Psychiatry selection panels use clinical scenarios to find out whether you can be the registrar on call in a mental health service, and two scenarios recur more than any other: the patient who has taken an overdose and still wants to die, and the patient who is acutely agitated and threatening staff. Both test structure, safety, knowledge of the legal framework, and how you work with the team. This guide covers each.
The overdose patient who still wants to die
A 25 year old presents to the emergency department after an overdose and says they still want to die. How do you assess risk and decide what happens next?
Safety first. The medical consequences of the overdose are managed by the emergency team; your assessment waits until the patient is medically stable enough to be interviewed, and the patient is observed in the meantime.
The assessment. The overdose itself: what, how much, planned or impulsive, alone or with others around, any steps to avoid discovery, what the patient expected to happen. Current intent: do they still want to die, do they have a plan, do they have access to means. Static risk factors: previous attempts, mental illness, substance use, family history, recent losses. Dynamic factors: current mood, hopelessness, intoxication, psychosis, recent events. Protective factors: reasons for living, relationships, engagement with services. Collateral history from family or the GP. The mental state examination throughout.
The decision. Whether the patient can be discharged with a safety plan and follow up, or needs admission, voluntary or under the mental health legislation of your state. Say what the legislation requires: a mental illness or disorder, risk of serious harm, no less restrictive alternative, and who can make the decision. Involve the consultant for any decision about involuntary treatment.
The team. The emergency department staff, the mental health liaison nurse, the family, the community team for follow up. The safety plan written with the patient, the means restriction, the early follow up.
Say what you would do if the patient wanted to leave before the assessment, which is the usual probe: the legislation allows the patient to be detained for assessment where there is a risk of serious harm, and you would involve the consultant and the emergency department.
The acutely agitated patient
A patient on the ward is acutely agitated and threatening staff. Talk us through your management.
Safety of everyone: the staff, the other patients, the patient themselves. Call for help early; the duress system, security if needed, and enough staff to be safe. Remove hazards and other patients from the area.
De escalation first. One person speaking, calm and at a distance, acknowledging the patient's distress, finding out what they want, offering choices, time and space. Most agitation settles with this if it is done well, and the panel wants to hear that you would try it properly before anything else.
The least restrictive option. If de escalation fails, oral medication offered before intramuscular, with the right choices for the likely cause and the patient's history, and monitoring afterwards. Restraint and seclusion only as a last resort, under the policy and the legislation, with documentation and review. Say that you know your state's rules on restrictive practices.
Find the cause. Agitation has causes: psychosis, intoxication or withdrawal, delirium, pain, fear, a dispute on the ward. Assess once it is safe, treat the cause, and review.
Afterwards. Documentation, the incident report, a debrief for the staff and for the patient, and a review of what could have prevented it.
The probe: the patient has a weapon; a staff member has been hurt; the patient demands to leave. Each has an answer: security and police if there is a weapon, the staff member's care and the incident process, the legislation for the patient who wants to leave while unwell.
What the panel scores
Structure, safety for everyone, knowledge of the legal framework in your state, de escalation attempted properly, the least restrictive principle, the team used well, and the aftermath including the staff. The common failures are going to medication too early, not knowing the legislation, and forgetting the staff member who was threatened.
Preparing
Learn your state's mental health legislation at the level of a registrar: the criteria for involuntary assessment and treatment, who decides, and the rules on restrictive practices. Talk both scenarios through aloud in two minutes with the probes. Then do the variations: the elderly confused patient, the first episode of psychosis, the new mother, lithium toxicity, clozapine and the sore throat. The structure transfers.