Psychiatry, substance use & safeguarding

Introduction and acknowledgement

“Hello. My name is Dr Smith and I am one of the doctors working in the Emergency Department today.”

“Before we start, can you confirm your name and date of birth for me please?”

“Are you comfortable? Do you need any pain relief?”

Offer a drink or other comfort when clinically appropriate. Check communication needs and arrange an appropriate interpreter if needed.

Current problem

“Are you OK to tell me about why you have come to hospital today?”

Let the person give their account, then explore the onset, course, impact and relevant symptoms. Ask directly and sensitively about self-harm, suicidal thoughts, intent, plans and access to means, as well as risks from others and to others. Explore what helps them cope and who can support them.

Background

“Can I find out a little more about you and the support you have at the moment?”

• Past history: medical, surgical, psychiatric and relevant reproductive history; previous crises, admissions and support.
• Medicines and allergies: prescribed, over-the-counter and other substances; recent changes and adherence.
• Family and social context: family history, smoking, alcohol and recreational drugs; work, housing, relationships and support. Ask about travel when relevant.
• Safeguarding: children or other dependants, caring responsibilities and existing support services. Ask sensitively about safety at home, coercion, abuse and exploitation, in private when appropriate.

Mental state examination: ASEPTIC

Use ASEPTIC to organise what you observe and what the person describes. It supports the conversation; it should not replace listening.

Appearance and behaviour

• Describe dress, self-care, activity, engagement and behaviour objectively and in context. Avoid assumptions based on appearance.

Speech

• Rate, volume, tone, fluency and quantity; note pressured speech or long pauses.
• Record disturbances in the organisation of ideas under thought form below.

Emotions: mood and affect

• Ask how the person describes their mood, such as low, anxious, elevated or irritable.
• Describe observed affect: range, reactivity and whether it fits the conversation.

Perceptions

• Explore illusions (misinterpretations of real stimuli) and hallucinations, including auditory, visual or other experiences.
• For voices, ask what they say, whether they address or discuss the person, and whether there are commands or associated safety concerns.
• Explore depersonalisation or derealisation when relevant: feeling detached from oneself or from the surrounding world.

Thoughts

• Form: the organisation and flow of ideas. Examples include flight of ideas, loosely connected or “knight’s move” associations, thought blocking, neologisms and markedly disorganised speech.
• Content: preoccupations, obsessions, hopelessness and delusional beliefs, such as persecutory or grandiose ideas. Delusions belong here, rather than under perception.
• Ask about experiences of thought insertion, withdrawal, broadcasting or external control when indicated.

Insight

• What does the person understand about their experiences? Do they think they are unwell, and what help do they think they need?
• Insight and decision-making capacity are related considerations, but are not interchangeable.

Cognition

• Consider attention, orientation, memory and change from usual functioning. Obtain collateral history where appropriate.
• Choose a cognitive assessment for the clinical question. Acute or fluctuating confusion should prompt delirium assessment; see the cognitive screening section.

Summary to the examiner

Summarise the presenting problem, relevant ASEPTIC findings, immediate concerns and your working formulation. State what you have not assessed; do not present an assumption as a normal finding.

“In summary, Mrs Jones has presented with X. On my assessment her appearance and behaviour are…; speech…; mood and affect…; perceptions…; thought form and content…; insight…; and cognition… . My immediate concerns are… . I still need to clarify… .”

Plan

“Thank you for your time and for speaking to me.”

“I am worried about X and I think it would be useful to ask the mental health team to come and speak to you. What would you think about this? Are you happy to stay for this?”

After self-harm, explain the next steps in language the person can understand. For example:

“I would like us to work out what support you need and how we can help you stay safe. I will ask the mental health team to assess you while we continue any physical treatment. What matters most to you at the moment?”

Summarise immediate needs, safeguarding concerns and any decision-specific capacity questions. Agree the care plan with the person and relevant team; use the self-harm section below.

“Does that sound reasonable to you? Do you have any questions or concerns?”

Read more: RCEM mental health in the ED toolkit (2023).

Do not use SADPERSONS, other risk scores, or low/medium/high categories to predict suicide or repeat self-harm, or to decide treatment or discharge. Use an individual assessment of needs and safety.

• Assess and support. Address physical treatment and urgent safety concerns; arrange early, age-appropriate mental health assessment. Explore the person’s circumstances, current suicidal thoughts, concerns, strengths and support. An ED history does not replace specialist psychosocial assessment.
• Formulate and plan. A mental health professional should develop a risk formulation during psychosocial assessment. Consider developing a personalised safety plan with the person, covering warning signs, coping strategies, supportive contacts, crisis help and reducing access to means. Make it accessible to them.
• Plan discharge and aftercare. Before general-hospital discharge after self-harm, complete psychosocial assessment and a management plan, hold a discharge planning meeting with the appropriate people and agencies, and specify aftercare with written communication to primary care. If safety concerns continue, ensure the responsible team provides initial aftercare within 48 hours of psychosocial assessment.

Station focus. In a FRCEM station, explain the concerns, uncertainties and support informing your plan. Coordinate care with the mental health team and document who is responsible for follow-up.

Self-harm guidance updated 5 October 2026. See NICE NG225: Self-harm — assessment, management and preventing recurrence, particularly sections 1.5–1.6, 1.7, 1.9–1.11.

The AMTS is a brief cognitive screen. Each correct answer scores one point, giving a total out of 10. Use the wording and interpretation of your approved local version and record factors such as language, hearing or educational background that may affect the result.

The traditional prompts in the BGS AMTS form cover:

1. Age
2. Time to the nearest hour
3. An address to recall at the end, for example 42 West Street
4. Current year
5. Hospital or current location
6. Recognition of two people
7. Date of birth
8. The year the First World War began
9. The current monarch or other leader specified by the form
10. Counting backwards from 20 to 1

A score alone does not diagnose delirium or dementia and does not establish capacity. Interpret it alongside the history, baseline function and examination.

If there is acute or fluctuating change suggesting delirium, use the 4AT in the usual ED setting, with appropriate clinical assessment. NICE specifies CAM-ICU or ICDSC in critical care or postoperative recovery instead.

Read more: NICE CG103 — delirium assessment (updated 2023).

The Mini-Mental State Examination (MMSE) is a structured cognitive assessment. If it is required, use the approved form and administration instructions available in your service, with appropriate communication support.

It is one part of a wider assessment. Consider baseline ability, collateral history, language, education, sensory difficulties and potentially reversible causes. A normal cognitive score does not, by itself, rule out dementia.

For acute confusion, prioritise assessment for delirium. For a treatment decision, assess capacity for that particular decision; neither an MMSE nor an AMTS score substitutes for that assessment.

NICE NG97 — cognitive assessment for suspected dementia · NICE CG103 — delirium

England and Wales: the Mental Capacity Act 2005 (MCA) applies from age 16. Capacity concerns a particular decision at the time it is needed. Other UK nations have different legislation.

• Presume capacity; take all practicable steps to support the person to decide.
• An unwise decision alone is not evidence of incapacity. A diagnosis, intoxication or being disorientated does not automatically establish incapacity.
• A person lacks capacity for the decision only if, because of an impairment or disturbance of mind or brain, they cannot perform one or more of the relevant decision-making functions.

The functional assessment

• Understand the relevant information, options and reasonably foreseeable consequences.
• Retain that information long enough to make the decision.
• Use or weigh the information as part of deciding.
• Communicate the decision by any means.

Identify the impairment or disturbance, the functional difficulty and the link between them. Orientation questions can contribute to the clinical assessment, but they are not the legal test.

Children and young people

At 16 and 17, capacity to consent is generally presumed. A child under 16 may be able to consent when they have sufficient understanding and maturity for the proposed decision (Gillick competence). Fraser guidelines concern contraceptive advice and treatment for under-16s; they are not a general substitute for assessing competence.

Refusal by a child or young person can raise complex legal issues. Seek senior, paediatric and legal advice where necessary, especially for refusal of potentially lifesaving treatment; avoid the blanket statement that a competent young person can never refuse.

NICE NG108 — decision-making and mental capacity · GMC 0–18 years — making decisions

Introduction

“Hello. My name is Dr Smith and I am one of the doctors working in the Emergency Department today.”

“Before we start, can you confirm your name and date of birth for me please?”

“Are you comfortable? Do you need any pain relief?”

Explain the reason for meeting

“I gather you came to hospital because of… . The nursing staff are concerned about… and have asked me to come and talk to you. Would that be OK?”

Explore the patient’s understanding

“What is your understanding of what is going on and why you are in hospital?”

Specify the decision—for example, whether to accept treatment for this injury or remain for this assessment. Explain the options and support decision-making with an interpreter, communication aids, pain relief, a quieter space or a trusted supporter as appropriate. Consider whether it is safe to wait for a reversible impairment to improve.

Assess capacity for this decision

Assess the possible impairment or disturbance clinically. Ask about confusion and relevant symptoms; do not equate orientation with capacity.

Understand and retain

“So I can check we both understand one another, can you summarise what the options are and what my concerns for you are?”

Check understanding of the relevant consequences, including declining treatment, and retention long enough to decide. Explain again in a different way where needed.

Use or weigh

“I recommend that you stay in hospital/have… because… . My concerns if you don’t are… . What do you think about this? Can you tell me your reasons for not wanting it?”

Communicate

“Based on what we have discussed, can you tell me what your wishes are? Is there anyone you would like to discuss this with?”

Allow communication by any effective means. Record the person’s answers and your reasoning, including whether any functional inability results from the impairment or disturbance.

The patient has capacity

“I understand your decision. Could we discuss an alternative plan and how to get help if things change?”

Respect a valid, informed refusal by an adult with capacity. Offer alternatives, safety-netting and follow-up, and document the discussion. Capacity alone is not an automatic discharge decision: consider the full clinical situation and whether separate Mental Health Act criteria require urgent specialist assessment.

The patient lacks capacity

Explain your conclusion and involve the person as much as possible. Identify who has legal responsibility for the decision; check for a relevant attorney or deputy and any valid, applicable advance refusal. Consider the person’s wishes, values and beliefs, consult appropriate people, and select the least restrictive option that meets their best interests.

Seek senior input, a second opinion or legal advice for uncertainty or dispute, and involve an advocate where required. Lack of capacity is not a blanket authority for restraint or deprivation of liberty; establish the applicable lawful basis and safeguards.

Document and review: the specific decision, support offered, evidence for the assessment, the agreed plan, who is responsible and when capacity needs reassessment.

NICE NG108 · NHS — assessing capacity · GMC — decision making and consent

England and Wales; adult patient. Start with immediate physical needs, a calm conversation and early senior ED and liaison psychiatry help. Explore why they want to leave and address practical barriers to staying.

“I hear that you want to go home. I’m concerned about the overdose and how you’re feeling. Can we talk about what is making it difficult to stay, and what could happen if you leave before we finish assessing and treating you?”

Work through the decision

• Support and assess capacity: specify the decision about refusing the recommended care. Explain the options and consequences; check understanding, retention, use or weighing of information, and communication. Link any inability to an impairment of mind or brain. Alcohol use or an unwise choice alone does not prove incapacity.
• Assess safety: explore current suicidal thoughts, intent, access to means, mental state, support and safeguarding. Assess safety and mental health before departure; offer psychosocial assessment alongside physical care.
• Choose the lawful next step: if mental disorder and serious safety concerns suggest MHA criteria may be met, urgently involve liaison psychiatry and the AMHP service. Establish the actual legal authority for any restriction while assessment is arranged. If the person lacks capacity, use the MCA best-interests process for necessary care, checking relevant advance decisions and safeguards. If an adult has capacity, makes a valid informed refusal and no other lawful authority applies, respect that refusal.

Do not assume that requesting an MHA assessment authorises detention. Section 5 holding powers do not apply to ordinary ED attenders. Seek immediate senior and legal advice when the lawful basis is uncertain.

Make the plan explicit

Document the discussion, capacity reasoning, safety concerns and legal basis. Agree observation or follow-up, crisis contacts and who is responsible. Offer a written safety plan and appropriate support; follow the local pathway if the person leaves before care is complete.

NICE NG225 — assessment and leaving before care is complete · NICE NG108 — capacity · NHS — Mental Health Act · NHS — limits of Section 5(2)

England and Wales: the Mental Health Act (MHA) provides powers and safeguards for assessment and treatment of mental disorder. It is separate from the Mental Capacity Act: a person may have capacity and still meet criteria for detention under the MHA.

Seek early liaison psychiatry, approved mental health professional (AMHP) and senior ED input. Consider voluntary care and the least restrictive safe option; the legal criteria and process for the particular section must be met. “Best interests” alone is not the MHA detention test.

2025 reform: changes are being introduced in stages. Use the provisions currently in force, current statutory guidance and your local Mental Health Act team. The quick reference below reflects the NHS guidance checked on 5 October 2026; it is not a complete statement of each section’s criteria.

Sections at a glance

ED points that matter

• Section 5 does not apply to ordinary ED attenders or other outpatients. It is an inpatient holding power; do not assume it becomes available simply because someone is physically in hospital.
• Section 136 can apply in places other than a private dwelling and its associated private garden/buildings, including an ED. It is a police power, not a power an ED doctor can simply impose.
• For Section 136, record arrival at the first place of safety, including ED: transfer does not restart the clock. An extension of up to 12 hours is possible only under the statutory conditions relating to the person’s condition, not simply because assessment or a bed is delayed.
• Explain rights and the assessment plan; agree observation, handover and responsibility with the relevant teams. Detention does not automatically authorise every treatment, including unrelated physical treatment.

NHS — current Mental Health Act overview · RCEM Section 136 guide (2025) · NHS inpatient Section 5(2) procedure (2026) · Mental Health Act 2025: commencement

Alcohol and other substance use are common and important ED presentations. Possible stations include:

• The acutely intoxicated person: physical assessment and communication.
• An intoxicated person wishing to leave: a decision-specific capacity assessment.
• Severe agitation or acute behavioural disturbance: early senior assessment, de-escalation and treatment of the cause.
• A Making Every Contact Count (MECC) conversation.

The approach below focuses on an alcohol conversation. Adapt the history for other drugs, including what was taken, route, amount, timing and other substances.

Introduction and immediate needs

“Hello. My name is Dr Smith and I am one of the doctors working in the Emergency Department today.”

“Before we start, can you confirm your name and date of birth for me please?”

“Are you comfortable? Do you need any pain relief?”

“The nursing staff are concerned that you are a little shaky and sweaty. How are you feeling?”

Assess urgent illness or withdrawal before a brief intervention. Check observations, glucose and relevant physical problems. Do not assume altered consciousness is solely due to alcohol.

Background

• Past history: medical, surgical, psychiatric and relevant reproductive history; previous crises, admissions and support.
• Medicines and allergies: prescribed, over-the-counter and other substances; recent changes and adherence.
• Family and social context: family history, smoking, alcohol and recreational drugs; work, housing, relationships and support. Ask about travel when relevant.
• Safeguarding: children or other dependants, caring responsibilities and existing support services. Ask sensitively about safety at home, coercion, abuse and exploitation, in private when appropriate.

Alcohol focus

“It sounds as though you drink alcohol fairly regularly. Would it be OK if I asked you some more questions about that?”

• What do you drink, how much, how often and over what period? Clarify container size and strength to estimate UK units.
• When was the last drink? What happens if you reduce or stop? Ask about morning drinking, previous withdrawal, seizures, delirium tremens and previous treatment.
• Explore physical and mental health effects, nutrition, injuries, relationships, work, caring responsibilities and safety. Ask about medicines and other substances.

Use the UK AUDIT questionnaire or its brief consumption screen, AUDIT-C, rather than relying on CAGE alone. An AUDIT-C score of 5 or more prompts the full AUDIT. Screening informs further assessment; it does not establish a diagnosis.

Read more: DHSC identification and brief interventions (updated 2026).

Explore views and agree a plan

“What do you think about the amount you drink? Do you think alcohol might have played a part in what happened today?”

“Have you thought about talking to someone about your drinking? Would you like me to ask the alcohol team to see you?”

Ask permission to offer advice and link it to the person’s priorities. For adults who drink, UK lower-risk guidance is not to regularly exceed 14 units a week, spread over 3 or more days. Lower risk does not mean no risk.

If dependence is possible, do not advise abrupt unsupported cessation. Arrange assessment and a safe plan for withdrawal and ongoing treatment. Severe withdrawal, seizures, delirium or suspected Wernicke’s encephalopathy require urgent hospital treatment.

Close

“Thank you for talking openly with me. Let us agree what help you need today and what will happen next.”

Offer referral and agree realistic follow-up. If withdrawal treatment is indicated, use the local regimen with skilled monitoring. Assess the need for oral or parenteral thiamine according to risk; suspected Wernicke’s requires prompt parenteral treatment. Explain the treatment proposed, rather than promising a routine drip and sedative for every patient.

“What questions do you have? Could you tell me what you understand about the plan and when to seek urgent help?”

DHSC — alcohol care in acute hospitals (updated 2026) · NICE CG100 — physical complications · NHS — lower-risk drinking advice

Acute behavioural disturbance

This describes a presentation, not a diagnosis. Assess for physiological disturbance and causes such as intoxication, withdrawal, hypoglycaemia, hypoxia or head injury. Seek senior ED help promptly. Use verbal and environmental de-escalation where possible; severe cases may need early sedation by trained staff with appropriate monitoring and resuscitation capability. Follow the current local protocol and RCEM guidance (2026).

Address the injury and immediate safety, and involve a senior clinician and the paediatric safeguarding team promptly. Listen at the child’s pace, using age-appropriate, open questions. Record their own words and your findings; avoid leading questions or repeated investigative interviewing.

“I’m glad you told me. You haven’t done anything wrong. My job is to help keep you safe. I need to tell the team who help children, and I’ll explain what happens next.”

Turn the concern into a plan

• Refer: make a referral to children’s social care through the local safeguarding pathway. If there is immediate danger, contact children’s social care and/or the police urgently.
• Share carefully: explain what needs to be shared and with whom. Ask about other children at risk. Take safeguarding advice before telling a parent or alleged abuser if doing so could increase danger or compromise an investigation.
• Agree immediate safety: with the relevant teams, establish where the child will be safe, who will care for them and who will follow up. Involve the child and appropriate carers, check their understanding, and document named responsibilities, timescales and emergency contacts. Resolve immediate safety arrangements before discharge; a referral alone is not a completed plan.

Pause and check: have you explained the referral without promising secrecy, asked what worries the child, and made clear who will do what next?

Read more: NICE NG76 — child abuse and neglect (communication, referral and planning).

• Section 136 — RCEM guide (2025)
• Mental health in the ED — RCEM toolkit (2023)
• Decision-making and mental capacity — NICE NG108
• Consent — GMC current guidance
• Children and young people — GMC decision-making guidance
• Domestic violence and abuse — NICE PH50
• Child abuse and neglect — NICE NG76
• FGM: child protection assessment and mandatory reporting — 2026 guidance
• Sexual assault and rape — RCEM adult ED guidance (2026)
• Suspected internal drug trafficking — RCEM (2020, currently listed)
• Paediatric clinical guidelines — RCPCH directory

For abuse of an older person, use your local adult safeguarding pathway and the applicable national framework. Consider care needs, coercion, neglect, financial abuse and the person’s wishes; do not assume that age alone means incapacity.

• Mental health assessment and psychiatric emergencies — RCEM toolkit
• Self-harm — NICE NG225
• Autism in adults — NICE CG142
• Bipolar disorder — NICE CG185
• Depression in adults — NICE NG222
• Delirium — NICE CG103
• Generalised anxiety and panic disorder — NICE CG113
• Obsessive-compulsive disorder — NICE CG31
• Post-traumatic stress disorder — NICE NG116
• Psychosis and schizophrenia — NICE CG178
• Eating disorders — NICE NG69
• Medical Emergencies in Eating Disorders (MEED), CR233 — replaces MARSIPAN and Junior MARSIPAN
• Paediatric clinical guidelines — RCPCH directory

• Drug misuse and the ED — RCEM (2019, currently listed)
• Acute behavioural disturbance — RCEM (2026)
• Alcohol care in acute hospitals — DHSC (updated 2026)
• Identification and brief interventions — DHSC (updated 2026)
• UK AUDIT and AUDIT-C screening forms — GOV.UK
• Alcohol withdrawal and physical complications — NICE CG100
• Lower-risk drinking advice — NHS
• Opioid dependence — NICE CKS (UK access)
• Smoking cessation — NICE CKS (UK access)
• Paediatric clinical guidelines — RCPCH directory

Older RCEM documents remain labelled with their publication dates. Check the current RCEM guidance directory and your local pathways when revising or practising.