Psychiatric emergencies: agitation, violence risk and the suicidal patient
- Topic
How to calm an agitated patient safely, judge the risk of violence, approach the suicidal patient and rule out medical causes.
What it is
A psychiatric emergency is a situation in which a mental or behavioural disturbance puts the patient or others at immediate risk, such as severe agitation, threats of violence, a suicide attempt or acute psychosis. The priorities are safety, a search for medical causes and the least coercive response that works. Verbal de-escalation comes first; medication is offered, with a choice of how to take it; and restraint is a last resort.
Key facts
- Intoxication lowers impulse control, which links it to violence.
- Even in psychosis, violence within five years of diagnosis typically affects fewer than 10 % of people, so risk is assessed for each person and not assumed from the diagnosis.
- For the suicidal patient, follow the suicide risk page.
Step by step
- Keep at least two arm’s lengths away, stand at an angle and make sure there are adequate exits.
- One person speaks: give your name and title, and ask how the patient prefers to be addressed.
- Use short sentences and simple words, and repeat your message.
- Ask what the patient wants; listen and repeat back what they said.
- Agree where you honestly can, or agree to disagree.
- Set clear limits calmly.
- Offer choices, such as food and something to drink, or medication by mouth or by injection.
- If danger persists despite this, restraint is a last resort.
- Afterwards, debrief with the patient and with the team.
Medical causes of acute agitation to rule out
| Cause | Clues |
|---|---|
| Hypoglycaemia | Low fingerstick glucose; easily reversible when treated |
| Delirium from infection, hypoxia or organ failure | Fever, changes in breathing pattern, poor attention; meningitis, sepsis, kidney or liver failure |
| Alcohol or drug intoxication or withdrawal | Abnormal vital signs, odour of alcohol, drug paraphernalia; withdrawal can cause disorientation, hallucinations and seizures |
| Medicines with anticholinergic effects | Recent anticholinergic medicine with confusion and poor attention |
| Neuroleptic malignant syndrome | Recent antipsychotic, lead-pipe rigidity, fever, tachycardia, labile blood pressure |
| Serotonin syndrome | Recent serotonergic drug, myoclonus, hyperreflexia, fever, tachycardia |
| Head injury, seizure or postictal state | Headache, memory loss or loss of consciousness after trauma; confusion after a recent seizure |
Clinical notes
- When medication is needed, it is offered and the patient may choose by mouth or by injection; intravenous benzodiazepines are the drugs of choice for alcohol or benzodiazepine withdrawal.
- Benzodiazepines are avoided in delirium from other causes; the underlying disorder is treated, and antipsychotics are only sometimes used for severe agitation.
- Restrained patients are more likely to be admitted to a psychiatric hospital, and de-escalation can take less time than restraint.
Test yourself
Think of the answer, then tap the question to see it.
What is the first-line approach to an agitated patient?
Verbal de-escalation in a safe setting, with one person talking calmly and briefly, after checking for medical causes.
In people with psychosis, which group of risk factors carries the greatest risk of violent crime?
Criminal history; past violence, recent victimisation and substance misuse also raise risk.
Which quick bedside checks are done in every agitated patient?
A full set of vital signs and fingerstick glucose, plus oxygenation if not measured at triage.
When is restraint used?
Only as a last resort, when verbal de-escalation and other less coercive measures have failed.
A 60-year-old with no psychiatric history becomes agitated and confused with fever. What is the most likely problem?
A medical cause such as an infection: new agitation after 45 with no psychiatric history suggests a medical cause, and it needs a medical work-up, not just sedation.
Elsewhere in DurgiPedia
- Physical restraints: a last resort and their safe use
- The limits of confidentiality: duty to warn and legal disclosure
- Consent in emergencies and the exceptions to consent
- Decision-making capacity (competence) and how to assess it
- Vital signs: what they are and how to record them
Connections
In Pharmacology2
Educational content on behavior and the clinical relationship; not a diagnostic or treatment guide and no substitute for assessment by a health professional. If you or someone near you is at risk, seek help now from an emergency service or a mental-health helpline.
Sources: Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup (Western Journal of Emergency Medicine, PubMed Central, 2012); Medical Evaluation and Triage of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Medical Evaluation Workgroup (Western Journal of Emergency Medicine, PubMed Central, 2012); Systematic review of risk factors for violence in psychosis: a 10-year update (British Journal of Psychiatry, PubMed Central, 2025); Delirium (MSD Manual Professional Edition, 2025).
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Representative model, for educational purposes only.