The challenge of psychiatric emergencies

 Also referred to as behavioural disorders, these emergencies correspond to sudden disturbance in the behaviour, thoughts and mood of an individual and, if left untreated, may lead to severe or life-threatening self-harm (suicidal intent) and/or aggression to others (homicide). 

As there are often no obvious premonitory symptoms prior to the first episode in young individuals with no known mental problems, acute psychiatric events induce an enormous amount of stress on family and friends and severely impact the education or profession of the sufferer. 

In Western Europe, acute psychiatric conditions today account for about five per cent of cases arriving at the emergency department and suicide attempts make up a massive 25 per cent of these emergencies. Acute mental health incidents have also steadily increased over the past two decades, probably due to higher numbers of severe depressions, alcohol and/or drug abuse as well as malicious bullying (verbal and/or online) among younger people. Amongst individuals aged 15-24 years suicide is now the third leading cause of death in these countries. 

Although few data are available among children of international expatriate families, commonly referred as third culture kid (TCK), acute psychiatric problems are also not infrequent. While multiple country exposure could and should represent a substantial benefit in terms of cultural enrichment and adaptability, frequent overseas relocations can also be unsettling and highly stressful for some teenagers. While many handle the challenge in an effective and resilient way, others face tough psychological adjustment or various levels of mental health difficulties. Moreover, as some of these young people never have lived in their home country, a return home can well be the most strenuous experience. 

Acute psychiatric illnesses can present a broad variety of manifestations, among them profound apathy, sadness, emotionless and delusional communication revealing vivid auditory and/or visual hallucinations or intense agitation with self-injury or violent behaviour towards other people. Suicidal ideas can be observed from relatively low-risk intentions such as the intake of few medicines or the minor scarification of the veins of the wrist to acts of often lethal consequences such as jumping out of the window, shooting, poisoning or hanging. 

Any psychiatric emergency requires a prompt patient evaluation by an experienced child or adult psychiatrist as soon as possible. Other specialists including emergency physicians and psychologists are not qualified to diagnose such mental illnesses. Unfortunately, and adding pressure to the already nerve-racking circumstances, in-patient facilities handling serious psychiatric cases are very limited even in large cities. Moreover, distressed families may fall into the hands of numerous self-proclaimed psychotherapists who are merely unscrupulous individuals proposing counselling or psychotherapy without proper qualifications.

Even when the mental origin appears evident, an organic or |non-psychologically related cause must be ruled out such as ingestion of toxic products or the presence of a brain tumour, which may require clinical investigations. 

As there is no specific test to diagnose a psychological disorder, the precise type of mental illness underlying the first event is often challenging to determine and may need repeated evaluations over a few weeks or even months. In addition, acutely mentally ill persons may have limited acceptance of their predicament and be reluctant to collaborate with the medical staff, which could pose serious difficulties if the patient needs to be mechanically restrained. 

The treatment of sudden psychiatric cases essentially relies on the physician’s personality and expertise as well as the support of the medical assistants and of course the close relatives. Successful outcomes come from the ability to calm and reassure agitated patients and subsequently from the development of a trusted relationship between the therapist and the patient. 

In most cases, the acute symptoms rapidly improve with appropriate psychotropic medications. Long-term treatment, supervised by a psychiatrist is often needed and depending on the final diagnosis of the crisis may include medications, psychotherapy as well as other types of supportive behavioural, emotional and social integration therapies. 

 

DR GERARD LALANDE is managing director of CEO-Health, which provides medical referrals for expatriates and customised executive medical check-ups in Thailand. He can be contacted at [email protected].