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 ] 198 R E S E A R C H T O P R A C T I C E do you routinely apply when you evaluate a suicidal patient in the ED? Dr. Pacheco: First, we begin with safety. We always place people with a one-to-one sitter until they sober up, are in adequate behavioral control, or state that they are no longer contemplating suicide. Once we believe that the patient is safe, we review our electronic medical records to see if we have seen the patient before. My emergency consultation service documents each visit, including past psychiatric history and contact information from caregivers, physicians, caseworkers, and group home/shelter staff that have had contact with the patient. We take a lot of time to get enough information so as not to reinvent the wheel on cases we have seen before. We also check the Massachusetts Prescription Drug Monitoring Program to detect cases of doctor shopping for patients seeking benzodiazepines, opiates, or stimulants. It is important to caution that the information in these databases is often incomplete and for now limited only to the state where you are licensed. We determine if the patient is able to engage in an interview. The patient may be acutely intoxicated or too psychotic to interview. We'll use involuntary medication or restraint only as a last resort for agitated patients. When patients can be interviewed, we ask about their current state and the events or triggers that precipitated the suicidal behavior. We ask about prescription bottles and where they fill their prescriptions so we can find out who their prescribers are. We check their belongings for recent discharge summaries from outside hospitals or prisons. We also ask for contact information about family members, roommates, spouses/partners, or treaters/clinicians that know the patient. Often patients are reluctant to provide contact information, but non- confrontational approach can often work. We coordinate with our emergency medicine colleagues to assure that all necessary lab studies have been ordered. Labs should include a urine and serum toxicology screen to elucidate if any suicidal statements or behaviors are taking place in an intoxicated state. If any case involves someone never having being seen by medical/psychiatric personnel then a more comprehensive investigation takes place to uncover any medical causes of behavioral, affective, or cognitive changes. If there has been an abrupt change in behavior in a previously healthy individual then neuroimaging is ordered—usually a head computed tomography scan to start. Other labs are ordered depending on clinical suspicion or differential diagnoses. We usually order a complete blood count with differential and Chemistry 10 panel especially if there is a good chance that the patient will end up being transferred to a locked psychiatric unit. If neuroleptics are necessary to control violent or uncontrolled behavior, then a 12 lead electrocardiogram at some point is warranted to assess their QTc interval or to elucidate any occult cardiac disease. It has been reported that the risk of suicide is 20 times greater in persons with a diagnosis of major depressive disorder (MDD) than it is in the general population. 5 How often do you diagnosis untreated MDD among suicidal patients in the ED? Dr. Pacheco: It is difficult to diagnosis MDD in a patient seen for the first time in the ED setting because it is a diagnosis of exclusion, especially in patients new to the system. If after collateral information gathering, warranted physical examination, history, and lab/imaging studies have been done and there is no other plausible explanation for the suicidal behavior and expression of depression, we will make a diagnosis of depressive disorder not otherwise specified (NOS) or mood NOS. Some of these patients may actually be in the depressed phase of bipolar or schizoaffective disorder. Psychosis is also strongly linked to suicidal ideation. In addition to occurring with illnesses like schizophrenia or during alcohol withdrawal, psychotic symptoms can be associated with mood disorders, such as depression or bipolar disorders. 5 Dr. Pacheco, how do you manage these types of psychotic patients? Dr. Pacheco: Many suicidal patients seen in the ED are psychotic. The severity and implications of psychotic symptoms vary from patient to patient. Command auditory hallucinations telling patients to kill themselves or harm others are extremely dangerous and require immediate intervention. Psychotic symptoms may include delusions of persecution such that patients firmly believe that someone is out to harm them or someone they care about will be harmed. There may also be an element of hyper-religiosity in psychotic, suicidal patients as well. We manage these patients by asking if they have been off their antipsychotics, mood stabilizers, or antidepressant medications. As mentioned before, we also inquire if they have used substances such as cocaine, amphetamines, or cannabis recently as they can exacerbate an existing psychotic disorder or bring about new psychosis. Many psychotic patients have

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