This chapter discusses the evaluation of patients who present to the ED with behavioral disorders and, in particular, reviews the initial assessment and management of psychotic, suicidal, and violent patients.


Behavioral disorders constitute a significant and increasing burden of care in U.S. EDs. In the last two decades, mental health–related visits to U.S. EDs increased 38% from 17.1 to 23.6 per 1000 U.S. population (p <.001).1 Explicit mental health problems have been documented as the primary reason for the visit in 6.3% of all ED attendances, but covert mental health problems may be present in over a third of all ED patients. Increases in mental health–related ED visits are especially significant among older persons and those living in urban areas. ED visits related to mood, anxiety, and suicide attempts are all increasing, tracking significant parallel increases in the most common type of mental health–related ED visits of all: those involving substance-related disorders.


Because there are approximately 3800 general EDs in the U.S. (American Hospital Association, personal communication, August 2008) and only 146 psychiatric EDs (American Association for Emergency Psychiatry, personal communication, August 2008), the vast majority of acute behavioral problems are assessed and treated in general hospital EDs. The closure of psychiatric inpatient facilities, reductions in inpatient beds, moves to treat people in the community, and increased out-of-pocket costs for mental health visits have coincided with, and likely contributed to, increased visits to EDs by psychiatric and suicidal patients who previously would have been admitted or seen in other settings. As the de facto mental health care safety net, EDs serve as the default option for urgent and acute care of psychiatric patients within the health care system.


Given that psychiatric visits to EDs are increasing and that mental health patients frequently have few alternatives available beyond the ED safety net, it is important that emergency providers resist the temptation to dismiss these patients as nuisances or “frequent fliers” who “abuse the system.” Health care systems are difficult to negotiate for those without behavioral disorders, let alone those in the throes of psychosis, intoxication, anxiety, or depression. Not only do they have acute psychotic or depressive symptoms, but many mental health patients in the ED have previously exhausted their psychosocial support and the goodwill of relatives, family, and even mental health care workers. Their poor hygiene, homelessness, and/or repeated presentations to EDs are often both a cause and a consequence of this alienation in the ED as well. Staff may see difficult psychiatric patients who present repeatedly as unwelcome and fodder for gallows humor; their frustration notwithstanding, ED staff must resist their own feelings of alienation, because these may lead to dismissal of legitimate patient needs and less than thorough assessments at each visit. One way to remain vigilant and mindful of professional duties to patients is to promote an ED attitude of unconditional positive regard and nonjudgment as an important preventive measure against alienation.2 Nonjudgment ...

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