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 197 also affects a person's risk level. Dr. Friedman, How do you determine lethality? Dr. Friedman: I always ask about what an individual has actually done or contemplated doing to harm him- or herself. But, I also like to ask two probing questions to someone who overtly claims to be suicidal: 1) Why didn't you kill yourself? And 2) "What do you see yourself doing in a year?" Patients are often shocked by my first question, but their response can be very informative about their true intent. Some patients say, "I'm here because I want help," or "I was afraid of what I might do," which suggests an urgent need for help. Patients who are reactive and just get angry at me about my question actually worry me less. A positive response to my second question about goals for the future generally indicates that the person plans to be alive and hasn't already given up on life. Someone once said that the only truly justifiable reason for suicide is if one hates oneself, so I will sometimes ask about self-loathing as well. How do you decide whether to admit a patient or discharge him or her? Dr. Friedman: There is no blood test or single screening tool that determines the risk of an individual repeating a suicide attempt. We look at the whole picture—Does the person belong to an established higher risk group? Has a serious attempt or concerning plan been described? What is the previous psychiatric history? Is the person currently intoxicated? What is the social support? Saying "I'm suicidal" is probably one of the least likely reasons, in and of itself, that will lead to a patient being hospitalized. Our records show that last year 108 of the 704 patients (15.3%) that presented with an initial chief complaint of "suicidal" were admitted to our institution and 105 other patients (14.9%) were transferred to an inpatient psychiatric facility elsewhere—so about 30 percent were admitted. Most patients are discharged after several different clinicians have evaluated them, and are discharged to the care of someone they know. How do you determine if a potentially suicidal patient simply wants a place to sleep for the night and really has no genuine suicidal intent? Dr. Friedman: Some patients will actually admit that they just want a safe, warm place to sleep if you ask them bluntly, especially if they've already alluded to the fact that they are undomeciled and don't like where they've been staying. For most patients though, it is a matter of inference—a lack of firm suicidal plan or even a gesture, and they seem more interested in a meal and a blanket immediately upon arrival. Dr. Pacheco, as the psychiatric consultant to the ED, how do you decide whether to admit a suicidal patient or discharge him or her? Dr. Pacheco: The assessment of suicide risk ranges from low to high and that affects our decision. Some factors that increase suicide risk include the following: • Chronic, untreated, or poorly treated mental illness • Chronic housing problems or new homelessness • Uncontrolled substance use placing them or others in dangerous potentially fatal situations • Recent diagnosis of a terminal illness • Advancing medical disease burden • Alienation or lack of the usual support systems (e.g., family, physicians) • Previous suicide attempts • Recent divorce or ending of a valued relationship • Previous successful suicide attempts in close friends or family • Possession of a viable plan and means to kill him- or herself (e.g., firearm or medication) • Patients from ethnic cultural groups that disdain or don't accept mental illness. How any ED physician, nurse, or physician assistant in the end gauges any patient's risk stratification is based on experience and individual judgement. However, once a critical mass of these factors are reached, most of us will either hold the patient for further evaluation or transfer the patient to a locked psychiatric unit. Dr. Friedman, how often do you ask for a psychiatric consultation? How do you make that decision? Dr. Friedman: There are no hard and fast rules for which suicidal patients will get a psychiatric evaluation. Everyone presenting to the ED receives a "medical screening examination" to evaluate and stabilize their condition. Every potentially suicidal patient coming to the ED is evaluated by an attending emergency physician (EP). We serve as gatekeepers for all sorts of medical utilization. Asking to see a psychiatrist (by the patient) is no more of a guarantee of a consult than asking to see someone from any other specialty or asking for a test like a magnetic resonance imaging scan. The EP has to believe that it is medically warranted as part of an emergency evaluation (some might be given outpatient follow-up information and asked to make an appointment). Dr. Pacheco, as a psychiatrist, what procedures and questions R E S E A R C H T O P R A C T I C E R E S E A R C H T O P R A C T I C E

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