When unstable patients put you in danger

My first experience with a mentally unstable patient was certainly an eye-opening one.

During my 4th-year psychiatry clinical rotation in medical school, there was a disheveled female patient in the ER of the psychiatric hospital. My job was to take a thorough history and examine her.

She talked a mile a minute, switching topics every few seconds—then sitting, standing, pacing, and sitting again. I couldn't follow what she was saying, I couldn't redirect her, and I couldn't get a word in. She was pleasant one moment and hostile the next, threatening me with physical harm. At one point, she pulled her pants down and ran out of the room.

I knew I needed to ask for help. I recognized there was no way I’d be able to obtain a history from her, let alone a physical exam. So I called my attending to give him the scoop and ask if we could give her medication to calm her down.

His response: "If you can convince a nurse and maybe a security guard to hold her down while administering the medication, I can put the order in."

The thought of physically restraining her to administer medication didn’t cross my mind at first, but this was the only way. It wasn't pretty; in fact, it was violent. She was thrashing and trying to bite everyone who got close.

I wondered how this woman got to this mental state. Was this her first psychotic episode? Did she ever have any baseline periods that resemble normalcy? Did she use drugs to help calm her erratic thoughts, only to make her more psychotic?

The importance of compassion

I truly felt our medical team, made up of psychiatric nurses and doctors, did the best it could and treated her with the utmost empathy and compassion.

But unfortunately, many years after this incident, I witnessed many other patients with severe manic/psychotic/drug-induced episodes, and the medical teams were not as compassionate. 

Instead, they were irritated and borderline angry because they "didn't have the time to deal with a mentally unstable patient who couldn't help themselves"—words spoken from both medicine residents and attending ER physicians.

I’ve heard my fair share of healthcare professionals say they will never work with psych patients. But regardless of which specialty you practice, chances are you will, at some point in your career, care for someone who’s experiencing a mental health crisis. After all, consider the statistics:

• 21% of US adults (52.9 million individuals) experienced mental illness in 2020.

• 5.6% of US adults (14.2 million people) experienced serious mental illness in 2020.

• People with depression have a 40% higher risk of developing cardiovascular and metabolic diseases than the general population. People with serious mental illness are nearly twice as likely to develop these conditions.

• 32.1% of US adults (17 million individuals) with mental illness also experienced a substance use disorder in 2020.^[]

Additional tips

Caring for patients with mental health disorders can quickly leave healthcare professionals feeling vulnerable and unsafe at times—especially if the patient has the potential to become violent. 

Although most individuals who are seriously mentally ill are not dangerous to others, some may be—particularly when their mental health deems them mistrustful, belligerent, and even hostile.^[]

Follow these guidelines when working with mentally unstable patients:

• Assess the patient's mental state.

• Establish (and build) good communication with the patient. Use language that shows consideration.

• Provide sensitive, patient-centered care.

• Consult with knowledgeable mental health professionals.

• Refer patients to community services.

Restrain as necessary

These steps are pretty cut and dry. When physical and chemical restraints are involved, it is best to wait until the patient is out of their acute state before having an honest, empathetic conversation about their mental health.

Address underlying pathologies

When working in the trenches with acutely mentally unstable patients, keep in mind they most likely have severe underlying pathologies or other factors that triggered this episode: past trauma, depression, loneliness, stress, chronic medical illnesses, or drug use.

It’s not only our job to stabilize patients, but also to provide the care they need to address these underlying triggers. Sometimes that means diagnosing and treating any chronic underlying medical conditions that could be contributing to their mental illness. 

Help break the stigma

Mental health disorders do not discriminate. They can affect everyone, including both you and me. While giant strides are being made in today's society, individuals with mental health disorders still face considerable stigma from community, family and society. And this is often the primary barrier to treatment. 

If we're throwing our hands up, getting angry, walking away, judging or doing anything besides treating our patients with compassion and dignity, then we’re contributing to this stigma—not to mention breaking the Hippocratic Oath.