Initiating Psychiatric Medications in the Emergency Department: The Depressed Patient

The Growing Burden of Psychiatric Presentations in the ED

Emergency departments (ED) across the United States are experiencing a sustained increase in psychiatric presentations. Between 2016 and 2022, the proportion of ED visits with a psychiatric complaint as the primary diagnosis rose steadily, with depressive and anxiety disorders accounting for the largest share (CDC, 2026; CDC NSSP, 2026). National surveillance data confirms that mental health-related ED visit rates have climbed year after year, placing growing pressure on emergency departments that were never designed to serve as the entry point for psychiatric care (CDC, 2024; CDC, 2025).

This demand collides with a well-documented shortage of outpatient psychiatric services (HRSA, 2024). Many patients have no established provider, and even those with a primary care physician may wait weeks or months for an appointment. Primary care physicians routinely initiate psychiatric medications — emergency physicians can do the same for appropriate, dischargeable patients.

Case Presentation

A 21-year-old female college student with no past medical history presents to the ED under an involuntary psychiatric hold for suicidal ideation after her parents became concerned when she stated that she doesn’t think “life is worth living.”

On evaluation, she reports sleeping only 3–4 hours per night, poor appetite, difficulty concentrating, and guilt about not meeting her parents’ expectations after failing organic chemistry. She states, “If I fail my O-chem class, again, my life is over.” She asks to leave, frustrated that the psychiatric hold is keeping her from studying for her final exam.

She denies access to firearms, has no history of self-harm, and no prior psychiatric admissions.  When asked what prompted today’s evaluation, she reports that she simply told her parents, “I wish I could get some sleep, I don’t care if I wake up.”

Collateral from parents: The patient’s parents who initiated the psychiatric hold report that the patient is always stressed during exams. She has never mentioned wanting to kill herself, made plans to end her life, or engaged in self-harm. They confirm that she does not have access to guns.

Collateral from roommate: Her roommate reports, “She always gets like this around exams” When asked about how long her mood has been down, the roommate reports that two months ago, around her birthday, the patient was very social — going out dancing every night, celebrating her “birthday month.” The roommate was surprised she still had energy to keep up with classes but figured it was because she was using MDMA and cocaine at the time. The roommate also noticed the patient buying a significant amount of new jewelry, designer bags and clothes, which she attributed to celebrating her 21st birthday. Roommate notes no safety concerns at home, is willing to lock up knives, medications, and cleaning chemicals.

ED course: Patient was offered voluntary admission but declined. Patient acknowledges she has been depressed recently and is willing to seek care in the outpatient setting. However, she is reluctant to stay for an inpatient psychiatric admission, noting her organic chemistry final is in 2 days. Social work schedules a therapist appointment in 3 days and a psychiatrist in 6 weeks. Her PCP agrees to see her in 2 weeks.

MDM: 21-year-old woman presenting with depression with acute exacerbation in the setting of acute psychosocial/school stressors, not currently engaged in outpatient psychiatric care or psychotherapy. The roommate’s collateral raises concern for a possible manic or hypomanic episode preceding patient’s current depressive presentation. However, the possible manic episode occurred in the context of concurrent substance use (MDMA, cocaine) confounding the clinical picture. Although the patient’s presentation today is most consistent with a depressive disorder, it remains unclear if her underlying diagnosis is unipolar depression vs. bipolar disorder with current depressive episode.

Today’s presentation and collateral are most consistent with passive death wish — opposed to suicidal ideation. Provided the limited diagnostic clarity in the ED, this patient will benefit from initiation of olanzapine 5 mg at bedtime, which is therapeutic for both unipolar and bipolar depression while avoiding the risk of inadvertently triggering a manic episode.  Reassuringly, she has no active SI at the time of evaluation and no plans for self-harm.

Although she may be at elevated chronic risk in the setting of her mood disorder and substance use, she is at low acute risk for self-harm at this time. Patient was offered a voluntary psychiatric admission which she declined and does not meet criteria for involuntary psychiatric admission. The patient has support in her parents and roommate who is willing to reduce access to sharps and chemicals. The patient is willing to engage with mental health resources in the outpatient setting, has completed a safety plan prior to discharge, and will be provided with crisis resources including 988 at the time of discharge.

Recognizing the Dischargeable Psychiatric Patient

Many emergency physicians hesitate to discharge patients who present with psychiatric complaints. Obtaining collateral from reliable informants is critical for identifying patients who are safe for discharge. Patients can mask their psychiatric symptoms to achieve alternative goals, such as avoiding hospitalization.

Reaching out to the patient’s outpatient team, family/friends, and/or the individual who initiated the psychiatric evaluation is critical for understanding of the patient’s illness course and identifying acutely decompensated patients who may benefit from psychiatry consultation and possibly admission.

A patient who presents clinically sober, without overt psychosis, and with a linear thought process allows for a more reliable and comprehensive assessment. Key elements supporting safe discharge include future-oriented thinking, denial of access to lethal means (firearms), protective factors such as family/friend support and future-oriented goals, and often, willingness to engage in outpatient care. Documentation should reflect that the patient was clinically sober without signs of psychosis, was not an imminent harm, had low acute risk (even if chronic risk is elevated), that admission was considered, and that a safe discharge plan was established including the components of the plan.

As with any emergency patient, a thorough history with collateral and examination helps identify patients who are safe for discharge.

Initiating Medications:

Initiating psychiatric medications at discharge can be a critical step in progressing care. The shortage of psychiatrists and primary care physicians often delays care for patients who need more timely treatment. The emergency physician, as with so many other conditions, can play a critical role in bridging this gap.

The first medication trialed may not provide adequate relief, and patients often need to trial multiple regimens. Initiating treatment in the ED gives patients a “head start,” providing their outpatient team with a datapoint to assess medication effectiveness.

Screening for Mania Before Prescribing

Before initiating an antidepressant, screen for manic or hypomanic episodes. Starting an SSRI in undiagnosed bipolar disorder can precipitate mania (Hirschfeld et al., 2010). The DSM-5-TR criteria for a manic episode require a distinct period of abnormally elevated, expansive, or irritable mood and increased goal-directed activity or energy lasting at least one week (APA, 2022).

The episode must not be attributable to the physiological effects of a substance or another medical condition. When there is any suspicion of a bipolar spectrum disorder — even if uncertain — it is safer to initiate an atypical antipsychotic rather than an antidepressant (Hirschfeld et al., 2010).

Antidepressants

For patients presenting with depression — without concerns for previous mania — and appropriate for discharge, first-line options safe for ED initiation include the following (Gelenberg et al., 2010; Wagner et al., 2018):

Selective Serotonin Reuptake Inhibitors (SSRIs)

• Fluoxetine: start at 10 mg daily, increase to 20 mg after one week
• Sertraline: start at 25 mg daily, increase to 50 mg after one week
• Escitalopram: start at 5 mg daily, increase to 10 mg after one week

Norepinephrine Dopamine Reuptake Inhibitor (NDRI)

• Bupropion: 150 mg daily (taken in the morning)

Patients should be counseled that SSRIs are typically increased from the starting dose to the target dose after one week, and that full therapeutic effect takes four to six weeks. Setting these expectations helps with adherence and prevents premature discontinuation.

Considerations for SSRIs

SSRIs carry a black box warning for increased suicidal ideation in young adults (FDA, 2007), which should be discussed with patients and documented. Other notable adverse effects include serotonin syndrome, appetite changes, and the potential to precipitate mania in patients with undiagnosed bipolar disorder (Gelenberg et al., 2010; Wagner et al., 2018).

Among the SSRIs, fluoxetine has a long half-life and is less likely to result in withdrawal symptoms if the patient is unable to obtain refills. On the other hand, sertraline and escitalopram have been shown to be more effective than fluoxetine in head-to-head comparisons (Cipriani et al., 2018).

Bupropion Considerations

Bupropion should be avoided in patients with eating disorders, seizure disorders, or a history of mania. It can worsen anxiety and cause sleep disturbance, making it less ideal when depression is accompanied by prominent anxiety or insomnia (Gelenberg et al., 2010). Bupropion may be helpful in treating concurrent ADHD (Wilens et al., 2001).

Atypical Antipsychotics:

Atypical antipsychotics are not only a safer alternative to avoid triggering mania — they are also independently therapeutic for depression and bipolar disorder (Nelson & Papakostas, 2009). For patients with suspected or confirmed bipolar disorder who do not meet criteria for admission, low-dose atypical antipsychotics can be safely initiated in the ED (Cipriani et al., 2011; Yildiz et al., 2015):

• Olanzapine: 2.5–5 mg at bedtime
• Risperidone: 0.5–1 mg at bedtime
• Quetiapine: 50–100 mg at bedtime

Atypical Antipsychotic Considerations

Important adverse effects include metabolic side effects (weight gain, glucose dysregulation), orthostatic hypotension, QTc prolongation, akathisia, extrapyramidal symptoms, and — rarely — neuroleptic malignant syndrome. Consider a baseline EKG before initiation, especially if the patient is taking multiple QTc prolonging medications (Cipriani et al., 2011; Yildiz et al., 2015).

Discharge Planning

Prescribing a medication is only part of the intervention. Thoughtful discharge planning bridges the gap between the ED visit and ongoing outpatient care.

Safety Planning. The walks patients through warning signs, coping strategies, social supports, professional resources, and lethal means reduction.

Follow-Up Scheduling. Schedule follow-up before the patient leaves. National resources such as SAMHSA’s treatment locator (findtreatment.gov) allow providers to locate therapy, medication management, substance use programs, and crisis centers by geography and population served (SAMHSA, 2026).

Leveraging Informants. Collateral contacts provide context for baseline functioning and serve as a safety net after discharge.

Follow-Up Phone Call. Tell your patients you plan to call them in a few days. This helps hold patients accountable to the outpatient plan and provides an opportunity to recommend more urgent or repeat ED evaluation if needed.

Crisis Resources. Ensure every patient leaves with crisis contact information, including the 988 Suicide & Crisis Lifeline.

Summary

The increasing utilization of emergency departments for psychiatric care places emergency physicians in a unique position to fill the gap caused by the national shortage of PCPs and psychiatrists. To do so, we must first identify which psychiatric patients are at low acute risk and safe for discharge. Second, we must identify which first-line agents a patient could safely benefit from pending outpatient follow-up. By taking these two steps, we can better care for low-risk patients suffering from depression while helping partially fill the gap in mental healthcare.

link to website

https://sprc.org/resources/stanley-brown-safety-plan/

Photo Credit: Pavel Polyakov