Introduction
Important
XZ/1. Interventions in emergency psychiatry.
The most important steps of the emergency psychiatric care after the examination of the patient:
- Immediate treatment (reduction or elimination) of the psychiatric emergency
(symptom).
- Deciding if the patient needs further care?
- If yes, psychiatric or medical?
- Is hospitalisation necessary?
- Is cooperation with other services (social services, child welfare services, guardianship authority, police) necessary?
- Deciding if the patient’s behaviour is dangerous to himself or others?
- If yes, emergency (involuntary) hospitalisation is needed.
- Is the use of restraints necessary?
XZ/1.1. Pharmacological and non-pharmacological interventions in emergency psychiatry.
XZ/1.1.1. Pharmacological interventions in emergency psychiatry.
In psychiatric emergency, antipsychotics and anxiolytics (high-potential benzodiazepines) are the most frequently administered drugs. Before administering these agents, their contraindications, as well as indications, should be carefully considered in each case. Formulations for oral administration (tablets, solutions, orodispersible tablets) are preferred as they are associated with the lowest risk potential for complications.
Most common indications of antipsychotics in emergency psychiatry:
agression or hostility,
agitation or psychomotor retardation,
acute psychotic symptoms (e.g. hallucination, delusion).
Most common indications of anxiolytics in emergency psychiatry:
severe anxiety (e.g. due to panic attack, psychosis or substance use),
insomnia or hypervigilance,
agitation or psychomotor retardation,
agression or hostility,
withdrawal symptoms (e.g. alcohol, benzodiazepine).
Indications of parenteral administration of medication (intramuscular or intravenous injection or infusion following the instructions of the label):
lack of cooperation,
dangerous behaviour,
urgent need of action of medication (particularly iv. benzodiazepines).
Additionally, in case of comorbid disorders administration of other medicines may be indicated (e.g. beta blocker, supplementation of potassium and thiamine, antibiotics in alcohol withdrawal; anticholinergic agent, beta blocker, dopamine agonist in antipsychotics induced side effects; emergency treatment of heart failure, hyperglycaemia etc.).
XZ/1.1.2. Non-pharmacological interventions in emergency psychiatry.
Main goals of non-pharmacological interventions in emergency psychiatry:
- giving appropriate information,

Important
Important
- improving the cooperation of patients and/or relatives,
- reducing anxiety.
Some types of non-pharmacological emergency interventions may be considered as the very first step of the therapeutic process (e.g. crisis intervention).
Most common non-pharmacological interventions in emergency psychiatry:
- psychoeducation of the patient and/or relative(s): giving appropriate information about present symptoms, necessary interventions, prognosis,
- informing the relative and/or guardian of the patient (following the laws of the country), and allowing the patients to contact their relative(s)/guardian,
- crisis intervention (please see the related chapter in the fourth year e-learning material of Medical Psychotherapy).
XZ/1.2. Psychiatric hospitalisation.
In a number of patients, symptoms subside or disappear, with their origin sufficiently clarified, as a result of emergency care; these patients can be discharged and/or referred to outpatient care. Some of the patients, however, require further hospitalisation and are admitted to psychiatric or other
(toxicological, medical etc.) wards.
Hospitalisation is mandatory (even against the patient’s will) in cases where the security of the patient or their environment makes it necessary:
risk of suicide,
agression due to mental disorder (e.g. psychosis or substance use),
psychomotor retardation or agitation or their alternation,
first psychotic state in life,
disorder of consciousness,
the etiology of symptoms has not been cleared up and further examination is needed.
Hospitalisation (immediate or elective) is not mandatory but is to be considered in the following instances:
- examination/treatment cannot be implemented in the framework of outpatient care or can be implemented only with difficulty (e.g. insufficient cooperation, uncontrollable behaviour, distant place of residence, risk of deterioration),
- withdrawal from the environment may lead to improvement of the patient’s symptoms.
A cooperating patient can be referred to outpatient care even with severe symptoms, such a step, however, requires attending physicians with high professional standards and sufficient experience on the one hand and state-of-theart outpatient clinics with emergency facilities on the other, as well as direct communication between health professionals in emergency and outpatient care.
XZ/1.3. Restrictive interventions in psychiatry.
Regulations for restrictive interventions may vary from country to country and, therefore, mental health professionals must be aware of relevant legislation in their respective countries. According to Hungarian law, the freedom of patients in psychiatric wards can be restricted by physical, chemical, biological or psychic means in case of threatening behaviour, with the aim of averting such threat, to the extent and for the duration absolutely necessary for achieving this aim.
Most commonly used restrictive interventions in psychiatry:

Literature
involuntary admission (and treatment) of a patient to a psychiatric inpatient unit,
seclusion or admission to a "locked ward",
psysical restraint.
It should be pointed out that even when restrictive interventions are implemented, the patient must be sufficiently informed and psychotherapeutic interventions applied, in accordance with the patient’s needs. Adequate information and empathic approach can improve patient's cooperation and reduce the risk of injury even when physical coercion/restraint is used against an aggressive/hostile patient in an emergency situation!
Under the terms of current Hungarian legislation, the competent regional court must be informed of the fact of emergency (involuntary) hospitalisation in 24 hours; on being informed, the court has 72 hours to review the case and decide if hospitalisation (and restraint) was legitimate and professionally justified. If it is deemed legitimate and justified, and the patient’s behaviour continues to be threatening, the court orders compulsory medical treatment of the patient, with the order revised every 30 days.
The patient and/or their relative must be informed of the order on restrictive interventions. During the restriction period, the patient’s condition must be continuously monitored and the neccessity of maintaining restriction revised every
72 hours (every 2 hours in case of physical restraint). The patients’ advocate must be informed of the restriction every 72 hours.
References:
Sadock BJ és Sadock VA. Kaplan&Sadock's Synopsis of Psychiatry (10th edition). Lippincott Williams Wilkins, Philadelphia, 2007: 897-918.
Act CLIV of 1997 on health care, §188 – 201.
ESzCsM Decree 60/2004 (July 6) on regulations on hospitalisation of psychiatric patients and on restrictive measures which can be used during their care, §4 – 8.