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Suicidal Patients

Suicidal Patients. Dr. Gamal Salah Mousa. Suicidal Patients. Those patients should first be referred to the appropriate medical or surgical services for emergency treatment Call to assess a suicidal patient from medical, surgical or emergency room if: -

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Suicidal Patients

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  1. Suicidal Patients Dr. Gamal Salah Mousa Dr. Gamal Salah Mousa

  2. Suicidal Patients • Those patients should first be referred to the appropriate medical or surgical services for emergency treatment • Call to assess a suicidal patient from medical, surgical or emergency room if: - • -Recently has attempted suicide after being stable and medically clear. • -With suicidal ideation. Dr. Gamal Salah Mousa

  3. Aim of consultation • Discover the underlying diagnosis • Take steeps necessary to ensure the safety of the patient • Initiate appropriate treatment Dr. Gamal Salah Mousa

  4. Causes • Major depressive disorder • Depressive disorder NOS • Adjustment disorder • Dysthymia • Cyclothymic disorder Dr. Gamal Salah Mousa

  5. Causes /2 • Bipolar I or II disorder /depressive disorder • Mood disorder duo to general medical condition • Schizophrenia • Schizoaffective disorder Dr. Gamal Salah Mousa

  6. Causes/ 3 • Alcohol or substance abuse • Anxiety disorders • Personality disorders • Malingering Dr. Gamal Salah Mousa

  7. Risk factors • The patient is threatening and has a plan • Age above 45 years • Male : sex • Violent behaviour • Previous suicidal attempts Dr. Gamal Salah Mousa

  8. Risk factors/ 2 • Alcohol dependent • Previous psychiatric admission • Family history of suicide • Medical illness • Social isolation Dr. Gamal Salah Mousa

  9. Assessment 1 – Chart review • Cause of admission • Medical problems • Medication • Psychiatric history • Substance abuse • History of suicidal ideation or attempts Dr. Gamal Salah Mousa

  10. Assessment / 2 2 –Vital signs and airway • fever • Signs of airway obstruction • Signs of withdrawal (autonomic instability ) • Signs of intoxication Dr. Gamal Salah Mousa

  11. Assessment / 3 3 – Quick look test • look for the patient: sad, depressed, angry, confused, manipulative or demanding • psychomotor agitation or retardation • withdrawn, isolated or communicating with others • presence of psychotic symptoms Dr. Gamal Salah Mousa

  12. Golden Rules during interview • Identify your self and cause of your coming • Basic information about the patient • What has been happening? If the patient is reluctant to talk, it may be more effective to talk about general history first and try to develop rapport with the patient. If the patient is disorganized or psychotic, structured interviewis indicated Dr. Gamal Salah Mousa

  13. Golden Rules during interview /2 • Encourage the patient to discus the plan if present • Not to put words into the patient mouth • Remember that you cannot plant thoughts in the patient “s head • If there are pauses in the interview, try to wait. Dr. Gamal Salah Mousa

  14. 4 – Selective history 1 - Recent history (Major depression, adjustment disorder, or dysthymia) • What has been happening? • Any recent stresses • Patient’s feeling (sad, blue, or down in the dumps) • Any changes in sleep or appetite • Anything the patient enjoy doing Dr. Gamal Salah Mousa

  15. 4 – Selective history /2 2 - Suicidal ideation: (Elicit positive feelings from the patient, e.g. religious and children) • Suicidal thoughts (what, how long and when) • Is there a wish to be dead? • Is there a sense of hopelessness, guilt or self-recrimination? Dr. Gamal Salah Mousa

  16. 4 – Selective history /3 2 - Suicidal ideation ( cont.) : • Details of the plan if present • Does he have the means and intention to carry out the plan? • What would happen after his death? • What prevents the patient from actually attempting suicide? Dr. Gamal Salah Mousa

  17. 4 – Selective history /4 3 - Substance abuse: • Alcohol, opiate, cocaine or benzodiazepine • How much/day – how long- when last dose 4 -Medical history: • Full medical history • Current medical status and medication Dr. Gamal Salah Mousa

  18. 4 – Selective history /5 5 - History of suicide attempts or gestures: • Much details as possible (discovering the trial, treatment, regret not having succeeded) • Planned or impulsive • Was it manipulative? Dr. Gamal Salah Mousa

  19. 4 – Selective history /6 6 - Past psychiatric history: • Previous hospitalization and treatment • History of depressive episode • History of mania • History of psychosis Dr. Gamal Salah Mousa

  20. 4 – Selective history /7 7 - Family and social history: (Seriousness of the attempt) • Psychiatric illness • Suicide • Patient’s interpersonal relationship • Work history Dr. Gamal Salah Mousa

  21. Mental status examination • Appearance • Behaviour • Psychomotor level of activity • Speech (slow / pressured) • Affect • Psychotic manifestation • Insight and judgment • Level of impulsiveness Dr. Gamal Salah Mousa

  22. Management • No matter what the underlying diagnosis is, the safety of the patient is paramount. • Admit the patient if he is a substantial risk to himself (voluntary or involuntary) • If admission is not indicated, a prompt referral to out patient clinic should be made. Dr. Gamal Salah Mousa

  23. Management /2 • If the patient is impulsive or has an active plan, it may be necessary to transfer him to a psychiatric unit or initiate a one- to- one observation. • The treatment and management start during the interview, a supportive style, with emphasis on encouraging the patient to discuss concerns, can be very therapeutic. Dr. Gamal Salah Mousa

  24. Management /3 • If the patient is already hospitalized and has passive suicidal ideation and would approach the staff if not feeling well, it would be reasonable to refer the patient to the psychiatric liaison service to follow up in the morning Dr. Gamal Salah Mousa

  25. Management /4 • Routine tests should include a CBC, electrolytes, liver function test, thyroid function tests, a VDRL for syphilis, and an ECG, check a urine toxicology screen. • If depression duo to medical condition, notify the internist to discuss further management. • If there are psychotic symptoms, you may want to start a neuroleptic. . Dr. Gamal Salah Mousa

  26. Management /5 • If the suicidal ideation is secondary to substance abuse or withdrawal from a substance, observation for signs of withdrawal. Caution in using anxiolytic or hypnotic medication in a patient with substance abuse. • If the suicidal ideation is related to a personality disorder, assess the need for one- to –one observation and set limits with the patient as to what can be done immediately Dr. Gamal Salah Mousa

  27. Management /6 • The patient may require medication for insomnia, temporary use of an anxiolytic • In general you do not need to start antidepressant medication immediately Dr. Gamal Salah Mousa

  28. Liaison Cases 1999 Dr. Gamal Salah Mousa

  29. THANK YOU DR GAMAL Dr. Gamal Salah Mousa

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