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Online Nursing Continuing Education

Mental Health Crisis Management

COURSE PRICE: $30.00

CONTACT HOURS: 4

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Wild Iris Medical Education, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

Provider approved by the California Board of Registered Nursing, Provider #12300.

Course Availability: Expires June 1, 2017. You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity. Wild Iris Medical Education, Inc., provides educational activities that are free from bias. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional healthcare.  Medical Disclaimer   Legal Disclaimer   Disclosures

Mental Health Crisis Management

COURSE OBJECTIVE:  The purpose of this course is to prepare healthcare professionals to respond to and manage care for persons experiencing mental health crises and emergencies, in particular those associated with mood, anxiety, anger, substance use, and major mental illness.

LEARNING OBJECTIVES

Upon completion of this course, you will be able to:

  • Discuss the definitions and characteristics of mental health crises and emergencies.
  • Explain triage considerations for patients experiencing mental health crises.
  • Identify legal and ethical issues related to the care of patients with mental health crises.
  • Describe the decision-making process utilized in providing care to patients in mental health crises.
  • Outline the appropriate care for patients experiencing mental health crises and emergencies related to mood, anxiety, anger, substance use, and major mental illness.

INTRODUCTION


Everyone experiences crises. Crises are acute, time-limited events experienced as overwhelming emotional reactions to one’s perception of an event. Crises are experienced by people of all ages, cultures, and socioeconomic conditions and may or may not be related to a specific mental disorder.

Crises are self-defined and environmentally based. What is a crisis for one person may not be for another, and what is now a crisis may not have been a crisis before or would not be a crisis in a different setting. Crises can be looked upon as a system out of balance. Crises occur when balance cannot be regained, even though a person is trying very hard to correct the imbalance.

Most often clinicians encounter an individual in crisis in emergency departments and on crisis hotlines. However, these individuals may also be encountered in other healthcare settings, such as inpatient units, clinics, nursing homes, assisted living facilities, and home health. Healthcare providers may lack the educational preparation to provide appropriate intervention and satisfactory care for the person in crisis.

Because the initial care of people in crisis most often does not occur in psychiatric institutions, there is scant documentation by few controlled studies and very little reliable data available about the diagnosis and treatment of mental health crises (Mavrogiorgou et al., 2011). The U.S. Department of Veterans Affairs Office of Research & Development, however, conducts studies into many areas of mental health that lead to crises and emergencies. Such research can result in better education and training of healthcare professionals who provide initial treatment for those in crisis.

WHAT IS A MENTAL HEALTH CRISIS?

A mental health crisis is an intensive behavioral, emotional, or psychiatric response triggered by a precipitating event. If this crisis is left untreated, it could result in an emergency situation, placement of a person into a more restrictive setting such as inpatient hospitalization, or significantly reduced levels of functioning in the person’s primary activities of daily living. A mental health crisis can be either urgent or emergent in nature (see table below).

URGENT VERSUS EMERGENT CRISES
Type Urgent Emergent
Definition The acute onset of a behavioral condition not constituting an immediate substantial risk of harm but that, if left untreated, may worsen into a mental health emergency or cause the person to become overwhelmed and unable to function without assistance The acute onset of a behavioral condition that becomes apparent by an immediate and significant possibility of serious harm to oneself or others
Response Requires attention but is not a life-threatening emergency Requires immediate action
Examples Suicidal gestures, intoxication, bizarre gestures, acute agitation, acute post-trauma/assault responses Imminent suicide, drug toxicity, violent or threatening behavior toward others
Caregiver Action Perform a physical examination and mental status assessment and take appropriate action After making above assessment, intervene immediately

Types of Crises

Although crises arise from many different sources, most healthcare professionals agree there are at least three causal categories of crises: maturational, situational, and adventitious (rare/unexpected/disastrous).

MATURATIONAL CRISES

Maturational crises have to do with the predictable transitions individuals experience as they move from one stage of human development to another. In his classic text, Erik Erikson (1963) identified eight stages of maturity delineated by developmental tasks:

  • Infancy
  • Early childhood
  • Preschool
  • School age
  • Adolescent
  • Young adult
  • Mature adult
  • Late adulthood

He declared that each of these stages constitutes a crisis in personal growth and development. For example, toddlers are developing autonomy and self-esteem and may have a temper tantrum when they do not get what they want. Having a child and retiring from the workforce are also situations that will cause major changes in what an individual and/or family have previously considered “normal.” Taking a “wait and see” approach has the potential to exaggerate the impact of the event.

Maturational crises are predictable and can be prepared for and prevented. Proactively identifying actual or possible changes that the event will cause and then taking steps to become more prepared for those changes can minimize the disruption. For example, a young couple can take parenting classes to help prevent pediatric head trauma that could result from shaking their infant out of frustration during a period of uncontrollable crying.

SITUATIONAL CRISES

Situational crises arise from an external source and are events or circumstances that threaten the physical, social, and psychological integrity of individuals. These events may originate in the physical body as a result of disease or injury or in social or emotional situations, such as the loss of a job or death of a child. Sometimes maturational and situational crises occur at the same time, and occasionally, one crisis triggers another, compounding the problem.

For example, a teenage boy and girl are attracted to one another and experiment with sexual intimacy. When the menstrual period of the girl is late, both adolescents are thrust into a state of emotional disequilibrium as they experience both the maturational crisis of adolescence and the situational crisis of a potential pregnancy. The actions they take to resolve the crisis may thrust them into even greater confusion and tumult.

ADVENTITIOUS CRISES

Adventitious crises have been called events of disaster. They are rare, unexpected happenings that are not part of everyday life and may result from 1) natural disasters, such as floods, fires, and earthquakes; 2) national disasters, such as airplane crashes, riots, and wars; 3) interpersonal disasters, such as assault and rape; and 4) acts of terrorism.

The National Incident Management System (NIMS) provides a systematic approach to the work necessary during such disaster situations (FEMA, 2013). Training material for Community Emergency Response Teams (CERT) can be found on their website (see “Resources” at the end of this course).

Phases of Crisis

In 1964 Gerald Caplan, a pioneer in the field of crisis intervention, identified four predictable phases of crisis:

  1. Initial threat or triggering event. People are faced with a problem or conflict. In an effort to lower the level of anxiety (fear), they employ various defense mechanisms, such as compensation (using extra effort), rationalization (reasoning), and denial. If the problem is resolved, the threat disappears, and there is no crisis.
  2. Escalation. If the problem persists and the usual defensive response fails, anxiety continues to rise to serious levels, causing extreme discomfort. The person becomes disorganized and has difficulty thinking, sleeping, and functioning. Trial-and-error efforts are initiated to solve the problem and restore emotional equilibrium.
  3. Crisis. When trial-and-error attempts fail, anxiety intensifies to a severe level and then to panic, and people mobilize automatic relief behaviors (flight or fight). Some form of resolution may be made, such as redefining the problem, attacking it from a new angle, and trying again to find a solution.
  4. Personality disorganization. If the problem is not resolved and new coping skills are ineffective, anxiety may overwhelm individuals and lead to serious disorganization, confusion, depression, or violence against themselves as suicide or others (Varcarolis, 2013).

Balancing Factors

In her seminal work on crisis, Donna Aguilera (1998) noted that the equilibrium of people in crisis is significantly affected by three balancing factors: their perception of an event, their support system, and their coping mechanisms.

  • Perception of an event refers to the importance of a problem to the individual in crisis and includes such things as health, career, financial status, and reputation.
  • Support system refers to the resources possessed by the person in crisis, such as other people the individual trusts who can provide support and assistance during a time of need.
  • Coping mechanisms are skills or methods people use to reduce anxiety and solve problems, such as reasoning, meditation, physical exercise, sleep, and denial.

(This will be discussed in further detail below under “Assessment.”)

Resolution

When a crisis is resolved and emotional equilibrium is restored, individuals again face the everyday issues of life. Ideally, as a result of a crisis, they learn new coping skills, gain greater self-confidence, enlarge their support system, and raise their level of functioning. The goal of crisis intervention is to restore the pre-crisis level of functioning and, when possible, raise it to a higher level than before the crisis. An important part of all crisis interventions, whether they take place over a hotline or in a counseling session, is anticipatory guidance, whereby the caregivers help the patients learn more effective coping mechanisms for future crisis events.

CASE

Peter, a teenager, failed to make the football team. His world crumbles as he tries to cope with both a maturational and situational crisis. To make himself feel better, Peter takes a bottle of whiskey from the kitchen cabinet, climbs into the family car, drives to an isolated park, and drinks several ounces of the whiskey. After an hour or so, he feels groggy and nauseous, decides to drive home, and crashes the car, suffering serious injury.

Peter’s perception of the event (making the football team) was the most important thing in his life. He was devastated when he did not get on the team. Instead of calling on a support system (family or friends who could bolster his feeling of worth), he self-medicates with alcohol, becomes inebriated, drives and damages the family auto, and suffers painful physical injury. Now he feels even worse than before.

During his recovery, Peter works with a counselor on a weekly basis to gain an understanding of his response to his maturational and situational crises and learns new coping mechanisms to utilize in the future. He recognizes that more effective coping mechanisms could have been to take a long walk (physical exercise), talk about his disappointment with a friend (counseling), or think about other ways to gain recognition (reasoning).

TRIAGE CONSIDERATIONS

When individuals who are in distress call a telephone hotline or go to an emergency department, healthcare professionals assess the person and the problem, identify the precipitating event, consider influencing factors, and plan appropriate intervention. Triage is the process of determining priority for treatment based on severity of condition. In every crisis event, triage must address each of the following factors: safety concerns, immediacy challenges, ethical principles, and legal issues.

Safety Concerns

The most urgent concern of healthcare professionals is the safety of people in crisis as well as others who may be in danger. Clinicians gather information about:

  • The presence of guns, knives, explosives, or other harmful devices
  • Threats of violence by the person in crisis to self or others
  • History of harm by the person in crisis to self or others
  • Intoxication of the person in crisis or others through various substances
  • Environmental hazards that might complicate interventions (e.g., fire, wind, water, trauma, toxic fumes, random gunfire)

Immediacy Challenges

Mental health triage may occur in emergency departments, call centers, community health centers, and many other crisis assessment settings. Central to triage is a risk assessment that identifies the nature and severity of a mental health problem in order to determine how urgently a response is required and the type of service response that would best meet the patient’s needs.

CASE

Jeremy is a nurse with three years’ experience working in an emergency room and two years on an acute psychiatric unit. He has volunteered to answer the crisis hotline one night a week at the Northside Healthcare and Crisis Center. Jeremy arrives for his initial orientation and training with the crisis center manager, Daniel, who proceeds to instruct him, offering tips and suggestions along the way. Jeremy’s training includes the following:

  • An introduction to the triage algorithm utilized by the center
  • Recognizing the difficulty of developing a rapport with a caller when you are unable to see the person
  • Maintaining an even, unhurried tone of voice
  • Identifying oneself at the beginning of the call and explaining what the triage process is
  • Remembering the caller’s name by writing it down immediately
  • Ensuring that the caller has enough time to explain what the situation is
  • Completing the assessment following the triage algorithm
  • Determining the urgency and type of response required
  • Requesting callers to repeat instructions and asking them to write them down
  • Encouraging a call back if the situation changes or if more assistance is needed
  • Documenting the call in the crisis records
  • Using active listening skills
  • Using open-ended questions and offering suggestions to help callers remember details
  • Learning about barriers to effective telephone communication such as inappropriately using language, making assumptions, being judgmental

Jeremy listens in on two hotline calls and then answers a third call while Daniel listens in. Using all the skills he has honed working with people in the emergency department and the acute psychiatric unit, Jeremy establishes rapport quickly by actively listening, speaking calmly, and giving the caller adequate time to tell her story. Daniel observes Jeremy completing his assessment following the triage algorithm, his correct determination of the urgency and need of the caller who was distraught and having thoughts of harming herself, as well as Jeremy’s appropriate intervention. Jeremy enters the call in the crisis records, and Daniel tells him he is ready to work on his own.

Ethical Principles

Healthcare professionals follow ethical standards of care at all times, whether or not a patient is in crisis. These standards are based on ethics, the branch of philosophy concerned with the rightness or wrongness of human behavior and the goodness or badness of its effects. However, in emergency circumstances where there is a need to intervene rapidly, caregivers may sometimes be challenged to remember the importance of such principles.

Ethical principles are fundamental concepts by which people make decisions. These principles serve as criteria against which people measure behavior. In contrast, laws flow from ethical principles and consist of rules about specific situations. These rules are enforced by an authority with the power to see that they are obeyed.

Unlike laws, ethical principles serve as general guides for behavior. Five ethical principles mark the practice of healthcare professionals: 1) respect for human life and dignity, 2) beneficence, 3) autonomy, 4) honesty, and 5) justice.

Respect for human life and dignity is one of the most basic of ethical principles. It asserts that “individuals must be treated as unique beings, equal to every other individual” (Rawls, 1999). When applied to psychiatric emergencies, respect for human life and dignity means healthcare professionals:

  • Refrain from abuse, harassment, or discrimination
  • Respect the personhood, lifestyle, and belief system of patients
  • Demonstrate regard for patients’ physical, psychological, and socioeconomic well-being
  • Strive to sustain human life and dignity
  • Respect and hold in confidence all personal information
  • Require specific legal justification for interference with a patient’s civil liberties

Beneficence means doing good for the benefit of others and maintaining professional competence. The concept of nonmaleficence is closely associated with beneficence and says that if one cannot do good, then he or she should at least do no harm. Ideally, it means acting in ways that demonstrate care and nurturance. When applied to mental health crises and emergencies, beneficence means caregivers:

  • Relate to patients professionally and objectively
  • In consultation with other clinicians, follow treatment plans
  • Choose the option that will do good and avoid harm
  • Recognize that under certain conditions beneficence overrides autonomy and that compulsory treatment may be justified

Autonomy means respecting the right of self-determination, independence, and freedom. To prevent injury in psychiatric emergencies, caregivers may need to choose between actions that support autonomy (freedom) and those that support beneficence (safety). Clinicians may need to restrain patients, administer tranquilizing drugs, or place patients in seclusion against their will.

Laws governing involuntary commitment address the ethical dilemma created by the conflict of the ethical principles of autonomy and beneficence. Except for legally defined situations, when applied to mental health crises and emergencies, autonomy means caregivers:

  • Inform patients about treatment options and risks, making sure they understand
  • Respect and accept decisions made by patients about their personal care
  • Implement and evaluate interventions chosen by patients
  • Hold in confidence all personal information, divulging it only when patients or their legal guardians give permission

Honesty (veracity) means being truthful in word and deed, even when you must convey unwelcome information about a condition or treatment. Clinicians must be truthful yet compassionate, withholding information only when the patient is a minor child or an adult with a legal guardian. When applied to mental health crises and emergencies, honesty means caregivers:

  • Accurately report and record critical data
  • Place the welfare of patients above personal or professional gain
  • Keep promises and abide by contracts
  • Provide factual, scientific, and relevant information about treatment, including benefits and risks

Justice implies fairness and equality and requires impartial treatment of patients. Like other ethical principles, justice is based on respect for human life and dignity. The historic image of justice is a blindfolded woman with a scale, weighing an issue on the basis of objective evidence and judicial precepts. Justice means that scarce resources will be distributed equally, using the same criteria for everyone. When applied to mental health crises and emergencies, justice means clinicians:

  • Assess all patient needs with equal diligence and professionalism
  • Attend to the needs of patients, no matter how difficult their personality, complex their disorder, or challenging their behavior
  • Evaluate and communicate information about treatment options without prejudice
CASE

Victoria, a 48-year-old woman with a long-standing manic disorder, built a fire on her living room floor, and when her husband tried to extinguish the fire, she attempted to stab him with a knife. She was taken by police to the emergency department and admitted involuntarily for treatment, where she accepted medications to help her sleep but declined to take any mood-stabilizing drugs. She said, “They make me feel like I’m moving in slow motion, going through Jell-O. I can’t stand them.”

The healthcare team recognized the dilemma between the three ethical principles of beneficence (providing treatment), autonomy (right of self-determination), and respect for human life and dignity (equal treatment). They knew that ethical clinical decision making follows four steps in order of their importance: clinical indications, patient preferences, quality of life, and socioeconomic or external factors.

In Victoria’s case, a crisis situation, it was readily accepted that treatment with medications was clinically indicated and likely to be of benefit (beneficence). They also recognized that Victoria has significant mental illness and her ability to make informed decisions was seriously impaired (autonomy). The decision to involuntarily commit her was based on dangerousness evidenced by the attempt to stab her husband. Equal treatment would require Victoria to be charged with a criminal act (respect for human life and dignity). Instead, Victoria was court-ordered to be detained and started on lithium 600 mg per day in three divided doses.

Legal Issues

In the past, people could be hospitalized under the flimsiest of pretexts, by almost anyone, for nearly any length of time. Unbelievably, it took nearly 200 years for the Fifth Amendment to the U.S. Constitution to be applied to mentally ill individuals. The amendment says “No person shall … be deprived of life, liberty, or property without due process of law.”

In Humphrey v. Cady, the U.S. Supreme Court (1972) recognized that involuntary civil commitment to a mental hospital was a “massive curtailment of liberty” and required “due process protections.”

In recent years, the number and scope of state, federal, and case laws that affect the treatment of people with psychiatric disorders has increased dramatically. Of special interest to those who care for people in crisis are laws concerning civil rights, confidentiality, patient rights, treatment decisions, restraints, seclusion, and hospital confinement.

CIVIL RIGHTS

Under federal and state laws, people with mental illness are guaranteed the same civil rights as every other citizen in the land. These laws guarantee the rights of all people to humane care, to interact socially, to press charges against others, to vote, to speak, to enter into contractual relationships, to make purchases, to obtain a license to drive an automobile, to follow religious practices, to participate in legal activities, and to travel within the United States.

CONFIDENTIALITY

In 1996, to protect the privacy of individuals and the confidentiality of patient records at the dawn of the age of electronic data collection, the U.S. Congress passed the Health Insurance Portability and Accountability Act (HIPAA). Phased in between 2000 and 2003, HIPAA provides that without the prior consent of patients or their legal guardian, medical records may not be read or copied. The act affirms the right to privacy and supports the concept of respect for all human beings. (See “Resources” at the end of this course for more detailed information.)

PATIENT RIGHTS

People have the right to receive medical and dental care, entertain visitors, receive uncensored mail, and be free from excessive medication, isolation, or physical restraints. Individuals have the right to refuse to participate in research studies or experimental treatment, and they cannot be discriminated against on the basis of gender, age, religion, disability, or ethnic origin.

If people do not speak English or can use only sign language, they must have access to an interpreter. Individuals cannot be forced to work without remuneration.

Finally, people have a right to voice grievances without fear of punishment (Varcarolis, 2013).

TREATMENT DECISIONS

The Hospitalization of the Mentally Ill Act of 1964 required that all patients in public hospitals have a right to treatment. Prior to that time, patients could be hospitalized for indefinite periods of time without treatment. Since then, the courts have ruled that patients must be cared for in a humane environment by sufficient numbers of qualified clinicians according to individualized care plans.

In other rulings, both federal and state courts have ruled that patients have the right to refuse electroconvulsive therapy (ECT) and antipsychotic medications. Furthermore, according to the Federal Patient Self-Determination Act of 1990, patients have the right to prepare an “advance care directive” that will be respected in case they become incapacitated (NRCPAD, 2013).

RESTRAINTS AND SECLUSION

When people in crisis become so distressed that they are a danger to themselves or others, it may be necessary to place them in restraints or to isolate them. Because history is replete with accounts of the excessive use of restraints and seclusion, current state laws and recent court decisions affirm that least restrictive measures must be used.

Restraints and seclusion may be used only when absolutely necessary or when patients request seclusion to reduce sensory stimulation. If restraints or seclusion are deemed essential, a physician may prescribe them but must specify the length of time they may be used, for example, “for 2 hours within a 12-hour period of time.”

Restraints should be applied only by healthcare professionals who are adequately trained in correct techniques and in protecting patient rights and safety.

Currently there remains a lack of consensus about the use of seclusion and restraint. There are as yet no uniform national standards over how and when to use restrictive measures. Few states even require the reporting and investigation of deaths in private or state psychiatric facilities, and the federal government does not collect data on how many patients are injured or killed by these techniques (MHA, 2011).

Least Restrictive Alternative

The doctrine of least restrictive alternative is another important concept that applies to the care of patients. This doctrine affirms that caregivers must use the least restrictive means to achieve a specific end. For example, if four-point restraint of both arms and both legs is enough to protect disturbed patients from harming themselves or others, they may not be placed in five-point restraint of the waist, both arms, and both legs.

Chemical Restraints

Chemical restraints are medications such as typical and atypical antipsychotics and benzodiazepines used to restrain agitated or out-of-control persons in mental health crises. Medications have been considered less invasive than physical restraint and seclusion. Currently, however, no drugs have been approved by the U.S. Food and Drug Administration (FDA) for use as chemical restraints, and Black Box warnings for the off-label use of medications have been issued.

There remain unresolved issues concerning the use of chemical restraints:

  • Are chemical restraints ever appropriate?
  • If appropriate, what are the reasonable thresholds for their appropriate use?

Experts disagree on the use of the term chemical restraint, and a survey done for the Expert Consensus Guidelines on Behavioral Emergencies revealed that most experts believe that medications used to treat specific psychiatric diagnoses should be considered treatment measures rather than restraints, even in the absence of provisional diagnosis (CDPH, 2012).

CASE

Sarah Fink, age 87, lived two blocks from the center of a small tourist town in a renowned wine-growing area. She read about a wine-tasting event scheduled for that afternoon and decided to attend. Sarah enjoyed the ambiance and tasted freely at each tasting booth. About 4 p.m. she felt woozy, slumped to the ground, and closed her eyes. Several strangers offered to help her get up, but Sarah waved them off: “I’ll be all right, just leave me alone.”

The deputy sheriff assigned to the event noticed the gathering around Sarah and went to investigate. He asked her if he could help. Groggy and dazed, Sarah asked the officer to call her husband. Instead, he called an ambulance and backup deputies. Someone helped Sarah get up, and she started to walk away. The officer grabbed her and told her to stand still. Sarah pushed him away and shouted, “Leave me alone!” The other deputies jumped into action, pulled her arms behind her back, and applied handcuffs. Again, Sarah turned to walk away. The deputies went after her, put her on the ground, and applied ankle restraints.

Finally, the ambulance arrived, as did Sarah’s husband. He said his wife had a drinking problem; he was her legal guardian and would take care of her. After considerable discussion, the deputies released Sarah to his custody.

A newspaper story of the event outraged the community and led to an official review. The hearing official judged that the deputies’ use of handcuffs to keep Sarah from striking others and ankle shackles to prevent her from walking away was, in fact, the “least restrictive way to achieve specific ends,” and the deputies were exonerated. Nonetheless, the entire incident might have been prevented had the officers communicated more effectively with the client. (See also “Anger-Generated Crises” below.)

HOSPITAL CONFINEMENT

Admission to the hospital may be either voluntary or involuntary.

  • Voluntary means the patient is in control and decides when to enter the facility and when to leave.
  • Involuntary means the patient does not have to agree.

Though a few states require patients to submit a written notice to the hospital before they leave, most do not. Furthermore, in most states a patient can institute a court proceeding seeking a judicial discharge through a writ of habeas corpus order (right to the body), a constitutional means to challenge the unlawful detention of individuals.

Discharge from the hospital depends on the status of patients at the time they were admitted. In general, those who entered voluntarily have the right to be released voluntarily unless their condition changes significantly during their hospitalization. Some states provide a conditional release of people who were admitted voluntarily. Such a provision allows physicians or administrators to arrange for ongoing treatment on an outpatient basis.

Emergency involuntary commitment of people in crisis, also called civil commitment, is controlled by state statutes specifying the conditions under which people can be held against their will. In general, involuntary admission is permitted when people are a danger to themselves, a danger to others, or gravely disabled (unable to provide for their basic human needs such as food, clothing, shelter, health, or safety).

Many states give police officers, physicians, and certain mental health professionals authority to judge the mental status of individuals and to indicate the length of time they are to be held against their will. Often, that time is 72 hours, during which the person is evaluated and a plan of care is devised.

Civil commitment for observation, also called temporary involuntary hospitalization, is for a longer period of time than emergency hospitalization. Its primary purpose is observation, diagnosis, and treatment of people who have a mental illness or pose a danger to themselves or others. The length of time is specified by statute and varies from state to state. Application for this type of commitment can be made by a guardian, family member, physician, or other public health officer and may require a certificate affirming mental illness.

Long-term commitment for involuntary hospitalization is intended to give patients extended care and treatment. As with patients who undergo temporary involuntary hospitalization for observation, extended involuntary hospitalization can occur only with judicial or administrative action and medical certification. This type of involuntary hospitalization may be for 60 to 180 days or, under some circumstances, for an indeterminate period of time.

Involuntary outpatient commitment is a relatively new legal category of care that was initiated in 1990. Involuntary outpatient treatment is court-ordered, community-based treatment for people with untreated severe mental illness. These individuals are often too ill to know they need medical care and have a history of medication and treatment noncompliance. The goal is to provide treatment before they require inpatient treatment by reducing homelessness, violence, and noncompliance. Opponents feel it removes a person’s civil right to choose where and how to receive treatment.

THE DEBATE OVER INVOLUNTARY COMMITMENT

Current debate between those who wish to preserve the status quo (civil rights) and those who want to change involuntary treatment and/or involuntary commitment laws to make it easier to treat the mentally ill has been going on for the past few years. There are several reasons for this trend:

  • Media stories about mentally ill killers on the rampage are creating fear in the public.
  • The public is becoming angry and feeling helpless at seeing so many homeless mentally ill people on the streets.
  • Families are distressed over having to wait until an ill family member becomes a danger to self or others to get care. They believe “laws should prevent dangerousness, not require it.”

From a civil rights perspective, however, involuntary commitment creates a class of people who can be taken, however briefly, into police custody and then placed in “preventive” detention (incarceration). No other members of the public can be confined somewhere for something people believe they will do but have not yet done (danger to self or others).

Both points of view have validity and remain in contention.

Source: Jaffe, 2011.

MEDICAL/NURSING CARE PROCESS AND MENTAL HEALTH CRISES

The medical/nursing process is a five-part, systematic decision-making method used to identify and treat responses of persons with alterations in mental or physical health. Assessment, diagnosis, planning, intervention, and evaluation are the steps used in the process of providing appropriate care for a person in crisis. This process requires collaboration by many individuals working as members of a team to improve the patient’s quality and enjoyment of life. Below is listed a range of professionals who may comprise the team:

  • Patients are the most important members of any healthcare team.
  • Psychiatrists are physicians responsible for the diagnosis and treatment of mental disorders. They prescribe medications and function as the leader of the mental health team.
  • Medical doctors, physicians’ assistants, and nurse practitioners provide ongoing management of physical healthcare concerns and assess for underlying physical causes of symptoms.
  • Psychologists conduct psychological testing, interpret and evaluate their outcomes, and implement programs of behavior modification.
  • Inpatient nurses (RNs, LPNs) provide holistic care by assessing patients’ mental, social, physical, psychological, and spiritual needs; making nursing diagnoses; formulating nursing care plans; providing nursing interventions; and evaluating the outcomes.
  • Caregivers are nurse aides or psychiatric technicians who maintain the therapeutic milieu, provide care under supervision, and contribute to the ongoing assessment of patients.
  • Counselors and therapists identify problems a person is facing in various aspects of life and help discover effective ways of dealing with them.
  • Social workers assess the patient, the family, and his/her community support system. They help with discharge planning, counsel for job placement, and advocate for the patient’s rights. They are skilled in interview techniques and group dynamics.
  • Occupational therapists assess the interpersonal responses of patients and help them adapt to their environment, cope with daily life, and integrate back into life outside the healthcare setting. They supervise and assess people’s abilities to care for themselves and may use different types of therapy on an individual or group basis.
  • Community psychiatric nurses see people living in the community, provide support, monitor medications, help with goal setting and getting patients involved in finding work, and assist family and caregivers.

Each member of the team employs a variety of assessments, and together they set goals and plan treatment.

Assessment

When the safety of a person in crisis is secured, the formal data-gathering process begins. It is conducted in person or by telecommunications and starts with an assessment interview. Of course, the interview is modified to match the circumstances, age, and cognitive ability of the person in crisis.

INTERVIEW

The purpose is to assess the mental and physical status of the person and the problem. Data collection is enhanced by information gathered from family members, other healthcare providers, and authorities such as police officers. Professionals may find the influencing (balancing) factors of crises a useful framework for an assessment interview, specifically the person’s perception of the event, situational supports, and coping skills.

Perception of the event. Something has happened to create a crisis in a person’s life, motivating the person to seek help from a crisis hotline or emergency department. By gaining information about the precipitating event, both healthcare professionals and patients gain a better understanding of the problem. Questions clinicians might ask about a precipitating event are:

  • What happened to make you so upset?
  • How are you feeling right now?
  • How does this event affect your life?
  • How will this event affect your future?
  • What needs to be done to fix the problem?

Situational supports. The support system of a patient includes the resources available to the person in crisis. Family and friends, social clubs, church groups, and networks of professional associates are all sources of support. When these resources are not available, caregivers act as a temporary support system for the patient. The plan of care should include the identification of a support system. Some questions a clinician might ask about a support system are:

  • With whom do you live?
  • When you feel lonely and overwhelmed by life, whom do you talk to?
  • Is there someone in your life whom you trust?
  • In the past, during difficult times, whom did you want to help you?
  • Where do you go to school (to worship, to have fun)?

Coping skills. In crisis situations, it is important to evaluate the patient’s level of anxiety and their usual coping methods. Some people drink, some eat, some sleep, and some gamble. Others engage in physical activity, work harder, pick fights, or talk to friends. Some questions clinicians may ask about coping methods are:

  • What do you do to make yourself feel better?
  • Did you try doing that this time?
  • If you did, what was different this time?
  • Have you thought of killing yourself or someone else?
  • How would you go about doing this?
MENTAL STATUS EXAMINATION

The mental status examination (MSE) is used to evaluate critical areas of cognition and emotion. In psychiatry, the MSE is “analogous to the physical examination in general medicine” (Varcarolis, 2013). Caregivers use their findings to diagnose unmet needs, identify desired goals, and create a plan of care. In an emergency, clinicians may need to modify the examination, however a complete mental status examination includes the following.

ELEMENTS OF A MENTAL STATUS EXAM
Personal Information
  • Age
  • Sex
  • Marital status
  • Religious preference
  • Ethnic background
  • Employment
  • Living arrangements
Appearance
  • Grooming and dress
  • Hygiene
  • Facial expression
  • Height, weight, nutritional status
  • Unique body markings: scars, tattoos, piercings
  • Age related to appearance
Behavior
  • Body movement: excessive or reduced
  • Peculiar movement: scanning, gesturing, balance, gait
  • Abnormal movement: tremors, teeth chattering
  • Eye contact
Speech
  • Rate: slow, rapid, normal
  • Volume: loud, soft, normal
  • Disorganized, rapid
Affect and Mood
  • Affect: flat, bland, animated, angry, withdrawn, appropriate to context
  • Mood: sad, labile, euphoric
Thought
  • Process: coherent, flight of ideas, neologism, thought blocking, circumstantiality
  • Content: delusions, obsessions, suicidal ideations
Perceptual Disturbances
  • Hallucinations: auditory, visual
  • Illusions: perceptual misinterpretations
Cognition
  • Orientation as to time, place, person
  • Level of consciousness: alert, confused, clouded, stuporous, unconscious, comatose
  • Memory: remote, recent, immediate
  • Fund of knowledge (historically accumulated and culturally developed knowledge essential for functioning and well-being)
  • Abstractions: performance on tests involving similarities, proverbs
  • Insight into problems
  • Judgment
PHYSICAL STATUS EXAMINATION

A basic physical examination is essential at the initial in-person interview with persons in crisis because medical conditions sometimes mimic psychiatric ones. Furthermore, people with psychiatric disorders are more likely to have medical or drug-related conditions. When an interview is conducted by telephone, the caregiver should urge the caller to obtain a physical examination by a qualified clinician and should provide a referral list for such services.

In an emergency situation, healthcare professional use what is called a “focused physical examination” rather than a general examination, and if this suggests a need for a general examination, then that is performed. The elements of a physical examination are as follows:

ELEMENTS OF A PHYSICAL EXAMINATION
Source: Antai-Otong, 2009.
Measurements
  • Temperature
  • Pulse
  • Respirations
  • Blood pressure
(Abnormal vital signs suggest an underlying medical or drug-related condition.)
Review of body systems
  • Cardiovascular
  • Gastrointestinal
  • Pulmonary
  • Genitourinary
  • Musculoskeletal
  • Integumentary
  • Endocrine
  • Neurosensory
Medications
  • Names and dosages
  • Prescribed and nonprescribed
Last physical examination
  • Date and provider
Laboratory tests
  • Complete blood count
  • Alcohol and sugar levels
  • Thyroid panel
  • Urinalysis
  • Hematocrit
  • Hemoglobin
  • Chemistry profile
  • Folate and thiamine levels
  • STDs
  • Hepatitis
  • Electrocardiogram
  • Liver and renal function
  • Drug toxicology screen
  • Pregnancy (as appropriate)

Diagnosis

After assessing the person in crisis, clinicians make a tentative diagnosis using one of three major diagnostic classification systems, all of which identify the problem or unmet need, the probable cause, signs and symptoms, and other supporting data. These systems include:

  • International Statistical Classification of Diseases (ICD-10)
  • Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5)
  • Nursing Diagnoses: Definitions and Classifications (NANDA)

All caregivers need to be familiar with ICD codes and DSM-5 codes because healthcare organizations and government agencies use these codes to pay clinicians for their professional services.

ICD-10

The International Statistical Classification of Diseases, 9th Revision (ICD-9) was adopted in the United States in 1979, and in 1988 Medicare required physicians to report conditions using this code. In 1990 the International Statistical Classification of Diseases, 10th Revision (ICD-10), was published by the World Health Organization (WHO) and adopted worldwide in 1994. The United States was ready at that time also to adopt ICD-10 to align with WHO and other countries, but this was put on hold following the enactment of HIPAA (Health Insurance Portability and Accountability Act) in 1996. Since then, legislative steps have been ongoing, and in October 2014 ICD-10 becomes effective in the United States.

ICD-10 is not a revision of ICD-9 but rather a replacement that is more clinically accurate and offers more available codes and a less-restrictive coding structure (CDC, 2013). The ICD-10 classifies both psychiatric and medical syndromes (clusters of symptoms) using a number and a word or phrase, such as “295.30 Schizophrenia, paranoid,” or “577.1 Pancreatitis, chronic.” The code number facilitates research studies, demographic data collection, and the reimbursement of providers.

DSM-5

The Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) was published by the American Psychiatric Association in 2013. DSM-5 is a standard classification of mental disorders used by mental health professions and contains a listing of diagnostic criteria for every psychiatric disorder recognized by the U.S. healthcare system. It is used in both clinical settings as well as with community populations. In addition to supplying detailed descriptions of diagnostic criteria, DSM-5 is also used for collecting and communicating accurate public health statistics about the diagnosis of psychiatric disorders (APA, 2014).

NANDA

A complete nursing diagnosis states a response to a health problem related to a medical or psychiatric disorder, as evidenced by signs and symptoms exhibited by the patient. For example, “risk for suicide, related to depressed mood, as evidenced by statements of patient and reckless behavior such as drinking and driving.”

Planning

When clinicians assess a person in a mental health crisis and diagnose the disorder, they and the patient decide what goals and outcomes are desirable and feasible. They then determine the process by which each outcome can be achieved. Naturally, outcomes depend on the setting and condition of the person in crisis.

For example, for a patient who hears voices telling him to hurt himself, a NANDA diagnosis might be “disturbed thought processes related to schizophrenia, paranoid type, as evidenced by persecutory hallucination.” The outcome criteria might be “to consistently refrain from doing what the voices command.”

Intervention

Interventions are the actions healthcare professionals take to achieve identified outcomes. Such actions are based on the clinical knowledge, judgment, and skill of the professional; how acceptable the intervention is to the person in crisis; and whether the action is feasible given the circumstances of the individual.

When a patient is a danger to self or others, as with the patient who hears voices telling him to hurt himself, it may be necessary to call the authorities for “emergency involuntary commitment,” whereby the individual is restrained and taken to a locked facility for evaluation and treatment. Emergency departments and telephone crisis centers often develop standardized procedures called clinical protocols to assist caregivers in giving more appropriate and effective emergency care to people in crisis.

For example, when a victim of sexual assault comes to an emergency department, clinicians implement what is called a “rape protocol.” As well as physical and forensic interventions, this type of protocol will include mental health interventions such as:

  • Providing emotional support and privacy
  • Staying with the patient
  • Referring the person to a rape advocacy program

Evaluation

The effectiveness of an intervention is judged by its outcome. When outcome goals are met, the crisis is resolved, and the person in crisis is returned to a prior level of functioning, then the healthcare professional can rightfully say the intervention was successful. Ideally, as a result of the intervention and anticipatory guidance, individuals who have been in a crisis also learn new coping skills, increase their social support network, and are better equipped to cope with future disruptive events in their lives.

EMERGENCY-PRODUCING CRISES

Emergency-producing crises can be grouped into five categories: 1) mood-related (mania, depression, and suicide), 2) anxiety-related, 3) anger-generated, 4) substance use, and 5) major mental illness. All of the conditions require immediate assessment and knowledgeable interventions from caring professionals.

Mood-Related Crises

All people experience a range of moods, from great joy to profound sadness. They express these moods in an array of behaviors, from laughing and smiling to weeping and withdrawing. When moods become exaggerated at either end of the emotional spectrum, they become disorders, limiting the ability of the person to function socially or occupationally.

In their extremes, mood disorders produce the frenzy of mania, the melancholy of depression, and suicide. When people experience mood disorders and seek help in emergency departments or on crisis hotlines, clinicians need to recognize typical symptoms, identify their cause, plan a course of action, implement the plan, and evaluate its effectiveness.

MANIA

Manic episodes are periods of extreme elevation of mood when people feel expansive, energetic, grandiose, and, sometimes, irritable and short-tempered. Typical manic behaviors are:

  • Inflated self-esteem or grandiosity
  • Decreased need for sleep (feel rested after only 3 hours of sleep)
  • More talkative than usual or pressured to keep talking
  • Subjective experience that thoughts are racing or flight of ideas
  • Distractible, attention easily drawn to unimportant or irrelevant external stimuli
  • Intense, goal-directed activity either socially, sexually, or occupationally
  • Hyperactive behaviors and symptoms occurring in episodes of a week or more
  • Excessive involvement in pleasurable activities with a high potential for painful consequences, such as unrestrained buying sprees, gambling, foolish business investments, and sexual indiscretions
    (APA, 2013)

Hypomanic episodes last less than a week and are more moderate than manic episodes. The symptoms, though noticeable, are not severe enough to keep the person from functioning. During these times many individuals are exceptionally creative, productive, and focused, often becoming successful standup comedians, performers, inventors, teachers, and artists.

Assessment

Caregivers assess patients who suffer mood disorders for a potential danger to themselves and to others and the need for hospitalization. Patients who are experiencing a manic episode may not eat or sleep for several days, may harm themselves or others because of their poor impulse control, and may become exhausted to the point of death. Thus, emergency assessment includes:

  • Medical status, by means of a physical examination to determine if mania is primary or secondary to a medical condition or to a substance disorder
  • Behaviors that indicate a psychiatric condition, such as bipolar disorder and schizoaffective disorder, using diagnostic criteria identified in ICD-10 and DSM-5
  • Level of understanding by patients and their family about the disorder, prescribed medications, support groups, and medical care
Diagnosis

Medical Diagnoses. DSM-5 identifies mania as a symptom in all of the following medical diagnoses:

  • Bipolar I disorder
  • Bipolar II disorder
  • Cyclothymic disorder
  • Substance/medication-induced bipolar and related disorder
  • Bipolar and related disorder due to another medical condition
  • Other specified bipolar and related disorder
  • Unspecified bipolar and related disorder

Caregiver/Nursing Diagnoses. Because patients exhibit constant and excessive motor activity, poor judgment, difficulty evaluating reality, probable dehydration, and lack of impulse control, the following NANDA diagnoses may be appropriate:

  • Risk for other-directed violence
  • Risk for self-directed violence
  • Risk for suicide
  • Ineffective coping
  • Defensive coping
  • Disturbed thought processes (delusions)
  • Disturbed sensory perception (hallucinations)
  • Impaired verbal communication
  • Impaired social interaction
  • Imbalanced nutrition
  • Deficient fluid volume
  • Self-care deficit
  • Disturbed sleep pattern
Planning

The goal of care for patients in an acute manic episode is to prevent injury and instill hope for the future. Therefore, outcome criteria for the patient are as follows:

  • Be well hydrated within 24 hours, as evidenced by good skin turgor and normal urinary output and concentration
  • Maintain or obtain stable cardiac status as evidenced by stable vital signs within normal limits
  • Maintain or obtain tissue integrity as evidenced by absence of infection or wounds
  • Get sufficient sleep and rest as evidenced by 4–6 hours of sleep at night
  • Demonstrate self-control with the help of staff or medications as evidenced by absence of harm to others
  • Make no attempt at self harm with the help of staff or medications as evidenced by safety checks during acute mania
    (Varcarolis, 2013)
Intervention

To meet outcome criteria and ensure safety, medical stabilization, and external control, people in crisis manifesting manic symptoms need hospitalization. If they are not cooperative and are a danger to themselves or others, emergency involuntary commitment may be necessary (see “Legal Issues” above). To gain their cooperation and communicate more effectively, clinicians:

  • Use short and concise statements and explanations
  • Use a calm but firm approach
  • Remain neutral, avoiding power struggles
  • Coordinate care with other staff members to avoid manipulation

Medications prescribed for acute manic episodes include:

  • Mood stabilizers and anticonvulsants: lithium and valproic acid
  • Atypical antipsychotics: olanzapine, risperidone, quetiapine
  • Typical antipsychotics: chlorpromazine, haloperidol
  • Benzodiazepines (anxiolytics): diazepam, lorazepam, clonazepam

The most successful treatment is with a combination of medications such as lithium and quetiapine. Lithium and valproic acid are the drugs of choice for maintenance therapy for persons with bipolar disorders (Preston et al., 2013).

Evaluation

The mental healthcare team achieves treatment goals when outcome criteria are met, the person is safe, and families are informed of resources for ongoing assistance. If these goals are not met, the team needs to begin the steps of the medical/nursing process over again, adjusting the plan to make changes for the future.

DEPRESSION AND SUICIDE

Depression is a “dis-ease” in a true sense of the word. Those who experience depression feel sad, joyless, and empty. They believe that life is not worth living. According to the World Health Organization (2012), depression is the leading cause of disability worldwide. Depression is twice as common in women as it is in men and is not related to education, income, ethnicity, or marital status. Many of those who suffer from the disorder also suffer from anxiety. Typical symptoms of major depression are:

  • Depressed mood most of the time
  • Lack of interest or pleasure in almost everything, most of the time
  • Significant weight gain or weight loss when not dieting
  • Insomnia or hypersomnia
  • Psychomotor agitation or retardation
  • Fatigue and loss of energy
  • Feelings of worthlessness and inappropriate guilt
  • Diminished concentration
  • Indecisiveness
  • Recurrent thoughts of suicide and death, but without a specific plan
  • Symptoms that are not attributable to the effects of a substance or to another medical condition
  • Morbid preoccupation with worthlessness and guilt
  • Symptoms are not better accounted for by the normal grieving process
  • Clinically significant distress or impairment in social, occupation, and other areas of functioning
    (APA, 2013)

Adolescents with depression have most of those same symptoms, with the addition of the following:

  • Anger or irritability, rather than sadness, as the predominant mood
  • Frequent unexplained aches and pains, such as stomachaches or headaches
  • Extreme sensitivity to criticism
  • Unlike adults who isolate from everyone, withdrawal from some, but not all, people
    (Smith et al., 2014)

Sufferers of persistent depressive disorder (dysthymia) have less severe symptoms than those who suffer major depression. Nonetheless, the symptoms occur over two or more years and cause significant distress in every area of life (APA, 2013).

Assessment

Guidelines for assessing depressed patients include the following:

  • Evaluate the person’s risk of harm to self or others.
  • Perform a thorough medical and neurologic examination to determine if depression is secondary to another disorder or to drugs.
  • Evaluate whether the person is psychotic, has taken drugs or alcohol, has medical conditions, or has a history of psychiatric syndromes.
  • Ask if the person has a history of depression.
  • Assess support systems, family, significant others, and the need for referral.

In crisis situations, there may not be time to complete an assessment according to these guidelines. Assessing a person in these circumstances requires observing for:

  • Verbal clues
    • Expressing strong feelings of hopelessness
    • Making covert statements such as “Things will never work out”
    • Making overt statements such as “I wish I were dead”
  • Delusional thinking
    • “God wants me dead.”
  • Cognitive function
    • Slowed speech and understanding
    • Difficulty concentrating or making up one’s mind
  • Behavioral clues
    • Psychomotor agitation
    • Giving away prized possessions
    • Acting recklessly
  • Affect
    • Flat, without expression
    • Exhibiting a sudden and unexpected improvement in affect after being depressed or withdrawn
      (Varcarolis, 2013)

The risk for suicide in people with major depressive disorder is higher than that of the general public. It is the tenth leading cause of death in the United States and third leading cause of death for ages 15–24 years (NAMI, 2013a).

Guidelines for assessing suicidal patients include the following:

  • Assess risk factors, including history of suicide, degree of hopelessness and helplessness, and lethality of plan (gun, poison, hanging).
  • If there is a history of suicide attempts, assess intent, lethality, and injury.
  • Determine whether the patient’s age, medical condition, or psychiatric diagnosis puts the person at higher risk.
  • Note whether a patient’s mood changes suddenly from sadness to a happier state. Often a decision to commit suicide gives a feeling of relief and calm.
  • If the patient is to be managed on an outpatient basis, assess social supports and knowledge of potential suicide signs.
ASSESSMENT QUESTIONS FOR THOSE AT RISK OF SUICIDE
  • Are you feeling hopeless about the present or future?
  • Have you had thoughts about taking your life?
  • When did you have these thoughts?
  • Have you ever attempted suicide?
  • Do you have a plan to take your life?
  • Have you ever had a suicide attempt?

Source: U.S. Dept. of Veterans Affairs, 2011.

CASE

SHEILA
Sheila came to the community counseling center for help. She told Mary, the counselor, that the man she had been dating had left her and returned to Mexico to marry a girl from his home village. Sheila burst into tears: “I don’t think I can live without him.”

Mary listened attentively and asked, “Have you been thinking about not living? Sheila nodded and whispered, “Yes,” and began to sob. The counselor said, “And what have you thought about doing?” After a long pause, Sheila said, “I just want to go to sleep and never wake up.”

Mary hypothesized that Sheila did not have a specific plan to end her life but was at risk of overdosing on alcohol or drugs, the most common means women use to commit suicide. She told Sheila to refrain from taking alcohol in any form until she felt better; asked if Sheila had a friend or relative who could stay with her for a few days, just to be there for her; gave Sheila her card and the crisis hotline number to call if she felt like harming herself; and referred Sheila to a support group of others who had suffered loss.
(continues)

Diagnosis

Medical Diagnoses. The APA (2013) recognizes eight types of depressive disorders that do not have manic features. The eight types of depressive disorders are:

  • Disruptive mood dysregulation disorder in children
  • Major depressive disorder
  • Persistent depressive disorder (dysthymia)
  • Premenstrual dysphoric disorder
  • Substance/medication-induced depressive disorder
  • Depressive disorder due to another medical condition
  • Other specified depressive disorder
  • Unspecified depressive disorder

Caregiver/Nursing Diagnoses. Because depressed individuals have many needs and may suffer from other psychological and physical disorders, numerous nursing diagnoses may be appropriate. However, risk for suicide is a constant. Other diagnoses may be:

  • Hopelessness
  • Ineffective coping
  • Social isolation
  • Spiritual distress
  • Self-care deficit
  • Powerlessness
  • Chronic low self-esteem
  • Imbalanced nutrition
  • Sexual dysfunction
    (NANDA, 2014)
Planning

The planning of care for depressed individuals in crisis is based on the circumstances that bring them to emergency care. For example, the outcome criteria for the nursing diagnosis of risk for suicide might be: Patient will 1) value and nurture himself/herself and 2) refrain from hurting himself/herself.

When depressed persons are judged to be a danger to themselves or others, clinicians must consider the need for emergency hospitalization (see also “Legal Issues” above).

Intervention

There are three phases in the treatment and recovery of persons with major depression:

  • Acute phase (6–12 weeks). The goal of treatment is to reduce depressive symptoms and restore psychosocial and work function. Hospitalization during this phase may be necessary.
  • Continuation phase (4–9 months). The goal of treatment is to prevent relapse with pharmacotherapy, education, and depression-specific psychotherapy.
  • Maintenance phase (1 or more years). The goal of treatment is to prevent further episodes of depression.

Antidepressant interventions are classified as first line (preferred) and second line (back-up, used when a preferred intervention cannot be used).

First-line interventions include:

  • Selective serotonin reuptake inhibitor (SSRI) drugs
  • Serotonin/norepinephrine reuptake inhibitor (SNRI) drugs
  • Atypical, newer antidepressant drugs
  • Cyclic antidepressants, such as tricyclic drugs

Second-line interventions include:

  • Monoamine oxidase inhibitor (MAOI) drugs
  • Electroconvulsive therapy (ECT)

For children and adolescents, SSRI drugs are the preferred pharmacological treatment for depressive disorders (Halverson, 2014). The FDA warns, however, that antidepressants can increase the risk of suicidal thoughts and behavior in children, adolescents, and young adults ages 18–24 during initial treatment (FDA, 2013).

The most common psychosocial interventions for depression include:

  • Psychotherapy
  • Cognitive-behavioral therapy
  • Interpersonal therapy
  • Problem-solving therapy
  • Supportive therapy
  • Psychosocial intervention
  • Bereavement groups
  • Family counseling
  • Participation in social events
  • Psychoeducation
  • Exercise

Nursing interventions for severely depressed patients include providing food and fluids, suicide precautions, personal hygiene, supportive communication, and psychotherapy using cognitive-behavioral, psychodynamic, and interpersonal approaches. If a person is hospitalized because they are deemed at risk for suicide, suicide risk precautions are implemented.

Suicide risk precautions include:

  • Search patient and belongings for harmful objects.
  • Make sure visitors do not leave potentially harmful objects or gifts in patient’s room.
  • Keep electric cords to minimal length.
  • Hang-proof and jump-proof bathrooms.
  • Provide plastic eating utensils.
  • Do not assign patient to a private room.
  • Lock utility rooms, kitchens, stairwells, windows, and offices.
  • Conduct one-to-one nursing observations and interaction 24 hours a day.

Occupational therapists most often work in hospital settings and provide interventions to help patients with depression examine how to balance leisure, work, and relationships so they are able to meet the responsibilities of the roles that are meaningful to them.

Evaluation

Treatment of depressed persons is considered successful if, after treatment, they are able to think clearly, behave appropriately, and express greater hope and self-esteem.

CASE

SHEILA   (continued)
Eight days following her visit to the community counseling center, Sheila was taken to the emergency department by a coworker, Liz, who stopped by to see why Sheila had been absent from work for the past week. Liz said that she found Sheila lying on the sofa, tearful, and saying she wanted to die.

When Sheila arrived at the hospital emergency department, she was interviewed by a nurse, who obtained her history. Sheila indicated she had not attended the recommended support group and had forgotten about the hotline number the counselor had given her. The nurse noted that Sheila had a very flat affect, her speech and movements were slow, and she had problems understanding some of the questions asked. She was unkempt and admitted that she had not been eating or drinking much over the past week. She denied using any medications or alcohol during this time. Sheila told the nurse, “I don’t want to live anymore. I’m so tired.”

The nurse asked Sheila if she was thinking of harming herself, and Sheila replied that she was. She admitted that she was planning to lay in a tub of hot water and slit her wrists, but “I haven’t gotten the energy to do it so far.” The nurse assigned an ER tech to stay with Sheila until the emergency department physician could see her.

The ED physician interviewed Sheila, performed physical and neurological examinations to rule out medical conditions, and recommended she be hospitalized for treatment of major depression with the need for suicide precautions. Sheila agreed to voluntarily enter the hospital.

Nursing diagnoses for Sheila on admission included:

  • Risk for suicide, related to depressed mood, as evidenced by statements of patient
  • Hopelessness, related to depressed mood, as evidenced by statements of patient
  • Self-care deficit, related to depressed mood, as evidenced by statements of patient and patient appearance
  • Imbalanced fluids and nutrition, related to depressed mood, as evidenced by statements of patient

Her care plan included:

  • Appropriate medications
  • Serial laboratory tests to accurately determine her fluid and electrolyte status
  • A nutritional assessment leading to a meal plan including preferred foods, small frequent meals and snacks, and documentation of food intake
  • Individual and group therapy
  • Assistance with and reinforcement of personal care practices
  • Suicide precautions
  • Early start of discharge planning to allow adequate time to develop an outpatient support plan

Anxiety-Related Crises

Anxiety is a feeling of apprehension, uneasiness, uncertainty, or dread resulting from real or imagined threats whose actual source is unknown or unrecognized. Unlike fear, which is a reaction to a specific danger, anxiety affects us at a deeper level. Anxiety “invades the central core of the personality. It erodes the individual’s feeling of self-esteem and personal worth” (Varcarolis, 2013). Anxiety disorders “develop from a complex set of risk factors, including genetic, brain chemistry, personality, and life events” (ADAA, 2011).

Normal anxiety is a natural response to the demands of life. It provides energy to achieve goals and carry out the activities of daily living. It energizes people and helps them manage the usual demands of life, including such things as arriving for work on time, fulfilling commitments, and pursuing worthwhile goals.

Acute anxiety is a sudden, intense feeling of fear caused by an imminent threat to one’s sense of security. It is the feeling new graduates may experience as they sit for a licensing examination, singers may experience as they walk to center-stage to audition for a leading role, and patients may feel as they climb into a dentist’s chair. Like other emotions, the intensity of anxiety varies with the situation, ranging from mild to panic.

Mild anxiety can improve performance, sharpen focus, increase attention, and help people grasp information. Even so, as anxiety increases, the perceptual field narrows and people are less able to see, hear, and grasp information. Their ability to think lessens, and their bodies respond with profuse perspiration and rapid pulse and respirations.

As anxiety intensifies to severe, people feel dazed and confused, unable to solve problems or focus on more than one thing at a time. They may feel dizzy and experience a sense of impending doom.

Panic is the most extreme level of anxiety. Persons experiencing panic have a sudden, overwhelming fear, with or without cause, which produces hysterical or irrational behavior. They may behave automatically, lose touch with reality, and experience false sensory perceptions.

Chronic anxiety is a long-lasting, fear-based condition that persists over many years. Children with this condition appear apprehensive and high-strung. Adults with the disorder experience unrelenting angst and often develop physical and emotional disorders such as insomnia or chronic fatigue syndrome.

Self-harm is the most severe complication of acute anxiety and panic. The majority of persons experiencing acute anxiety or panic do not really want to die, but they genuinely want to break free from suffering. They may see suicide as a way to escape from oneself, rather than from daily life.

ASSESSMENT

As with everyone who comes to an emergency facility for help, a physical examination and at least a modified mental status examination should be performed. Although all anxiety disorders are fear-based, the symptoms they display differ greatly.

Assessment guidelines for anxious individuals in crisis include the following:

  • Assess for potential self-harm, because people with high anxiety are more likely to become desperate and suicidal.
  • Conduct a physical and neurologic examination to determine whether the anxiety is the cause or the result of substance use or a medical or psychiatric disorder.
  • Assess for psychosocial and environmental problems that may be affecting the person, such as stressful relationships, recent loss of job, and economic pressures.
  • Consider cultural differences that may affect the way people exhibit anxiety.
ANXIETY VERSUS CARDIAC CONDITIONS

Persons experiencing acute anxiety or panic may appear in the emergency department with symptoms that closely resemble cardiac conditions, including:

  • Palpitations, heart pounding
  • Diaphoresis
  • Shakiness, unsteadiness
  • Sensation of choking
  • Chest pain
  • Nausea
  • Dizziness
  • Feeling of impending doom

Evaluation must ensure that there is no underlying medical condition to explain these symptoms.

DIAGNOSIS
Medical Diagnoses

DSM-5 identifies anxiety as a symptom in all of the following medical diagnoses:

Anxiety Disorders

  • Separation anxiety disorder
  • Selective mutism
  • Specific phobia
  • Social anxiety disorder (social phobia)
  • Panic disorder
  • Panic attack (specifier)
  • Agoraphobia
  • Generalized anxiety disorder
  • Substance/medication-induced anxiety disorder
  • Anxiety disorder due to another medical condition
  • Other specific anxiety disorder
  • Unspecified disorder

Obsessive-Compulsive and Related Disorders

  • Obsessive-compulsive disorder
  • Body dysmorphic disorder
  • Hoarding disorder
  • Trichotillomania (hair-pulling disorder)
  • Excoriation (skin-picking) disorder
  • Substance/medication-induced obsessive-compulsive and related disorder
  • Obsessive-compulsive and related disorder due to another medical condition
  • Other specified obsessive-compulsive and related disorder
  • Unspecified obsessive-compulsive and related disorder

Trauma- and Stressor-Related Disorders

  • Reactive and attachment disorder
  • Disinhibited social engagement disorder
  • Posttraumatic stress disorder
  • Acute stress disorder
  • Adjustment disorders
  • Other specified trauma- and stressor-related disorder
  • Unspecified trauma- and stressor-related disorder
Caregiver/Nursing Diagnoses

Although many anxiety disorders described by the APA differ markedly from one another, certain NANDA diagnoses may appear in all of the anxiety conditions. For example:

  • Ineffective coping
  • Fatigue
  • Anxiety
  • Disturbed sleep pattern
  • Chronic low self-esteem
  • Hopelessness
  • Self-care deficit
  • Powerlessness
    (NANDA, 2014)
PLANNING

Patients in crisis with anxiety disorders usually do not require hospitalization. However, clinicians encounter these people in homes, clinics, and acute and skilled nursing facilities. Healthcare professionals encourage people with symptoms of anxiety to participate in planning their treatment. For example, if the nursing diagnosis is “self-control of anxiety,” the outcome criteria might be “patient will monitor the intensity of anxiety and use relaxation and regular exercise to decrease anxiety.”

INTERVENTION
Medical Interventions

Both psychotherapy and pharmacotherapy are used to treat anxiety disorders.

Psychotherapy of various types has proved useful, especially cognitive therapy in which patients learn to recognize behaviors and take action to change them. Therapists teach cognitive restructuring or reframing (replacing irrational negative statements and beliefs with positive statements), relaxation to help reduce anxiety, systemic desensitization to overcome phobias, and thought-stopping to reduce obsessions.

Pharmacotherapy includes:

  • Antidepressants: selective serotonin reuptake inhibitors
  • Antiseizure medications that replace the use of anxiolytics
  • Anxiolytics (benzodiazepines) only for short-term treatment of acute anxiety
    (Bystritsky et al., 2013)
Caregiver Interventions

Teaching interventions include:

  • Medication management
  • Behavioral therapy techniques to reduce anxiety
  • Relaxation exercises
  • Cognitive reframing (changing negative thoughts to positive ones)
  • Lifestyle personal care, such as nutrition, exercise, and sleep

Referral interventions include:

  • Community resources, such as an obsessive-compulsive disorder (OCD) support group
  • Personal psychotherapy to gain self-knowledge
EVALUATION

The treatment of anxiety disorders is considered successful if symptoms of anxiety in patients are reduced and they are able to live a happier, less fearful life.

Anger-Generated Crises

Anger-generated crises that involve assault and battery are well known to clinicians in emergency departments and on crisis hotlines. In recent times, violence has become a serious public health issue, affecting individuals, families, entire communities, and healthcare providers. For this reason it is essential that clinicians understand anger and aggression, recognize its signs and symptoms, plan appropriate interventions, and evaluate those interventions. The goal of such care is to ensure safety for everyone concerned.

In his classic study of human emotions, Robert Plutchik (1991) identified anger as one of the primary emotions, an inborn response to the frustration of desire. The purpose of anger is to remove whatever is blocking a desire or need.

Aggression is the physical or verbal action people take to overcome obstacles that block their desires. As with other emotions, a stimulus event evokes a feeling and the feeling motivates a response. The decision to express anger aggressively depends on many factors, including cultural influences, genetic predisposition, low serotonin levels, and brain abnormalities, especially in the limbic system.

As with other crises, anger and aggression are mediated by three balancing factors: 1) the perception of an event, 2) the availability of a support system, and 3) coping mechanisms. On feeling angry, some people use aggression as their primary coping mechanism. Such a response is common in disorders like substance abuse, mania, antisocial personality, and cognitive deficit.

ASSESSMENT

Because of the danger to themselves and others in aggressive patients, it is important for clinicians to recognize common predictors of violence. These include:

  • A history of recent acts of violence
  • Intoxication with alcohol or drugs
  • Possession of a potential weapon
  • Situations that lead to violence: overcrowding, arbitrary rules, apparent favoritism
  • Signs and symptoms of violence: hyperactivity, restlessness, clenched jaw, fierce facial expression, increasing tension, mumbling to self, clenched fist, profanity, loud voice, soft voice, argumentative, avoidance of eye contact, and intense eye contact

Guidelines caregivers can use to assess anger and violence in patients include:

  • Hyperactive, irritable, impulsive behavior
  • Risk factors: wish or intent, plan to harm, means to carry out plan
  • Demographic factors: male aged 14–24, low socioeconomic status, lack of support system, limited coping skills, frequent use of intimidation to meet needs
  • Intolerance of limit-setting by authorities
AGGRESSION AND MEDICAL CONDITIONS

Assessment must include ruling out medical conditions that can lead to aggression, such as:

  • Head injury
  • Substance use and intoxication
  • Underlying mental illness
  • Metabolic disturbances (hypoglycemia)
  • Hypoxia
  • Infection (sepsis, encephalitis, meningitis)
  • Seizures
  • Vascular stroke
  • Subarachnoid hemorrhage

Guidelines caregivers can use to assess their own anger:

  • Personal triggers, such as physical characteristics of patients or situations
  • Sense of personal competence in a situation of potential danger
  • Ability to ask for assistance
DIAGNOSIS
Medical Diagnoses

DSM-5 identifies loss of self-control of emotions and behaviors leading to aggressive acts in all of the following medical diagnoses:

Disruptive, Impulse-Control and Conduct Disorders

  • Oppositional defiant disorder
  • Intermittent explosive disorder
  • Conduct disorder
  • Antisocial personality disorder
  • Pyromania
  • Kleptomania
  • Other specified disruptive, impulse-control, and conduct disorder
  • Unspecified disruptive, impulse-control, and conduct disorder
Caregiver/Nursing Diagnoses

Diagnoses for patients who display aggressive behavior include

  • Risk for self-directed violence
  • Risk for other-directed violence
  • Aggression self-control
  • Ineffective coping
    (NANDA, 2014)
PLANNING

Without question, de-escalation of anger and prevention of violence is the primary outcome criteria for interventions with angry patients. Such planning takes into account resource availability and situations in which violence may occur, is occurring, or has occurred.

In planning interventions, it is important to consider the stages of violence. These are the:

  • Pre-assaultive stage: tension increases and person becomes increasingly agitated
  • Assaultive stage: person loses control and becomes violent
  • Post-assaultive stage: person is calm and incident is reviewed
INTERVENTION

Pre-assaultive stage interventions focus on de-escalation of anger. Clinicians follow these practices:

  1. Assess patients and their situation and reassure them of your concern and expectation that they will stay in control of themselves.
  2. Place patient in a quiet and secure area and inform staff of what is happening. When possible, interact with patients in a quiet place that is in plain view of other caregivers.
  3. Never turn your back on or walk ahead of the individual.
  4. Ensure you have a safe escape route.
  5. Demonstrate respect for personal space, thus decreasing the threat. If the person is sitting, sit. If the person is standing, stand.
  6. Remain calm and nonconfrontational in words and actions.
  7. Interact with patients respectfully in a slow, low, and nonthreatening voice.
  8. Verbalize options. Encourage patients to assume responsibility for the choices they make and acknowledge the difficulties they have in making choices.
  9. Use time wisely. Give adequate time for depressed or suicidal patients to consider options. Set limits with manipulative patients.
  10. Provide continuous observation and record behavior changes in patient notes.
  11. Secure personal safety:
    • Avoid dangling jewelry.
    • Alert other caregivers.
    • Eliminate hazards caused by furniture or other objects.
    • Stand to the side of patients, not directly in front of them in a threatening way.
    • If patients begin to escalate, provide feedback, assure them that they will be safe.
    • Avoid confrontation and “show of force” by security guards.
    • Wear an alarm if available.
  12. Use LEAPS:
    • Listen
    • Empathize
    • Ask questions
    • Paraphrase
    • Summarize
      (Butler, 2011)

Assaultive stage interventions include application of restraints, administration of medication, and seclusion. These measures should be used only after alternative interventions have been tried (verbal intervention, decreased sensory stimulation). Restraints, medications, and seclusion are used only when patients present a clear and present danger to themselves or others and have been legally detained for involuntary treatment, or when they request seclusion.

When physical restraint is necessary, a team of at least five staff members trained in the techniques of management of assaultive behavior (MAB) subdues the patient. Guidelines for MAB allow for one member (the leader) to speak to the patient and instruct other members of the team. Only the leader communicates with the patient. When the patient is restrained, caregivers administer physician-prescribed sedatives and the patient is placed in a quiet, secluded area.

MAB certification requires that staff receive training and demonstrate current competency in all aspects of dealing with behavioral emergencies, including seclusion and restraint. All healthcare workers should be familiar with the techniques of MAB and be prepared to become trained as a member of a team if that should be necessary. MAB training courses are available through the Internet or provided by healthcare facilities.

Post-assaultive stage interventions begin when the patient has become calm. These measures include establishing rapport, engaging in a therapeutic discussion of stressors, and teaching alternative coping behavior. When it is available, patients are referred to longer-term counseling and anger management group therapy.

EVALUATION

After an assault by a patient, clinicians need time to regroup and regain a sense of personal safety, control, and security. It is important to take time to debrief and to discuss what happened, what went right, what went wrong, and what they will do in future situations. All incidents of violence are reported and documented according to agency protocol.

CASE

Curt and his nine-year-old son were tossing a football back and forth when the son fell backward onto a sharp rock, which cut a deep gash in his scalp. Curt rushed the boy to the emergency department (ED) at the local hospital and stood by anxiously as the triage nurse examined his injury. She said the doctor would come to see the boy soon and left, closing the cubicle curtain behind her.

Curt waited as minutes went by. Getting anxious, he went to the curtain, pushed it aside, and gazed out at the busy unit. Workers rushed this way and that, but no one came to see his son. Curt went to the desk and asked the clerk when the doctor would come to see his son. The clerk said the doctor was seeing other patients and would be there shortly. Curt returned to his son’s cubicle and waited, leaving the curtain open. After some time, Curt went back to the clerk. “How much longer is it going to be?” The clerk barely looked up and said, “It won’t be much longer.”

More minutes crawled by, and Curt became more and more agitated. His perception of the event was that this was a life-and-death situation. He had no support system except the ED staff, and they were too busy to help. His usual coping mechanism was action—often aggressive—not passivity. His son groaned in pain, and Curt became angrier by the minute. He set his jaw and went to the clerk, clenched his fist, pounded on the counter, and shouted, “You said the doctor would come and take care of my son! That was ages ago! Where is he? Where’s the f**king doctor?!”

A nurse overhearing this exchange immediately approached Curt and quietly and calmly asked if she could be of assistance. She listened to Curt, asking open-ended questions and acknowledging his anger. She empathized with his concern and frustration, paraphrasing Curt’s frustration about how hard it is to have a child hurting and not be able to help him right away. She guided Curt back to the cubicle, while asking him what happened to his son. She carefully examined the boy and offered reassurance to Curt that he was not in imminent danger. She spoke to the boy, who told her his head hurt but that he was “okay.” By this time, Curt’s anger had subsided and he was speaking calmly. The nurse summarized the event and acknowledged that emergency rooms are busy places in which someone else might need attention sooner than his son.

At this point, the nurse told Curt she would return to check on them both in a few minutes. Shortly thereafter the physician entered, apologized for the delay, closed the wound, and discussed the boy’s care with Curt.

The nurse’s use of the mnemonic LEAPS was effective in reducing Curt’s anger and avoided an incidence of violence in the ED.

Substance Use Emergencies

We are a drug-oriented society. We use drugs to reduce pain, lessen anxiety, induce sleep, increase energy, restore health, create feelings of euphoria, and enhance alertness. At least two thirds of the U.S. adult population consume alcohol regularly, and more than half of those with mental illnesses use or have used mind-altering substances (Smith-Dijulio, 2011).

Because of the widespread use of substances, clinicians in emergency departments and on crisis hotlines must assess, diagnose, plan, intervene, and evaluate not only physical but also psychiatric disorders, including substance use disorders.

SUBSTANCE USE–RELATED TERMINOLOGY
Term Description
Physical dependence Physiologic adaptation to a drug, confirmed by the appearance of signs and symptoms that occur if the drug is withheld
Psychological dependence (addiction) Compulsive and maladaptive dependence on various substances, such as methamphetamine, cocaine, and tobacco
Polysubstance abuse The simultaneous use of many legal and illegal mind-altering, addictive substances
Substance abuse The repeated use of mind-altering substances, resulting in a failure to meet obligations at home, work, or school
Substance use The ingestion of a chemically active agent, such as legally prescribed medication, alcohol, tobacco, or illegally obtained drug
Tolerance A condition in which people take progressively higher doses of a substance to achieve a desired effect; withdrawal symptoms appear when individuals stop taking the substance
Withdrawal syndrome A group of symptoms that occur when a drug is discontinued or when its effect is counteracted by a specific antagonist
ASSESSMENT

People in crisis often resort to mind-altering substances to dull their senses, lift their spirits, or in some way relieve their discomfort. Usually, they appear in emergency departments because they have been brought there by someone else for some other reason than abuse of a substance. In any case, clinicians routinely assess patients for substance use, especially when they exhibit bizarre behavior typical of mind-altering substances.

Specifically, caregivers inquire about:

  • History of substance abuse: What substance have you taken, how long ago, what symptoms? Have you had blackouts, overdoses, complications, recent accidents, head trauma? Do you have a family history of substance abuse? Have you been treated previously for substance abuse?
  • Medical history: What medical disorders do you have? What medicines do you take?
  • Psychiatric history: Have you been diagnosed with any psychiatric disorder? Have you undergone treatment for a specific disorder? Do you have a history of physical or sexual abuse or family violence?
  • Suicide attempt history: Have you ever thought about ending your life or hurting yourself? Have you tried to end your life? When, and under what circumstances? Are you currently having suicidal thoughts?
  • Psychosocial issues: Do you have a family or friends? What do you do for a living? What do you do to feel happy? Have you had a crisis in your life recently? How has substance use affected your ability to meet usual role expectations? Do you have a police or criminal record or legal problems related to substance use?

When people do not know or will not tell caregivers what substance they have taken, clinicians look for typical signs of stimulants, depressants, inhalants, hallucinogens, intoxicants, opiates, and other drugs. Signs and symptoms of the most common types of drugs are described in the following table.

SIGNS AND SYMPTOMS OF SUBSTANCE USE
Type of Intoxication Examples of Substances Signs and Symptoms
Source: Webb et al., 2000.
Central nervous system (CNS) stimulants Cocaine, crack, amphetamines Tachycardia, dilated pupils, elevated blood pressure, nausea and vomiting, insomnia, belligerence, grandiosity, impaired judgment, impaired social and occupational functioning, euphoria, increased energy, severe to panic levels of anxiety, paranoia with delusions, hallucinations (visual, auditory, and tactile)
Opiates Opium, heroin, meperidine, morphine, codeine, fentanyl, methadone, hydromorphone Constricted pupils; decreased respiration; drowsiness; decreased blood pressure; slurred speech; psychomotor retardation; initial euphoria followed by impaired judgment, attention, and memory
Hallucinogens Lysergic acid diethylamide (LSD), mescaline, psilocybin Pupil dilation; tachycardia; diaphoresis; palpitations; tremors; elevated temperature, pulse, and respirations
Phencyclidine piperidine (PCP) n/a Vertical or horizontal nystagmus; elevated blood pressure, pulse, temperature; ataxia; muscle rigidity; seizure; blank stare; chronic jerking; agitation; repetitive movements; belligerence; impulsiveness; impaired judgment and functioning
Inhalants Volatile solvents that vaporize at room temperature, such as model airplane glue, nail polish, rubber cement Excitement, then drowsiness, agitation, and lack of self-control
Nitrates Room deodorizers Enhanced sexual pleasure, euphoria
Anesthetics Nitrous oxide Giggling, acting silly
CNS depressants Alcohol, benzodiazepines, barbiturates Slurred speech; unsteady gait; drowsiness; decreased blood pressure; impaired judgment, memory, and occupational function; irritability; aggressiveness
Alcohol withdrawal n/a Irritability, hyper-alertness, jerky movements (“shakes”), usually developing within a few hours after the last drink, peaking sometime between 24–48 hours, and then gradually disappearing
Complicated alcohol withdrawal with delirium tremens (DTs) n/a Disorientation, agitation, tremors, anxiety, visual and tactile hallucinations, paranoid delusions, fluctuating levels of consciousness, hypertension, tachycardia, diaphoresis, fever (100 °F–103 °F), usually occurring 48–72 hours after the last drink; death, if untreated
DIAGNOSIS
Medical Diagnoses

In the DSM-5, the APA (2013) lists a large number of substance-related disorders: 6 alcohol, 4 caffeine, 6 cannabis, 9 hallucinogen, 4 inhalant, 5 opioid, 5 sedative/hypnotic/anxiolytic, 5 stimulant, 4 tobacco, and 6 other substance disorders.

Studies have suggested that almost one third of persons with a mental illness and about one half of persons with severe mental illness also experience substance abuse. Likewise, more than one third of all alcohol abusers and one half of all drug abusers have mental illness. When more than one disorder presents, patients are described as suffering from dual diagnoses or co-morbid conditions (NAMI, 2013b).

Caregiver/Nursing Diagnoses

Many caregiver/nursing diagnoses are appropriate to substance abusers, indicating just how dysfunctional their lives may be. Some common diagnoses include:

  • Disturbed sleep pattern
  • Ineffective health maintenance
  • Imbalanced nutrition
  • Deficient fluid volume
  • Risk for electrolyte imbalance
  • Ineffective impulse control
  • Impaired environmental interpretation
  • Disturbed thought processes
  • Hopelessness
  • Nonadherence to healthcare regimen
  • Anxiety
  • Self-care deficit
  • Ineffective coping
  • Dysfunctional family processes
  • Risk for suicide or violence to others
    (NANDA, 2014)
PLANNING

The goal of emergency care of substance-using individuals is to provide immediate, life-saving measures, identify the drug or drugs the individual has taken, and give supportive emotional care. The goal of long-term care is to encourage abstinence from substance abuse, meet physical and emotional needs, restore self-respect, and assist patients to establish a support system.

INTERVENTIONS

In the emergency department, interventions for a substance-abusing individual include identifying the specific drug or drugs he or she has taken, giving immediate life-saving care, providing food and fluid, and transporting the patient to inpatient care or referring to outpatient care.

Sadly, many substance abusers are homeless and friendless and afflicted with serious co-morbid conditions. Some communities provide shelter and drug treatment facilities, but persons must agree to the rules and regulations of such facilities. Many refuse, preferring to live on the street until another crisis sends them back to the emergency department.

EVALUATION

Clinicians in emergency departments evaluate how well they have met the immediate needs of patients, though they may find it difficult to empathize with those who return over and over again. Nevertheless, it is important to determine the success of interventions by evaluating whether the principles of ethics were involved in providing care to each individual patient.

CASE

The owner of a small downtown café called the police. “One of those homeless drunks is out cold on my doorstep. Yep, I know the man … name’s Ken. He hangs around all the time, bothering customers and begging for leftovers … sells cheap newspapers and uses the money for booze.”

The owner hung up and went back to the entrance of his café. Ken had vomited all over himself. When the owner nudged him with his foot, Ken groaned but didn’t move. When the police arrived, they called an ambulance.

The emergency department (ED) staff knew Ken well. He had a long history of coming to the ED, responding to care, being discharged, and then repeating the cycle. This time the staff was determined to do things differently. They gave emergency care, admitted Ken to a medical unit, and referred him to social services. When Ken was sober and his condition stable, social workers devised a long-term plan that included housing and alcohol rehabilitation.

Major Mental Illness Crises

When precipitating events occur in the lives of people with major mental illnesses, they may become so distressed that they seek help in an emergency department or by means of a crisis hotline. This is not surprising, since the coping skills and support systems of these individuals often are limited. Clinicians need to assess the signs and symptoms of such individuals, diagnose their disorders, plan their care, intervene, make appropriate referrals, and evaluate the effectiveness of interventions. Some of the more common major mental illnesses seen in emergency departments are:

  • Delirium (acute confusional state): Individual experiences a disturbance of consciousness and change in ability to think that develops within a few hours or days. Delirium is a syndrome and is always secondary to another condition, such as a general medical condition, medications, or substance use.
  • Dissociative disorders: Individual experiences a disturbance of memory (amnesia), depersonalization (disconnected or detached), or confusion about personal identity. A dissociative identity disorder is present when the individual exhibits two or more distinct personalities.
  • Mania: Individual exhibits a period of expansive or irritable mood, lasting at least a week. The person is talkative, grandiose, sleeps very little and experiences a flight of ideas, psychomotor agitation, distractibility and excessive involvement in pleasurable activities that have a high potential for painful consequences.
  • Panic disorder: Individual experiences intense fear that develops suddenly, reaching a peak within minutes, with rapid heart rate, palpitations, sweating, tremor, shortness of breath, feelings of being smothered or choked, fear of going crazy or dying, and dizziness. Symptoms gradually subside.
  • Posttraumatic stress disorder: Individual repeatedly experiences memories or dreams of an overwhelming traumatic event, causing intense fear, helplessness, horror, dissociative reactions, and avoidance of stimuli associated with the trauma.
  • Schizophrenia: Individual may experience delusions (false ideas), hallucinations (false perceptions),disorganized thinking, grossly disorganized or abnormal motor behavior, and negative symptoms such as flattened affect, diminished motivation, and disturbed work and social functioning.
    (APA, 2013)
ASSESSMENT

When individuals come to the emergency department with psychotic symptoms, caregivers interview them and, when possible, interview relatives and associates. Initial information may suggest the need for laboratory or other diagnostic studies. If patients have been hospitalized recently, their records may be available. If they are agitated and assaultive, it may be necessary to restrain or seclude them for a period of time, as described above under “Legal Issues.”

DIAGNOSIS

Clinicians consider carefully the signs, symptoms, history, medical record, and laboratory test of each patient. Medical and nursing diagnoses are made using the standard medical references: ICD-9-CM, DSM-5, and NANDA.

PLANNING

Individuals must have an individualized plan of care that includes their immediate needs as well as ongoing ones. Many patients require medication, some need hospitalization, and most will need referral to outpatient care. The goal of all care is stabilization and appropriate ongoing interventions.

INTERVENTIONS

Immediate interventions for individuals suffering from the disorders listed above are carried out in the emergency department in consultation with their personal physician. Ongoing interventions are provided by either a facility to which they are sent or to their family or other responsible caregivers. Discharge planning and referral to social service agencies is essential.

EVALUATION

As discussed earlier, clinicians evaluate the care they give patients, especially the care they give vulnerable persons who arrive alone, without family or friends. In a way, the arrival of a patient in an emergency department constitutes a precipitating event of a potential crisis for the staff. Clinicians use their coping skills (experience, knowledge, and reasoning) and support system (professional colleagues) to meet the needs of each patient. Thus, a potential crisis is resolved.

CASE

Jack Wild had an emergency appendectomy in the morning and was admitted to the surgical unit just before the evening nurses came on duty. His nurse, Sally, received reports and began rounds, visiting each of her patients. As she entered Jack’s room, she found him holding the disconnected IV tubing watching the fluid pour onto his chest. Blood covered his left hand where the cannula had been inserted. Sally reached for the tubing, but Jack grabbed it away, shouting, “You can’t have that. That’s holy water. It’s going to heal my stomach.”

Sally was shocked. She had never faced a situation like this before. She wanted the man’s cooperation, not his hostility, but she couldn’t let this go on. She paused for a moment and tried to think of the issue from his point of view. She said, “That is valuable water. We mustn’t waste it. I’ll help you save it.”

With that, Jack released his hold on the tubing. Sally stopped the flow and called for assistance. When the caregivers had made Jack comfortable, Sally went to call the surgeon. He discontinued intravenous fluids and called for a psychiatric consult.

The psychiatrist prescribed a psychotropic medication and explained that an event such as emergency surgery disrupts the chemical and emotional balance of people with major mental illnesses. He noted that sometimes it is useful to “enter into a patient’s delusion” as Sally had done when she offered to help Jack “save the healing water.”

CONCLUSION

Individuals experiencing an emergency-producing mental health crisis need immediate, appropriate, and sensitive care, whether the crisis is caused by a mood disorder, anxiety, anger, substance use, or a major mental illness. Although clinicians who work in emergency departments and on crisis hotlines encounter these individuals every day, all healthcare professionals meet people in crisis who are overwhelmed by mental and emotional distress. It is important that all caregivers be educated to rapidly assess, diagnose, plan, and intervene in such situations.

Mental health crises have a high risk for poor outcomes, and it is imperative that healthcare professionals respond appropriately. Evaluation of responses requires the determination that ethical principles be followed and that these individuals receive compassionate care.

RESOURCES

Addiction Recovery Basics

Bipolar Disorder (National Institute of Mental Health)

FEMA National Incident Management System (Federal Emergency Management Agency)

Health Information Privacy and the Health Insurance Portability and Accountability Act (HIPPA)

Mental Health (U.S. Department of Veterans Affairs Office of Research & Development)

National Suicide Prevention Lifeline

Violence Prevention (CDC)

REFERENCES

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