Pre-assessment

Psychiatrists commonly receive a referral via a psychiatric liaison nurse (PLN), but direct engagement with the initial referrer is often valuable. Taking time to clarify details included in Box 2 can ultimately save time and help to establish a collaborative working relationship with ED personnel. Where the referrer’s request is non-specific or unrealistic under the circumstances, direct discussion can also facilitate agreement on the nature and timing of psychiatric input from the outset. Although we focus in this section on assessment, beyond this the mental health liaison team (MHLT) has much to contribute to the management and subjective experience of patients in the ED. We therefore recommend an open-minded and supportive approach to all referrers.

Referrals from triage are now encouraged (Brown Reference Brown, Eales and Hayhurst2020). Occasionally this provides an opportunity for the MHLT to signpost patients to alternative services that better suit their needs, including their general practitioner (GP), community mental health services or a local crisis assessment unit. Where there is a clear need for mental health assessment in the ED, referral from triage allows for swifter flow through the department and supports parallel working between mental health and ED teams. In our experience, ‘first contact’ by a member of the MHLT at triage can facilitate an understanding of the situation and enable early contribution of expertise to management of the case within the ED. The latter includes planning of special observations or a security search and advocacy for concomitant medical review in cases where the need has been overshadowed by the person’s mental state. Examples of common referrals are given in Box 3. It is important to take heed of local ED procedures and community resources that affect which referrals warrant psychiatric assessment in the ED setting and which may be reasonably redirected.

Once the referral has been received and clarified, collateral information from electronic record systems can be sought with the specific goals of the assessment in mind. A detailed understanding of the patient’s psychiatric history is not always required to address the urgent task at hand. For patients in crisis, understanding previous engagement and any difficulties with previous treatments allows for targeted discussion within the assessment to better inform the plan. For patients who attend the ED frequently, records should be checked for an individualised care plan. Familiarity with this will help ensure a consistent and constructive approach to both assessment and management.

Assessment

It is considered essential by both the Psychiatric Liaison Accreditation Network (Baugh Reference Baugh and Talwar2022) and the Royal College of Emergency Medicine (RCEM) (RCEM 2021) to have available in the ED a customised mental health assessment room. This should have two doors that open both ways and cannot be locked from the inside, an observation window, a panic button, a risk-assessed ceiling, no ligature points or potential weapons, and calming decor. Regrettably, this will not be available in every ED or at all times. Where a patient is to be observed or assessed in a more traditional cubicle or the resuscitation area, a brief risk assessment of the space should be carried out beforehand (RCEM 2021).

It is to everyone’s advantage that psychiatric assessment proceeds as soon as the patient is capable of engaging and a suitable space has been secured. Parallel working between acute hospital and liaison psychiatry staff is now considered a fundamental standard by the Royal Colleges of Psychiatrists, Emergency Medicine, Nursing and Physicians (Brown Reference Brown, Eales and Hayhurst2020). Although critical illness, reduced consciousness or severe intoxication might delay a complete interview, it is neither practical nor sensible to await ‘medical clearance’ or ‘medical optimisation’ to begin assessment. In some places, the value of parallel working is understood in theory better than it is practised. A key role of a psychiatrist in the ED is to model for the wider team a collaborative working style.

There are many reasons why psychiatric input should not be delayed. First, there are no widely agreed criteria for deeming a patient medically ‘cleared’ or ‘optimised’. Second, the key target of seeing, treating and planning the ongoing care of patients within 4 h of arrival in the ED is incorporated into the NHS constitution (Department of Health & Social Care 2025). Declining to become involved until the patient is ‘medically cleared’ is likely to anger pressured ED staff, result in rushed and inadequate physical health assessments and compromise effective collaboration. Third, delay undermines parity of esteem for mental health (Brown Reference Brown, Eales and Hayhurst2020). Where the patient cannot yet be interviewed, a collateral history of mental health concerns and communication of relevant background will be invaluable early contributions. Further, early MHLT involvement can prevent escalation of the patient’s distress in the unsettling environment of the ED, minimising associated disruption and aiding cooperation with medical investigations. Box 4 describes a fictitious case illustrating that the value of psychiatric input is maximised when integrated with medical input rather than added as an afterthought following segregated review.

During assessment in the ED, it is not uncommon for multiple unresolved problems to become apparent and to tempt detailed exploration. It is best to keep this question in mind: ‘Why has this patient presented with this problem at this point in time?’ Further issues not requiring urgent attention should be flagged for the relevant in-patient or community team. Figure 1 gives a template for a full psychiatric assessment in the ED, which can and should be adapted for more targeted assessments and well-known patients.

FIG 1

Example emergency department (ED) liaison psychiatry assessment proforma. CMHT, community mental health team; MSE, mental state examination; MHLT, mental health liaison team; PRN, pro re nata (when required; as necessary); GP, general practitioner.

It is worth remembering that assessment shapes more than the immediate plan. The patient’s first account of events leading to presentation is naturally the most authentic, unadulterated by progressive fatigue, forgetting and evolution of emotion. Documentation of it will become an invaluable resource for the treating mental health team and is likely to influence ongoing formulation and management. For many patients, a long relationship with mental health services begins in an ED cubicle. Subjective experience of this encounter may determine ongoing engagement with services, with potential consequences for the trajectory of illness. Hence, it is important that despite the constraints of the noisy, crowded, chaotic ED environment, the psychiatrist aims to conduct the initial psychiatric assessment in the most therapeutic manner possible.

In-hospital and post-hospital planning

Components of care taken for granted in specialised psychiatric settings may not be as reflexively considered by staff in the ED. This includes consideration of patient location and access to potential ligatures, regular observations independent of vital sign monitoring, precautions against risk to others, appropriate response if the patient absconds (leaves before they are discharged) and least restrictive management of agitation. Particularly where such factors are crucial, the plan may need to be highly specific.

In post-hospital planning, the psychiatrist has responsibility as a gatekeeper of in-patient and community mental health services. The available resources can be viewed as sitting on a spectrum ranging from least specialised and intensive (e.g. follow-up with a GP) to most specialised and intensive (e.g. in-patient admission under mental health legislation). Options falling between these extremes will vary depending on locality. They commonly include community mental health team (CMHT) follow-up, crisis team follow-up, temporary accommodation at a crisis house and voluntary admission to a traditional in-patient unit. Methods of referral to the range of services will also vary locally. Members of the multidisciplinary MHLT are likely to be helpful guides.

A template in-hospital and post-hospital plan is included in Fig. 1.

It is useful to come to the assessment ‘armed’ with information relevant to the patient’s address, which may not be in the same locality as the hospital. For those likely to be discharged, this should preferably include a relevant crisis line telephone number to be given the patient. Patients not previously known to mental health services may benefit from explanation of how these are locally structured and what they can expect after discharge from the ED.

A natural effect of parallel working is that plans will often be dynamic, evolving with the patient’s progress. Given the acute shortage of in-patient psychiatry beds, patients may remain in the ED long after a decision to admit has been made. The medium-term management of mentally unwell patients in the ED requires close liaison between the MHLT and the ED team. Verbal handover to the patient’s nurse and/or treating doctor at each review provides opportunities for both sides to ask clarifying questions and develop a shared understanding, fostering collaborative relationships that are fundamental to effective liaison psychiatry. ED clinicians may engage more thoroughly with the physical health needs of a behaviourally ‘difficult’ patient if feeling supported by the MHLT. In some cases, these interactions also provide powerful opportunities to correct misperceptions about the patient’s mental illness, helping to reduce the widespread stigmatisation disturbingly common in healthcare settings (Clarke Reference Clarke, Usick and Sanderson2014).

Holding without consent

In the ED, a psychiatrist’s grasp of law permitting detainment without the patient’s consent may be rigorously tested. This is because a broad variety of circumstances present themselves, often evolving over minutes or hours and necessitating change in approach. Where a psychiatrist has completed an assessment, pre-emptive guidance about what staff should do if the patient attempts to leave the ED before formal discharge is desirable. This helps to avoid a situation in which a vulnerable patient without the capacity to decide to leave does so without intervention because staff do not fully appreciate either the risks involved or their legal and ethical obligations. In other scenarios, multidisciplinary staff, including security officers, may seek to quell uncertainty about the right course of action or to know precisely the law justifying their restrictive actions. In our experience, reassurance gained from the brief advice of a psychiatrist can have a palpable effect on the composure of staff at the scene. Box 5 provides a fictitious example.

Nuances of current mental health law in England and Wales frequently pertinent in the ED include the following. Sections 5(2) and 5(4) of the Mental Health Act 1983 (MHA) cannot be used in the ED (they relate respectively to a doctor’s and a nurse’s power to hold for the purpose of MHA assessment). Although they may be used in adjacent short-stay units where the patient is briefly ‘admitted’ to hospital, a patient cannot be admitted for the sole purpose of a section 5(2). The only mental health legislation allowing detention in the ED is section 136 of the MHA (a police officer’s power to transfer to a place of safety someone who appears to have a mental disorder and to be in urgent need of care or control). In this case an MHA assessment must be completed within 24 h, starting from the time of first arrival. A transfer between places of safety can be facilitated only when it is considered in the patient’s best interest and not on grounds of convenience or patient flow. Similarly, one 12 h extension is permitted only to allow the patient to become assessable. Police are required to remain present until expiry unless hospital staff agree to take on responsibility for the patient’s safety (RCEM 2017).

Holding a patient in the ED either while awaiting an MHA assessment or while awaiting a mental health bed required to complete an application for detention under section 2 of the MHA is permitted under the MCA or under the common law doctrine of necessity, depending on the circumstances. (Even after two medical recommendations are made, the application cannot be completed by an Approved Mental Health Professional (AMHP) until an in-patient bed is identified.) Common law is likely to be employed where the risk of harm is exclusively to others or where the patient has the capacity to decide to leave but is of ‘unsound mind’ (Black v Forsey [1987]). Although the MCA (outside of its Deprivation of Liberty Safeguards (DOLS)) and common law permit only restriction of liberty, there is neither a statutory definition of deprivation of liberty nor any case law demonstrating precisely where the line between restriction and deprivation is crossed in the ED setting. Alex Ruck Keene’s analogy of ‘legal ice’ is useful here. Taking immediately necessary and proportionate action to protect a patient’s life or the safety of others in an emergency is in accordance with the European Convention on Human Rights and likely to rest on ‘thick legal ice’. That is, it is likely to be legally justifiable even if the legal basis is not defined by clinicians at the time. However, the ice will thin as time passes (Ruck Keene Reference Ruck Keene2021). Once immediate action has been taken, it is imperative to ensure that an appropriate legal framework is actively pursued, to escalate any delays in the process and to continually reassess the necessity and proportionality of the restrictions.

Emergency medical treatment

Enforcing medical intervention can be pragmatically very challenging. It will sometimes require sedation and intubation in an intensive care setting and a spate of associated risks that would not have developed had the patient acquiesced. It may be necessary to resist pressure to take the lead on such decisions. Instead, a psychiatrist’s biopsychosocial approach can help inform the medical team’s views of what care is in the patient’s best interests. For example, cognisance of the psychological impact of a previous traumatic experience of being restrained may raise the threshold for taking this approach.

To psychiatrists’ dismay, a presumption that any indicated medical treatments can be given without consent under mental health legislation is not uncommon. A psychiatrist in the ED might find a colleague seeking assurance that a non-consenting psychiatric patient is ‘sectioned’ before proceeding with treatment. Such misconceptions highlight contributions that psychiatrists can make outside of patient assessment.

Rapid tranquillisation

Where intramuscular pharmacological intervention is warranted, National Institute for Health and Care Excellence (NICE) guidelines currently recommend either lorazepam or a combination of haloperidol and promethazine (NICE 2015). More specialised national (Patel Reference Patel, Sethi and Barnes2018) and international (Roppolo Reference Roppolo, Morris and Khan2020) guidelines draw attention to special circumstances such as pregnancy, intoxication and withdrawal states and stipulate that agents are ideally targeted at the likely aetiology. We suggest an open dialogue between the ED physician and the psychiatrist when advice is requested, although ultimately in the ED it is the former who must manage physical complications and be comfortable with the balance of benefit and risk in each choice. In some cases, redirection to intensive care or anaesthetic teams will be appropriate, although a psychiatrist’s opinion on the cause of agitation will nonetheless guide colleagues’ choice of agents.

An understanding of the term ‘acute behavioural disturbance’ (ABD) in use by emergency services staff, including police, will be helpful, although we suggest refraining from adopting it. ABD essentially denotes a state of extreme behavioural disturbance associated with adrenergic overdrive. Prompt intervention is considered important to prevent excessive motor activity and sympathetic stimulation from generating severe metabolic derangements and cardiovascular collapse (RCEM 2023). However, like the older term ‘agitated delirium’, the term ABD is controversial. The Royal College of Psychiatrists’ (RCPsych’s) position statement casts doubt on its helpfulness (RCPsych 2022). A recent Delphi study attests that it is not distinct from agitation but rather an extreme form of it (Humphries Reference Humphries, Kelly and Sadik2023). Both propose that attention to ‘red flags’ suggestive of a physical health emergency would be preferable to maintaining a separate diagnostic category. Our recommendation is certainly to consider the assessment and management of agitation as a transdiagnostic concept rather than to reify ABD as a separate entity. We also wish to emphasise that as well as being a consequence of extreme agitation, a physical health emergency can cause or contribute to agitation of any severity. In the ED, cases at both ends of the spectrum often benefit from concomitant medical and psychiatric involvement.

As the RCEM recommends either ketamine or droperidol as first-line agents where their criteria for ABD are met (RCEM 2023), these may be encountered on the drug charts of some referred patients. Ketamine is favoured for its dissociative properties and rapid onset (RCEM 2023) and should only be administered in the ED by a level 2 sedation-trained clinician (RCEM 2022). We do not suggest that a psychiatrist should ever advise on its administration in the ED. However, familiarity with the drug can be valuable in the aftermath of its use. Of particular note, ‘emergence phenomena’ are common and may include a ‘dream-like’ state, a floating sensation, illusions and visual hallucinations (Electronic Medicines Compendium 2024) which could potentially be confused with features of the patient’s underlying mental state. Its other psychiatric effects have been helpfully summarised by Evanoff et al (Reference Evanoff, Baig and Taylor2023).

Suicidality contingent on social needs

Psychiatrists often encounter patients in the ED who present with suicidal ideas that are expressed in the form ‘I will kill myself if you don’t provide me with x’. The latter might include housing of the patient’s choice or a particular intervention to relieve pain. This usually comes up when discharge from the department is discussed. Often these patients do have demographic factors that indicate a high risk of dying by suicide. It is important not to dismiss the patient’s statements but to take them as indicators of distress and unmet need. One also needs to be aware of one’s own psychological and emotional reactions to the patient and other drivers for discharge, such as bed pressures. The dilemma for the psychiatrist is about managing discharge when the demands of the patient are usually not within the remit of psychiatry, and other agencies say that they have done their best and that the demands are unrealistic.

In such cases, we recommend following the excellent recommendations of Bundy et al (Reference Bundy, Schreiber and Pascualy2014). They suggest documenting such decisions in six steps: (1) define and document the clinical situation – summarise the dilemma; (2) assess and document current suicide risk – consider risk factors, protective factors, acute stressors that elevate the risk and access to means; (3) document modified dynamic factors – what you have done to manage the dynamic risk factors so far; (4) document why continued care in the ED is inappropriate – patient’s uncooperativeness with treatment, why being in the ED might interfere with a more appropriate care plan in the community, etc.; (5) document discharge discussion with the patient – safety planning, follow-up plans, any onward referrals; (6) document consultation discussion with a colleague.

High-intensity ED use

Psychiatrists working in the ED often come across patients who attend the department frequently. An exact definition of ‘frequent attendance’ or ‘high-intensity use’ is elusive. Although different definitions are used depending on the context, ‘five attendances in a 12 month period’ is one that may be clinically useful. Such patients are usually well-known to both emergency medicine and liaison psychiatry staff and may attract negative views and pejorative labels such as ‘frequent flyers’. Not all those attending frequently will have mental health needs. However, a significant number will have a combination of social adversity, substance use disorder, mental disorders or personality disorders and health anxiety.

It is important that an individual formulation of the patient’s needs and the reasons for frequent attendance are considered. It is never justified to withhold or delay care and attention in a punitive way. A few years ago, there was a vogue in the UK to treat some cases of high-intensity use of emergency services as misuse of public services and to involve the police. There has been resistance to such approaches from patients and professionals and current official guidance strictly discourages punitive measures (House Reference House2023). Most EDs have a dedicated group of professionals from emergency medicine, liaison psychiatry, psychology, substance misuse services, homelessness services, social services and others that take a lead on frequent attendances. These multidisciplinary teams often draw up individualised care plans, ideally with the agreement of the patient. When seeing a patient who frequently attends the ED, it is worth checking for this in the notes. Some services may also offer case management, with one professional taking the lead in coordinating and managing care (Budhwani Reference Budhwani, Capanna and Baban2022).

Feigning and deception

In emergency medicine, as in most other medical specialties, the practice is to take symptoms presented at face value and to investigate and treat them. In some cases, the question ‘Is the patient feigning symptoms and trying to deceive the medical practitioner?’ is raised. This could apply to physical, psychological or cognitive symptoms. The first point to make is that lack of an obvious medical explanation should not lead to suspicion of feigning. Functional symptoms, including functional neurological symptoms, are common in the ED. Even when functional symptoms are excluded, there are differing views about suspecting and acting on feigned symptoms.

Beach et al (Reference Beach, Taylor and Kontos2017) encourage psychiatrists to ‘think dirty’. They use this maxim to advise taking nothing at face value and being alert to the presence of deception and hidden motives. They encourage budding psychiatrists to be explicitly taught to ask the question ‘What other motivations might be underlying these symptoms or this behaviour?’. The opposite viewpoint is presented by Thomson & Albert (Reference Thomson, Albert, Thomasson, Guthrie and House2024), who draw attention to the problem of incorrectly assuming that patients are feigning symptoms when they are not. This leads to harms such as exclusion from medical services and punitive reactions from staff.

We feel that second-guessing the motivations of all patients presenting to the ED with mental health concerns is unlikely to be helpful. On the other hand, there may be patients with a well-documented history of feigned symptoms from multiple sources. In these cases, recognising the pattern is essential in avoiding unnecessary investigations and interventions and iatrogenic harm.

Comorbid substance misuse

The complications that dual diagnosis presents to psychiatric care across all settings are beyond the scope of the current article. Suffice to say, intoxication and withdrawal states frequently complicate assessment. A psychiatrist in the ED needs to be familiar with syndromes associated with intoxication and withdrawal and remain attentive to the possibility of one contributing to an emergency psychiatric presentation such as florid psychosis or suicidality. It should also be remembered that intoxication and withdrawal can occur concomitantly.

In the case of an intoxicated or withdrawing suicidal or agitated patient, consideration should ideally be given to short-term (in-hospital) and longer-term (discharge) risks. This may necessitate a staged assessment, the former warranting early review and the latter depending on assessment of mental state after intoxication or withdrawal symptoms resolve. Early involvement may help to minimise the disturbance such patients cause in the ED, facilitate advocacy for any overshadowed medical needs and ultimately reduce resistance to delaying full assessment.