African-American paramedic with a patient

How to Treat Behavioral & Psychiatric Emergencies

Learn How EMTs & Paramedics Identify, Treat and Care for Patients with Behavioral and Psychiatric Emergencies

African-American paramedic with a patient

Behavioral and psychiatric disorders are the fifth most common emergency that EMS professionals respond to, accounting for almost 8% of all EMS calls.

(Click here for our list of the most common EMS Emergencies for EMTs and Paramedics).

Behavioral and psychiatric disorders are behavioral or mental patterns that cause significant distress or impairment of personal function.

A behavioral or psychiatric disorder is defined by the patient showing any of the following signs:

  • Is a danger to themselves
  • Is a danger to others
  • Is so mentally impaired that they cannot provide for their own food, clothing, or shelter
  • Appears at risk to evolve into one of the above conditions

Mental illness can sometimes be associated with aggressive or violent behavior. However, people living with a mental illness and receiving effective treatment are no more violent or dangerous than the rest of the population. People living with a mental illness are more likely to harm themselves—or be harmed than to hurt other people.

Violence is not a symptom of psychiatric illness. The relationship between mental illness and violence is complex. Research suggests there is little relationship between mental illness and violence unless substance use is involved.

For current or aspiring EMS professionals, this post discusses the pre-hospital treatment for behavioral and psychiatric disorders, one of the most common emergency calls for EMTs and paramedics.

Behavioral and Psychiatric Disorder Definition

What Is a Psychiatric Disorder?

Behavioral and psychiatric disorders are behavioral or mental patterns that cause significant distress or impairment of personal functioning. The condition may be persistent, relapsing and remitting, or occur as a single, isolated episode.

The causes of behavioral disorders are often unclear, but they are usually defined by a combination of how the patient behaves, feels, perceives, or thinks.

Treatment for behavioral and psychiatric disorders can be found in psychiatric hospitals or the community. Assessments are carried out by mental health professionals, such as psychiatrists, psychologists, psychiatric nurses, and clinical social workers, using various methods, including psychometric tests, observation, and questioning.

The two primary treatment methods for psychiatric disorders are psychotherapy and psychiatric medication. Other treatments include lifestyle changes, social interventions, peer support, and self-help. A small number of cases might require involuntary detention or treatment. Prevention programs have been shown to reduce depression.

In 2019, common mental disorders around the globe were:

  • Depression
  • Bipolar disorder
  • Dementia
  • Schizophrenia
  • Developmental disorders

For current or aspiring EMS professionals, this post discusses the pre-hospital treatment for behavioral and psychiatric disorders, one of the most common emergency calls for EMTs and paramedics.

Causes of Psychiatric Emergencies

The psychiatric conditions associated with psychiatric emergencies include:

  • Schizophrenia
  • Bipolar Disorder (especially Bipolar Mania)
  • Depression
  • Anxiety States
  • Intoxication
  • Withdrawal
  • Delirium (not actually a psychiatric condition)
  • Dementia (not actually a psychiatric condition)

Paramedic attending to a female patient

When to Call 911 for Psychiatric Disorder

Many mental health advocacy organizations offer similar advice regarding when to call 911 for a psychiatric disorder. Basically, “if you or a loved one is experiencing a mental health crisis or emergency, call 911.” While this advice is somewhat vague, below are the key signs that it’s time to pick up the phone.

Signs of a Mental Health Emergency:

  • Individual has harmed themselves or others
  • Individual is likely to harm themselves or others
  • Serious property damage
  • Individual is unable to care for self
  • The caller feels scared or unsafe

Signs of a Mental Health Crisis:

  • Need for immediate action or intervention—if the individual has disappeared, is likely to harm themselves or others, or is threatening, talking about, or making specific plans for suicide
  • Excessive substance use
  • Individual cannot resolve the situation with skills and resources available
  • Individual is unable to care for self
  • Individual is participating in unlawful behavior

How to Treat Behavioral and Psychiatric Emergencies

People living with a mental illness require psychiatric care. If the person shows signs of a psychiatric emergency, such as agitation or violence, call 911. You can also take steps to calm them and de-escalate the situation.

If a person living with a mental illness becomes aggressive or violent, some suggestions include:

  • Try to remain calm and speak in a relaxed, clear, and slow voice
  • Give the person some physical space
  • Avoid a confrontation – sometimes leaving the house to wait for everyone to calm down is more productive

A more detailed list of calming techniques designed for EMS professionals is included in this article.  Look for “The Ten De-Escalation Commandments” below.

How Do EMTs & Paramedics Treat Behavior and Psychiatric Disorders?

For all clinical emergencies, the first step is a rapid and systematic assessment of the patient. For this assessment, most EMS providers will use the ABCDE approach.

The ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach is applicable in all clinical emergencies for immediate assessment and treatment. It can be used in the street with or without any equipment. It can also be used in a more advanced form where emergency medical services are available, including emergency rooms, hospitals, or intensive care units.

Treatment Guidelines & Resources for Medical First Responders

Treatment guidelines for behavioral and psychiatric emergencies can be found on page 53 of the National Model EMS Clinical Guidelines by the National Association of State EMT Officials (NASEMSO). NASEMSO maintains these guidelines to facilitate state and local EMS system clinical guidelines, protocols, and operating procedures. These guidelines are either evidence-based or consensus-based and have been formatted for use by EMS professionals.

The guidelines include a rapid assessment of the patient for symptoms of psychiatric disorder, which may include:

  1. Note medications/substances on scene that may contribute to the agitation or may be relevant to the treatment of a contributing medical condition
  2. Maintain and support airway
  3. Note respiratory rate and effort – If possible, monitor pulse oximetry and/or capnography
  4. Assess circulatory status:
    • Blood pressure (if possible)
    • Pulse rate
    • Capillary refill
  5. Assess mental status
    • Check blood glucose (if possible)
  6. Obtain temperature (if possible)
  7. Assess for evidence of traumatic injuries
  8. Use a validated risk assessment tool such as RASS (Richmond Agitation Sedation Score), AMSS (Altered Mental Status Score), or BARS (Behavioral Activity Rating Scale) to risk-stratify violent patients to help guide interventions

EMS providers should reference the CDC Field Triage Guidelines for decisions regarding transport destination for injured patients.

Paramedic loading a stretcher into the ambulance

EMS Protocol for Behavioral and Psychiatric Emergencies

Protocols for pre-hospital treatment of behavioral and psychiatric disorders vary by EMS provider and can also depend on the patient’s symptoms or medical history.

A typical protocol might follow these initial steps, called “Zeller’s Six Goals” of emergency psychiatric care:

  • Exclude medical etiologies of symptoms
  • Rapidly stabilize the acute crisis
  • Avoid coercion
  • Treat in the least restrictive setting
  • Form a therapeutic alliance
  • Formulate an appropriate disposition and aftercare plan

Patients with a potentially life-threatening illness or injury should be transported to the closest, most appropriate receiving hospital for the patient’s medical needs.

Field Medical Clearance Criteria

To determine if a medical clearance is required for all other patients, EMS personnel are to ask themselves the following questions. If the answer to any of them is “yes,” the patient should be transported to the nearest, most appropriate receiving facility.

  1. Is there a medical or traumatic reason why this patient should not be transported to an emergency psychiatric facility?
  2. Is the patient unconscious or unresponsive?
  3. Is the patient pale, sweaty, dizzy, or showing signs of shock?
  4. Does the patient have chest pain?
  5. Does the patient have abdominal pain?
  6. Does the patient have significant bleeding from trauma?
  7. Is the patient significantly intoxicated or overdosed on drugs and unable to ambulate? (Patients with ANY evidence of ingestion should be treated as an overdose, even if the patient is now denying it
  8. Do you suspect the patient may be experiencing an overdose of medication?
  9. Is the patient 65 or older and showing an abrupt change in behavior or cognition?

Medical causes that can mimic psychiatric symptoms include:

  • Delirium
  • Mental retardation
  • Hyperthyroidism
  • Dementia
  • Hypoxia
  • Seizures
  • Hypoglycemia
  • HIV encephalopathy

De-Escalating Agitated or Potentially Violent Patients with Suspected Psychiatric Disorder

The Ten De-Escalation Commandments, developed by Avrim Fishkind, MD, has been included or referenced in some EMS protocols for verbally de-escalating a potentially violent or agitated patient.

The Ten De-Escalation Commandments:

  1. You shall be non-provocative:
    • Calm demeanor, facial expression
    • Soft-spoken with an angry tone
    • Empathic—genuine concern
    • Relaxed stance—arms uncrossed, hands open, knees bent
  2. You shall respect personal space:
    • 2x arm’s length
    • Normal eye contact
    • Offer a line of egress
    • Expand space if paranoid
    • Move if told to do so
  3. You shall establish verbal contact:
    • Tell them who you are
    • Establish you are keeping them safe
    • You will allow them no harm
    • You will help them regain control
  4. You shall be concise:
    • Use short phrases or sentences
    • Repeat yourself, repeat yourself
    • Get the patient’s attention and don’t confuse
  5. You shall identify their wants and feelings
  6. You shall lay down the law:
    • Set limits
    • Offer choices; propose alternatives
    • Establish consequences
    • Use positive reinforcements
  7. You shall listen:
    • Don’t argue
    • Don’t up the ante
    • Listen and agree
    • Check understanding
  8. You shall agree or agree to disagree
  9. You shall have a moderate show of force and be prepared to use it
  10. You shall debrief with patients and staff

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