Emergency Psychiatry

Question 1

What two interventions have been shown to decrease suicide mortality? How can we find out if they are going to?

Answer 1

1. Physician education in risk assessment
2. Restriction of lethal means - i.e. less guns available

Ask them if they are considering it, and ask them if they have access to the means

Question 2

What are the static risk factors for suicide? Include descriptions of these qualifiers.

Answer 2

1. Gender - male
2. Age - Increasing age increases risk, but 45-64 is currently highest rate
3. Personal or family history of suicide
4. Previous events - trauma / abuse
5. Race - being native american / white
6. Marital status - being single

Question 3

How does gender influence risk of suicide?

Answer 3

Males complete, females more non-lethal attempts, more attempts in gays

Question 4

How does personal history of suicide increase risk?

Answer 4

One of the most robust risk factors -> 40% have tried before, 2/3 of those who ultimately killed themselves occur 15+ years after first attempt

Question 5

What adolescent factors increase risk of suicide?

Answer 5

Physical / sexual abuse, homosexual or bisexual, homeless, recent loss, or “cluster suicides”

Question 6

What elderly factors increase risk of suicide?

Answer 6

Physical / mental illness
Bereavement
Loss of independence

Question 7

What family genes are thought to correlate to increased suicide risk?

Answer 7

1. Tryptophan hydroxylase - serotonin production

2. Serotonin transporter

Question 8

What are the “previous events” which predispose to suicide?

Answer 8

1. Physical or sexual abuse in childhood
2. Interpersonal stress
3. Health-related events
4. Suicide of others
5. Whole population events (i.e. natural disasters)

NOT WARS

Question 9

What races are more likely to commit suicide?

Answer 9

Native / Alaskan Americans > European Americans&raquo_space; Hispanic / African Americans

Question 10

What are the dynamic risk factors for suicide?

Answer 10

1. Mental illness
2. Neurobiology of suicide correlates
3. Physical health is poor
4. Lethal means available (males use more violent means like firearms / hanging)
5. Unemployed or work as a healthcare provider / farmer

Question 11

What are some mental disorders which increase risk of suicide? Are most suicides tied to mental illness?

Answer 11

90% of suicides are
MDD
Schizophrenia with increased academic achievement -> will see how much they are going to lose
Substance use disorder
Anxiety disorder
Borderline and Antisocial Personality Disorders (aggressive, impulsive)

Question 12

What are some neurobiological markers associated with suicide?

Answer 12

1. Decreased serotonin metabolites in CSF
2. Inflammation in CSF / periphery
3. Low cholesterol (how serotonin is transported across membranes)
4. HPA axis dysfunction

Question 13

What are some medical factors associated with increased risk of suicide?

Answer 13

1. Agitated delirium
2. Chronic or terminal illness
3. Disfigurement - as in treatment for head and neck cancer
4. Pain and other annoying conditions

Question 14

All healthcare professionals have increased risk of suicide. What specialty is the worse? And what other job is associated / why?

Answer 14

Anesthesiology - have better access to lethal drugs

Farmers - have access to pesticides

Question 15

What are you trying to assess when asking the patient questions regarding their suicide intent? What is most concerning?

Answer 15

Imminence
-> Do they have an intent to die, with lethal means now

Most concerning: Direct threats to harm / kill oneself, actively looking for ways to do so, talking / writing about death, dying, and suicide

Question 16

Who should be consulted in determining risk of suicide?

Answer 16

The patient’s family members, if available.
-> Do they ask about killing themselves, have ways to do this, been using substances / acted depressed / tearful? Attempted suicide before?

Question 17

How do you treat suicidal patients generally?

Answer 17

Remove their means, being sure not to prescribe risky drugs (opioids, sedatives, TCAS)

Determine inpatient vs outpatient by telling if active vs passive thoughts

Treat their underlying psych and medical conditions aggressively

Question 18

What biological treatments can be used for treatment of suicidality?

Answer 18

1. Lithium
2. Clozapine - Schizophrenia / Schizoaffective disorder
3. ECT or ketamine - decreased suicidality acutely
4. Antidepressants can be used, but beware of initial suicidality increases in younger people (black box warning)

Question 19

What therapies can be used for suicidality?

Answer 19

Repeated visits to PCP

Cognitive behavioral therapy
Especially: dialectical behavioral therapy -> reduce self-injurious behavior (used commonly in borderline PD)

Question 20

What scale is best used in the detection of suicidality?

Answer 20

Columbia Suicide Scales

Question 21

What is an Acute Suicidal Affective Disturbance?

Answer 21

A sudden increase in suicidal intent occurring over minutes to days
-> patient feels a disgust in others and themselves which they feel can never be changed

Question 22

What is the #1 risk factor for violence?

Answer 22

History of violence

Question 23

What are the three stages of violence?

Answer 23

1. Anxiety / agitation
2. Verbal threats -> with menacing posture / swearing / demanding specific threats
3. Overt aggression -> hitting / physical damage to things / throwing things in the room

Question 24

At what point is verbal de-escalation helpful and how do you do this?

Answer 24

Before overt aggression. If they get aggressive, contact security.

Do this by giving them space, asking them how to be more comfortable, if they would like you to come back later.

Question 25

What are some safety precautions which can be taken when dealing with potentially violent patients?

Answer 25

Avoid seeing them alone, observe before hand, have security ready, don’t assess intoxicated patients until they’ve sobered up, interview in a quiet place, be aware of an escape plan while keeping door slightly ajar. Use panic buttons / personal alarms, and know that anything can be used as a weapon.

Question 26

How can you treat mild and severe adjitation?

Answer 26

Mild - benzos and antipsychotics
Severe - Physical restraints, high potency antipsychotic (Haloperidol - can use if patient is in danger of harming self or others)

Question 27

What are three general causes of psychosis? How to tell them apart?

Answer 27

1. Delirium - fluctuating, decreased awareness and attention, medical problem
2. Substance use: history or physical exam, toxiciology
3. Primary psych disorder: i.e. auditory hallucinations, or from history

Question 28

When can a patient be involuntarily committed?

Answer 28

If someone files an order over age 18, they must be evaluated by a psychiatrist within 24 hours, and a court hearing will be held within 72 hours.

Question 29

When is involuntary commitment allowed? Give three reasons.

Answer 29

1. Risk of intentionally or unintentionally harming oneself or others
2. Made serious threats to harm others
3. Unable to take care of basic physical needs (i.e. schizophrenic patient not wearing a coat in the winter)

Question 30

What is meant by duty to warn?

Answer 30

If a provider determines the patient is a serious threat of violence to another, they are responsible to report that to the person to protect the intended victim against such danger. (call the victim or police so they know)

Question 31

When are we allowed to go forward with involuntary lifesaving treatment?

Answer 31

Following a psych eval

1. Patient has a legal status such that someone else can make decisions
2. Patient does not understand illness or treatment due to cognitive dysfunction
3. Patient is self-destructive / mentally ill