Acute Psychosis on a Bridge, in a Hospital With No Psychiatric Unit
Brian, 26, is brought to the casualty department of a district hospital at 02:00 by two police officers. He was found sitting on the railing of a bridge over a dry riverbed. He is shouting that his neighbours are poisoning his food and reading his thoughts through the radio. He has not slept for four nights, is pacing, sweating and will not sit down. He is unkempt and smells of alcohol. Glasgow Coma Scale 15, pupils equal and reactive, random glucose 6.1 mmol/L, pulse 128, blood pressure 152/94 mmHg, temperature 37.9 °C, oxygen saturation 97%. He refuses physical examination and says, "I don't need a doctor, I need you to arrest them." There is an old healed scar on his left wrist. His brother arrives and says this is the third episode; last time Brian "went quiet" after three weeks of medication and stopped attending clinic. There is no psychiatric inpatient unit at this hospital; the nearest is 200 km away.
1. Set out your risk formulation and the immediate management priorities for the first two hours.
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Risk formulation - not a diagnosis.
- Suicide/self-harm: high and immediate. He was on a bridge railing, has a healed wrist scar, is sleep-deprived, persecuted and intoxicated. Delusional beliefs can drive acting on them.
- Absconding: high - he is pacing, refusing examination and does not see himself as ill.
- Aggression: moderate - no expressed intent, but fear-based agitation, alcohol and 128 pulse raise it.
- Self-neglect: high - unkempt, four nights without sleep.
- Diagnosis undetermined: acute psychosis could be primary (schizophrenia, mania), substance-induced (alcohol, cannabis, stimulants), or organic. Sweating, tachycardia and temperature 37.9 °C also fit alcohol withdrawal.
Immediate priorities.
- Safe environment: a quiet, well-lit room near the nurses' station; remove sharps, cords, belts, glass; search; one trained nurse plus security within sight; move other patients away. Continuous 1:1 observation.
- Medical screening in parallel, not later: full observations every 15–30 minutes, repeat glucose, check for head injury, look for infection, send urine, electrolytes, renal function and a drug screen if available; monitor for withdrawal (tremor, sweating, hallucinations that worsen).
- De-escalation first: short sentences, low voice, one person speaking, give choices, offer food, fluids, a blanket, and a chair - reduce the stimulation rather than argue about the radio.
- Treat agitation with oral antipsychotic plus benzodiazepine as prescribed once medical causes are reasonably excluded and observation is in place.
- Arrange the psychiatric assessment and transfer early - 200 km takes planning; start now, not after the behaviour settles.
- Contact the brother for collateral and support, with Brian's involvement where possible.
2. He stands up and says he is leaving. What is the legal and ethical basis for what you do next, and what must be recorded?
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First, assess capacity, not compliance. Can he understand the decision, retain it, weigh the risks and communicate a choice? An unwell man who believes the radio reads his thoughts and who was on a bridge is unlikely to have capacity to refuse assessment for that specific decision. Say so explicitly in your notes.
Legal basis. The mental health legislation in your jurisdiction (in Kenya, the Mental Health Act and its amendments) allows a person with a mental disorder to be detained for assessment and treatment where it is necessary in the interests of their own health or safety, or for the protection of others, subject to prescribed documentation - usually an application by a relative or authorised officer supported by medical recommendations. Follow your facility's statutory forms and get the medical officer or psychiatrist to complete the medical recommendation; the police who brought him can lawfully assist. Do not cite or invent section numbers - check the current forms with the hospital's mental health focal person.
Ethical basis. Least restrictive option, duty of care, and the person's best interests. Physical restraint is a last resort after de-escalation and oral medication have failed, must be time-limited, monitored (circulation, breathing, dignity) and reviewed by a doctor.
Record: his exact words and behaviour; the capacity assessment and reasoning; the risk assessment; who was called and at what time; the advice received; the legal form used; nursing observations; any restraint, its indication, duration, monitoring and review; and what was explained to him and his brother.
3. His brother asks: "Last time he went quiet on the tablets - was that the illness or the medicine?" How do you answer, and what follow-up plan do you set out?
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Answer honestly about the uncertainty. 'Both are possible, and that matters.' Reduced speech and flatness can be the psychosis resolving, but it can also be over-sedation from the drug or a drug-induced parkinsonism with slowed movement and expressionless face. Ask what exactly he saw - was Brian sleeping 16 hours, drooling, stiff, shuffling, or was he calm and back to himself? That description distinguishes sedation and extrapyramidal effects from recovery and determines what to tell the psychiatrist.
Make the point about stopping. Stopping after three weeks, when he felt better and the clinic felt unnecessary, is one of the commonest routes to relapse - and each relapse can take longer to recover from. Medication is not a course with a finish line; it is maintenance.
Practical follow-up plan:
- Ensure a written appointment, depot or long-acting option discussed with the psychiatrist if adherence is the problem.
- Identify an early-warning plan with the brother: poor sleep, withdrawal, suspiciousness, stopping medication - the brother is usually the first to notice.
- Side-effect discussion: what to report, not what to endure silently.
- Address the 200 km: a shared-care arrangement with the nearest clinic, a community mental health worker, and a named contact.
- Include Brian in the conversation - the plan is his, not one done about him - and obtain consent for sharing information with his brother.
- Document the discussion and give written contact details, including what to do out of hours if he deteriorates again.