Innovations In Clinical Neuroscience

SEP-OCT 2014

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

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Innovations in CLINICAL NEUROSCIENCE [ 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 ] 196 R E S E A R C H T O P R A C T I C E present during periods of new homelessness or joblessness, or related to marital strife, divorce, or breakup. One other group, newly released prisoners, are a frequent occurrence in our ED if they have alienated family and/or spouses/partners and are being banned from the family. Do you think that adolescent suicide attempts create a unique situation? Dr. Friedman: Yes. Adolescents are different. Suicide is the third leading cause of death in adolescents Although the ratio of attempted to completed suicides in adolescents has been estimated to be about 200 to 1 in contrast to approximately 20 to 1 in the general population, every suicidal adolescent patient I see in the ED represents a special risk in my opinion. Sadly, in the Boston area we have witnessed a near epidemic of adolescent suicides in the past several years: three in suburban Newton in 2011 and six in South Boston in 1997, among others. We tend to have a very low threshold to obtain a psychiatric consult in an adolescent with either suicidal ideation or after a gesture, and most of these patients are either hospitalized or are discharged to home only after a lengthy and comprehensive evaluation assuring a competent social environment to which to return the individual Dr. Pacheco: Adolescent patients come to the ED during periods of new stressors. For instance, in Boston we often see adolescents and young adult students at the beginning of the school year or during exam periods. Exam time can be especially stressful if the student has been failing but has not shared their dire academic straits with their family. If a patient is a minor there may be an additional consent wrinkle. If the parents/guardians disagree with any recommended treatment plan, the physicians need to consult with the hospital risk management staff on how to proceed. On the other end of the age dimension, the suicide rate for people over 65 years of age is 50 percent higher than for the rest of the nation as a whole. 5 How do you manage suicidal geriatric patients? Dr. Friedman: As long as the older adult is not someone who comes into the ED frequently (we have a few well-known older patients), being older than 60 or so and verbalizing suicidal thoughts or despondency are taken as a major red flag and will often result in hospitalization. Dr. Pacheco: We see older, geriatric patients presenting with suicidal ideation following a new terminal diagnosis or advancing serious illness. Occasionally, we'll see caregivers who are simply burned out and are no longer able to cope with taking care of a totally dependent loved one at home. What happens when a suicidal patient is brought to the ED? Dr. Friedman: The first role of the ED is to determine if the suicidal patient is "medically clear" for a psychiatric evaluation. If someone has made a serious gesture—a significant medication overdose or self-injury— hospital admission is indicated and psychiatry is not involved until the patient's condition has been stabilized. "Medical clearance" involves simply being a good doctor—taking a good history and physical exam for any other conditions or concerns besides the psychiatric complaint. In a young and otherwise healthy person, no further testing might be required other than a toxicology screen for drugs of abuse. For an older individual with several chronic illnesses, a full set of routine blood and other ancillary testing may be required. The reason for this is two- fold: We want to exclude an organic explanation for a patient's condition and because many psychiatric hospitals are free-standing with few healthcare resources to address medical complaints. Many psychiatric hospitals will not even consider a patient for hospitalization unless certain tests have been performed and were normal. The literature describes three lethality factors that need to be assessed in suicidal patients: predisposing factors, risk factors, and protective factors. 5 Predisposing factors are usually long-standing conditions (like chronic illness), whereas risk factors are generally more acute symptoms, stressors, or conditions that could trigger the suicidal act. Alternatively, the presence or absence of protective factors, such as a strong social support network, Dr. Manuel N. Pacheco is an Assistant Professor of Psychiatry at Tufts University School of Medicine, Chief of the Consultation/Liaison Service and of the Emergency Service, Department of Psychiatry at the Tufts Medical Center

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