Emergency mental-health assessment and disposition — branching viva

Stem

The examiner will test whether you can classify an emergency mental-health presentation on two independent axes, run a structured risk assessment with a validated tool, synthesise a risk stratum, match the level of care to risk, and navigate intoxication, capacity and boarding. [1] [4]

Branch 1 — Classification on two axes

Examiner: A 15-year-old is brought in calm and cooperative after telling a teacher she wants to die. Triage has placed her in a low-acuity category. How do you classify this presentation? [3]

Strong answer: I classify on two independent axes. The acuity, or triage, axis decides how soon she is seen; the suicide-risk stratum axis decides where she goes. Low acuity does not exclude high risk — a calm young person can still be at high risk of suicide — so I would assess both axes regardless of how she presents, place her in a safe, observed space, and proceed to the structured risk assessment rather than leaving her in a general waiting area. [1] [3]

Examiner: Why two axes and not one? [6]

Strong answer: Because acuity and risk are independent. If I conflate them, I reassure myself with the wrong one — a calm, well-looking young person can still be planning to die. Assessing both axes every time is how I avoid being reassured by composure and missing a high-risk presentation. [6] [3]

Branch 2 — Structured risk assessment and stratification

Examiner: Walk me through your structured risk assessment and how you reach a stratum. [1]

Strong answer: I perform a focused risk history — the method, the intent, the expectation of death, the planning, the access to means, the precipitant, the prior history, the substance use, and an abuse and bullying screen — a mental state examination looking for hopelessness, a sense of being a burden and active intent, and a validated brief screen, the Ask Suicide-Screening Questions, supported where available by the computerised adaptive CASSY. I take collateral from a parent, carer or school on the baseline and the recent change, and I weigh the protective factors. I then synthesise all of that into a working risk stratum — low, moderate or high — because the stratum, not the tool result, drives the level of care. [1] [2] [6]

Examiner: She screens positive on the ASQ. Does that decide her disposition? [3]

Strong answer: No. A positive screen is a trigger for a full follow-up risk assessment, not a disposition in itself. Universal screening identifies at-risk youth who selective screening misses, as Ballard showed, but the disposition follows the synthesised stratum — never a single score. [3] [1]

Branch 3 — Disposition and the safety plan

Examiner: She is assessed as high risk. What is her disposition and what do you build before she moves? [6]

Strong answer: High risk means inpatient psychiatric admission, with involuntary status considered under local mental-health statute if she lacks capacity or refuses. Before she moves I build a collaborative safety plan — warning signs, internal coping, social distraction, social support, professional contacts, and means restriction — I counsel the family to remove or secure access to lethal means, because the work on reducing firearm access for at-risk youth shows means restriction is feasible and effective in the paediatric ED, and I confirm a follow-up contact within 24 to 72 hours because the period after an attendance carries the highest repeat risk. [7] [5] [6]

Examiner: Why is a 24 to 72 hour contact so important? [5]

Strong answer: Because the population-based cohort evidence shows a markedly elevated risk of repeat self-harm and of suicide after an attendance, concentrated in the period immediately afterwards. Early contact is a risk-reduction intervention, not a courtesy. [5] [4]

Branch 4 — Intoxication, capacity and boarding

Examiner: Suppose instead she arrives intoxicated and cannot be fully assessed. What changes? [4]

Strong answer: I treat any medical consequences — check glucose, consider co-ingestion, monitor the airway — and I treat the assessment I can perform now as provisional, because intoxication invalidates a definitive assessment of intent, capacity and protective factors. I observe her in a safe, ligature-aware place and repeat the structured risk assessment as she sobers. I also keep delirium and a medical or toxicological driver in the differential and exclude them. [4] [6]

Examiner: She later refuses admission once sober. How do you decide? [6]

Strong answer: I assess her capacity formally — it is decision-specific and time-specific, and a young person may have capacity for some decisions and not others. If she has capacity but the risk is high and unmanageable, her refusal does not end the matter: the question of involuntary assessment or treatment is governed by the local mental-health statute, and I would involve the mental-health team and apply that statute rather than relying on parental consent alone. [6] [5]

Examiner: No bed is available and she is boarding in the ED. What do you do? [6]

Strong answer: I recognise boarding as a system failure with patient harm — delayed care, deterioration, loss of trust — and I escalate actively for an inpatient bed, including transfer to another service, while maintaining the observation level and the safety plan throughout the wait. I do not reduce observation or treat the wait as harmless. [6] [4]

Examiner extras

• Risk drives the level of care; acuity and risk are independent axes assessed every time. [1] [3]
• A positive ASQ mandates a full assessment, never an automatic disposition. [1] [3]
• Exclude the organic and toxicological driver — delirium, hypoglycaemia, intoxication — before attributing the crisis to a psychiatric cause. [4] [6]
• No young person leaves without a safety plan, means restriction and a confirmed 24 to 72 hour follow-up. [7] [5]
• Capacity is decision- and time-specific; involuntary care is governed by local mental-health statute. [6] [5]