Innovations In Clinical Neuroscience

SEP-OCT 2014

A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience

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[ V O L U M E 1 1 , N U M B E R 9 – 1 0 , S E P T E M B E R – O C T O B E R 2 0 1 4 ] Innovations in CLINICAL NEUROSCIENCE 195 R E S E A R C H T O P R A C T I C E University School of Medicine, Chief of the Consultation/Liaison Service and of the Emergency Service, Department of Psychiatry at the Tufts Medical Center. How many patients visit the Tufts Medical Center ED each year? How many of these patients have suicide-related issues? Dr. Friedman: We saw 40,669 patients in the ED last year. Although only 704 of these patients actually listed "suicidal" as their entering chief complaint, it is clear that many more patients were evaluated for this possibility. Dr. Pacheco: I get called to the Tufts ED several times a day for suicide evaluations. So the "real" number has to be higher than the listed chief complaint. How do you determine that patients are "suicidal" if they don't acknowledge it? Dr. Friedman: Some patients may say, "I want to see a psychiatrist," or describe "depression," or "anxiety" as their chief symptom, or arrive intoxicated after a suicide gesture and initially say nothing at all. Ultimately, during the course of our evaluation, it becomes clear when a patient is feeling suicidal. Do you think that the number of ED visits for suicide attempts has increased? Dr. Pacheco: It has notably increased. I think that increased drug abuse, fewer psychiatric beds, the move to treat more patients in the community, and the mere cost to simply see a doctor has contributed to increased ED visits by suicidal patients. Of course, there are many differences among the types of suicidal patients we see in the ED. Can you describe the different types of suicidal patients that you see in the ED? Dr. Friedman: First of all, we see a lot of patients who have made serious suicide attempts. But we also see patients who have just expressed some suicidal ideation and may have been referred to the ED because they said something of concern to somebody (their doctor, a psychiatrist, or a family member). Some patients present following relatively trivial gestures such as, "I took 10 Advils" or with very superficial cuts of the wrist (with many other old scars present), and a lot of patients with suicidal behavior are brought to the ED after a substance abuse binge. As the first physician to evaluate the patient, I recognize five broad categories of suicidal patients ranging from the most severe who are at the highest risk to those with the least risk: 1) the highest risk are those patients who have just made a serious gesture or attempt prior to arriving in the ED; 2) patients in a traditionally high-risk group (like the elderly) who are particularly despondent or voicing suicidal ideation; 3) patients with significant chronic psychiatric illnesses or substance use and current suicidal ideation with a plan; 4) patients with significant substance utilization who say "I'm suicidal" but seem to have no particular plan; and 5) patients who simply announce that they are requesting psychiatric (or dual- diagnosis) hospitalization. This last group may just want a place to sleep. We see children much more often than we used to for all sorts of psychiatric complaints. It seems that nearly any child who acts out in school is now sent for an evaluation rather than in-school disciplinary action. Any off-hand remark that can be interpreted as a musing about suicide will result in a trip to the ED too. I have occasionally seen children as young as five years old sent in for an evaluation because they said something like "I wish I was dead." Dr. Pacheco: A lot of patients are seen with ethanol intoxication and suicidal ideation. I divide them into two groups as either intoxicated or sober because the suicidal ideation is best assessed when they are sober. A good rule of thumb is "no one is suicidal until they are sober and suicidal." Unfortunately, it may take several hours for some patients to "sleep it off" to achieve sobriety. For instance, a seasoned alcoholic may not appear clinically intoxicated even with a blood alcohol level over 300. Incidentally, that level could be lethal in most ethanol-naive cases. We also see suicidal patients who have taken multiple substances as well. In Boston, as is other eastern United States cities, crack is notably prevalent in our homeless population and methamphetamine abuse in the gay male population. Otherwise, suicidal adult patients Dr. Frank Friedman is an Assistant Professor of Emergency Medicine at Tufts University School of Medicine and the Director of Prehospital Care and Emergency Preparedness at Tufts Medical Center in Boston, Massachusetts.

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