p. k. bridges - postgraduate medical journal · p. k. bridges found for complaints have a...

Postgrad. med. J. (September 1967) 43, 599-604.

Psychiatric emergencies

P. K. BRIDGESM.D., D.P.M.

Department of Psychological Medicine, Royal Free Hospital, London, W.C.1

UNTIL recent times, the suspicion and fear ofmental illness shown by the community has re-sulted in a tendency to reject and isolate psychia-tric patients. It is probably as a consequence ofthis that many mental hospitals have been sitedaway from centres of population and this hascontributed to the unreasonable division whichhas developed between psychological medicine andgeneral medicine, a segregation only now slowlybeing overcome. But still psychiatry has insuffi-ciently been accepted into the general hospitaland, therefore, Casualty Departments, where theneed can be most acute, usually have considerabledifficulty in obtaining psychiatric advice when itis required.

Casualty officers understandably may lack con-fidence in dealing with psychiatric cases, partlybecause of limited training in this subject andpartly because of the lack of specialized support.In addition, psychiatric patients are not easy todeal with, even by those experienced in doing so.The patients are often unco-operative, aggressiveor unpredictable, and they tend to arouse con-flicting emotions both in relatives and in doctorsand nurses. Diagnosis and prognosis are oftendifficult to formulate and considerable time maybe needed to assemble the necessary information.Disposal problems can be complex, and all thesedifficulties are enhanced in a busy CasualtyDepartment where many other patients requireattention, who by contrast are usually both co-operative and responsive to the help given them.

IncidencePsychiatric illnesses

It is unnecessary to stress the prevalence ofpsyckiatric associations with physical illness ingeneral, and estimations of incidence depend uponthe criteria used and the sample studied. In generalpractice, for example, it has been shown thatabout 10% of patients attending their doctors werepsychiatrically ill, and 1% were seriously disabled(Watts, Cawte & Kuenssberg, 1964). Bellak et al.(1964) reported that as many as 50% of patientsattending an emergency clinic were suffering froma psychiatric condition, either directly related to

the presenting somatic complaint or independentof it. The incidence of primarily psychiatric casesin Casualty Departments has been variously re-ported from 14% to 6'6% (Errera, Wyshak &Jarecki, 1963; Blackwell & Mallett, 1964;O'Regan, 1965). Whiteley & Denison (1963) haveshown that the junior casualty officer in theirstudy saw twice as many new psychiatric patientsas the psychiatric out-patient clinic of the hospitalin the same period of time. The incidence ofpsychiatric emergencies is more difficult to assessbut Bridges, Koller & Wheeler (1966) found that apsychiatrist was called to the Casualty Depart-ment of one hospital to give urgent advice for0 09% of all new patients seen in the department.However, this was not regarded as a true incidenceas it was known that in some psychiatric emer-gencies where the necessary management wasobvious, this was often carried out withoutspecialist help being requested; advice was usuallyneeded more for problems in diagnosis.The recognition of psychiatric conditions in the

Casualty Department is often complicated by thefrequency of physical associations. Blackwell &Mallett (1964) found that 43 % of psychiatricpatients diagnosed at a Casualty Department hadpresented with physical complaints while the re-mainder had psychological symptoms. Frequentlypsychiatric illness is suspected when no organiccause for physical complaints is found, and thesecases amounted to 27% of patients attending aCasualty Department in one study, the incidencerising to 50-60% when the complaints were oflassitude or transient loss of consciousness(Mestitz, 1957). In another investigation ofpatients in a general hospital referred for apsychiatric opinion only because no organic causehad been found for their symptoms, one-thirdwere found to be suffering from endogenousdepression and two patients were schizophrenic(Bridges et al., 1966). Thus, the presence ofpsychiatric illnesses may be obscured by somaticpresentation and such cases are not necessarilydiagnostically distinct from those with recogniz-able psychological symptoms. On the other hand,while many cases in whom no organic cause is

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found for complaints have a psychiatric aetiology,sometimes physical disease remains undiscoveredand, therefore, a psychiatric diagnosis may onlybe made on the basis of positive evidence ofmental illness.

DiagnosisAn estimation of the prevalence of various

diagnoses among cases in a psychiatric emergencyclinic has been reported by Brothwood (1965) whofound that 22% were suffering from psychoses,59% had psychoneuroses and 11% personalitydisorders. These findings are similar to those ofWhiteley & Denison (1963) in a general casualtydepartment.Disposal

In the studies already quoted, from 15% to45% of psychiatric' emergencies required admis-sion, either to psychiatric care or to medical wardsafter suicide attempts. The largest proportion,usually about half, were referred to psychiatricout-patient departments and the remainder weredischarged, referred to their general practitionersor to social services. Whiteley & Denison (1963)have stressed that a common feature amongpsychiatric patients seen in the Casualty Depart-ment is that their presenting symptoms oftenrapidly resolve after the crisis has been dealt withand a high proportion later discontinue the treat-ment arranged for them; they either do not keepsubsequent appointments or may discharge them-selves if admitted. But the need of such patients isa real one and effective emergency treatment canbe of prime value to them.

AssessmentBy contrast with physical illness, where symp- -

toms and signs are primarily sought for and maybe relatively clear-cut, psychiatric conditions areoften more difficult to diagnose from the patient'spresentation and usually require information fromother sources for their clarification. Sometimesmanagement must be decided upon only in rela-tion to the patient's behaviour without otherinformation being readily available. But 'in mostcases independent information is essential forformulating decisions, and although its collectionmay be time-consuming, the time is well spent andmay otherwise be wasted in errors of judgement orin doubt and indecision. Difficulties associatedwith managing an unco-operative and unaccom-panied patient may be resolved by taking thetrouble to contact the relatives, the general prac-titioner or a psychiatric hospital where the patientmay be known.Adequate assessment of the psychiatric emer-

gency requires information about the following:

(1) The patient's behaviour.(2) The patient's complaint. (His own account,

allowing him to tell it as freely as possible.)(3) Physical examination.(4) History from others (e.g. relatives, G.P.,

psychiatric hospitals, Mental Welfare Officer).(5) Observation of the patient over a period of

time, if necessary.

Problems and managementAnxiety and panicAn acute anxiety state consists of an intense

feeling of fear together with symptoms such aspalpitations, dyspnoea, tremor, sweating and rest-lessness. These patients are often in severe distress,their panic being enhanced by physical accom-paniments such as difficulty in breathing andswallowing, so that secondary accentuation of theanxiety may ensue with fears of being over-whelmed by a serious physical illness. In thesecases there will usually be evidence of earlierneurotic traits and there may be a history ofproneness to anxiety under stress. The urgenttreatment consists of firm, calm reassurance of thepatient and also those accompanying him. Sodiumamylobarbitone 200 mg or more by mouth andthe company of a reassuring nurse usually sttlesthe patient effectively. These patients may be givena small supply of barbiturates to ensure a goodnight's sleep and they may be assessed again later,perhaps by their own doctor. Recurrent attackscan be controlled by chlordiazepoxide (Librium)10 mg t.d.s. or diazepam (Valium) 5 mg t.d.s., andhigher doses may be used if necessary.

Similar symptoms are encountered in cases ofhysterical excitement, anxiety being sometimesassociated with hysterical symptoms and quiteoften experienced by those with hysterical per-sonalities when reacting adversely to stress. Thesepatients will tend to be histrionic and manipula-tive, but the treatment is similar. Adequate seda-tion should be given and the patient looked afterby a mature nurse in a room separated from otherpeople who may be over-involved in the emotionalturmoil.These acute neuroses cause considerable distress

but do not usually present undue difficulties inmanagement. However, care is needed in differen-tiating them from other, more serious conditions.Hypomania may present with much restlessnessand overactivity but there will be elation andgrandiosity present with little insight into theillness. Some schizophrenics may experienceanxiety associated perhaps with their perplexity,suspicions or hallucinations. Patients with earlyorganic confusional states sometimes experienceanxiety and restlessness which can mask early

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symptoms of confusion and disorientation so thatan organic aetiology may be missed. The anxiousmisery and restlessness of the agitated depressivemust always be considered as these cases are likelyto constitute a suicidal risk.Aggressive and bizarre behaviourThe most serious diagnosis in patients showing

these symptoms is schizophrenia. These patientsoften show evidence of abnormal social behaviourand occasionally they may be violent. There willbe other symptoms of schizophrenia such asabnormalities of thinking, flattened or incon-gruous emotions, catatonic symptoms, delusions,hallucinations and loss of insight. In acute casesthe diagnosis may be obvious but sometimes thesymptoms are difficult to elicit and, in particular,older paranoid schizophrenics who conceal theirdelusions can be very difficult to recognize. Theymay show no abnormality unless their delusionscan be revealed, and this is facilitated if the natureof the paranoid ideas is known from an informant.Acutely disturbed schizophrenics are likely torequire compulsory admission for treatment butthere are chronic cases whose behaviour has beenstrange for a long time who may not necessarilyrequire admission although further psychiatricassessment and social care may have to bearranged.

Patients with mania and hypomania are notcommon but they may also present with aggres-siveness and irritability. There will usually be, inaddition, an infectious elation, overactivity, over-confidence and grandiose ideas. Some of thesecases may be difficult to differentiate from schizo-phrenics and mixed states do occur. Epilepticsoften show aggressive behaviour, either associatedwith a deteriorating personality or during post-ictal states. Sometimes patients with organicconfusional states present with abnormalbehaviour and it is important to recognize thesecases in order that the underlying physical con-dition is not missed. Patients with psychopathicpersonalities are easily provoked and may becomeuncontrollably aggressive; they are diagnosed bya history of impulsive antisocial behaviour and bythe absence of psychotic symptoms. Psychopathsin general are regarded as being responsible in lawfor their actions and if over the age of 21 yearsthey may not be compulsorily admitted on thebasis of this diagnosis.With severely disturbed patients prompt and

effective sedation is needed, one of the mainhazards being in its administration. Thereforephysical control over the violent patient may berequired and this is likely to fail unless reallyadequate resources are assembled before necessaryforce is employed, the usual recommendation

being one person per limb and one in addition.There is no doubt that inadequate control of thepatient tends to increase fear, anger andstruggling. On the other hand, there is the well-known description of the confident psychiatristcalling off the fighting attendants and leading themollified patient away for a quiet consultation.The best drug to use is a phenothiazine such as

chlorpromazine 50-100 mg given intramuscularlyand repeated if there is an inadequate response inabout 1 hr. Thereafter it may be given 4-6-hourly.A potent injection in exceptional circumstances isa mixture of morphine sulphate 10-15 mg andhyoscine hydrobromide 04-0-6 mg given sub-cutaneously, and in a few cases, if special care istaken, sodium thiopentone intravenously might beindicated. The use of intramuscular paraldehydehas often been condemned, and rightly so, forreasons that are well known and which include thepain of injection and the possibility of abcessformation. Therefore this drug should not be usedroutinely but, nevertheless, it is safe and rapidlyeffective, so that it probably has a use sometimeswhen dealing with very disturbed patients,although not more than 10 ml should be given inone site.Confusion and impaired consciousness

Patients may present with symptoms of con-fusion, disorientation and impaired consciousnessor defective memory. In addition, they may ofcourse be restless, violent or anxious as well. Insome cases there may be evidence of personalitychange and deterioration in social behaviour. Withthis group of symptoms the principal generalaetiology is likely to be organic. Any illness pro-ducing a systemic disturbance, and in particularany cerebral disease may result in a confusionalstate. These patients may show the acute symp-toms of delirium or a subacute fluctuating state ofawareness (clouding of consciousness) in whichthey are correctly orientated only for limitedperiods and at other times tend to become con-fused, frightened and hostile. Dementia is achronic and usually irreversible condition. In thesecases the first essential is to recognize that anorganic pathology is responsible for the psycho-logical symptoms so that appropriate physical in-vestigations are carried out and a very wide rangeof conditions needs to be considered, among whichmay be electrolyte disturbances, infections, poison-ing, states of anoxia, space-occupying lesions, headinjuries and cerebro-vascular conditions. Epilep-tics may also present similar symptoms duringpost-ictal confusion.

If physical abnormalities can be confidentlyexcluded there are some less common conditions,primarily psychiatric, which may result in altered

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consciousness and stupor, but psychiatric illnessesare not associated with clouding of consciousnessand dementia, which are typical of organic states.Hysteria may present as an amnesia and some-times quasi-confusion. Patients with schizophreniasometimes appear to be confused and bothschizophrenia, endogenous depression and hysteriacan be associated with stupor. In such cases thedifferential diagnosis between psychiatric andorganic aetiology is often difficult so that observa-tion and detailed investigation are usually needed.

Disturbed behaviour resulting from organicstates requires the usual symptomatic treatment.The phenothiazines (chlorpromazine, promazine)are especially useful in these cases as barbituratesmay increase the confusion and thus aggravatedisturbed behaviour. In general, confusional statesneed medical observation and treatment, andpatients should be adequately sedated so thatadmission to a medical ward is possible, a side-ward often being needed at first. While some ofthese cases may be so disturbed that admission toa psychiatric hospital would seem appropriate,these hospitalt may not be able to carry out thephysical investigations and treatments needed andtherefore medical admission must be consideredinitially.Alcohol and drugsThe effects of excessive intake of alcohol and

some drugs, either acutely or chronically, is toproduce a toxic confusional state so that much ofthe foregoing will apply, but there are also otherconsiderations in these cases.

If the patient smells of alcohol he tends to beregarded with some hostility as merely havingover-indulged, and in most cases this may be theextent of the problem. But other concealed aspectsfrequently co-exist in drunken people. Forexample, many suicidal patients take tabletstogether with alcohol, some patients with severemental illnesses drink in an attempt to relievetheir distress, and head injuries occurring whilethe patient is drunk are a well-known possibility.Hence, these patients require careful assessmentand examination including investigation of theaspirated gastric contents if suicidal attempts aresuspected. It is also wise to keep patients underobservation for a time if there is any doubt. Theraging drunk is a frequent problem and it shouldbe realized that this behaviour results fromdepression of higher cortical control. Therefore,inadequate sedation and also sedation with bar-biturates tends to decrease control further andenhances confusion. The best drugs for use inthese cases are the phenothiazines given intra-muscularly,.and they are particularly effective inpatients with delirium tremens. The earlier treat-

ment of giving more alcohol to such patients hasbeen superseded by high doses of phenothiazinesand vitamins. Finally, Alcoholics Anonymous,whose address appears in most telephone direc-tories, can be helpful in assisting with somealcoholic patients.

Addiction to drugs is increasing, and the ratherdisorganized individuals involved are especiallylikely to attend Casualty Departments for help.The drugs most commonly abused by youngpeople in probable order of frequency areamphetamines and amphetamine-barbiturate mix-tures such as Drinamyl, cannabis (marihuana),heroin and cocaine, and lysergic acid diethylamide(LSD) (Brit. med. J., 1967). The patient's usualcomplaint will be that he is suffering from with-drawal symptoms and requires more of his drug.These patients frequently have psychopathic per-sonalities so that they are very liable to bemanipulative and to exaggerate their symptoms toobtain more drugs. But it is unnecessary to givethe medication asked for as withdrawal symptomscan usually be adequately controlled by pheno-thiazines, which provide effective emergency treat-ment. Subsequent psychiatric help can then beoffered but this is likely to be rejected by thepatient. However, severe withdrawal reactions,especially when associated with physical symptomsand signs, suggest that admission is necessary. Insome cases there may be difficulties in diagnosis.For example, amphetamine addiction may pro-duce not only excitement but paranoid states andac,,te conditions resembling schizophrenia, andLSD may result in florid psychotic states. Someaddicts present problems as to whether an exces-sive dose of drugs was taken in order to increasetheir effect or with suic;dal intent and sometimesthe distinction is only theoretical. If there isserious doubt the patient needs psychiatric admis-sion. Unless a suicidal risk is present, or there is anassociated psychosis or the patient is seriouslyaffected by drugs, it is not legally appropriate toarrange compulsory admission in order to ensuretreatment for addiction.Depression and suicide attempts

Depression is the most common psychiatricsymptom and suicide is closely associated withdepression (Bridges & Koller, 1966). Therefore,the emergency management of depression and ofsuicidal attempts is essentially the prediction of anattempt, or the possibility of further attempts,occurring. The diagnosis of depression is com-plicated by controversies about classification, butthe precise nature of the depression is likely to beless important ia emergency situations than theseverity of the illness. Patients with severe depres-sion reactive to misfortune may be as likely to

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take their lives as those with typical endogenousdepressions which are, however, especiallydangerous in this respect even in apparently milderforms. In addition, a considerable suicidal risk ispresent in some schizophrenics whose tendency tounpredictability has to be taken into account. It isthe view of the Ministry of Health (H.M. [61] 94)that all patients who have made suicidal attemptsshould be seen by a psychiatrist, and while thismay be idealistic in many hospitals, great careshould be exercised in discharging these caseswithout adequate assessment and arrangements forsupervision.The belief that people who threaten to attempt

suicide do not do so is untrue, for it has beenshown that the majority of patients who haveattempted suicide previously communicated theirintention (Delong & Robbins, 1961). Equally it isnot valid to make a clear distinction between the'gesture' and the 'real attempt'. For as Stengel(1963) has shown, seriousness of intent is a con-tinuum and all attempts carry some risk so thateach must be considered in its individual circum-stances. Furthermore, those who have made anattempt have an increased likelihood of repeatingit, sometimes with greater determination (Ettlinger,1964).The assessment of depression involves consider-

ation of the symptoms, the patient's social cir-cumstances and history. Regarding the symptoms,in general the greater the unhappiness and distress,the more likely the patient is to require admission.This is especially so if suicidal thoughts arepresent, and questions must be asked to elicit this.Symptoms typical of endogenous depression mustbe taken very seriously and these particularlyinclude a diurnal variation of mood with exacer-bation in the morning, guilt and self-blame,pessimism about the future, early morning wakingand insomnia, and retardation or agitation. Thisillness can be very deceptive. For example, thereis the 'smiling depression' with the patient main-taining a front despite his misery, and some casespresent principally with anxiety which mayobscure the basic depressive symptoms and thedesperation. In addition, the diurnal mood varia-tion may result in the patient being reasonablyoptimistic when seen in the afternoon, only toplunge into a suicidal depression next morningafter being allowed to return home. Suicidalattempts may notoriously be made as a patient isbeginning to recover, in the early stages whenretardation lessens but the unhappiness remains.The history will also yield important informa-

tion. A previous attack of the illness, especiallyone requiring admission or electro-convulsivetherapy, a positive family history, especially in-

cluding a suicidal attempt, and a previous suicidalattempt by the patient will suggest that admissionis imperative and even arranging it for the nextday at the request of the patient may prove toolate. Patients at special risk are those who arealcoholic, who have disabling physical illnessesand those who are socially isolated, especiallysingle, divorced or widowed patients (Stengel,1964). The highest rate of suicide attempts occursamong patients in their third decade, especiallyfemales, while that for completed suicide occursamong patients over 60 years, especially males.When a suicidal attempt has occurred, both the

method employed, events leading up to it, and thesituation in which it happened must be carefullyelicited in order to assess the case. Clearly, theseriousness of intent of an angry woman rushinginto the next room to take aspirin tablets after anargument with her husband is less than that of thepatient who travels to a remote spot in order tojump from a height. In addition, the events follow-ing an attempt may also be important and it isworth investigating whether there has been aresolution of difficulties as a result of the episode.Another aspect of suicide attempts is the likeli-hood of concealment. The patient and relatives areoften anxious to avoid the implications of theevent, and explanations of taking tablets bymistake or just to sleep or to ease pain, must betreated with suspicion. Sneddon (1965) has alsodescribed various physical conditions which maymask attempts: examples are young people withhaematemesis and no history of peptic ulcer,sudden dizziness or drowsiness, accessible straightlacerations attributed to being attacked, andepileptics not recovering from their fits.

AdmissionPsychiatric hospitals

It has been shown that a large proportion ofpsychiatric emergencies require admission. Somewill need urgent medical or surgical treatmentafter suicide attempts when further psychiatricassessment will be carried out subsequently. Somepatients require observation for only a few hoursor overnight, as the situation may become clearerwhen acute symptoms subside, or after a visit byrelatives. The remaining patients need psychiatriccare and while a psychiatric ward may be avail-able in some general hospitals, the majority ofpatients will have to be transferred to psychiatrichospitals although there may be difficulties withthis, usually associated with their inaccessibility.Communication may not be easy, transport maybe a problem and patients are often understand-ably reluctant to go to what is usaIlly a ratherdistant hospital. In addition, most psychiatric

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604 P. K. Bridges

hospitals have a rigidly defined catchment areaand will only accept patients living within it, asituation which is particularly complicated inLondon. Advice about catchment areas and aboutdifficulties in getting a patient admitted can beobtained from Mental Welfare Officers (M.W.O.)who are available at any time at the offices of localauthorities.

Mental Welfare OfficerThe office of Duly Authorized Officer (D.A.O.)

disappeared with the Mental Health Act of 1959<and was replaced by the new Mental WelfareService which was a new service and not merelya new name, as the functions are different. TheD.A.O. was primarily responsible for the legalaspects of compulsory admission, but the M.W.O.,although he may also be involved with applica-tions for compulsory admission, is primarily con-cerned with psychiatric care in the community inits widest aspects. Therefore, his special knowledgeof local psychiatric services, of psychiatricpatients, hospitals and hostels, and his practicalexperience of psychiatric problems in general, maybe utilized by- the casualty officer in cases ofdifficulty.Compulsory admission

This is an unpleasant necessity in psychiatryand such an interference with personal libertyshould never be undertaken lightly; it certainlymust not be used merely because patients are anuisance or are aggressive. However, it should notbe avoided where a patient's life and health maybe at stake.The Mental Health Act of 1959 made consider-

able changes in the law regarding compulsoryadmission, the main one being abrogation ofjudicial authority with the abolition of the D.A.O.and its replacement in England and Wales solelyby medical recommendations. In Scotland theapproval of a Sheriff is also needed.Compulsory admission now requires only: t

1. An application, preferably by the nearestrelative, but if he is unobtainable theM.W.O. can act in his place.

2. A medical recommendation by one or twodoctors.(a) Section 29. In cases of urgent necessity

any doctor alone may recommendadmission for observation for 3 days.

(b) Section 25. Normally two doctors areneeded to recommend admissionwhich is then for up to 28 days. Oneof these doctors must be approved forthis purpose by the local authority.

t These sections paraphrase parts of the Act and do notgive the officiatwWrding.

The medical recommendations are made on thegrounds: t

(a) That the patient is suffering from mentaldisorder of a nature or degree whichwarrants detention in a hospital for atleast a limited pariod, and

(b) That he should be so detained in theinterests of his health or safety or with aview to the protection of others, and

(c) That informal admission is not appro-priate.

The final requirement is important: if patientsagree to go into a psychiatric hospital they may betransferred without any formalities, subject to theconcurrence of the hospital. If the patient con-sents to admission he must not be placed on anorder except in those unusual cases whereadmission is imperative but the patient's insightand co-operation cannot be relied upon.

AcknowledgmentsI am grateful to Dr Irving Kreeger for advice in preparing

this paper, and to Drs Felix Brown, Alick Elithorn and BricePitt for their helpful criticisms and suggestions. I would liketo thank Miss Gillian Rattey for secretarial assistance.

ReferencesBELLAK, L., PROLA, M., MEYER, E.J. & ZUNKERMAN, M.

(1964) Psychiatry in the medical-surgical emergency clinic.Arch. gen. Psychiat. (Chic.), 10, 267.

BLACKWELL, B. & MALLETT, B.L. (1964) Psychiatric illnessin a casualty department. Guy's Hosp. Rep. 113, 122.

BRIDGES, P.K. & KOLLER, K.M. (1966) Attempted suicide: acomparative study. Comprehens. Psychiat. 7, 240.

BRIDGES, P.K., KOLLER, K.M. & WHEELER, T.K. (1966)Psychiatric referrals in a general hospital. Acta psychiat.scand. 42, 171.

Brit. med. J. (1967) Drug-taking by the young. Brit. med. J.i, 67.

BROTHWOOD, J. (1965) The work of a psychiatric emergencyclinic. Brit. J. Psychiat. 111, 631.

DELONG, W.B. & ROBBINS, E. (1961) The communication ofsuicidal intent prior to psychiatric hospitalization. Amer.J. Psychiat. 117, 695.

ERRERA, P., WYSHAK, G. & JARECKI, H. (1963) Psychiatriccare in a general hospital emergency room. Arch. gen.Psychiat. (Chic.), 9, 105.

ETTLINGER, R.W. (1964) Suicides in groups of patients whohad previously attempted suicide. Acta psychiat. scand. 40,363.

MESTITZ, P. (1957) A series of 1,817 patients seen in acasualty department. Brit. med. J. iH, 1108.

O'REGAN, J.B. (1965) A psychiatric emergency service. Can.med. Ass. J. 93, 691.

SNEDDON, J. (1965) Casualties in the casualty department.Practitioner, 195, 785.

STENGEL, E. (1963) Attempted suicide, its management in thegeneral hospital. Lancet, i, 233.

STENGEL, E. (1964) Suicide and Attempted Suicide, p. 22.Penguin Books, London.

WATTs, C.A.H., CAWTE, E.C. & KUENSSBERG, E.V. (1964)Survey of mental illness in general practice. Brit. med. J.if, 1351.

WHITELEY, J.S. & DENISON, D.M. (1963) The psychiatriccasualty. Brit. J. Psychiat. 109, 488.



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