrenia in the ED that incorporates relevant research from pharmacotherapy, psychology, and 

 can be very useful in the acute care of these patients.

Attempts to distinguish schizophrenia from the psychotic symptoms that occur in other mental and medical disorders date at least to Kraepelin’s pioneering work in the late 1800s. Another German psychiatrist, Kurt Schneider, proposed the “first-rank symptoms” of schizophrenia in 1939, and his theory held widespread popularity throughout the 20th century (

). A recent Cochrane review of Schneider’s first-rank symptoms (FRS) concluded that FRS correctly identifies individuals with schizophrenia 75% to 95% of the time.

 While reliance on FRS alone may not be sufficient to diagnose schizophrenia,

 recognition of FRS can aid ED physicians and mental health workers in the triage and care of patients presenting with psychotic disturbance.

Patients presenting to EDs may be well-known to ED staff; the course of schizophrenia is generally chronic and, in many geographic regions of the United States, comprehensive mental health systems are sorely lacking. In cases wherein the patient is a poor historian, or past records are otherwise unable to be obtained, reliance on clinical skill, such as knowledge of FRS, is necessary to ascertain the diagnosis of 

In certain instances, such as a clinical suspicion of new-onset schizophrenia or abnormal neurologic exam findings, use of brain imaging may be necessary to rule out organic disease of the nervous system. While a comprehensive review of brain imaging in psychosis is outside of the scope of this paper, Coentre et al

 note that neuroimaging is particularly useful in first-episode psychosis when patients are elderly, have neurological symptoms, or have an atypical clinical picture.

In the ED setting, the first and most important consideration upon presentation of the acutely agitated patient with psychosis or schizophrenia is the level of risk of harm they pose to themselves and staff.

 The resulting answer will help determine the route and type of medication for the specific patient. Speed of onset can dictate the route of administration, as those who are violent will need more rapid calming. These therapies should be used with verbal de-escalation techniques or directly after such attempts have failed.

Benzodiazepines, which are pharmacologically active on the gamma-aminobutyric acid (GABA) receptors, act on the central nervous system and are among the most common medications used for calming and sedation in the ED.

 The largest concentrations exist in the thalamus, cortex, and cerebellum. There are many different subclasses of GABA receptors, including the main α- and β- subunits. The biochemical neurotransmitter effects include reversable binding of the excitatory neuroreceptors and neuronal firing. The primary clinical effects are anxiolysis, 

 are also commonly used as the first-line agent of emergency treatment of seizure disorders and epilepsy.

 Potential adverse events include respiratory depression, hypoxia, hypotension, and paradoxical excitation reaction in those with organic brain disease. Depending on the lipid solubility of the agent and route of metabolism with patient comorbidities, half-lives vary widely (

Patients who are successfully verbally calmed and de-escalated can be considered for therapy with oral management with benzodiazepines alone or in combination with antipsychotics. Intramuscular medications combined with antipsychotics, often with the help of physical restraints, are used for those patients who cannot be de-escalated and pose a risk of injury to themselves and staff.

The 2 main categories of antipsychotics in the emergency setting are first-generation (typical) and second-generation (atypical) agents. The class distinctions are mostly important because of the associated adverse effects.

 First-generation antipsychotics were developed for the treatment of schizophrenia; they act on the multiple dopaminergic receptor, anticholinergic, and histamine pathways. Each drug has its own mechanism of action and level of antagonism of those pathways.

The hallmark first-generation drug is haloperidol, commonly used in the ED. It has been used with great success in treating the positive symptoms of schizophrenia. One of its main limitations, and ultimately a reason that prompted the development of the second-generation drug class, consists of extrapyramidal symptoms such as tremor, slurred speech, akathisia, dystonia, and 

The second-generation class of medications further treats the negative symptoms of schizophrenia and improves upon the adverse event profile of the first-generation group.

 Olanzapine and ziprasidone are common second-generation antipsychotics used in the ED. Significant adverse event of the second-generation drugs include sedation, hypotension, 

Many of the antipsychotics can be administered by mouth to those who are receptive to such and calm enough for safe administration. Antipsychotics can also be administered by intramuscular and intravenous injection for those who are severely agitated.

 Careful observation of the patient’s respiratory status by cardiac monitoring and continuous pulse oximetry must be done after administration, as adverse event can also include respiratory depression and hypoxia. The regular combination of benzodiazepines and antipsychotics can compound this risk. In addition, many of the antipsychotics can have adverse cardiac electrophysiologic effects, including prolonged QT intervals and the development of ventricular tachycardic arrythmias, necessitating electrocardiogram screening once the patient is chemically calmed.

 and antipsychotics used in the ED include lorazepam plus haloperidol or ziprasidone; and midazolam plus haloperidol or ziprasidone. The addition of the antihistamine diphenhydramine is also sometimes added to the aforementioned 2-drug cocktail for patients who are extremely violent. This practice is falling out of favor as seen in a recent retrospective cohort study.

 has also been examined for the acute management of the violently agitated patient.

 Ketamine is a dissociative agent that works at the N-methyl-D-aspartate (NMDA) receptor, which is thought to play a partial role in the development in schizophrenia. Ketamine, when given intramuscularly, can produce more rapid de-escalation and sedation vs the more traditional method of benzodiazepines plus an antipsychotic.

 The drawback to the use of ketamine is the theoretical possibility of exaggerating schizophrenic episodes due to activity on the NMDA receptors. There does not appear to be an increased need for inpatient psychiatric admission or ED psychiatric evaluation vs the traditional therapy.

 More research is needed to further assess the use of ketamine in the acute agitated schizophrenic patient.

Schizophrenia is a complex, multidimensional problem that requires appreciation of both biomedical and psychosocial aspects of disease management. This is true not only in the psychiatric treatment setting but also in the ED, since patients with schizophrenia may exhibit the most severe symptoms in the acute care setting.

Of greatest importance, perhaps, is the recognition that the patient’s heightened state of 

 has contributed to their current psychotic disintegration.

 The patient with schizophrenia often feels alone and afraid, isolated, and without any sense of basic trust or security. The threat of interpersonal contact is too much for them to bear, so they escape even deeper into their psychotic world. Care must be taken to avoid any unnecessary situations in which the patient’s anxiety is increased, as this will only worsen the psychotic symptoms.

Any attempt to challenge or question the validity of delusional themes will result in utter failure, so the ED clinician must avoid these types of confrontations. At the same time, the clinician should not tacitly agree with the patient’s deluded ideas but instead explain empathically that there are reasons they are experiencing things differently. Again, the clinician must do everything they can to foster an environment in which some semblance of trust can be established. For the patient who is mute or otherwise difficult to engage in an interview, speaking about neutral subjects, such as the weather or sports, may help alleviate anxiety and open up the patient to answering some basic questions.

While it is, of course, necessary to gather some information from the patient to establish a history and determine appropriate disposition, the patient with schizophrenia may experience too many questions as an imposition. As Silvano Arieti, MD, noted, “The request for information is often interpreted by the patient as ‘an attempt to take something from him.’”

 The aim of the ED interview should be less the collection of detailed information and more of a process of relating to the patient, while gathering an assessment of current symptoms, an attempt to relay a sense of warmth, security, and trust which will serve as the foundation for ongoing treatment.

As previously discussed, the administration of psychotropic medications in the ED is sometimes necessary to stabilize an aggressive or violent patient. In these cases, the ED physician and mental health professional should maximize the patient’s sense of autonomy and self-determination; for example, the staff can allow the patient to choose the route of administration. Most likely, the patient feels that they have been violated in some way—either due to intrusive voices, paranoia, somatic delusions, or some other terrifying symptom—so the ED clinician should attempt to avoid coercion to the greatest degree possible.

Lastly, in many cases of schizophrenia, psychotic symptoms are ongoing, sometimes in spite of good pharmacological and psychotherapeutic management. The mere presence of psychotic symptoms in a patient who experiences such symptoms at baseline does not warrant 

, and it is unlikely that any such admission would do anything to improve the patient’s chronic illness.

Psychiatric Emergencies

New 988 Suicide Hotline: Hope or Hype?

“I Want to Do This for My Baby”: The Woes of Pregnancy and Addiction

Schizophrenia in the Emergency Department: Psychologically and Psychodynamically Informed Practices

What the Mental Health Crisis Looks Like on the Ground Level

Psychologically-Informed Management of Schizophrenia in the Emergency Department

The Need for Better Crisis Prevention

Teamwork and Trauma: a Conversation With Kasey Grewe, MD, and Niesha Voigt, MD

How to Talk to Patients About Firearms

Agree to Disagree: Excited Delirium Syndrome as Volatile as the Term Itself

Fast-Acting Options for Mood Disorders and Psychiatric Emergencies