Emergency psychiatry, suicide risk, aggression, and ethics/legal issues
The exam tests safe decision-making under time pressure and the ethical framework that justifies restriction of liberty.
Core rules
- Suicide risk assessment: ask directly; prior attempt is the strongest single predictor. Other high-risk features include male sex, older age, living alone, hopelessness, agitation or mixed features, access to lethal means, recent discharge and substance use. Document protective factors and a formulated risk level rather than a checklist score alone.
- No-suicide contracts are not evidence-based; safety planning with means restriction is.
- Aggression: verbal de-escalation first, then offered oral medication, then intramuscular medication, and physical restraint only as a last resort with monitoring of vital signs and documentation. Common combination is haloperidol plus lorazepam intramuscularly; monitor for over-sedation and dystonia.
- Emergency differentials to exclude before escalating: hypoglycaemia, hypoxia, delirium, anticholinergic toxicity, serotonin syndrome, NMS, thyroid storm and intracranial pathology.
- Ethical principles: autonomy, beneficence, non-maleficence and justice. Confidentiality yields when there is serious risk to a third party (duty to protect), or when law requires disclosure.
- Involuntary admission is justified by danger to self, danger to others or grave inability to care for self; it must be time-limited, reviewed, and accompanied by the least restrictive option. Document capacity in every refusal-of-treatment case.
Worked example
A 40-year-old man with psychotic depression refuses admission and has stockpiled his medication. He can recite his treatment options but cannot appreciate that his illness leads to his intent to die. Appreciation is impaired, so capacity to refuse is absent; involuntary admission is justified by danger to self, with documentation of the reasoning and the least restrictive plan.
Traps
Assuming a high score alone decides disposition; using restraint without monitoring; breaching confidentiality without a legal or safety basis; failing to document capacity when the patient refuses care.