Mental Health Emergencies Study Guide for the CEN

General Information

While the area of mental health emergencies is not as widely covered as some other fields, about 7% of the CEN questions assess it. It is important to be able to identify many different mental health symptoms and understand possible treatments for them.

Aggressive and Violent Behavior

Aggressive and violent behavior is any action that involves a patient potentially or actually harming themselves or someone else, such as a healthcare worker. This harm can be unintentional or intentional. The patient can be alert and oriented x 4 (to person, place, time, and event) or have altered mental status due to psychiatric conditions, drug overdose or withdrawal, a head injury, or other medical conditions. The primary objective is to keep both the patient and the people caring for them safe.

Assessment

The patient should be assessed carefully to evaluate the potential for potential aggressive or violent behavior. Always give yourself a clear exit from any uncertain situations. Consider the following factors to determine the potential for violence:

• physical setting—Are there any nearby objects that can be used as a weapon? Anything that can be thrown or a cord that could be used in strangulation can be dangerous.

• patient’s history—Does the patient have any history of violence or making threats against themselves or others? Do they have any history of substance use disorder or any psychiatric conditions?

• patient’s activity—Is the patient sitting at the edge of their seat or pacing? Are they gesticulating wildly or grimacing?

• patient’s presentation—Are they shouting or speaking with a raised voice? Are their fists clenched?

Treatment

The initial treatment is to keep both the patient and healthcare workers safe. Healthcare workers should remain calm and serve as a neutral and reassuring presence for the patient. Use non-threatening body language, listen respectfully to the patient, and speak clearly and calmly to them.

Keeping everyone safe may involve the use of physical restraints or chemical restraints like antipsychotics and benzodiazepines that can be administered orally, intravenously, or intramuscularly. Any patient who requires chemical or physical restraints requires close monitoring, including appropriate vital signs.

Long-term interventions include antipsychotic medications, medications to treat various substance use disorders, psychiatric therapy, and speech therapy to address cognitive issues caused by head injuries. Other interventions can vary based on the patient’s specific condition.

Anxiety Disorders

Anxiety is a feeling of fear, dread, or nervous anticipation that can be generalized or related to a specific situation or stressor. It can range from mild to severe, which completely prevents a patient from functioning. Post-traumatic stress disorder (PTSD) develops when the patient develops permanent effects from witnessing or experiencing a terrifying, shocking, or traumatizing event. Panic attacks are sudden waves of fear or discomfort that occur without a clear trigger or event.

Assessment

Anxiety can cause the patient to appear nervous, restless, irritable, or unable to focus. Panic attacks can cause chest pain, tachycardia, shortness of breath, diaphoresis, and nausea and can even mimic a heart attack. An EKG and troponin may be needed to rule out any cardiac involvement. The patient will feel like they can’t breathe or think clearly. Patients with PTSD can experience flashbacks and nightmares, have involuntary emotional and physical reactions to stress, startle easily, have negative thoughts about themselves, and feel socially isolated. The Generalized Anxiety Disorder 7-item (GAD-7) can be used by nurses to assess the severity of a patient’s anxiety disorder. An official anxiety disorder diagnosis needs to be made by a mental health professional or healthcare provider.

Treatment

Multiple medications can be used to treat anxiety. Benzodiazepines can be used for quick relief for situational anxiety or in the event of a panic attack. Selective serotonin reuptake inhibitors (SSRIs) and atypical antidepressants can help to manage a patient’s anxiety and stabilize their mood long term. Beta blockers can help to moderate the physical effects of anxiety, such as tachycardia. A wide variety of different types of psychotherapy can be used to teach the patient coping techniques to manage their anxiety. The patient may also be encouraged to make lifestyle changes such as getting enough rest, minimizing caffeine and alcohol intake, encouraging exercise, and avoiding stressful situations when possible. For patients with particularly severe anxiety or PTSD, a service dog can help to moderate anxiety as well.

Mood Disorders

Mood disorders are mental health conditions that affect the patient’s emotional state. Examples include bipolar disorder, depression, premenstrual dysphoric disorder (PMDD), and disruptive mood regulation disorder (DMDD). The disorders are most common in women, children/adolescents, and patients with a history of chronic illness.

Assessment

The patient’s symptoms vary depending on the type of disorder that they experience. In depression, patients describe feeling sad, down, or hopeless. Depression can cause difficulty with thinking, insomnia, and eating. Patients with bipolar disorder will alternate between depression and mania (over-the-top energy and impulsivity). Premenstrual dysphoric disorder is a more serious form of PMS that occurs 7-10 days prior to the onset of menses and goes away with the start of menstruation. Disruptive mood regulation disorder occurs in children and adolescents and consists of angry outbursts and out-of-proportion irritability. There is no definitive diagnostic test for a mood disorder. Instead, the patient will receive a formal diagnosis from a mental health professional.

Treatment

Treatment for depression consists of medication and psychotherapy. Medications commonly prescribed include SSRIs, serotonin and norepinephrine reuptake inhibitors (SNRIs) and atypical antidepressants. Bipolar disorder is treated with antipsychotic medications and mood stabilizers like lithium. Psychotherapy is also useful in teaching coping techniques. Treatments such as electroconvulsive therapy can be used for particularly persistent disorders. Treatment for PMDD can include prescription medication taken just during the part of the menstrual cycle when symptoms occur. DMDD is treated with psychotherapy, antidepressants, and stimulants.

Homicidal and Suicidal Ideation

Homicidal ideation is the intention to kill another person, while suicidal ideation is the intention to kill oneself. Suicide is the second leading cause of death in ages 10-34 and the fourth leading cause of death in ages 45-50. Globally, more than 720,000 people commit suicide annually.

Conditions such as depression, anxiety, situational crises, and substance use disorders all predispose patients to suicidal ideation. Men are more than three times more likely than women to commit suicide, and suicide rates are highest among older adults (age 65+). Homicidal ideation is most common in patients diagnosed with a psychotic disorder. Patients with a history of homicidal ideation also have a higher risk of suicidal ideation.

Assessment

Monitor patients who are at risk of suicide especially closely based on their health history. The patient may be tearful or make statements of hopelessness or despair. Watch for statements such as “I don’t want to be here anymore” and “I want to go to sleep and not wake up.” Other patients are remote and detached; they may speak slowly, avoid eye contact, and refuse to discuss the future. If a patient who has previously been extremely depressed suddenly becomes euphoric, they may have created a plan to commit suicide. Use a standardized scale such as the Columbia-Suicide Severity Rating Scale to determine the patient’s risk of suicide. Calmly ask the patient if they have any suicidal ideation—most patients will be relieved when the topic is brought up.

Treatment

A patient who has suicidal or homicidal ideation requires one-to-one monitoring with a safety companion, ideally in a dedicated psychiatric unit. Any potentially harmful objects should be removed from their immediate vicinity. A psychiatrist or psychologist should immediately evaluate the patient and work with them to determine an appropriate treatment plan that involves therapy and prescribed medications. Staff should supervise all visits with friends and family, who should also be closely involved in the patient’s treatment plan (with patient permission) until the psychiatrist has cleared the patient as no longer being an immediate danger to themselves or others.