A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience
Issue link: http://innovationscns.epubxp.com/i/425963
[ 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 199 R E S E A R C H T O P R A C T I C E stopped taking their prescribed medication. Administering the prescribed antipsychotic or judicious administration of a novel one can often resolve the acute psychotic episode. Often, the suicidal ideation dissipates when the patient is no longer acutely psychotic. The clinical treatment may require larger or repeated doses of antipsychotic medications to achieve benefit. Physical restraint or parenteral administration of an antipsychotic may also be warranted in agitated patients as a last resort. One should always be prepared for this contingency in new patients unknown to the system or intoxicated patients. It is far better to be prepared for the worst than have to deal with serious injuries after a patient becomes assaultive. Is it common or uncommon for psychiatric patients to take an overdose of their own medications? Dr. Pacheco: It is common. Overdose of their own medication is especially common in patients with comorbid substance use issues or personality disorders. The attempts often happen during a period of intoxication where there is decreased inhibition. Patients with personality disorders often overdose on their medications and then text or phone their families or spouses/partners to inform them of their actions. How important is a support system? Can you send someone home without a support system? Dr. Pacheco: A support system is crucial. Desperate and lonely people do desperate things, including killing themselves. Sending a patient home by him- or herself after the patient has presented or vocalized suicidal ideation is risky and should be avoided if at all possible. If someone comes to the ED in the middle of the night, keep them until the morning when family or treaters/clinicians are reachable. Ask family members or roommates, "Do you feel comfortable taking him or her home?' If they say no, ask "why not?" Often, their answer will provide you with some dimension of the patient of which you have not been aware. Can you describe any cases that served as "teaching" moments for you or your staff? Dr. Friedman: I find one of the most useful factors in evaluating the patient with suicidal ideation is getting another perspective. The picture painted by a loved one or coworker, which may be completely different from what the patient is describing, is invaluable. I have evaluated patients whom I thought were safe to be discharged until somebody telephoned in or showed up and described an incredibly risky or dangerous recent event that makes one stop in ones tracks to re-assess the whole situation. Dr. Pacheco: There have been many teaching moments for me but the most difficult ones have been physicians themselves, mainly because their stories hit close to home. The most important point I'd like to make though is that the majority of suicides happen within one month of any clinical contact, whether it be in the ED or outpatient clinic. Don't be worried that by merely asking you will trigger suicidal thoughts in any patient. Usually it is the contrary. They are often relieved they have permission to discuss these unthinkable urges and feelings that they have been hiding. How often do you see the same suicidal patient again? What happens the second time around? Dr. Friedman: We've had patients call 9-1-1 from the ED lobby phone after discharge or go lie down in the street across from the hospital. Generally most of these patients are more likely to carry a diagnosis of personality disorder than truly worry us that they will cause self-harm. However, one of the cardinal rules of residency training in emergency medicine is that any unexpected return of a patient is a red flag. One must force oneself to be as objective as possible in reassessing the patient to make sure that one is really comfortable with one's original diagnosis. Has the critical importance of the ED's role in suicide prevention been recognized on a national level? Dr. Friedman: Yes it has. The International Association for Suicide Prevention (IASP) has organized a Task Force on Suicide and Emergency Medicine that addresses this challenge. 8 Where can clinician's get more information about the assessment and treatment of suicidal patients in the ED? Dr. Pacheco: Some excellent practice guides have been developed. The American Psychiatric Association published a guide in 2003 and the United States Department of Health and Human Services published one in 2008. Both would probably be good places to start. 9,10 REFERENCES 1. Larkin GL, Beautrais AL. Emergency departments are underutilized sites for suicide prevention. Crisis. 2010;31(1):1–6. 2. United States Centers for Disease Control and Prevention (CDC). Fact sheet on suicide, 2011. http://www.cdc.gov/ViolencePreventi on/suicide. Accessed October 1, 2014.