Psych Emergency? What’s that?…and what to know about the acute care evaluation

If you didn’t know, I worked in a large, very busy Children’s Hospital Emergency Department (ED) for over 15 years before I started this whole digital health gig.  This particular ED is among the top 5 busiest pediatric emergency departments in the country. It was hoppin’ 24/7/365. Lots of “experience” to be had there. We took care of everything- from all of the regional major trauma patients under age 15 to the fairly large emergency psychiatric service as well. At first glance, many of the mental health patients seem a bit out of place amidst all the kids getting stitches placed, casts applied, and breathing treatments administered because the patients with psychiatric complaints just don’t look sick. We all know that the degree of their internal pain may be astronomical but for all intents and purposes their bodies look well. It makes for quite a visual juxtaposition, especially at 11:45pm on a Friday night.

The acute psychiatric patients I saw really ran the gamut in terms of age (though adolescents are more common), previous psychiatric history (a lot vs none), and reason for presentation. Some got admitted to the psychiatric inpatient unit and some got discharged home with a well wish and the crossing of many fingers that an outpatient plan could be adhered to and make a positive difference. Here’s a number for perspective: between the years 2001-2010, there were about 560,000 children who went to an ED for psychiatric reasons. That’s about 2% of all ED visits for kids. It’s not a small number. I was the firsthand witness and caretaker of a few in that statistic, and I thought I’d describe the general course of what happens during one of those encounters because that might be helpful to know somewhere down the line, so you’ll know what to expect.

It’s been reported widely in the general media that emergency mental health services are overwhelmed with volume.

Too many patients, too few resources. True story. This means that right away the expectation should be set for an emergency trip that is not fast. The assessment and insurance approval process (if inpatient admission is necessary) takes a long time and requires a lot of patience and waiting.

So what happens during that assessment?

First things first. Every person who comes to the ED with a psychiatric complaint needs a medical evaluation before proceeding to make sure that the symptoms they are having aren’t coming from an organic cause: like hallucinations or behavioral changes from a brain infection (like encephalitis), or an irregular heart rhythm due to a drug ingestion. In addition to an interview that includes questions about family history, medications, general wellness, development, and a description of recent events, there’s a general physical examination that occurs to check for any infection or potential medical cause of the current illness.

The next step is to do some laboratory studies

to double check the exam findings, and while this nearly always includes a “tox screen” (drug screen of the urine or blood to look for any substances in the system like marijuana, opioids or benzodiazapenes such as Valium), it may include additional tests such as an EKG, thyroid tests, or others specific to the results of the history and physical examination. Once all that looks ok, we consider a patient “medically cleared” for psychiatric evaluation. And then the conversation really begins.

The fortunate EDs have a dedicated team of mental health professionals whose job it is to determine if a psychiatric emergency is truly occurring.

Seems like a bit of a simple statement, right- of course it’s occurring; otherwise why would a patient be there? But in fact, in the current climate, a true psychiatric emergency is defined as the active desire to hurt or kill oneself or others (we call this suicidal or homicidal ideation) where the patient cannot “contract for safety” (agree not to attempt to harm themselves) and is therefore unsafe to be discharged. That one is pretty cut and dry. Automatic admission. Other situations are less clear: the teenager whose grades have been declining, who has been behaving anxiously, or sleeping more and becoming more withdrawn from family and friends…or the 9 year old with worsening behavior and escalating aggression at school and home. It’s hard to know for sure what segment of kids with these types of issues can be successfully managed as outpatients or which ones need more intensive inpatient therapy. It can be tough to say how emergent each particular emergency truly is.

The clinical team does their best to make this determination, and sometimes it takes awhile and many conversations to come up with a plan.

Inpatient beds for child and adolescent psychiatric patients are scarce, and searching for open beds requires multiple phone calls and detailed documentation. If you find yourself/your child in this situation, I humbly ask for as much patience as you can muster as you tell your story for the fourth time in the course of a few hours, and as you wait longer than you’d like to hear back from the team about bed status and results. No one is trying to delay forward motion; but the current system can be onerous and slow, especially after hours and on weekends.

What are important points to know about psych emergencies?

1. Any time there has been an attempt to hurt oneself or others, this is by definition an emergency.
2. Understand that a full medical evaluation will take place if anyone goes to the ED with psychiatric or behavioral complaints. It will be more than just a discussion of the current mental health situation.
3. Admission to an inpatient unit is most likely when there has been disclosure of suicidal or homicidal intent or an immediately preceding suicide attempt or gesture.
4. If you/your child has a counselor or therapist and symptoms are worsening, it is wise to enlist his/her help and guidance when trying to decide whether or not to proceed with a psychiatric emergency visit unless #1 applies above.

I’m sharing this “inside information” to help manage expectations for people who are facing the difficult situation of an escalating behavioral health scenario with the added unknown of what might happen as the clinical evaluation unfolds. Knowledge is power, certainly here, and understanding the different steps in the assessment process can help keep your own emotions and behavior in check during a time when the emotions and behavior of someone you love are just the opposite.

If you or someone you know is struggling emotionally or having a hard time, please consider the following resources:

National Suicide Hotline: 1-800-273-8255

Poison Control: 1-800-222-1222

Lifeline Chat

Suicide Safety on Social Media

The Jed Foundation

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