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Managing psychiatric patients in the emergency room

Vol. 12, No. 02 / February 2013

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The ever-increasing number of psychiatric visits to emergency room (ER) settings is a daunting clinical challenge.1 As psychiatrists, we must be prepared for these visits. The mnemonic FIRST can help when you encounter a psychiatric patient in the ER.

Frank conversation about why the patient came to the ER for evaluation and the need for observation or treatment is essential to obtaining an accurate history and providing appropriate care. Address a possible sense of isolation a patient may feel when being in a new environment. Be aware of nonverbal cues because they may lead to an appropriate and well-tailored conversation with your patient.

Individualize care by emphasizing to patients that they have choices in their treatment plan now and after discharge. Listen and communicate with the patient in a manner that decreases stigma because he or she may feel out of control, fearful, angry, or betrayed by loved ones. Doing so will help create a safe environment, can help alleviate the need for chemical or physical restraints, and may enhance treatment adherence.

Reach out to the patient’s family and friends to gather support for him or her and to obtain collateral information to formulate an appropriate course of treatment. Ask about family medical history, financial status, and a social support system because these can aid in diagnosis and optimizing the patient’s short- and long-term prognosis.

Somatic complaints can be used as a springboard to build rapport with patients. Many patients find it easier to talk about physical symptoms than emotional ones, so acknowledge and validate these concerns and explain that many psychiatric symptoms can present as somatic symptoms, such as panic disorder presenting as tachycardia. This also may indicate a need for a prompt, thorough physical examination.

Tease out secondary causes of psychiatric symptoms. Many organic conditions can initially present as psychiatric symptoms; for example, brain tumors or seizures can present with olfactory, gustatory, visual, or auditory hallucinations. Drug toxicology and laboratory testing can rule out medical causes of psychiatric symptoms.1 Geriatric patients or those with multiple, chronic medical illness can present with agitation, heavy sedation, or delusions. Keep a high index of suspicion to rule out medical conditions.


The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.


1. Zeller SL. Treatment of psychiatric patients in emergency settings. Primary Psychiatry. 2010;17(6):35-41.

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