Common ED Presentations: Mental Health

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Introduction

Mental health related presentations account for a significant proportion of emergency department (ED) attendances in the UK, and the number of patients attending the ED in a mental health crisis continues to increase year on year.

In this guide, we will cover some key concepts relating to mental health in emergency medicine, such as the legal framework surrounding capacity assessment, managing agitated patients and approaching common mental health presentations.

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Mental Capacity Act (2005)

The Mental Capacity Act (MCA) 2005 provides a legal framework for decision-making on behalf of adults and children over the age of 16 who lack the capacity to make decisions for themselves.¹

Understanding the principles of this act and how to assess capacity is a fundamental component of treating mental health problems in the ED.

Core principles

The five core principles of the Mental Capacity Act are as follows:

Presumed capacity: A patient is presumed to have capacity unless proved otherwise.

The right to be supported in making a decision: all practical steps should be taken to help support patients in making their own decisions.

The right to make an unwise decision: a patient should not be treated as unable to make a decision simply because they make an unwise decision.

• Distinguishing between a patient who makes an unwise decision and a patient who lacks capacity to make a decision is one of the most challenging parts of assessing capacity.

Best interest: any action taken on behalf of the patient using the Mental Capacity Act must be done with the patient’s best interest in mind.

Least restrictive intervention: any action or decision taken on behalf of the patient using the MCA must be the least restrictive option taking into account the patient’s rights and freedoms.

Capacity assessment in adults

The following criteria should be met for the patient to be deemed to have capacity (this applies to all patients over the age of 16):

• Understand: the patient should be able to understand the situation they are in or the information they have been given.
• Retain: the patient should be able to retain the information which has been given to them during the capacity assessment.
• Weigh: the patient should be able to weigh the information which has been given to them in such a way which enables them to make an informed decision.
• Communicate: the patient should be able to communicate their decision back to you. Communication can take many forms such as verbal, sign language or written. You should take care to facilitate the form of communication which best suits the patient.

It is important to remember that you are assessing the capacity for a specific decision at a specific time.

A patient’s capacity may fluctuate (i.e. according to their level of intoxication). Furthermore, the capacity to make one decision, such as having a blood test, does not mean they have the capacity to make another decision, such as to leave the emergency department against medical advice.

Children between the ages of 16 and 17 are presumed competent to consent to treatment under the Mental Capacity Act and are subject to the same capacity assessment outlined above. An exception to this is that 16 and 17 year olds cannot make an advanced decision to refuse treatment or appoint a lasting power of attorney.¹

Although parental consent is not required by law in this age group, it is good practice to encourage shared decision-making.

For a more detailed breakdown, see our OSCE guide to performing a mental capacity assessment.

Capacity assessment in children

The MCA does not apply to children under the age of 16. Instead, Gillick competence is used to determine whether or not a child under the age of 16 has the capacity to make decisions about their medical treatment.

This term is often used interchangeably with the Fraser guidelines. However, the latter refers specifically to providing contraceptive advice to children under the age of 16.

Gillick competence

There are no predefined criteria for assessing Gillick competence. The decision is made on assessing the child’s maturity and understanding and involves the following considerations.²

• The age, maturity and mental capacity of the child
• The child’s understanding of the issue
• The child’s understanding of the consequence of their decision
• The child’s understanding of the information and advice they have been given
• The child’s understanding of alternative options available
• The child’s ability to explain their reasoning and decision making

Children under the age of 16 who are not Gillick competent cannot consent to treatment and decision making rests with those who have parental responsibility. Additionally, a child who is deemed to be Gilick competent can still have their decisions overruled when it comes to refusing life saving treatment.

It is important to remain vigilant for the safeguarding of vulnerable people in the emergency department, and you should involve a senior decision maker whenever assessing a child presenting with a mental health issue.

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Mental Health Act

The Mental Health Act (2007) provides a legal framework for detaining (sectioning) patients with a mental health disorder to initiate the investigations, diagnosis and treatment they need.

A MHA assessment requires the participation of an approved mental health professional (AMHP) and two medical practitioners, including a section 12 approved doctor.

Section 136

Section 136 of the Mental Health Act gives the police the power to detain a person suspected of suffering from a mental health disorder and remove them from a public place to a place of safety.³

The police can take the patient to the emergency department, a 136 suite or a police cell (under specific circumstances).

The patient will only be brought to the emergency department if there are significant medical concerns which require urgent treatment or if no 136 suites are available and it has been locally agreed that they can come to the ED.

All patients under s136 require formal assessment under the Mental Health Act. Medical treatment should be provided where possible while you wait for the MHA assessment. Examples include suturing a patient who has sustained an injury or wound from self-harming.

Make sure you feel safe when treating these patients. The police should have searched any patient who is at risk of self-harm or harm to others. If you do not feel it is safe to provide treatment, then do not put yourself in harm’s way. Consult with one of your seniors for help. 

The police are responsible for the patient’s safety and should remain with them while under section.

A section 136 initially lasts for 24 hours and starts when the patient arrives in the emergency department. There is a possibility of a 12-hour extension under predefined circumstances.

Assessing risk

Mental health triage: patients should have a brief mental health assessment performed by the nursing staff at triage to gauge their risk of self-harm, suicide and of leaving the department before the initial assessment.

It is helpful to have a physical description of the patient documented in the notes so that this can be used to identify the patient if they abscond.

Patients at high risk of self-harm or suicide should be searched for objects and medication that could be used to cause harm. These patients should be allocated to an appropriate environment to observe them closely.

History taking and risk assessment

Several tools can be used to calculate risk, and many departments will use a traffic light system to help risk stratify these patients at the front door.

The Geeky Medics article on performing a mental state examination goes through the mental state examination in detail, and the following article on suicide risk assessment provides further information on risk stratifying these patients.

Examples of high-risk features include older age groups, men, social isolation, previous suicide attempts, leaving a note, organising affairs, violent methods, substance misuse, severe depression, and not wanting to be found.

It is also important to consider protective factors such as strong social support, meaningful employment and regret of their actions when making your overall risk assessment.

Observing high-risk patients 1:1

High-risk patients may require one-to-one observation in a safe environment, free from ligatures and other objects which can be used as a weapon or for self-harm.

Ideally, the one-to-one care, also referred to as ‘specialling’, should be provided by a registered mental health nurse (RMN). However, the Royal College of Emergency Medicine recognises that healthcare assistants (HCAs) often take on this role due to the high demand on mental health services.⁴

Specialling can be very difficult, and we should support all nursing and health care staff asked to take on this role.

Psychiatric liaison services / CAMHS

All emergency departments providing 24-hour care should have access to a round-the-clock mental health or psychiatric liaison service. Several national bodies have a recommended standard that a mental health professional should see every patient in a mental health crisis within an hour of referral.⁴

The mental health liaison team will be contactable via a bleep or telephone extension. Introducing yourself and making friends with your local team is a good idea, as you will undoubtedly work closely together in the ED!

The provision of mental health services for children and young people is less consistent in the UK and suffers from considerable under-resourcing.

In many trusts, children who require urgent assessment by Child and Adolescent Mental Health Services (CAMHS) will have to be admitted to hospital. This is suboptimal, but admission avoidance should improve as the service becomes more robust.⁵

You should always discuss with a senior clinician and liaise with the CAMHS team when treating a child who presents in a mental health crisis, such as with suicidal ideation or following an overdose.

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Safeguarding

It is important to consider safeguarding concerns when dealing with patients in a mental health crisis. A referral should be made to the local safeguarding team in any of the following situations:

• An adult who presents in a mental health crisis where there is a concern for their welfare (e.g. victim of domestic violence or abuse)
• A child who presents in a mental health crisis (e.g. suicidal ideation or following an overdose)
• An adult who presents in a mental health crisis who has dependents at home

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De-escalation and restraint

De-escalating an agitated patient is an artform and, if done well, can prevent the use of physical restraint and chemical sedation.

De-escalation

There are several factors to consider when attempting to de-escalate an agitated patient. These can be broken down into environment, communication and distraction.

Environment

If possible, move the patient to a calming environment with reduced external stimuli such as noise, people and bright lights. Many emergency departments will have a dedicated space for this. Remember that it is important to consider your personal safety. In some situations, it may not be safe to remove the patient to another area, in which case you should try to modify their local environment to aid de-escalation.

Communication

Both verbal and non-verbal techniques can be used to aid de-escalation.

Verbal communication tips to aid de-escalation:

• Refer to the patient by their name
• Introduce yourself and explain who you are
• Use a gentle and calming tone of voice
• Do not overwhelm them with information
• Do not use argumentative or confrontational language
• Speak slowly
• Break down tasks into small steps
• Let them speak
• Acknowledge the difficulties they are having
• Be understanding

Non-verbal communication tips to aid de-escalation:

• Respect the patient’s personal space
• Keep your hand visible
• Ensure body language is non-confrontational
• Face the patient
• Maintain eye contact and try to act in a friendly way

Distraction

Focussing attention away from the patient’s behaviour can be a useful de-escalation tool in some situations. For example, ask the patient to help you complete a task or have a conversation about something that interests them.

Restraint

Some situations require physical restraint when de-escalation techniques fail. Restraint should be performed by trained staff and should be proportionate, reasonable and necessary. The restraint should be in the patient’s best interest, and the least restrictive method should be used.

Local hospital guidelines should be followed when physical restraint is used and care taken to protect the patient’s airway, breathing and circulation.  

NICE guidelines advise against using manual restraint for more than 10 minutes, and instead, rapid tranquillisation or seclusion should be considered in violent and aggressive patients.⁶

Sedation

Chemical sedation (e.g. with the use of benzodiazepines or antipsychotics) may be needed when verbal and environmental de-escalation techniques have failed. Local protocols should be followed when using sedative drugs for agitated patients. The on-call liaison psychiatry team and senior ED clinicians will be able to help with the decision-making surrounding this. 

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Acute behavioural disturbance (ABD)

Acute behavioural disturbance (ABD) is an umbrella term used by the police and emergency services in the UK to describe patients who present with a significant behavioural disturbance which presents a threat of harm to either the patient or those around them.⁷

Previous terms used to describe this condition include excited delirium, acute behaviour disorder and agitated delirium.

ABD is not a single diagnosis but a clinical presentation with a range of underlying causes. Illicit drug use and underlying mental health disorders are the most common triggers for this type of behaviour. However, other causes should also be considered, such as substance withdrawal, anticholinergic syndrome, thyroid storm, head injury and neuroleptic malignant syndrome.

Clinical features

Clinical features of acute behavioural disturbance include:⁷

• Agitation
• Constant physical activity
• Bizarre behaviour
• Fear and panic
• Unusual or unexpected strength
• Sustained non-compliance with police or ambulance staff
• High pain tolerance
• Hot to the touch and sweating
• Tachypnoea
• Tachycardia

Management

The persistent psychomotor agitation in these patients can lead to significant harm, and the Royal College of Emergency Medicine advocates for the use of rapid tranquillisation once other non-invasive de-escalation techniques have been attempted.

Rapid tranquilisation should be carefully coordinated by senior clinicians and must include provisions to provide adequate monitoring and cardio-respiratory support.

Managing patients with ABD is a multi-disciplinary challenge which may involve security, the police, pre-hospital staff, senior ED clinicians and the mental health liaison team.

Don’t worry, this is not something you will be dealing with alone, and you might prefer to watch from a distance if you are new to emergency medicine!

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Confusion and acute delirium

Confusion and acute delirium are commonly encountered in the emergency department, and it is important to think broadly about the differential in patients who present in an acutely confused state.

• Could this be delirium triggered by an underlying infection or medication use?
• Have they suffered a head injury?
• Could there be an intracranial bleed?
• Is there any evidence of substance misuse or alcohol withdrawal? 

A thorough confusion screen should be performed, starting with a detailed history and examination looking for for possible triggers.

Blood tests requested in a confusion screen include a full blood count, CRP, U&Es, bone profile, haematinics (B12 and folate), thyroid function tests, liver function test and glucose. The medical team may add some of these tests later if a full inpatient workup is necessary.

You should consider doing a CT head in cases of acute confusion where the possibility of an intracranial pathology, such as a bleed or stroke, exists. Ask your seniors for help in the decision-making surrounding this.

Delirium

The National Institute for Health and Care Excellence (NICE) defines delirium as an acute, fluctuating syndrome causing disturbed consciousness, attention, cognition and perception.⁸

Three distinct subtypes of delirium have been recognised: 

• Hypoactive delirium characterised by decreased alertness and withdrawal
• Hyperactive delirium characterised by restlessness and agitation
• Mixed delirium with both hypoactive and hyperactive features

Delirium may be triggered by various factors in susceptible patients, including an underlying infection, medications and electrolyte disturbances. It is a common presentation thought to be present in approximately 20% of adult acute medical presentations.⁹

Managing delirium is a team effort between the ED, medical and/or care of the elderly team. Making the patient comfortable and trying to reassure and orientate them is an important first step.

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Eating disorders

Eating disorders carry the highest mortality rate of any psychiatric disorder and are poorly understood and managed in the emergency department. Eating disorders you may come across include anorexia nervosa and bulimia nervosa.⁴

Complications of these conditions include hypokalaemia, bradycardia, hypoglycaemia, hypothermia and syncope.

Most hospitals do not have a dedicated eating disorder service, and joint input from the psychiatric and on-call medical team is needed.

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Alcohol and substance misuse

Alcohol

Alcohol-related presentations are very common in the emergency department and account for a significant amount of morbidity and mortality. 

The list of alcohol-related presentations to the ED is expansive. It includes alcohol withdrawal seizures, head injuries, delirium tremens, pancreatitis, wernicke encephalopathy, korsakoff’s psychosis, alcoholic liver disease, alcoholic ketoacidosis, cardiomyopathies, cerebellar ataxia and more.

This is not a comprehensive guide to the management of alcohol abuse in the ED, but here are a few tips to get you started.

1. Always consider alcohol: there are several screening tools which can be used to identify at-risk patients. One such tool is the Audit C questionnaire, which consists of three simple questions.¹⁰ Bear in mind that patients frequently under-report how much alcohol they consume.

2. Alcohol withdrawal seizures: patients who are dependent on alcohol are at risk of suffering from alcohol withdrawal seizures if they stop drinking abruptly. These patients will need to be treated with benzodiazepines such as chlordiazepoxide to prevent them from having an alcohol withdrawal seizure. The CIWA scoring tool can be used to assess the severity of withdrawal and guide treatment. High doses of benzodiazepines may be needed in severely dependent patients (your department will have a guideline on this).¹¹

3. Wernicke encephalopathy: alcohol-dependent patients are at risk of wernicke encephalopathy, characterised by ophthalmoplegia, ataxia and acute confusion. This is caused by a deficiency in thiamine (vitamin B1), and patients should be started on replacement therapy with IV Pabrinex® as per your hospital guidelines.

4. Alcohol liaison team: many hospitals have an alcohol liaison service which can be accessed to help manage patients who are alcohol dependent. You should signpost your patients to community drug and alcohol services if the liaison team is not available out of hours.

5. Intoxication and a low GCS: severely intoxicated patients should be managed with an ABCDE approach and with senior support. Do not assume that a low GCS is always related to alcohol intoxication. You should consider an intracranial pathology, such as bleeding in a patient who is intoxicated and has hit their head.

6. Safeguarding: this is a common theme in mental health and substance misuse, and you will find yourself completing a lot of safeguarding forms while in the ED. These can be time-consuming, but looking after the welfare of vulnerable patients is an important part of the job.

Substance misuse

You will encounter substance misuse in the emergency department, both relating to recreational drug use and self-harm.

TOXBASE, the National Poisons Information Service’s toxicology database, is an essential resource when managing patients presenting following an overdose (OD).¹² Your department will have a generic login you can use. You should look up the TOXBASE guidelines for each of the drugs taken in the case of a mixed OD.

When taking a history, try to determine exactly:

• What they have taken (including doses and formulation e.g. modified release or slow release formulations).
• When they have taken it (was it taken in one go, or was it a staggered overdose).

A lot of information can be gleaned from the pre-hospital documentation, and the paramedics may even bring some empty packets of drugs found at the scene with them.

In cases where you do not know what has been taken, you should consider how the patient presents clinically and whether it fits into a specific toxidrome. For example, pinpoint pupils and respiratory depression are consistent with an opioid toxidrome, and that patient may require treatment with naloxone.

Other toxidromes include anticholinergic, cholinergic, sympathomimetic, hallucinogenic and sedative/hypnotic.

Unwell patients should be managed using an ABCDE approach and with senior support. The psychiatric liaison services should also be involved to review these patients once they are medically fit.

Geeky Medics has some excellent toxicology resources if you want to read more!

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Conclusion

Managing mental health presentations in the emergency department can be challenging. However, with a sound understanding of the legal framework and a structured approach to common presentations, you will be well equipped to start helping these patients.

Remember that you are working as part of a team, and you should ask for senior ED support and assistance from the mental health liaison team when needed.

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References

1. Royal College of Emergency Medicine (RCEM). RCEM best practice guidelines: the mental capacity act in emergency medicine practice. Published Feb 2017. Available from: [LINK]
2. National Society for the Prevention and Cruelty to Children. NSPCCLearning. Gillick competence and Fraser guidelines. Updated 05/08/2022. Available from: [LINK]
3. Royal College of Emergency Medicine (RCEM). A brief guide to section 136 for emergency departments. Published Dec 2017. Available from: [LINK]
4. Royal College of Emergency Medicine (RCEM). Mental health in emergency departments: a toolkit for improving care. Revised April 2021. Available from: [LINK]
5. National Health Service (NHS) England. Children and adolescent mental health service (CAMHs) inpatient services. Accessed Dec 2023. Available from: [LINK]
6. National Institute for Health and Care Excellence (NICE). Violence and aggression: short term management in mental health, health and community settings. 28/05/2015. Available from: [LINK]
7. Royal College of Emergency Medicine (RCEM). RCEM best practice guidelines: acute behavioural disturbance in emergency departments. Published February 2022. Available from: [LINK]
8. National Institute for Health and Care Excellence (NICE). Clinical knowledge summaries: delirium. Revised Nov 2021. Available from: [LINK]
9. Fordham, S. RCEMLearning: delirium in the elderly. 14/08/2023. Available from: [LINK]
10. Bradley, K. MD+Calc: AUDIT-C for alcohol use. Accessed Dec 2023. Available from: [LINK]
11. Sellers, E. M. MD+Calc: CIWA-Ar for alcohol withdrawal. Accessed Dec 2023. Available from: [LINK]
12. National Poisons Information Service. TOXBASE. Available from: [LINK]

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