The management of suicidal patients who present to the emergency depart-ment or an EMH unit includes a broad array of therapeutic interventions tar-geting the suicidal behavior, as well as any comorbid major mental illnesses, personality disorders, psychosocial issues, and interpersonal difficulties that may be present. According to the “Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors” (American Psychiatric Associ-ation 2003), “Psychiatric management includes establishing and maintaining a therapeutic alliance; attending to the patient’s safety; and determining the pa-tient’s psychiatric status, level of functioning, and clinical needs to arrive at a plan and setting for treatment” (p. 29). Once the initial evaluation is complete and the treatment plan has been determined, additional goals of psychiatric man-agement may be applied in the emergency setting; these include crisis interven-tion, facilitating treatment adherence, and providing education to the patient and family members.
Establishing Therapeutic Alliance
When a suicidal patient presents to an EMH unit, he or she may never have had an encounter with a mental health professional. During this initial en-counter, the psychiatrist must work to build trust and develop a therapeutic relationship, with the ultimate goal of reducing the patient’s suicide risk. An individual who is determined to commit suicide may be unmotivated to de-velop a cooperative doctor-patient relationship and may view the emergency intervention as adversarial. In working with a suicidal patient, no matter how brief the intervention, the psychiatrist should practice empathy and demon-strate an understanding of the suicidal individual, as well as provide emo-tional support and expand the patient’s sense of possible choices other than suicide (Jacobs et al. 2003).
Table 2–1. Guidelines for selecting a treatment setting for patients at risk for suicide or suicidal behaviors
Admission generally indicated
After a suicide attempt or aborted suicide attempt if:
Patient is psychotic
Attempt was violent, near-lethal, or premeditated Precautions were taken to avoid rescue or discovery Persistent plan and/or intent is present
Distress is increased or patient regrets surviving
Patient is male, older than age 45 years, especially with new onset of psychiatric illness or suicidal thinking
Patient has limited family and/or social support, including lack of stable living situation
Current impulsive behavior, severe agitation, poor judgment, or refusal of help is evident
Patient has change in mental status with a metabolic, toxic, infectious, or other etiology requiring further workup in a structured setting
In the presence of suicidal ideation with:
Specific plan with high lethality High suicidal intent
Admission may be necessary
After a suicide attempt or aborted suicide attempt, except in circumstances for which admission is generally indicated
In the presence of suicidal ideation with:
Psychosis
Major psychiatric disorder
Past attempts, particularly if medically serious
Possibly contributing medical condition (e.g., acute neurological disorder, cancer, infection)
Lack of response to or inability to cooperate with partial hospital or outpatient treatment
Need for supervised setting for medication trial or electroconvulsive therapy Source. Reprinted from “Practice Guideline for the Assessment and Treatment of Pa-tients With Suicidal Behaviors.” American Journal of Psychiatry 160(suppl):31, 2003.
Copyright 2003, American Psychiatric Association. Used with permission.
Determining the Appropriate Treatment Setting
Perhaps the most important decision made during the evaluation of a suicidal patient in a psychiatric emergency is the determination of appropriate treat-ment setting. Jacobs et al. (2003) suggested that patients with suicidal thoughts, plans, or behaviors should be seen and evaluated in the least restrictive safe and effective treatment environment. Treatment settings span a continuum of different levels of care, ranging from the most restrictive, involuntary inpa-tient hospitalization; through partial hospitalization and intensive outpainpa-tient programs; to the least restrictive setting of ambulatory care. The choice of treatment setting should be based on the best estimate of the patient’s current suicide risk, risk of harm toward others, and other aspects of the patient’s pre-sentation. These factors may include medical and psychiatric comorbidity;
strength and availability of a psychosocial support network; and ability to pro-vide adequate self-care, give reliable feedback to the psychiatrist, and cooper-ate with treatment.
Hospitalization, the most restrictive treatment setting, should always be considered when the patient’s safety is in question. Inpatient treatment is usu-ally indicated for individuals who pose a serious threat of harm to themselves or others. Significant factors favoring inpatient hospitalization over alterna-tive treatment settings for suicidal patients include psychosis, past suicide at-tempts, and persistence of a specific suicidal plan with high lethality or intent (Goldberg et al. 2007). Other considerations for inpatient treatment include factors based on the severity of illness and the intensity of services needed by the patient. For example, severely ill individuals may require inpatient care because they cannot be safe in a less restrictive environment or because they lack structure or social support outside of a hospital setting. In addition, hos-pitalization is indicated when there is a new, acute presentation that is not part of a repetitive or chronic pattern. Those individuals with a complicated psychi-atric or general medical condition that has not responded adequately to out-patient treatment may also need to be hospitalized. Some out-patients with lesser degrees of suicidality may end up needing more intensive treatment if they lack a strong psychosocial support system, are unable to gain timely access to outpatient care, have limited insight into the need for treatment, or are unable to adhere to recommendations for ambulatory follow-up. In geographic areas where partial hospital or intensive outpatient programs are not readily
acces-sible, inpatient care may be necessary at lower levels of suicide risk to keep cer-tain individuals safe (Jacobs et al. 2003).
It is important to recognize that hospitalization is not a treatment, but rather is a treatment setting that can facilitate continued evaluation and treatment of suicidal persons. In considering an intensive intervention such as inpatient hospitalization, a clinician should weigh the risks and benefits of hospitaliza-tion, and balance a person’s right to privacy and choice against the issue of po-tential dangerousness to self or others. The decision to hospitalize should not be taken lightly; although the benefits of treatment seem obvious to a trained professional, hospitalization carries the potential for negative effects for the patient, such as social stigma, financial difficulties, and loss of employment.
Some people may feel frightened or humiliated in the hospital, whereas others may feel a sense of emotional relief.
Hospitalization can occur on a voluntary or an involuntary basis. This de-cision is often made during the EMH evaluation and depends on a variety of factors. These factors include the estimated level of risk to the patient and others, the patient’s level of insight and willingness to seek care, and the legal criteria for involuntary hospitalization in the clinician’s jurisdiction. Gener-ally, patients who are at imminent risk for suicide will satisfy the criteria for involuntary hospitalization; however, specific commitment criteria vary from state to state, and emergency psychiatrists must know the specific state stat-utes regarding involuntary hospitalization. Under some circumstances, the decision to hospitalize may be made before additional history is available, based on the high potential of dangerousness to self or others, or the patient’s inability or unwillingness to cooperate with a psychiatric evaluation (e.g., in the presence of extreme agitation, psychosis, or catatonia).
For those patients who are not found to be at imminent risk for suicide and who do not require inpatient treatment, outpatient services may be ap-propriate. A “step-down” level of care from hospitalization includes two op-tions: an intensive outpatient program or partial hospitalization. Less intensive treatment may be more appropriate if suicidal ideation or actual attempts are part of a chronic, repetitive cycle and if the patient is aware of the chronicity.
For those patients with a history of suicidal ideation without suicidal intent and a strong ongoing doctor-patient relationship, the benefits of continued treatment outside of the hospital may outweigh the potential negative effects of hospitalization.
Under some circumstances, individuals who are not involved in outpa-tient treatment may be referred for care after a suicide attempt or emergency psychiatric evaluation. Adherence can often be a problem for those individu-als referred for outpatient follow-up after an emergency psychiatric evaluation.
Therefore, the clinician should discuss the referral with the patient during the course of the interview and, if possible, arrange a specific appointment time.
Related issues are discussed further in Chapter 13, “Disposition and Resource Options.”
Providing Treatment
Psychopharmacological interventions that modify risk factors may be helpful in preventing suicide. The following treatment modalities have been studied, and some limited evidence indicates that they may help reduce the risk of sui-cide in certain populations. In this section, we provide a broad overview of treatment modalities, with an emphasis on those interventions that can take place or begin in the emergency psychiatric setting.
Medications can be lifesaving not only in the long term, but also in the short term, such as in the treatment of severe acute anxiety in a depressed pa-tient. In the emergency setting, medications can provide significant immedi-ate relief, but have time-limited effects that require close supervision of the patient’s mental status, because the effects of the medications can wear off and symptoms may reemerge, with subsequent recurrence of suicidal impulses.
Even if medications are given for acute treatment, a patient at high risk for suicide must still be monitored closely or hospitalized until the crisis resolves.
Research will continue to investigate and delineate the role of different types of psychopharmacological interventions in acute suicide prevention.
Antidepressants
Currently, evidence remains inconclusive that any type of antidepressant or antianxiety treatment is associated with lowering the acute risk for suicidal behavior (Fawcett 2001). However, the American Psychiatric Association’s (2003) practice guideline suggests that a strong association exists between clinical depression and suicide, and that the reasonable effectiveness and safety of antidepressants support their use. In the EMH setting, although antide-pressants are rarely prescribed on an acute basis without secured outpatient follow-up, nontricyclic, non–monoamine oxidase inhibitor antidepressants
should be considered first and dosed in a conservative manner, because they are relatively safe and present minimal risks of lethality on overdose (Jacobs 2003).
Lithium
A recent meta-analysis of studies of suicide rates with versus without long-term lithium maintenance in patients with recurring bipolar disorder and major depressive disorder found an almost 14-fold decrease in suicidal acts. Lithium maintenance treatment was associated with an 80%–90% decrease in risk of suicide and more than a 90% decrease in suicide attempt rates (Jacobs 2003).
As with antidepressants, initiation of lithium should not be considered in an emergency department setting unless secured follow-up or inpatient psychi-atric hospitalization occurs.
Benzodiazepines
Clinical evidence suggests that aggressive treatment of panic, anxiety, and ag-itation with benzodiazepines or other anxiolytic agents may reduce suicidal risk. In the EMH setting, the concern for benzodiazepine dependency should be viewed as less important than the risk of suicide. However, benzodiaz-epines should be used cautiously in patients with borderline personality dis-order because behavioral disinhibition may occur (Fawcett 2001).
Anticonvulsants
Anticonvulsant medications, such as divalproex, have been used to reduce agi-tation in a whole host of psychiatric conditions. However, the long-term effec-tiveness of anticonvulsant agents in protecting against recurrent mood epi-sodes or reducing risk of suicidal behavior has not been well established (Jacobs 2003). As with all psychotropic medications, initiation of anticonvulsants should be carefully weighed against the risk of potential overdose or misuse.
Atypical Neuroleptics
Atypical neuroleptics, such as olanzapine and quetiapine, seem to produce anxiolytic and antiagitation effects in some patients and may play a role in re-ducing suicide risk. In patients with schizophrenia and schizoaffective disor-ders, studies have shown that clozapine substantially reduces suicide attempts.
Olanzapine has been found to be more effective than haloperidol in reducing
suicide attempts in patients with schizophrenia (Fawcett 2001). In the psychi-atric emergency setting, neuroleptics are used primarily to reduce aggression and agitation.