CEN Mental Health: Crisis, Suicide Risk, Eating Disorders and Abuse

In depth

The one-page summary above is what the PDF prints. These sections go further.

The suicide screen: how it is built and read

The Columbia Protocol (C-SSRS) is a set of plain-language questions that anyone can ask without mental health training; its shortest screener uses two to six questions depending on the answers, and versions exist for emergency departments, primary care, schools, corrections and law enforcement. It covers two things: how severe and how recent suicidal thinking is, and whether the person has done anything toward ending their life, including preparatory acts (gathering means, making arrangements) and attempts that someone else interrupted or that the person stopped. The Columbia triage page says a yes in the past month to the two most severe ideation questions (4 and 5), or any suicidal behavior in the past 3 months, indicates high risk. The question wording is licensed, so this page describes it rather than reprinting it.

Bjureberg and colleagues (2022) describe the screen as five ordered ideation items for the past month, from a wish to be dead to intent with a specific plan, plus one behavior item for the past 3 months. In their scoring, yes to items 1 or 2 is low risk, item 3 (thinking about a method) is moderate, and items 4, 5 or 6 are high. In 18,684 patients at a Stockholm psychiatric emergency department, the behavior item was linked to suicide at every time point and most strongly in the first week, while positive predictive values were low; the authors use it as a first step before a full clinical assessment, never to dismiss someone who voices suicidal concern. So a man who bought pills to overdose last month and today only wishes he would not wake up screens high risk on the behavior item, and the fact that someone took the pills away does not lower the category.

Communication, safety planning, 988 and discharge follow-up are on Therapeutic Communication; holds, capacity and restraint are on Mental Health Medications.

Continuous observation in a room that is not ligature-resistant

In the PSNet case, a woman on a hold after an alcohol and lorazepam overdose had a 24-hour sitter. Before a chest film she asked to go to the bathroom; the sitter was chatting outside, and she was found standing on an upside-down garbage can with her gown tied around her neck and the door hinge. The authors recommend clear orders that continuous observation includes toileting and bathing with a same-gender observer, a sign so that every staff member knows the patient is never to be alone, a search of the patient and belongings, supervised visitors, regular reassessment of suicidality as a vital sign, and care without contempt, because staff attitudes affect the patient's decisions.

In practice the nurse explains the reason calmly before the patient reaches the door, offers a gown or towel for modesty, and keeps the door ajar with the patient in view. Verbal contact through a closed door or a pause in observation for the bathroom leaves the patient unobserved where hinges and fixtures are within reach, as in the case above.

Eating disorders: recognition

Anorexia nervosa (Merck) commonly brings bradycardia, orthostatic hypotension and hypothermia; some patients have a prolonged QT interval related to electrolyte disturbances. Dehydration, metabolic alkalosis, hypokalemia and hyponatremia may be present and are aggravated by induced vomiting, laxatives or diuretics. A meta-analysis cited by Merck gives 5.1 deaths per 1,000 person-years, 1.3 of them suicides. Merck says hospitalization should be considered when weight is below about 75% of recommended, and patients should be hospitalized if any doubt exists.

Atypical anorexia nervosa (SAHM 2022) has the same restriction and body-image distress at a normal or even high weight after rapid loss; adolescents with it have similar rates of bradycardia, orthostatic instability and secondary amenorrhea, so a normal weight does not exclude medical instability.

Bulimia nervosa (Merck): recurrent binges with loss of control and compensatory vomiting, laxatives, diuretics, fasting or exercise, on average at least weekly for 3 months, usually at normal or above-normal weight. Signs are painless parotid swelling, dental erosion mainly of the front teeth, esophagitis, and scars or calluses on the back of the hand from triggering the gag reflex (classically called Russell sign). Hypokalemia is the main laboratory danger; rare esophageal tears and gastric rupture are life-threatening. When the patient offers another explanation, the nurse asks privately and without judgment about bingeing, vomiting, laxatives and diuretics, and expects electrolytes.

ARFID (Merck; SAHM 2022) restricts intake because of the sensory features of food, low interest in eating, or fear of an aversive result such as choking or vomiting, with no disturbance of body image. It causes weight loss or faltering growth, nutritional deficiency, dependence on supplements or tube feeding, and impaired functioning; SAHM states its medical complications can be as severe as those of anorexia and reports that about 40% of patients needed hospitalization, mostly for medical reasons. CBT and family-based treatment are commonly used (Merck). A child who has avoided solids since a choking episode, has lost weight and is bradycardic with orthostatic change has a disorder, not a picky phase.

SCOFF (Morgan 1999) is five yes-or-no questions covering induced vomiting, loss of control over eating, recent major weight loss, body image and preoccupation with food; the wording is not reproduced here. Two or more yes answers flagged all 116 cases in the original sample (sensitivity 100%) with specificity 87.5%. Asking the adolescent privately first is usual practice.

Eating disorders: medical instability and hypoglycemia

Haines (2023) describes symptomatic hypoglycemia (under 55 mg/dL with symptoms) as uncommon in anorexia and seen mostly with BMI under 15; it signals that hepatic glycogen and gluconeogenic substrate are exhausted, carries a poor prognosis, may be masked by hypoglycemia unawareness, and may contribute to sudden death, so it is evaluated and managed promptly. A strong insulin response during refeeding can worsen it. The glucagon label states that glucagon works only when enough hepatic glycogen is present and that patients in starvation, with adrenal insufficiency or with chronic hypoglycemia should be treated with glucose. So after the IV dextrose bolus, the nurse anticipates a continuous dextrose infusion, frequent glucose checks continuing overnight, electrolytes including phosphate, and admission; juice and a glucagon kit for home do not protect this patient.

Refeeding: SAHM reports that refeeding hypophosphatemia correlates with the degree of malnutrition at admission rather than the starting calories, and now recommends higher starting calories with faster advancement than the old cautious protocols (oral refeeding from 2,000 kcal/day in a trial shortened instability without more refeeding syndrome). Prospective data are still lacking below 60% median BMI. Electrolyte monitoring as feeding begins is the nursing priority.

Hyperventilation and caffeine

A panic attack (Merck) has at least 4 of 13 symptoms, including palpitations, chest discomfort, shortness of breath, choking, dizziness, paresthesias, trembling and fear of dying; panic disorder is diagnosed only after medical causes such as acute coronary syndrome, hyperthyroidism and substance effects are excluded. Reassurance and education help, and slow, steady breathing is one of the relaxation strategies Merck lists. Callaham (1989) reported three deaths after paper-bag rebreathing in patients who were actually hypoxemic or having myocardial ischemia, and measured falling oxygen in healthy volunteers who rebreathed; the bag is no longer advised. Perioral and fingertip tingling from respiratory alkalosis settles as breathing slows, so calcium is not given and a tight nonrebreather adds to the sense of smothering without treating anything.

Caffeine (Willson 2018): a Red Bull can holds about 80 mg and a Monster about 160 mg, and one 473 mL product held 357 mg. Roughly 1 g may cause toxic symptoms, 2 g may need hospital care and 5 g or more is typically lethal; tachycardia is near universal above 10 mg/kg. Mild toxicity is irritability, palpitations, nausea, tremor and sweating; severe toxicity brings ventricular arrhythmias (VF is the usual cause of death), seizures, rhabdomyolysis and kidney injury. Labs show hypokalemia, hyperglycemia and metabolic acidosis. Care is supportive: cardiac monitoring and a 12-lead, potassium replacement, benzodiazepines for agitation, seizures and supraventricular tachycardia, isotonic fluid for hypotension, activated charcoal ideally within 1 to 2 h, and hemodialysis for severe cases, with the poison center involved. Willson reserves esmolol or propranolol for refractory hypotension and lists amiodarone, lidocaine or procainamide for ventricular arrhythmia, so rate and rhythm drugs are the provider's call once the rhythm is identified. The general approach to sympathomimetic toxicity is on Toxicology and Antidotes.

Crisis intervention and acute stress disorder

A crisis is an event that overwhelms a person's ability to cope, such as violence, a death, a serious diagnosis or the loss of a home. Crisis intervention (Wang and Gupta, StatPearls 2023) is brief and short-term: gather background, build trust, talk through what happened and give emotional support. The SAFER-R model (stabilize, acknowledge, facilitate understanding, encourage, recovery, referral) aims to return the person to their pre-crisis baseline. Referral is the last step of the model, not its goal. For a man whose house burned overnight, the nurse helps him choose the first concrete steps (shelter tonight, one call) with his family's support.

Acute stress disorder (Merck) needs at least 9 symptoms from intrusion, negative mood, dissociation, avoidance and arousal, lasting from 3 days to 1 month after a traumatic event and impairing function; if significant symptoms last beyond 1 month, PTSD is considered. Trauma-focused CBT (education, cognitive restructuring, exposure), generally started at least 2 weeks after the trauma, is the best-supported treatment. A single debriefing with a detailed account of the trauma in the first 72 h does not work and may worsen symptoms. Benzodiazepines may ease insomnia or agitation briefly, but prolonged use appears to interfere with recovery and routine medication is not supported; good sleep habits are part of self-care.

The team after a child dies

The joint AAP, ACEP and ENA technical report (2014) treats the death of a child as one of the hardest events in emergency care and includes care of staff alongside family presence, ending resuscitation and bereavement duties; an appendix describes a closing ritual when resuscitation stops. The Pause, a moment of silence after a death, has been proposed as a coping practice (Petelinsek 2026). In usual practice the charge nurse leads a short shared acknowledgment before the team disperses and the family comes in, and later defusing or peer support is offered to those who want it; ordering everyone to recount the event in detail resembles the single-session debriefing Merck says may worsen symptoms. Moral distress is covered on End-of-Life Care.

Partner violence, coercion and the children in the home

ACOG Committee Opinion 554 defines reproductive and sexual coercion as behavior by a current, former or prospective partner to gain or keep control over reproductive health: sabotaging contraception, pressuring unprotected sex, trying to cause a pregnancy, or controlling its outcome. It is tied to intimate partner violence, so a woman with no injuries still needs further screening. ACOG advises screening for IPV and coercion at periodic visits, education on health effects, harm-reduction counseling and offering long-acting contraception that partners are less likely to detect.

The USPSTF (2025) recommends screening women of reproductive age for IPV (grade B) and connecting those who screen positive to multi-component interventions with ongoing support. Barriers to disclosure include fear, the consequences of disclosure, mandatory reporting and fear of children being removed from the home. Child Welfare Information Gateway gives a general overview of state laws that protect children harmed by witnessing domestic violence, including how witnessing is defined and added penalties for offenders, with state summaries searchable by state; every state requires professionals who work with children to report suspected abuse or neglect (Merck). When a woman discloses that the children watched and are now at home with the abuser, the nurse first finds out whether they have been hurt or threatened and who is with them, then works with social work on the required report, explained honestly to her, and a safety plan that includes the children. Interviewing, documentation and strangulation are on Forensics, Abuse and Sexual Assault in the ED.

Caregiver-fabricated illness and STIs in children

Caregiver-fabricated illness (medical child abuse; formerly Munchausen syndrome by proxy) is maltreatment in which a caregiver falsifies or induces illness, leading to unnecessary and potentially harmful tests, treatment and surgery; it can cause serious illness and death. The caregiver, not the child, receives the diagnosis of factitious disorder imposed on another (Merck). The AAP (2013) advises a high index of suspicion when a persistent or recurrent illness cannot be explained and leads to repeated procedures, or when the history, the examination and the child's health do not match; Merck adds frequent hospitalizations for nonspecific symptoms and a caregiver who seems deeply concerned and protective. Methods include a false history, giving drugs or other agents, and contaminating specimens. The nurse records which events staff actually witnessed and which were only reported, raises the concern with the team, and leaves confrontation until the team and child protective services have a protection plan (usual practice). Repeated procedures without a firm diagnosis are the pattern the AAP warns about.

CDC (2021): gonorrhea, syphilis, chlamydia, Trichomonas vaginalis and nonperinatal, nontransfusion HIV acquired after the newborn period indicate sexual abuse; anogenital herpes or warts raise suspicion (perinatal infections can persist, chlamydia for 2 to 3 years, so very young children need care in interpretation). Merck says STIs in a child under 12 are nearly always the result of abuse. Only FDA-cleared NAATs are used for gonorrhea, chlamydia and Trichomonas in this setting, positives are confirmed, and Gram stains are inadequate in prepubertal children. A report is required when a provider has reasonable cause to suspect abuse, with details set by the state or local agency, so it does not wait for further tests or a better story about towels. Presumptive treatment is not routine after child sexual abuse, but a confirmed infection is treated. Physical-abuse patterns are on Pediatric Emergencies and forensic detail on Forensics, Abuse and Sexual Assault in the ED.

Exam pearls

• Recent preparatory behavior makes the screen high risk even when today's ideation is passive.
• One-to-one observation does not pause for the bathroom.
• A thin teen who feels fat: SCOFF and orthostatic vital signs, asked privately; normal BMI does not exclude danger.
• Hypoglycemia in anorexia recurs and does not answer to glucagon: dextrose infusion and admission.
• Fear of choking with weight loss and no body-image concern: ARFID.
• Knuckle scars, parotid swelling, eroded teeth: ask about purging, check potassium.
• Energy drinks and HR 148: monitor and ECG before calling it stress.
• Crisis intervention aims to restore the pre-crisis level of function.
• 3 days to 1 month: acute stress disorder; trauma-focused CBT, not a detailed one-off debriefing.
• Reproductive coercion goes with IPV; offer long-acting contraception the partner is less likely to detect.
• An STI in a prepubertal child is reported; Gram stain is inadequate.