Psychiatric Emergencies: Suicide, Agitation, Delirium, Catatonia and Crisis Management

Learning objectives

• Recognise the major psychiatric emergencies and the medical conditions that mimic them.
• Perform an immediate risk, capacity and ABCDE assessment.
• Respond safely to suicidal behaviour, severe agitation, psychosis, mania, delirium, catatonia and neuroleptic malignant syndrome.
• Select emergency medicines cautiously and monitor airway, breathing, cardiovascular and neurological status.
• Plan disposition, safeguarding, family communication, documentation and relapse prevention.

1. What makes a psychiatric presentation an emergency?

An emergency exists when there is imminent danger to life, serious injury, inability to meet basic needs, rapidly worsening mental state, severe self-neglect, a dangerous medical cause, or risk to another person. A calm-looking patient can still be at high suicide risk; an agitated patient may have hypoglycaemia, meningitis, head injury or stimulant toxicity rather than a primary psychiatric disorder.

2. Universal first assessment: SAFE-ABCDE

1. Scene safety: remove weapons and hazards, maintain an exit, use an adequate trained team and identify a quiet room. Do not crowd, shout or argue.
2. Airway/breathing/circulation: check respiratory rate, oxygen saturation, pulse, blood pressure, temperature and level of consciousness. Treat overdose, hypoxia, shock and trauma.
3. Examination: bedside glucose, pupils, hydration, neurological signs, head injury, meningism, pregnancy, infection, toxidromes and medication patches.
4. Risk: self-harm/suicide, harm to others, vulnerable dependants, absconding, access to weapons/medicines, exploitation and domestic violence.
5. Environment and consent: use a trained interpreter, ask permission where possible, preserve privacy, involve family with consent and document capacity and decisions.

Obtain collateral history from relatives, ambulance staff, pharmacy or the HIV/medical clinic when lawful and necessary. Ask about onset, baseline function, previous episodes, medicines, adherence, substances, sleep, recent losses, infection, head injury, epilepsy, pregnancy and access to means.

3. Self-harm and suicide emergency

Immediate actions

• Treat overdose, bleeding, strangulation, burns, fractures, poisoning, hypoxia and altered consciousness before a lengthy interview.
• Do not leave a patient with imminent intent alone. Remove or secure medicines, blades, ligatures, firearms, pesticides and other means while maintaining dignity.
• Ask directly about thoughts, intent, plan, access, timing, previous attempts, rehearsal, intoxication, psychosis, severe pain and reasons for living.
• Make a collaborative safety plan: warning signs, internal coping skills, supportive contacts, emergency numbers/facility, and means restriction. A “no-suicide contract” is not a substitute for safety planning.

Risk formulation

High-risk features include a recent attempt, persistent intent, a specific lethal plan, inability to agree to safety, command hallucinations, severe agitation, intoxication, severe depression/mania/psychosis, hopelessness, social isolation, recent discharge, violence, pregnancy/postpartum status and access to lethal means. Risk is dynamic; a low score does not rule out danger.

Follow WHO mhGAP principles: offer psychosocial support, treat the underlying condition, arrange urgent follow-up and provide only limited quantities of potentially lethal medicines when overdose risk is imminent. Admit or refer urgently when safety cannot be maintained in the community.

4. Acute agitation and aggression

Verbal de-escalation

• One calm clinician speaks; introduce yourself and use the patient’s name.
• Keep a safe distance, non-threatening posture, open hands and a clear exit.
• Use short sentences, offer choices (“quiet room or chair here?”), acknowledge fear and set one firm behavioural limit.
• Reduce noise, light, audience and physical stimulation. Offer water, toilet, food, nicotine replacement or a trusted support person when safe.
• Do not challenge delusions, threaten, shame, mock or make promises you cannot keep.

When medication is required

Medication is indicated when agitation is severe, escalating, causing imminent harm, or preventing essential medical care after de-escalation has failed. Select one pathway and monitor continuously:

Doses are not interchangeable and local protocols differ. Use the lowest effective dose, reassess before repeating, document indication/consent or legal authority, and monitor pulse, blood pressure, respiratory rate, oxygen saturation, consciousness, temperature and adverse effects.

Restraint and seclusion

Use restraint only as a last resort for immediate danger, for the shortest possible time, by trained staff and with continuous observation. Avoid prone restraint, pressure on the neck or chest, and leaving a restrained patient unattended. Record the reason, alternatives attempted, type, time, monitoring, injuries, capacity and review for release. Provide debriefing afterward.

5. Delirium: a medical emergency until proven otherwise

Delirium has acute onset and fluctuating inattention with altered awareness, disorganised thinking or perceptual disturbance. Causes include sepsis, hypoxia, hypoglycaemia, electrolyte disturbance, renal/hepatic failure, medication toxicity, alcohol/benzodiazepine withdrawal, meningitis, malaria, HIV-related CNS disease and urinary retention or constipation in vulnerable patients.

• Check vital signs, glucose, oxygenation, hydration, pain, bladder/bowel status, medications, substances and infection signs.
• Use a brief attention test and obtain collateral baseline cognition. Do not diagnose dementia or schizophrenia from one confused interview.
• Treat the cause, orient the patient, provide glasses/hearing aids, sleep support, familiar staff and a quiet environment.
• Use an antipsychotic only for severe distress or immediate danger after non-drug measures and contraindications have been considered; avoid routine benzodiazepines except for alcohol/benzodiazepine withdrawal or selected indications.

6. Acute psychosis and mania

Assess hallucinations, delusions, thought disorder, mood, sleep, grandiosity, impulsivity, command content, access to means, food/fluid intake and ability to care for dependants. Exclude delirium, epilepsy, intoxication/withdrawal, HIV/CNS infection, thyroid disease, steroid effects, postpartum illness and medication adverse effects.

Provide a low-stimulation setting, hydration, nutrition and sleep. Start or restart an antipsychotic according to diagnosis and local protocol; add a mood stabiliser for bipolar disorder with specialist review. In a person who may become pregnant, avoid sodium valproate unless a specialist determines that no safer effective option exists. Admit when there is imminent risk, severe inability to care for self, severe mania, treatment resistance or an unsafe environment.

7. Catatonia

Look for stupor, mutism, negativism, posturing, waxy flexibility, echophenomena, agitation without purpose, staring, refusal of food or marked psychomotor change. Catatonia can occur with mood disorders, psychosis, medical disease, epilepsy, autoimmune conditions and drugs.

• Check hydration, glucose, electrolytes, CK, renal function, infection, medication/substance exposure and complications such as thrombosis or pressure injury.
• A specialist may use a lorazepam challenge, often 1–2 mg orally/IV/IM with observation for improvement and respiratory safety; treatment is then scheduled and titrated according to protocol.
• Urgent ECT is indicated for malignant catatonia, severe refusal of food/fluids, autonomic instability or inadequate benzodiazepine response.

8. Neuroleptic malignant syndrome and serotonin toxicity

Both are potentially fatal. Do not wait for a textbook triad before escalating. Consider sepsis, malignant catatonia, heat stroke, anticholinergic toxicity and severe withdrawal in the differential.

9. Other high-risk presentations

• Postpartum psychosis: same-day emergency assessment; assess mania, depression, command hallucinations, infant safety and capacity. Never leave mother and infant unsupervised when risk is present.
• Severe eating disorder: check glucose, electrolytes, ECG, temperature and refeeding risk; medical admission may be needed.
• Intoxication/withdrawal: use the substance emergency pathway; agitation is not automatically psychiatric.
• Epilepsy and non-convulsive status: fluctuating confusion or abnormal behaviour may be seizure activity; check glucose, neurological signs and seek EEG/neurology help.
• HIV, TB or malaria: investigate infection, ART/TB drug interactions and CNS disease when mental state changes.

10. Capacity, consent, admission and documentation

Capacity is decision-specific and may fluctuate. Assess whether the person can understand, retain, weigh and communicate the relevant information. A refusal during delirium, severe intoxication or psychosis may not represent valid capacity. Follow Ugandan mental-health law and facility policy for involuntary assessment/treatment; use the least restrictive, rights-respecting option and involve senior clinicians.

Document time, mental state, risks, physical findings, differential diagnosis, tests, medicines/doses/routes/times, monitoring, capacity, consent/legal basis, family communication, safeguarding and disposition. Handover must include what could change the plan and who is responsible overnight.

11. Disposition and aftercare

• Admit medically: delirium, overdose, severe withdrawal, NMS/serotonin toxicity, catatonia, unstable vital signs, serious injury or inability to eat/drink.
• Admit to mental-health care: imminent self/other risk, severe psychosis/mania, unsafe home, failed community safety plan or need for ECT/close observation.
• Discharge only when: the medical cause is treated or excluded, consciousness and behaviour are stable, a safety plan is made, means are restricted, support is confirmed, medicines are reconciled and follow-up is booked.

Clinical cases

Quick self-test

1. What reversible medical causes must be checked before diagnosing a first-episode psychosis?
2. Name three features that distinguish delirium from a stable primary psychotic disorder.
3. When is chemical sedation justified in agitation?
4. What signs suggest serotonin toxicity rather than NMS?
5. List the minimum elements of a safe psychiatric-emergency discharge plan.

Key take-home messages

• Every psychiatric emergency begins with safety, ABCDE, glucose, physical examination and a search for medical/toxic causes.
• Use de-escalation first; medication and restraint are time-limited safety interventions, not punishment.
• Suicide risk is dynamic and requires supervision, means restriction, treatment and follow-up—not a score alone.
• Delirium, catatonia, NMS and serotonin toxicity require urgent medical treatment and specialist escalation.
• Document carefully and discharge only with a realistic, coordinated safety and follow-up plan.

References and further reading

• World Health Organization. mhGAP Intervention Guide, version 2.0: WHO mhGAP-IG.
• World Health Organization. mhGAP guideline, 2023 update: WHO guideline.
• WHO mhGAP training manual, Psychoses module: WHO psychosis module.
• WHO mhGAP evidence and tools for self-harm/suicide: WHO Intervention Guide PDF.
• Uganda Ministry of Health. Uganda Clinical Guidelines (current facility edition): Uganda Clinical Guidelines.