Evidence briefing

Assessment and management of psychosis in emergency departments

Written by a language model from the cited research, from 5 full texts and the abstracts of the other 7. No human author wrote or checked this text. Not peer reviewed.

Generated 21 August 2026 · 12 sources cited, 2011–2026 · Full text read for 5 of 12 sources · Not peer reviewed

SubjectWhat does the evidence show about psychosis in emergency departments?

QuestionWhat is known about the volume, assessment and management of psychosis among people who present to emergency departments, including substance-related and pandemic-period patterns?

AnswerDirect evidence on psychosis care in emergency departments appears thin. One scoping review identified no eligible studies of brief behavioural or care-process interventions for adults with acute psychosis. A 2016 consensus conference listed screening and management protocols as high-priority gaps. Remaining work is largely observational. Cannabis legalization in Ontario and Alberta was not associated with a detected step increase in cannabis-induced psychosis or schizophrenia emergency visits. Two uncontrolled COVID-period series reported higher psychosis or new-onset psychosis and mania activity early in the pandemic, without establishing a causal mechanism. A single naturalistic sample reported that a five-item agitation subscale tracked clinician-rated severity in a psychiatric emergency room. Related first-episode, substance-use and methamphetamine studies describe how patients reach emergency care but are not tests of emergency-department interventions. No controlled evaluation of de-escalation or follow-up protocols for primary psychosis in this setting was identified.

Keywords psychosis; emergency department; agitation; cannabis-induced psychosis; covid-19; first-episode psychosis; methamphetamine; de-escalation

What the evidence shows

Every figure in this review was checked against the material read for the cited sources — their abstracts, and the open-access full text where one was retrieved. † marks a figure that could not be found there; ‡ marks one found only in a source other than the one cited. See Limitations.

A scoping review searching multiple databases through March 2023 mapped brief emergency-department behavioural and care-process studies for suicide, overdose or psychosis and reported that none enrolled adults with acute psychosis from a primary mental health condition.¹ Of 40 included reports, most (n=34) examined suicide attempt or ideation and eight examined opioid overdose; the reviewers did not assess study quality or rate strength of effectiveness.¹
Using a nominal group technique, a Coalition on Psychiatric Emergencies working group of emergency and psychiatric specialists reduced 28 candidate questions to six ranked research needs on screening and identification and on intervention and management of psychotic spectrum disorders in the emergency department.² The group judged that standardised screening, intervention and outcome measurement in emergency settings had not moved beyond attention to agitation.²
In the observational NATURA sample of 278 patients^† with acute psychosis and agitation in a psychiatric emergency room, the Excited Component of the Positive and Negative Syndrome Scale was unifactorial, Cronbach alpha was 0.86, and scores rose 3.4^‡ points per Clinical Global Impression–Severity point.³ In the same sample, scores fell an average of 5.5 points per Agitation and Calmness Evaluation Scale point, and the effect size for detected change was 1.44.³
Seasonal autoregressive models of weekly Ontario and Alberta emergency counts from April 2015 to December 2019 detected no legalization step change for cannabis-induced psychosis (5832 presentations; 0.34^‡ visits per week, 95%^‡ CI −4.1^‡ to 4.8^‡) or schizophrenia-spectrum conditions (211661 presentations). Cannabis-induced psychosis presentations doubled across the whole interval.⁴ Parallel models likewise showed no significant step for amphetamine-induced psychosis (1.93 visits per week) or alcohol-induced psychosis (0.61 visits per week); the authors cautioned that Canada’s rollout may be idiosyncratic.⁴
A South Florida series of 508 psychiatric admissions, including 367 psychosis cases, found higher mean psychosis admissions in March–July 2020 than in the preceding five months (p = 0.04^‡), a 22.9%^‡ rise.⁵ Correlation with COVID-19 admissions in that series was positive (r = 0.5) but not statistically significant (p = 0.06), and substance-induced psychosis was excluded.⁵ Manual review of 5161 visits at two Israeli psychiatric emergency departments found new-onset psychosis or mania in 326 records, with the proportion increasing from 137 of 2479 visits (5.5%^‡) in 2019 to 189 of 2367 (8.0%^‡) in 2020 (p = 0.001^‡).⁶ The Israeli April 2020 peak (9.4% versus 4.7%, p = 0.015) did not track national COVID-19 incidence, and polymerase chain reaction tests were negative except in a single case.⁶
In linked Western Australian data on 7568 adults^‡ whose substance use disorder diagnosis preceded a primary psychotic disorder, the median diagnostic interval was 1.9 years and psychosis was most often recorded in emergency departments (46%^‡).⁷ Initial substance-use diagnoses in that cohort occurred most often as inpatients (62%), and women had a 7-month longer diagnostic interval than men.⁷ Among 279 first-episode patients in the Parma early-psychosis programme, 28.7%^‡ were referred from the emergency room or general hospital.⁸ Emergency-referred Parma participants showed a higher percentage of current suicidal ideation than those entering by other routes, and 31 (11.1%) dropped out during the first treatment year.⁸
In a propensity-matched Ontario cohort of incident nonaffective first-episode psychosis, early-psychosis-intervention users had lower emergency-department presentation rates over two years than non-users (hazard ratio 0.71, 95%^‡ CI 0.60^‡–0.83^‡); this finding is an extrapolation from specialised programmes rather than an emergency-department trial.⁹ Programme users also had lower all-cause mortality over two years (hazard ratio 0.24, 95%^‡ CI 0.11–0.53), without a significant difference in self-harm or suicide, and those service-use differences were not observed after two years.⁹
An integrative review of ten studies reported that methamphetamine accounted for 2.3%^‡ or less of emergency-department presentations and that these visits were more likely to involve psychosis, 24-hour^‡ psychiatric hold, agitation and police accompaniment.¹⁰ Presenters in that literature were predominantly male, with a mean age of 31–37 years, and were more often seen out of hours than other substance-related visits.¹⁰

What remains open

Controlled trials of brief emergency-department psychological, safety-planning or follow-up interventions for primary acute psychosis have not been reported in the scoped literature. That review identified one underway psychosis study, so the empty map may not persist, but results are not yet available.¹
Whether early-pandemic increases in psychosis visits reflect new incidence, delayed community care or case-shifting among settings remains unresolved, because neither COVID-period series established a causal mechanism. The Israeli investigators judged direct infection unlikely, given negative testing and a timeline that did not follow the second-wave caseload, whereas the Florida analysis could not attribute the rise to COVID-19 diagnosis.^5,6
Non-verbal de-escalation and Safewards adaptations have been described for emergency nursing and for police-accompanied mental health attendances, but no psychosis-specific controlled evaluation of restrictive-intervention outcomes was identified.^11,12 The Safewards emergency subgroup comparison was observational, mixed mental-health presentations, and has not been replicated as a psychosis trial.¹²
Emergency diagnostic coding often does not separate substance-induced from primary psychosis, which limits interpretation of legalization and stimulant-related series. How synthetic-cannabinoid or methamphetamine presentations should be counted alongside primary psychosis in emergency datasets is therefore uncertain.

Methods

Search strategy. Candidate records were retrieved on 21 August 2026 from OpenAlex, Europe PMC and arXiv, using the search strings ‘psychosis emergency department’; ‘acute psychosis emergency department’; ‘first-episode psychosis ED’. Records without a retrievable abstract were discarded, leaving 48 for screening. Each remaining record was assessed for how directly it addresses What does the evidence show about psychosis in emergency departments? and labelled direct, related or background; 12 were cited here and are listed in Table 1. A second, targeted search then looked up 3 works named in the most relevant abstracts (‘Safewards intervention’; ‘English-language trial’; ‘ED intervention’), which added 8 further records to the pool.

Evidence handling. Titles and abstracts were read for every record, and the open-access full texts of 5 sources were retrieved from their open-access copies and read alongside them (marked in Table 1); claims resting on the remaining sources draw on no data beyond an abstract. Decimals, percentages, effect estimates and quantities carrying a clinical unit were then checked automatically, each against the sources its own sentence cites, within exactly the material shown to the model — the abstracts plus those full-text excerpts. A figure that could not be located, or that appears only in a source other than the one cited, is flagged under Limitations.

Generation. Search planning, source curation and drafting were performed by a large language model (x-ai/grok-4.6). Source retrieval, relevance tabulation, citation numbering, Table 1, Fig. 1 and the statistical check are deterministic and were not model-generated.

Evidence assessment

Of the 12 sources cited, 7 address the review question directly, 5 are related and 0 provide background only; they were published in 2011–2026. The composition of the evidence base is shown in Fig. 1.

Limitations. This synthesis was prepared from the open-access full texts of 5 cited sources and the abstracts of the remaining 7. Where only an abstract was available, effect estimates, methodological detail, and the limitations that authors report only in a full text were unavailable, so the strength of those studies could not be appraised here. One numerical value reported above (278 patients), marked † where it appears, could not be located in the material read for the cited sources — their abstracts, and the open-access full text where one was retrieved. It may originate in a part of a source that was not read, or may be unreliable, and should be verified before being quoted. 20 numerical values reported above (0.86, 3.4, 0.34, 95%, 4.1, 4.8 and 14 other(s)), each marked ‡ where it appears, are found in cited sources other than the ones their sentences credit. The figures are present in the evidence base, but the attributions do not hold and should be checked before they are quoted. The text below should therefore be read as a working draft rather than a finished review.

Table 1 | Characteristics of the cited evidence. Design is inferred from each record's title, journal and index metadata and is left blank where it could not be inferred; no quality appraisal was performed. Relevance is the curation label for how directly each source addresses the review question. Read records whether the model saw the source's open-access full text or its abstract only.

Ref.	Study	Year	Source	Design	Relevance	Read
1	Nugent et al.	2024	BMJ Open	—	Direct	Full text
2	Peltzer-Jones et al.	2019	Western Journal of Emergency Medicine	—	Direct	Abstract
3	Montoya et al.	2011	Health and Quality of Life Outcomes	—	Direct	Abstract
4	Callaghan et al.	2022	The Canadian Journal of Psychiatry	—	Direct	Full text
5	Ross et al.	2023	Cureus	—	Direct	Full text
6	Segev et al.	2021	Scientific Reports	—	Direct	Full text
7	Chai et al.	2026	Early intervention in psychiatry	—	Related	Abstract
8	Landi et al.	2020	Early Intervention in Psychiatry	—	Related	Abstract
9	Anderson et al.	2018	American Journal of Psychiatry	—	Related	Abstract
10	Jones et al.	2018	Journal of Clinical Nursing	—	Related	Abstract
11	Kruczynski et al.	2026	Emergency nurse : the journal of the RCN Accident and Emergency Nursing Association	—	Direct	Full text
12	Daniel et al.	2025	International emergency nursing	—	Related	Abstract

Glossary

PANSS-EC: The Excited Component of the Positive and Negative Syndrome Scale, a five-item rating of agitation used in acute psychosis.
First-episode psychosis: The first treated episode of a psychotic disorder, often the point at which specialised early-intervention services are offered.
Safewards: A model of staff interventions intended to reduce conflict and restrictive practices, originally developed for inpatient mental health wards.

References

Nugent, S. M., Anderson, J. & Young, S. Behavioural mental health interventions delivered in the emergency department for suicide, overdose and psychosis: a scoping review. BMJ Open (2024). Cited by 10
Peltzer-Jones, J. et al. A Research Agenda for Assessment and Management of Psychosis in Emergency Department Patients. Western Journal of Emergency Medicine (2019). Cited by 24
Montoya, A. et al. Validation of the Excited Component of the Positive and Negative Syndrome Scale (PANSS-EC) in a naturalistic sample of 278 patients with acute psychosis and agitation in a psychiatric emergency room. Health and Quality of Life Outcomes (2011). Cited by 141
Callaghan, R. C. et al. Associations Between Canada's Cannabis Legalization and Emergency Department Presentations for Transient Cannabis-Induced Psychosis and Schizophrenia Conditions: Ontario and Alberta, 2015–2019. The Canadian Journal of Psychiatry (2022). Cited by 42
Ross, C. A., Kara, S. & Ferrer, G. F. COVID-19 and Psychiatric Admissions: A Comparative Study of Pre-pandemic and Post-pandemic Psychosis Admissions in a South Florida Emergency Department. Cureus (2023). Cited by 7
Segev, A. et al. Trends of new-onset psychosis or mania in psychiatric emergency departments during the COVID19 pandemic: a longitudinal comparative study. Scientific Reports (2021). Cited by 19
Chai, K. E. K. et al. Public Health Service Clinical Journeys of Patients With Primary Substance Use Disorders Who Are Subsequently Diagnosed With Non-Affective Psychotic Disorders. Early intervention in psychiatry (2026).
Landi, G. et al. The ‘Parma‐Early Psychosis’ programme: Characterization of help‐seekers with first episode psychosis. Early Intervention in Psychiatry (2020). Cited by 31
Anderson, K. K. et al. Effectiveness of Early Psychosis Intervention: Comparison of Service Users and Nonusers in Population-Based Health Administrative Data. American Journal of Psychiatry (2018). Cited by 109
Jones, R., Woods, C. & Usher, K. Rates and features of methamphetamine‐related presentations to emergency departments: An integrative literature review. Journal of Clinical Nursing (2018). Cited by 54
Kruczynski, J., Simpson, A. & Andoh, P. Using non-verbal communication to support de-escalation in patients experiencing acute psychosis in the emergency department. Emergency nurse : the journal of the RCN Accident and Emergency Nursing Association (2026).
Daniel, C. et al. The potential for Safewards to reduce restrictive interventions for people arriving to the emergency Department with police for a mental health assessment. International emergency nursing (2025). Cited by 2

Additional information

Data availability. No new data were generated. All evidence cited is published and openly indexed; 12 of the 12 cited records resolve through the links in the reference list.

Author contributions. Search planning, source curation and drafting were carried out by an automated pipeline (articlegen, x-ai/grok-4.6). No human author wrote or verified the text before publication of this draft.

Competing interests. None declared.

Peer review. This article has not been peer reviewed and is not a publication of record.