An acute disturbance of thought, mood, behaviour or social relationships that requires immediate intervention to prevent serious harm to the patient or others. Any nurse, in any clinical setting, may encounter a mental health crisis.
! Types of Psychiatric Emergency
Suicidal crisis — active ideation, plan, or attempt
Provide safe environment — 1:1 observation if needed
Involve family appropriately (with patient consent)
Maintain dignity and confidentiality
Handover and documentation before any shift change
✓ Mental Health Crisis First Response Checklist
Evidence-Based Fact: Asking About Suicide Does NOT Increase Risk
Direct questioning about suicidal ideation does not plant the idea or increase risk. Research is clear. Always ask directly: "Are you having thoughts of ending your life?" or "Are you thinking about suicide?"
▲ Risk Factors
Static (Non-Modifiable)
Previous suicide attempt (strongest predictor)
Family history of suicide
History of trauma / childhood abuse
Male sex (higher completion rates)
Dynamic (Modifiable — Current State)
Current suicidal ideation with plan/intent
Hopelessness — strong independent predictor
Active depression, psychosis, or substance misuse
Recent loss (job, relationship, bereavement)
Access to lethal means (medications, weapons)
Social isolation, lack of support
Recent discharge from psychiatric care
Anniversaries of trauma / losses
▼ Protective Factors
Reasons for living — especially children or dependants
Religious or cultural beliefs opposing suicide
Strong social support / connectedness
Engaged in mental health treatment
Problem-solving ability and coping skills
Fear of death or pain
Responsibility for others
SLAP Framework for Ideation Assessment
Specificity of plan | Lethality of method | Availability of means | Proximity to help
T Suicide Risk Assessment Tools
C-SSRS
Columbia Suicide Severity Rating Scale. Gold standard. Assesses ideation (5 levels) and behaviour (lifetime + recent). See interactive tool in this tab.
ValidatedFree to use
PHQ-9 Question 9
"Over the last 2 weeks, how often have you been bothered by thoughts that you would be better off dead or of hurting yourself?" Score 1+ triggers further suicide risk assessment immediately.
Integrated screening
SAD PERSONS
10-point scale: Sex, Age, Depression, Previous attempt, Ethanol use, Rational thinking loss, Social support lacking, Organised plan, No spouse, Sickness. Score 7+ = high risk.
Supplementary
S Risk Stratification & Actions
LOW
Passive ideation only — "better off dead" — no plan, no intent, strong protective factors. Actions: Document, safety plan, GP/psychiatry follow-up, provide crisis line numbers, check again next contact.
MODERATE
Active ideation, no specific plan, some protective factors, ambivalent about life. Actions: Urgent psychiatric assessment (same day), means restriction, safety plan completed, increased observation, consider voluntary admission.
HIGH
Active ideation with plan, access to means, intent, previous attempts, minimal protective factors. Actions: 1:1 constant observation immediately, emergency psychiatric review, remove all means from access, consider involuntary admission process.
IMMINENT
Active attempt in progress or immediately planned. Patient stating intent to act imminently. Actions: Emergency response, do not leave patient alone, call security/code team, activate crisis protocol, immediate involuntary admission if needed.
SP Brief Safety Plan Components
Warning signs — what does the patient notice before a crisis?
Internal coping strategies — things I can do alone (distraction, breathing, exercise)
Social contacts who provide distraction — names and numbers
Contacts to ask for help — trusted people the patient can call
Professional / crisis services — psychiatrist, crisis line numbers
Means restriction — removing access to lethal means from the home
Reasons for living — patient-identified reasons
C GCC Suicide Context
Suicide is officially classified as haram (forbidden) in Islam — may lead to significant under-reporting and family pressure to conceal attempts
Official GCC statistics likely underestimate true prevalence
Expat workers — particularly South and Southeast Asian labourers — face high-risk circumstances: debt, confinement, separation from family
Domestic workers represent a hidden high-risk group with limited access to help
Do not assume religious belief always protects — assess each individual
Family shame may prevent truthful disclosure to healthcare workers — build trust before assuming low risk
Interactive C-SSRS Simplified Assessment Tool
Columbia Suicide Severity Rating Scale — Clinical decision support only. Not a replacement for clinical judgement.
Ideation Scale (past month)
Q1. Passive Suicidal Ideation — Wish to be dead
"Have you wished you were dead or wished you could go to sleep and not wake up?"
Q2. Active Ideation — without plan or intent
"Have you had any thoughts of killing yourself?"
Q3. Active Ideation with Method (but no plan)
"Have you been thinking about how you might do this? (e.g. taking pills, shooting yourself, etc.)"
Q4. Active Ideation with Intent (no specific plan)
"Have you had these thoughts and had some intention of acting on them?"
Q5. Active Ideation with Specific Plan and Intent
"Have you started to work out or have you worked out the details of how to kill yourself? Do you intend to carry out this plan?"
Behaviour Scale (lifetime and last 3 months)
Q6. Preparatory Acts or Behaviour
Any actions taken to prepare for suicide attempt (giving away possessions, writing notes, stockpiling medications, obtaining a weapon)
Q7. Aborted or Interrupted Attempt
Started to attempt but stopped themselves (aborted) or was stopped by someone else (interrupted) before physical act
Q8. Actual Suicide Attempt
A potentially self-injurious act carried out with at least some intent to die
Recommended Clinical Actions
Safety Planning Prompt
Complete a brief safety plan with the patient now: (1) Identify warning signs, (2) Internal coping strategies, (3) Social supports, (4) Crisis contacts, (5) Means restriction discussion.
+ Positive Symptoms
Hallucinations — auditory most common (voices commenting, commanding); visual hallucinations more suggestive of organic cause
Delusions — fixed false beliefs: persecution ("being followed/poisoned"), reference ("TV speaking to me"), grandiose ("I am a prophet"), jealous, somatic
Thought disorder — loose associations, flight of ideas, word salad, thought blocking
Flat or blunted affect — reduced emotional expression
Poverty of speech (alogia) — reduced amount and content
Avolition — lack of motivation, inability to initiate activity
Anhedonia — inability to experience pleasure
Social withdrawal — reduced social interaction
Cognitive impairment — attention, memory, executive function
First Episode Psychosis (FEP)
Early identification and intervention significantly improves long-term outcomes. Average DUP (Duration of Untreated Psychosis) in GCC is prolonged due to stigma. Refer urgently to psychiatry at first episode.
DE De-escalation in Acute Psychosis
Calm Environment Reduce stimulation — dim lights if possible, reduce noise, limit number of people in the room, remove onlookers.
Use Patient's Name Speak slowly and clearly. Use the patient's preferred name to maintain orientation to reality.
Do Not Argue With Delusions Neither confirm nor confront delusions. Acknowledge the patient's feelings: "I can see you're very frightened right now."
Offer Choice and Control Give simple, concrete choices where safe to do so. This reduces perceived threat and agitation.
Non-Threatening Body Language Do not stand directly over patient, avoid direct staring, maintain 2m distance initially, keep hands visible.
Explain All Actions Narrate what you are doing before doing it. Unexpected touch or movement can trigger aggression in psychosis.
Seek Backup Before Escalating Ensure adequate staff present before attempting medication administration or restraint.
! Risk Assessment in Psychosis
Command Hallucinations — High Risk
Directly ask: "Do the voices tell you to hurt yourself or anyone else?" Command hallucinations instructing harm to self or others represent a psychiatric emergency. Assess compliance with commands and ability to resist.
Risk Factors for Violence in Psychosis
Persecutory delusions targeting specific individual
Command hallucinations (to harm others)
Active substance misuse alongside psychosis
Past history of violence
Non-compliance with treatment
Expressed threats or intent
Early Warning Signs of Escalation
Increasing agitation, pacing
Louder or pressured speech
Threatening language or gestures
Invasion of personal space
Clenched fists, muscle tension
Refusal to comply with requests
Fixed, intense stare
RT When De-escalation Fails — Rapid Tranquillisation Overview
If verbal de-escalation fails and there is imminent risk of harm to self or others, pharmacological intervention may be required. See Tab 4 for full RT protocol.
Oral Route Always First
Always offer oral medication before resorting to IM administration. Document refusal clearly if patient declines oral route.
RT Indications Only
Rapid Tranquillisation (RT) is indicated when a patient presents with imminent risk of harm to self or others AND verbal de-escalation has failed. RT is not a routine sedation measure. Resuscitation equipment must be immediately available before RT is administered.
Rx RT Medication Options
Step 1 — Oral Route (Always Offer First)
Drug
Dose
Notes
Lorazepam (benzodiazepine)
1–2 mg PO
Rapid onset; monitor respiratory depression
Olanzapine wafer (atypical antipsychotic)
10 mg orodispersible
Useful if patient refuses tablets; faster absorption
Promethazine (antihistamine/sedative)
25–50 mg PO
Can be combined with haloperidol; slower onset
Haloperidol (typical antipsychotic)
5 mg PO
QTc monitoring required
Step 2 — Intramuscular (If Oral Refused or Insufficient)
Drug
Dose
Notes
Haloperidol IM
5 mg IM
Often combined with promethazine; risk of dystonia, QTc prolongation
Promethazine IM
25–50 mg IM
Reduces dystonia risk when combined with haloperidol
Lorazepam IM
1–2 mg IM
May be used alone; monitor airway closely
Olanzapine IM
10 mg IM
Effective; see AVOID note below
CRITICAL: AVOID This Combination
Do NOT give IM Olanzapine AND IV/IM Benzodiazepines together. This combination carries significant risk of respiratory depression and cardiovascular collapse. If olanzapine IM has been given, wait at least 1 hour before considering IM/IV lorazepam.
Mon Post-RT Mandatory Monitoring
Monitoring Frequency: Every 5 minutes for the first hour, then every 30 minutes for 2 hours
Parameter
Action Threshold
Respiratory Rate
If RR <10 or >30 — call medical emergency team
SpO2
If SpO2 <92% — apply O2, call emergency team
Blood Pressure
If systolic <90 mmHg — lie patient flat, IV access, call doctor
Before administering RT: confirm crash trolley location, oxygen availability, suction, IV access equipment, and flumazenil (benzodiazepine reversal) and naloxone are accessible.
ECG QTc Monitoring for Haloperidol
Obtain a 12-lead ECG before administering haloperidol if possible
Repeat ECG at 1 hour post-administration
Do not use haloperidol if QTc >500ms
Haloperidol prolongs QTc — risk of torsades de pointes
Caution in patients with hypokalaemia, hypomagnesaemia, or concomitant QTc-prolonging drugs
✓ RT Administration Checklist
Doc Nursing Documentation After RT
Time and nature of the incident that triggered RT
De-escalation measures used and duration
Name, dose, route, and time of medication given
Name of prescribing doctor
Patient's response to medication
All monitoring observations with times
Any adverse effects and actions taken
Post-incident review plan
D DSH vs Suicidal Intent — Key Distinction
Deliberate Self-Harm (DSH)
Intentional self-injury without primary intent to die
Often functions as coping mechanism or emotional regulation
May communicate distress that cannot be verbalised
Most common: cutting, burning, hitting
Does NOT mean the patient is not in serious distress
Critical Point
DSH Does Not Rule Out Suicide Risk
Every patient presenting with DSH requires a full suicide risk assessment. DSH is one of the strongest predictors of future suicide attempt. Do not discharge from ED without psychiatric review.
W Wound Management — Self-Inflicted Lacerations
Apply standard precautions (PPE) and assess ABC first
Refer to surgery if: deep/complex wound, tendon/nerve/vessel involvement, wound contamination, wound that will not close with simple closure
Dress wound appropriately — involve wound care nurse if needed
Tetanus prophylaxis if indicated per wound type and immunisation history
OD Overdose Assessment & Management
Activated Charcoal
Indicated within 1 hour of ingestion of most drugs
Patient must be conscious and able to protect airway
Dose: 50g adult (1g/kg child)
NOT effective for: iron, lithium, alcohols, caustics, solvents
Do not give if airway compromised — aspiration risk
Benzodiazepine Overdose
Primarily supportive management
Monitor GCS, airway, RR, SpO2
Flumazenil (reversal) — use with caution: risk of seizures in chronic users or polypharmacy; short half-life means re-sedation possible
Paracetamol Overdose
Paracetamol — Staggered Overdose
If staggered ingestion (tablets taken over >1 hour), standard nomogram cannot be used. Use maximum reported dose approach — treat with NAC protocol if any doubt. Consult poisons centre / hepatology.
N-Acetylcysteine (NAC)
Refer to local NAC protocol (weight-based, 3-bag regimen)
Check LFTs, INR, creatinine, glucose before starting
Monitor for NAC hypersensitivity reaction (nausea, flushing, rash) — manage by slowing infusion rate
Re-check LFTs at end of treatment
A Aftercare & Psychiatric Assessment
Do NOT Discharge From ED Without Mental Health Review
Every patient presenting to ED following self-harm or overdose must receive a psychiatric assessment before discharge. Document clearly who reviewed the patient, when, and what the outcome and plan were.
Before Psychiatric Assessment — Safe Environment
Remove all sharps, scissors, scalpels from patient access
Remove medications from bedside (including patient's own medications)
Assess for ligature points — remove IV lines / lines not in use, secure call bell cords
1:1 nursing observation if high risk
Do not leave patient unattended in toilet or bathroom
Staff Nursing Staff Emotional Response
Avoid Punitive Attitudes Toward DSH Patients
Research shows DSH patients frequently encounter negative or punitive attitudes from nursing staff — including withdrawal of pain relief, dismissive language, or moral judgement. This significantly worsens outcomes and reduces future help-seeking.
Nurses must receive training in managing personal emotional responses to self-harm
Regular clinical supervision supports staff wellbeing and quality of care
Approach every DSH patient with the same non-judgemental care as any other medical presentation
Debrief after distressing incidents — seek support from senior colleagues, clinical psychologist, or EAP
✓ DSH ED Management Checklist
MH GCC Mental Health Services — Expanding Landscape
National Mental Health Policies
UAE: National Mental Health Policy implemented; Federal Mental Health Law No. 28 (2021) modernised framework; significant investment in community mental health
Saudi Arabia: Vision 2030 includes substantial mental health investment; expanding community services; Hafiz health portal includes mental health resources
Qatar: National Mental Health Strategy — community-focused; Hamad Medical Corporation mental health services expanding
Kuwait, Bahrain, Oman: Evolving frameworks with growing recognition of mental health as public health priority
Persistent Gaps
Psychiatric to population ratio remains below WHO recommended levels across GCC
Community mental health services limited — hospital-based care dominant
Crisis services often require attendance at hospital rather than community outreach
Mental health nurses remain underrepresented in workforce
Psychological therapies (CBT, DBT) limited in Arabic language
S Stigma and Help-Seeking
Stigma remains the primary barrier to mental health care in GCC populations
Patients commonly present to ED in acute crisis rather than accessing services earlier — shame prevents timely help-seeking
Family reputation and honour concerns frequently override individual need for care
Mental health diagnosis may affect employment, marriage prospects, and custody in GCC contexts
Nurses must approach mental health presentations with consistent non-judgemental care
When speaking with families, frame mental illness as medical — not character weakness or spiritual failure
Ex Expat Mental Health
Approximately 50–90% of GCC populations are expatriates. Common mental health stressors include:
Isolation and homesickness
Separation from family (common for South and Southeast Asian workers)
Financial stress and debt
Language barriers limiting care access
Precarious employment and immigration status
Discrimination and social marginalisation
Filipino Healthcare Workers
Filipino nurses constitute a significant portion of GCC nursing workforce. Research identifies elevated depression rates linked to family separation and cultural adjustment. Peer support networks and EAP services are important.
DW Domestic Workers — Silent Crisis
High-Risk, Under-Served Population
Domestic workers in GCC face compounded risk factors: isolation within employer households, potential abuse, no access to mental health services, language barriers, phone and movement restrictions, and fear of deportation if they report abuse.
Nurses in ED may encounter domestic workers brought by employers — ensure private interview without employer present
Assess for signs of abuse, coercion, or exploitation
Know your hospital's safeguarding referral pathway
Contact social work and, if appropriate, the relevant embassy
R Religious and Cultural Framing of Mental Illness
Jinn Possession
Belief in jinn possession as explanation for psychiatric symptoms is widespread in GCC and wider Muslim world
Patients and families may have sought ruqyah (Quranic recitation) or visited traditional healers before hospital presentation
This may significantly delay diagnosis and treatment
Nurses must approach this belief with cultural sensitivity while not colluding with practices that may cause harm (physical ruqyah, restriction, denial of psychiatric treatment)
Dual explanation approach: "Many people find religious support helpful alongside medical treatment"
Cultural Sensitivity in Practice
Do not dismiss or mock culturally held beliefs
Engage family using frameworks they understand
Seek hospital chaplain or cultural liaison where available
Use professional interpreters — not family members — for mental health assessments
Be aware that female patients may be reluctant to disclose to male healthcare workers
Respect modest dress, prayer times, halal meals during admission
L Involuntary Psychiatric Admission — GCC Legal Framework
General Principle Across GCC (Verify Local Policy)
Involuntary admission generally requires assessment by two doctors (usually including a psychiatrist), documented criteria met (danger to self or others, unable to consent due to illness), and family or guardian notification. Processes and rights vary by country. Always follow your hospital's specific protocol.
Nurse's Role in Involuntary Admission
Do not detain a patient unilaterally without medical authorisation
Document all observations that support the clinical concern
Maintain the patient's dignity throughout the process
Explain to the patient (in terms they can understand) what is happening and why
Record all communication with patient and family
Patient Rights During Involuntary Admission
Right to know reason for detention
Right to access a lawyer or patient rights office
Right to regular review
Right to refuse specific treatments (in most frameworks)
Right to communicate with family and consulate (for expats)
CR Crisis Resources & Helplines
24/7 Crisis Services
Befrienders Middle East (UAE & Kuwait): Emotional support helplines — check current numbers via befrienders.org
UAE Tawazun Mental Health App: Free mental health resource
KSA Nahu Al Seha: Psychological support line
International Association for Suicide Prevention: iasp.info/resources/Crisis_Centres/
For Nursing Staff
Access your hospital's Employee Assistance Program (EAP) for confidential support
Peer support after critical incidents — do not normalise vicarious trauma
Clinical supervision — mandatory in many GCC facilities; use it
Speak to your unit manager if you are struggling with a patient presentation