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Synthetic cannabinoids and cathinones are novel psychoactive substances (NPS) that have surreptitiously emerged on the market to mimic the effects of 

 These designer substances are gaining popularity due to their widespread availability and safety misperceptions. Temporal trend epidemiological data analyzed by the Centers for Disease Control indicate that acute poisonings related to synthetic cannabinoids and cathinones are increasing in the 

The rise in synthetic cathinone and cannabinoid use among patients susceptible to adverse neuropsychiatric reactions has been linked to a wide range of unpredictable effects, including 

 Emergency department (ED) psychiatrists are on the frontlines of care, and must provide the initial management and stabilization of the complex and challenging toxic effects of these drugs. Prompt recognition and management is essential to reduce morbidity and mortality.

, these designer synthetic cannabinoid receptor agonists have potent intrinsic activity at the cannabinoid (CB) 1 and 2 

 The compounds were originally developed to study the endocannabinoid system, but they emerged as 

 Initially designed to mimic the effects of delta 9-tetrahydrocannabidiol, synthetic cannabinoids are 2 to 100 times more potent than marijuana at the CB1 and CB2 receptor, resulting in a wide range of adverse neuropsychiatric symptoms.

 Furthermore, synthetic cannabinoids are often adulterated with additional ingredients to either enhance or attenuate the drug high, resulting in clinically unpredictable toxicological profiles.

 As a consequence, there is no specific toxidrome associated with synthetic cannabinoid intoxication, and patients will typically present with a constellation of sympathomimetic, anticholinergic, and marijuana toxic effects.

). The most common sympathetic nervous system cardiovascular effects are tachycardia (46%) and hypertension (21%). The anticholinergic effects closely overlap with signs and symptoms of a sympathomimetic toxidrome. Distinguishing symptoms specific to anticholinergic toxicity include: dry skin, cotton mouth, absent bowel sounds, blurred vision, and urinary retention. Moreover, patients may additionally present with marijuana intoxication symptoms (ataxia, delayed reaction time, and 

conjunctival injection). Laboratory studies are indicated in cases of severe intoxication with agitation or seizures due to the resulting life-threatening metabolic derangements.

Rates of synthetic cannabinoid use are increasing in the United States, with the lifetime prevalence estimated to be between 0.2% and 4%.

 Moreover, between January 2016 and September 2019, ED visits related to synthetic cannabinoid toxicity significantly increased in the country’s Midwestern and Northeastern regions.

 Overall, synthetic cannabinoids harms are increasing, and psychiatrists need to be cognizant about the clinical presentations and evidence based treatments. 

, these agents are synthetic psychostimulants structurally related to cathinone, a monoamine alkaloid found in the Khat plant. As substituted phenethylamines, synthetic cathinones are structurally and pharmacologically similar to amphetamine and 3,4-methylenedioxymethamphetamine (MDMA). These agents are commonly abused for their euphoric, empathogenic, and stimulating effects. The most commonly abused synthetic cathinones are 4-methylmethcathinone (mephedrone), 3,4-methylenedioxy-N-methylcathinone (methylone), and 4-methylenedioxypyrovalerone (MDPV).

 Synthetic cathinones produce major effects on the Central Nervous System (CNS), and are linked to adverse neuropsychiatric complications (

). Synthetic cathinones stimulate the release of dopamine and inhibit the reuptake of epinephrine, norepinephrine, and serotonin inducing a broad range of sympathomimetic, serotonergic, and hallucinogenic adverse toxidrome effects (

 The most frequent sympathetic nervous system cardiovascular effects are tachycardia (46%) and hypertension (21%). The hallucinogenic effects (perceptual distortions, depersonalization, synesthesia) can be highly distressing, which often prompts emergency psychiatric care. Ancillary lab studies should be ordered in cases of severe agitation because of the increased risk for acute kidney injury, rhabdomyolysis, lactic acidosis, stroke, and intracranial hemorrhage.

Self-reported prevalence of synthetic cathinone use is an estimated 0.05%. Current estimates are imprecise, however, as established surveys and standard immunoassay testing are not sensitive for detecting cathinones.

 The most recent data from the Drug Abuse Warning Network report indicates 22,904 ED visits were related to synthetic cathinone toxicity in 2014. The frequency of ED utilization is likely increasing, as synthetic cathinones are steadily becoming more popular despite the potential harms.

The diagnosis of intoxication is based on a history of exposure and presence of characteristic signs and symptoms. Patients may unknowingly or inadvertently administer synthetic cannabinoids and cathinones, as these compounds are oftentimes adulterated with other illicit drugs such as MDMA.

 Although there is no specific toxidrome, patients will typically present with signs and symptoms of adrenergic neurohumoral activation.

 The neurotoxic symptoms (including aggression, confusion, and psychosis) may overlap with a primary mental illness, and psychiatrists must rely on the clinical history and physical exam findings to accurately diagnose toxicity. Urine immunoassay testing is the most common method to screen for substance use. In the setting of acute intoxication, however, urine immunoassay testing has a low positive predictive value for synthetic cannabinoids and cathinones.

 While gas chromatography/mass spectrometry (GC/MS) is considered the gold standard for detecting substances, the molecular geometry of synthetic cannabinoids and cathinones is everchanging, making it increasingly difficult to directly identify these compounds.

 Moreover, GC/MS is not readily available in all emergency hospitals, and the results may not return in a timely manner to aid in the diagnosis process. An atypical onset of psychosis and agitation alongside hyper-sympathetic activation and a mixed toxidrome is strongly suggestive of intoxication.

Because of the variability in clinical presentations and lack of diagnostic testing, psychiatrists should strongly consider the possibility of intoxication in any patient with no known psychiatric history, a negative urine drug screen, and no known contributing medical mimickers (presenting with a mixed toxidrome). Patients will not necessarily fit neatly into a particular toxidrome, but rather present with overlapping signs and symptoms from multiple toxidrome classes. Consequently, differentiating synthetic cannabinoid and synthetic cathinone toxicity can be challenging. Regardless, supportive care and symptom management is the mainstay of the treatment. Benzodiazepines are considered the first line of treatment to reduce the sympathomimetic neural stimulation (including hypertension, agitation, and seizures).

Agitation is the most common neuropsychiatric complication associated with synthetic cannabinoid and cathinone ingestion. Katz and colleagues reported that 40% of intoxicated patients evaluated in an ED will experience severe agitation.

 The spectrum of psychomotor agitation can be objectively measured and identified with a standardized rating scale such as the Behavioral Activity Rating Scale (BARS). For patients with mild-moderate agitation (BARS score = 5 or 6), the patient may initially be calmed with verbal de-escalation techniques, and environmental modification. For patients with moderate-severe agitation (BARS score > 6), benzodiazepines remain the first line treatment for reducing moderate to severe agitation.

 Among the benzodiazepines, midazolam and lorazepam are considered the initial drugs of choice for decreasing agitation because of their rapid onset of action, short half-life, and parenteral route of administration availability.

 Antipsychotics are commonly administered with benzodiazepines to manage the psychotomimetic effects.

 However, risks associated with administering antipsychotics in acute poisonings settings must be carefully considered. Specifically, antipsychotics: may increase the risk of seizure induction; have anticholinergic effects; impair thermoregulation mechanisms; and prolong the QTc interval.

 Serotonergic sedatives such as fentanyl should be avoided because of the increased risk of serotonin toxicity associated with synthetic cannabinoids and cathinones.

A subset of patients will develop excited delirium following ingestion of psychostimulants. A systematic review reported that 25% to 94% of patients diagnosed with excited delirium were recently exposed to synthetic cannabinoids and/or cathinones. The American College of Emergency Physicians has provided guidance on evaluating excited delirium: a minimum of 6 out of 10 clinical criteria are required to make a diagnosis. If undertreated, the case-fatality rate is estimated to be 20%, partly due to catecholaminergic cardio-respiratory failure. The cornerstone of treatment is rapid sedation to reduce the sympathomimetic outflow and facilitate lifesaving treatments.

To date, no large scale randomized controlled trials have evaluated pharmacological treatments for excited delirium. Nonetheless standard of care is to administer benzodiazepines and antipsychotics to decrease psychomotor agitation. In the emergency setting, IM ketamine (4-5 mg/kg) is increasingly used for sedation of agitated patients with excited delirium. Initial studies in the pre-hospital setting (emergency medical services) reported that intubation rates following ketamine administration were as high as 60%. Emerging literature supports that IM ketamine administration in the hospital setting (emergency department) is a safe and effective treatment for excited delirium while not significantly affecting the cardiopulmonary system.

 Mankowitz and colleagues reported that more patients required intubation after ketamine administration in the pre-hospital setting (30%) compared to the hospital setting (1.8%).

 Prospective studies conducted in the emergency department have demonstrated that there is no significant difference in incidence of complications between IM ketamine and IM haloperidol.

 The side effects of single doses of IM ketamine for agitation are generally transient and self-limiting: emesis, hypersalivation, recovery agitation (also known as emergence reaction), hypertension, and tachycardia. Moreover, ketamine has other potential benefits, including a faster onset to sedation compared with benzodiazepines and antipsychotics.

 There are observational reports of ketamine exacerbating psychosis in susceptible patients. Larger studies, however, have concluded that acute- and short-term administration of ketamine for agitation does not increase psychiatric inpatient admissions or ED psychiatric evaluations.

 Physical restraints should be used as a last resort, primarily as a bridge to pharmacologic treatment, as prolonged use of physical restraints is likely to worsen delirium and rhabdomyolysis, leading to renal failure, electrolyte abnormalities, and arrhythmias.

Synthetic cannabinoids have been linked to psychotic reactions, such as paranoia, catatonia, dissociation, auditory, and/or visual hallucinations.

 Longitudinal studies have reported that consumption of potent cannabinoids quintuples the risk of a psychotic episode.

 The psychotomimetic effects are usually transient and resolve within 5 to 8 days; however, up to one-third of patients will transition to schizophrenia.

 Although there is no established antidote, preliminary reports suggest that cannabinol, an allosteric modulator at the CB1 receptor, may reverse the neurotoxic effects.

Similarly, synthetic cathinones have pro-psychotic effects, potentially triggering a psychotic state in vulnerable groups of patients. An observational study reported that synthetic stimulants were implicated in approximately 25% of ED visits involving drug-related psychosis. Specifically, mephedrone was the most common synthetic cathinone involved in stimulant psychosis, accounting for approximately 20% of stimulant related psychotic cases.

 Synthetic cathinone induced psychosis is typically brief and resolves within days to weeks; however, 25% of patients will transition to a schizophrenia spectrum disorder.

The psychotomimetic symptoms can be controlled with first- and second-generation antipsychotic medications with careful consideration of side effect profiles. Among the first-generation antipsychotics, the butyrophenone neuroleptics IM haloperidol and IM droperidol are reasonable pharmacotherapeutic options.

 In comparison to IM haloperidol, IM droperidol has a faster onset of action, rapidly preventing and treating emergent psychotic agitation within 5 to 10 minutes of intramuscular administration.

 Some expert panels have recommended avoiding butyrophenone neuroleptics in cases of substance-induced psychosis due to the pro-convulsant properties, cardiotoxic effects, and extrapyramidal symptoms. Among the second-generation antipsychotics, p.o. olanzapine has a track record of treating NPS-induced psychosis, and pro-drug websites have touted olanzapine as the ideal medication to terminate so-called “bad trips.”

 In spite of its efficacy, olanzapine has anticholinergic and central thermoregulatory effects impairing core temperature regulation. In theory, p.o. or IM aripiprazole and ziprasidone are probably the safest antipsychotics to administer because of the relatively favorable safety profile, and negligible anticholinergic and seizurogenic effects.

 epidemiological studies do not support a correlation between ziprasidone and torsade de pointes. In many instances, detoxification with benzodiazepines and rest will often quell the substance-induced symptoms without the added need for antipsychotics. Given the risks associated with neuroleptics, especially in antipsychotic naïve patients, it may be best to consider a benzodiazepine as the first line agent to reduce the psychotic agitation. Antipsychotics can be initiated if the psychosis continues to persist after the detoxification period, or if the patient has a underlying primary psychotic illness.

Synthetic cannabinoid and cathinone harms are increasing, and psychiatrists need to be cognizant of the clinical presentations and evidence-based treatments. Synthetic cannabinoids and cathinones have pro-psychotic and agitative effects, and the toxic reactions can mimic a primary mental illness. There is no definitive diagnostic test to differentiate primary versus secondary drug induced mental illness, and ED psychiatrists must rely on the history and physical examination. In a subset of cases, the overstimulation of catecholamines may result in an excited delirium. Benzodiazepines are considered the first line treatment to reduce the sympathomimetic neural stimulation.

is anassistant professor of Medical Education and Psychiatry at California University of Sciences and Medicine, Arrowhead Regional Medical Center in San Bernardino, CA. 

is a core faculty member for the Internal Medicine Residency Program at Arrowhead Regional Medical Center, San Bernardino, CA. The authors have no relevant financial disclosures to report.

1. Dignam G, Bigham C. Novel psychoactive substances: a practical approach to dealing with toxicity from legal highs. 

2. Riederer AM, Campleman SL, Carlson RG, et al. Acute poisonings from synthetic cannabinoids - 50 U.S. toxicology investigators consortium registry sites, 2010-2015. 

3. Cohen K, Weinstein AM. Synthetic and non-synthetic cannabinoid drugs and their adverse effects-a review from public health prospective. 

4. Tai S, Fantegrossi WE. Pharmacological and toxicological effects of synthetic cannabinoids and their metabolites. 

5. Wiley JL, Marusich JA, Huffman JW, et al. Hijacking of basic research: the case of synthetic cannabinoids. 

6. Castaneto MS, Gorelick DA, Desrosiers NA, et al. Synthetic cannabinoids: epidemiology, pharmacodynamics, and clinical implications. 

7. Zuba D, Byrska B. Prevalence and co-existence of active components of ‘legal highs.’ 

9. Loeffler G, Delaney E, Hann M. International trends in spice use: prevalence, motivation for use, relationship to other substances, and perception of use and safety for synthetic cannabinoids. 

10. Roehler DR, Hoots BE, Vivolo-Kantor AM. Regional trends in suspected synthetic cannabinoid exposure from January 2016 to September 2019 in the United States. 

11. Weinstein AM, Rosca P, Fattore L, London ED. Synthetic cathinone and cannabinoid designer drugs pose a major risk for public health. 

12. Baumann MH, Walters HM, Niello M, Sitte HH. Neuropharmacology of synthetic cathinones. 

13. Palamar JJ, Martins SS, Su MK, Ompad DC. Self-reported use of novel psychoactive substances in a US nationally representative survey: prevalence, correlates, and a call for new survey methods to prevent underreporting. 

14. The DAWN Report. “Bath salts” were involved in over 20,000 drug-related emergency department visits in 2011. Substance Abuse and Mental Health Services Administration. 2013. Accessed November 30, 2020. https://www.samhsa.gov/data/sites/default/files/spot117-bath-salts-2013/spot117-bath-salts-2013.pdf

15. Oliver CF, Palamar JJ, Salomone A, et al. Synthetic cathinone adulteration of illegal drugs. 

16. Arntson A, Ofsa B, Lancaster D, et al. Validation of a novel immunoassay for the detection of synthetic cannabinoids and metabolites in urine specimens. 

17. Moeller KE, Kissack JC, Atayee RS, Lee KC. Clinical interpretation of urine drug tests: what clinicians need to know about urine drug screens. 

18. Bonaccorso S, Metastasio A, Ricciardi A, et al. Synthetic cannabinoid use in a case series of patients with psychosis presenting to acute psychiatric settings: clinical presentation and management issues. 

19. Katz KD, Leonetti AL, Bailey BC, et al. Case series of synthetic cannabinoid intoxication from one toxicology center. 

20. Nordstrom K, Zun LS, Wilson MP, et al. Medical evaluation and triage of the agitated patient: consensus statement of the american association for emergency psychiatry project Beta medical evaluation workgroup. 

21. Hui D. Benzodiazepines for agitation in patients with delirium: selecting the right patient, right time, and right indication. 

22. Roberto AJ, Lorenzo A, Li KJ, et al. First-episode of synthetic cannabinoid-induced psychosis in a young adult, successfully managed with hospitalization and risperidone. 

23. Gonin P, Beysard N, Yersin B, Carron PN. Excited delirium: a systematic review. 

24. Li M, Martinelli AN, Oliver WD, Wilkerson RG. Evaluation of ketamine for excited delirium syndrome in the adult emergency department. 

25. Mankowitz SL, Regenberg P, Kaldan J, Cole JB. Ketamine for rapid sedation of agitated patients in the prehospital and emergency department settings: a systematic review and proportional meta-analysis. 

26. Heydari F, Gholamian A, Zamani M, Majidinejad S. Effect of intramuscular ketamine versus haloperidol on short-term control of severe agitated patients in emergency department: a randomized clinical trial. 

27. Heydari F, Gholamian A, Zamani M, Majidinejad S. Effect of intramuscular ketamine versus haloperidol on short-term control of severe agitated patients in emergency department; a randomized clinical trial. 

28. Lebin JA, Akhavan AR, Hippe DS, et al. Psychiatric outcomes of patients with severe agitation following administration of prehospital ketamine. 

29. Annas GJ. The last resort--the use of physical restraints in medical emergencies. 

30. Hurst D, Loeffler G, McLay R. Psychosis associated with synthetic cannabinoid agonists: a case series. 

31. Di Forti M, Marconi A, Carra E, et al. Proportion of patients in south London with first-episode psychosis attributable to use of high potency cannabis: a case-control study. 

32. Murrie B, Lappin J, Large M, Sara G. Transition of substance-induced, brief, and atypical psychoses to schizophrenia: a systematic review and meta-analysis. 

33. Hudson R, Renard J, Norris C, et al. Cannabidiol counteracts the psychotropic side-effects of Delta-9-Tetrahydrocannabinol in the ventral hippocampus through bidirectional control of ERK1-2 Phosphorylation. 

34. Vallersnes OM, Dines AM, Wood DM, et al. Psychosis associated with acute recreational drug toxicity: a European case series. 

35. Calver L, Drinkwater V, Gupta R, et al. Droperidol v. haloperidol for sedation of aggressive behavior in acute mental health: randomized controlled trial. 

36. Thomas H, Schwartz E, Petrilli R. Droperidol versus haloperidol for chemical restraint of agitated and combative patients. 

37. Valeriani G, Corazza O, Bersani FS, et al. Olanzapine as the ideal “trip terminator”? Analysis of online reports relating to antipsychotics’ use and misuse following occurrence of novel psychoactive substance-related psychotic symptoms. 

 Be on the lookout for these novel psychoactive substances. 

Assessing and Addressing Synthetic Cannabinoids and Cathinones in Neuropsychiatric Toxicological Emergencies 

Scott Zeller, MD, discusses emergency psychiatry in preparation for his Special Report introduction for the January issue of 

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

Scott Zeller, MD, previews his article in the January issue of Psychiatric Times, where he talks about emergency psychiatry and the tremendous growth it has seen over the past decade. 

Emergency Psychiatry: The Intertwining of Physical and Mental Health

Tony Thrasher, DO, DFAPA, discusses the importance of the psychiatric interview in this preview of his article for the January issue of 

is the president of the American Association for Emergency Psychiatry (AAEP) and the medical director of crisis services in Milwaukee county.

Tony Thrasher, DO, DFAPA, previews his article for the January issue on the art of the psychiatric interview. 

The Psychiatric Interview

The most common emergency presentations to emergency departments are identified.

10 Most Common Presentations in Emergency Psychiatry

Scott Zeller, MD, explains more about mental health crisises, learning about your community's resources, and being vigilant. 

 is Vice President for Acute Psychiatry at 

. He played an integral part in the development of guidelines for the evaluation and treatment of agitation. He is a past president of the 

American Association for Emergency Psychiatry

Watch for tips and tricks to help patients through psychiatric emergencies. 

Kept in the Shadows: Unpredictable Emergencies 

The sight was familiar: 2 law enforcement officers escorting a middle-aged Black man through the doors of the emergency department.

“Emotionally Disturbed. Found in Grand Central. Acting erratic. Name’s Jones.”

The attending glanced at the patient, nodded, signed the police form. As we returned to our workstations, I observed him writing a brief triage note and placing a diagnosis in the chart—

Erratic, disheveled, psychotic. African American male. Schizophrenia

Psychotic? I glanced back to see what I had missed.

Hours later, having slowly chipped away at our ever- growing list, it was time for “Mr Jones”* to be seen. I opened his chart and discovered that he had been brought into the Emergency Department (ED) by police before, always from Grand Central Station and always late at night. He was homeless and supported himself by panhandling. The psychiatric assessments consistently described him as logical, coherent, and intelligent. He was discharged immediately after each evaluation. Anger began to swell in my gut—why was this man without a psychiatric illness repeatedly brought to the ED by police?

A pleasant interview with Mr Jones confirmed the history and assessment in his chart. He was frustrated that police routinely took him to the hospital where he would be placed in a locked unit only to be discharged immediately after evaluation. I apologized. I found clean clothes and sandwiches for him and rushed to find the nearest attending to approve his discharge.

By the time Mr Jones had left the department, my anger had reached a full boiling rage. Had a senior psychiatrist in a renowned psychiatric department eyeballed a patient and concluded that he was psychotic, based only on his appearance and the circumstances under which he was brought to the hospital?

As a psychiatrist it is impossible for me to imagine practicing medicine without concurrent engagement in advocacy. After all, I would not shovel my walk while a blizzard was still raging. The pressing problems faced by our patients are almost invariably tied to large structural problems that must be addressed through legislative reform and community level interventions. They are also problems that disproportionately affect people of color. I could provide psychotherapy to my patient, who is newly homeless and grieving the loss of her partner to a drug overdose, but that is not much of a cure. I can prescribe a selective serotonin reuptake inhibitor to the gentleman who meets DSM-V criteria for general anxiety disorder, but will it truly help quell his anxiety as he navigates his racially hostile work environment—the place where his anxiety is worst?

Thankfully, I am far from unique in my thinking. My residency program has advocacy embedded in the curriculum. Many of my peers interact regularly with their government representatives and draft bills and testify before the legislature. Both the American Psychiatric Association (APA) and the American Medical Association (AMA) espouse advocacy as a core value in medicine, going so far as to provide guidance for physicians to become involved in legislative efforts. I celebrate this attention to advocacy. And yet it is also clear that we have ignored the very important work that needs to be done in our own home.

Mr Jones was brought to the psychiatric ED because of structural problems that include racism, poverty, unemployment. We might be tempted to externalize these problems, to see them as existing in spaces that are not our own. But Mr Jones was assumed to have a psychotic disorder because that same racism pervades our psychiatric spaces too. The attending’s misdiagnosis of Mr Jones was not an isolated incident, but rather a reflection of a broader issue in psychiatry. Racism is an inside problem for us in medicine. Focusing our efforts on only the former is tantamount to shoveling half the sidewalk in the middle of a blizzard.

Black males are incarcerated at greater than 5 times the rate of white males in the United States

 with evidence that differential treatment of black people in the legal system is an important factor.

 My anecdotal experience suggests that they also might be more likely to be brought to the hospital against their will for psychiatric evaluation. Equally distressing is that black males are more likely to be misdiagnosed with schizophrenia relative to their white peers who present with similar symptoms. The harms caused by each of these problems is severe. And with Mr Jones, the harms of each of these systems were compounded to perpetuate maximal injustice and harm. 

While community and legislative advocacy have become more mainstream in medicine, change within our own institutions has been stagnant. With current motivation and energy focused on making anti-racist changes, the time has come for us to turn our focus to ourselves, to fix the problems in our own house. This is especially true for white psychiatrists like me. A new advocacy moment is here. We must seize it.

It took a full week for me to have the schizophrenia diagnosis scraped from Mr Jones’ chart. Yet having it removed hardly felt like a victory. Would it happen to him again? How many other black male patients have a psychotic diagnosis inappropriately listed in their charts? And perhaps most distressing to me—for how many of those might I be responsible?

*The patient’s name and identifying information in this essay have been changed to protect confidentiality.

is a fourth-year resident in psychiatry. She completed her internship in NYC before transferring to Yale where she is currently completing her training.

1. Garland B, Sophn C, Wodahl E. Racial disproportionality in the American prison population: Using the Blumstein method to address the critical race and justice issues of the 21st Century. 

2. Bridges G, Crutchfield RD. Law, social standing and racial disparities in imprisonment. 

Racism is a problem that exists in our space. A new advocacy moment is here, and it needs to be seized.  

Looking Within: The Inside Problem of Racism in Psychiatry 

Many experts predict a sharp rise in psychiatric emergencies as the nation emerges from sheltering-in-place, especially since individuals are dealing with unprecedented stressors and have been unable to access traditional treatment settings. Mental health crises may be one area in which therapeutic professionals might be a logical substitute for traditional police interventions. But what services comprise the crisis spectrum of care? And, if you treat patients in a private office or clinic, how might you best access these services when you encounter a psychiatric emergency?

Crisis services for behavioral health emergencies may include a wide variety of approaches, and they tend to vary depending on your state, county, or community. Yet, there are general overall concepts applicable to most crisis programs and their target patient populations.

A mental health crisis is a situation in which a person’s thoughts, emotions, and behaviors can put them in jeopardy of harming themselves or others and/or put them at risk of being unable to care for themselves or access food, clothing, and shelter. Crises also include acute conditions that could quickly deteriorate into dangerousness or inability to care for self, even if those issues do not currently pose a problem.

A mental health crisis can surface anywhere—in public, in the home or work environment, or in any number of clinical settings. This discussion will focus on the considerations when an apparent crisis arises in patients under a clinician's direct care.

The following questions will help determine if a mental health crisis exists and if crisis services should be accessed 

1. Due to their behavioral health conditions, is this individual acutely dangerous to self or others, or unable to care for self?

2. If the answer to question 1 is not clear, are there concerns that, without prompt intervention, the behavioral health situation could evolve into dangerousness or inability to care for self?

If the answer to question (1) or (2 ) is “yes,” then answer (A) and (B) below.

A. Is this condition unlikely to be resolved by interventions without the need for a higher level of care?

B. Even if our interventions can temporarily stabilize the situation, is there a high degree of concern that dangerousness or inability to care for self will return shortly after our contact has ended?

If the answer to (A) or (B) is “yes,” then there is a crisis situation requiring acute external interventions.

Determining dangerousness and/or inability to care for self

The clinician should consider several factors when assessing a patient for dangerousness and ability to care for self.

. Is this the first time you have met with this individual, or are they well known to you?

. How certain are you about the veracity of their statements? Do you believe them when they say they will follow through with a plan?

. What is your understanding of how they have acted when experiencing similar behavioral issues in the past?

. Has this person made suicide attempts or become aggressive in the past?

. What do family, significant others, co-workers, and caregivers say about the patient’s current behavior and their concerns about these behaviors?

These considerations and questions help to determine the acuity and level of intervention needed. For example, an initial meeting with reported symptoms requires a different level of evaluation than if the patient and their symptom history are well-known to you. Similarly, a patient that is well-known who reports a sudden change or demonstrates a marked difference from their usual behavior should raise the level of acuity. Based on familiarity, you must evaluate your level of trust with the patient. If trust is nebulous, then it is paramount to delve into collateral opinions of family and significant others. Concerns may first arise from a patient’s report, their significant others’ report, or your personal assessment. Regardless of the source of the initial warning, the response should be comparable.

Although an individual’s mention of the word 

 in discussing previous thoughts or incidents may not be considered a reason for accessing crisis services, any concern that patients may be at risk to harm themselves should be considered a reason for action. It is most important to learn about an individual’s thoughts around suicide, especially if there is any suicidal plan or intent. To determine if a patient needs a higher level of care, clinicians should consider the following issues. 

 Is the person thinking/talking about suicide, or saying that death seems to be an option, or expressing that the world would not miss them/would be a better without them?

 Does the person have a specific idea about how they would kill themselves? How lethal is this method?

 How much does the person want to use a particular method to kill themselves? How serious are they about it?

 Does this individual have access to the means they have described to kill themselves?

 Does the person have strong religious or cultural beliefs that forbid suicide? Do they have others who rely on them that they feel they cannot leave?

Chronic symptoms of psychosis may be a well-controlled part of an individual’s life and not necessitate an emergency referral. Acute psychosis, however, may lead the patient to harm themselves or others or may cause an inability for them to care for themselves. For example, if the patient is currently stable and the hallucinations are tolerable and not placing the patient at risk, then long-standing auditory hallucinations (eg, a running commentary of what the patient sees) may be fine. On the other hand, a new delusion may necessitate intervention, especially if the hallucinations have negative consequences for the patient (eg, hallucinations dictating all food is poisonous and must be avoided, which results in the patient starving themselves). Similarly, command auditory hallucinations to attack family members or delusions that one has the ability to fly and should jump off a tall buildingare clearly psychiatric emergencies. Thus, there are many issues that must be considered.

 Is the person newly experiencing auditory hallucinations or experiencing a substantial increase in chronic hallucinations? Are the hallucinations commanding them to do things, especially to harm themselves, others, or objects? Are the hallucinations derogatory or highly critical of the patient? Does the patient feel they are unable to resist doing what the hallucinations are telling them?

 Does the person feel others wish to harm them and they might have to defend themselves or preemptively attack others? Does the person believe other people want to kill them? Is the person obsessively fixated on another person who may not share their feelings? Is the patient paranoid or delusional about anything that would prevent them from accessing food, clothing, or shelter (eg, if they go inside they will die, all foods are poisonous, they are impervious to cold and do not require a coat in subzero weather)?

. Has the individual become so confused or withdrawn that they are unable to appropriately interact with others and their environment and, thus, unable to access food, clothing and/or shelter?

When symptoms of mania are uncontrolled, there is risk for harm to self or others as a result of rash judgements, impulsivity, inability to rest, grandiosity, and impaired decision-making. Evaluating the severity of a manic or hypomanic episode may be determined with the following considerations.

 Is the person displaying poor judgment, unable to differentiate between right and wrong, spending money they do not have, placing themselves into dangerous situations unwittingly?

 Is the patient going without sleep or doing specific activities nonstop for long hours?

 Is the person easily angered, lashing out, or easily moved to anguish and sobbing?

, unlike uncontrolled mania, is often more objectively apparent in terms of current intoxication or effects of drug misuse. The severity of substance abuse may be apparent in terms of mood, judgement, or disorganization.

 Is the person despondent about their substance abuse or inability to quit? Have they mentioned suicide?

 Is their current intoxication or level of withdrawal clouding their judgment and putting them at risk?

 Can the person safely leave the facility and get home on their own?

Fortunately, there are a variety of crisis programs that can assist the clinician in providing help for their patient. Programs vary in their level of care and support as well as cost. By becoming familiar with the options in your area, you will be better able to offer information to patients before a crisis occurs as well as when the need arises.

 number is available in most areas; it can be reached via 800-273-TALK. The FCC has approved a 3-digit hotline number—988—to make it easier for people to access mental health resources, which should be available by summer 2022. If you are in direct contact with a patient, you likely will not need to refer them to a hotline; however, you will want to ensure patients are informed about such resources and should add the information to your voicemail message.

. Although technically not crisis programs, many county and municipal programs have a 24-hour mental health line, sometimes called an ACCESS line, to arrange for prompt mental health appointments, referrals, and links to services. These programs can also direct individuals to appropriate 

 These are crisis professionals, typically therapists or social workers, who will go to an individual in crisis for an onsite assessment. When possible, they will attempt to de-escalate and stabilize the patient at the site, so the patient does not need to be moved offsite to access a higher level of care. Based on the assessment, mobile crisis teams will often transport patients to an appropriate destination, which could be a community crisis center, a psychiatry emergency department (ED), a psychiatric inpatient unit, or a general hospital ED. Mobile crisis models can operate independently or may partner with the police; frequently the mobile crisis team can be accessed via police dispatch.

Community crisis programs/centers/mental health urgent care

. In recent years, many locations around the country have created drop-in crisis facilities. These can range from a simple set-up, like a section of the community mental health clinic staffed with crisis therapists, to a comprehensive crisis center with crisis intervention, 23-hour crisis stabilization units (intensive outpatient stabilization services which typically have a limit of 23 hours 59 minutes—anyone requiring a longer stay is moved to an inpatient unit), and substance abuse and/or detox programs. Patients typically need to arrive voluntarily, but mobile crisis teams, case managers, and police officers can also bring them to these centers. Although they may be able to accommodate involuntary detention patients, including initiation of involuntary holds, these patients are typically transferred to a medical ED or hospital rather than remaining onsite involuntarily.

. Although not available in every region,, a substantial number of locations have Psychiatric Emergency Programs that are designated as the main receiving site for involuntary and high-acuity psychiatric detentions. These programs typically accept voluntary patients and self-presenting individuals, but most patients tend to be involuntary cases that arrive via police or ambulance. These programs offer immediate assessment and treatment (including medication) with 23-hour crisis stabilization capacity. These units are invariably locked, so anyone entering will have to be discharged by a clinician before they can leave. For this reason, it may be the preferred option for individuals who refuse emergency care or who are flight risks.

. Most inpatient psychiatric hospitals accept the majority of their patients via direct referrals from psychiatrists with hospital admitting privileges or via referrals from regional medical and psychiatric EDs. However, many programs have intake hours in which an individual can self-present on recommendation from their outpatient therapist. In such situations, a member of the psychiatric hospital staff will assess for a possible admission to the inpatient unit.

. In the United States, the default location to send a crisis patient is the nearest general hospital medical ED, which is open 24 hours a day and obliged to evaluate any individual who requests services. The numbers of behavioral emergency patients presenting at medical EDs around the country has climbed in recent years, and it is currently estimated that 1 in every 8 patients in EDs 

with a behavioral emergency as the chief complaint.

 Most EDs, however, have little more to offer than a medical clearance, (perhaps) sedating medications, or a referral to an inpatient hospital bed.

A promising trend has been to offer higher levels of psychiatric care in medical EDs, including psychiatric assessment and treatment recommendations via on-demand telepsychiatry. Another new and useful trend is the availability of EmPATH (Emergency Psychiatry Assessment Treatment and Healing) units, which are specialized psychiatric emergency programs affiliated with the ED, analogous to an ICU dedicated for emergency behavioral health patients.

. When there are no other alternatives, calling 911 remains a legitimate best option for activating emergency services. It allows for a patient assessment and transport to a crisis facility or ED. Depending on your community or state as well as the acuity of the emergency, response may be from a crisis team, emergency medical services, and/or police.

 is Vice President for Acute Psychiatry with the physician partnership 

 and Assistant Clinical Professor of Psychiatry, 

is a registered nurse working as Operations Consultant for 

 Psychiatry/Neurology practice line. Dr Zeller and Ms Kircher have no disclosures to report regarding the subject of this article.

1. Kalter L. Treating mental illness in the ED. AAMC. September 3, 2019. Accessed July 27, 2020. 

https://www.aamc.org/news-insights/treating-mental-illness-ed

Inevitably, some of your patients will need of emergency psychiatric services. These tips will help prepare you and your patients when a crisis unfolds.

Understanding Crisis Services: What They Are and When to Access Them

Emergency Psychiatry: Principles and Practice (2nd ed); Walters Kluwer; 2020

Emergency Psychiatry: Principles and Practice

 are foundational repositories of knowledge and practice for all who care for patients with an acute behavioral health concern. Recent literature indicates that over 12.5% of all Emergency Department visits are related to psychiatric conditions and this is projected to increase. This figure does not account for acute presentations of behavioral health needs that may present to an urgent care, community clinic, or primary care provider’s office. Emergency psychiatry fills an unmet need in our complex health care system. We provide evidence-based and expeditious care for the most vulnerable patient population.

Emergency Psychiatry: Principles and Practice has something for everyone and is easily applicable to emergency and primary care providers, social workers, first responders, community crisis workers, peer coaches, and security personnel. The book is well written and focuses on the important concepts of a patient centered, trauma informed approach of patient care. The addition of up-to-date research in the field support the material presented within the text and make it clear that the authors have done their due diligence in presenting the best product possible.

The text is organized into six sections with concise yet thorough chapters focusing on high yield material encountered in the acute care setting. The inclusion of delivery models, quality standards, staffing models as well as safety and security provide a nice framework focused on the emergency department; however, the information is easily applicable to different care settings. Chapters dedicated to interview techniques, 

, and relevant information on common psychiatric presentations are comprehensively written. They are also written at a level that easily supports the needs of acute care and mental health providers.

The second edition includes an expanded section on 

Emergency Psychiatry: Principles and Practice has something for everyone and is easily applicable to emergency and primary care.

Psychiatric Emergencies