Psych Emergencies
"Silent Suicide" is defined as: A. an act of slowly killing oneself by nonviolent means, such as starvation or non-compliance with essential medical treatment B. a self-destructive act disguised as an accident C. recurrent self-destructive acts, such as heavy drinking in the presence of alcoholic liver disease D. suicide involving a number of willing and sometimes not so willing participants E. an attempted suicide
The answer is A. "Silent Suicide" is most common in elderly patients and frequently goes unrecognized. Such patients may present to the emergency department repeatedly because of non-compliance with treatment of their medical disorders. "Occult Suicide" is applied to self-destructive acts disguised as accidents and should be suspected in those who have "accidental" self-inflicted gun shot wounds, and in those who "unintentionally" overdose, or who fall from a height. "Chronic Suicidal Behavior" consists of recurrent self-destructive acts. "Mass or Group Suicide" is suicide involving a number of people. "Parasuicide" is an attempted suicide, which is seen more as a gesture than a serious act.
A 35 year old female is brought to the emergency department after family members called the police to say she was threatening to kill herself by jumping out a window. She has a long history of depression. Regarding suicide, which of the following statements is FALSE? A. All states have laws giving law enforcement the right to place into custody any individual suspected of being a danger to themselves or others. B. Family sitters provide the best option for close observation of suicidal patients since they often have a calming influence on the patient. C. The patient's room needs to be cleared of all potentially dangerous objects such as blunt instruments, glass objects, and the patient's belongings. D. The majority of suicide attempts involve minor injuries or drug overdoses.
The answer is B. For any patient presenting with suicidal ideation, the emergency department physician must first stabilize medical condition as most attempts involve minor injury or drug overdoses treatable by emergency room staff. Secondly, all objects and substances should be kept strictly out of reach of the suicidal patient. Once stabilized these patients may be kept under direct supervision. It is not recommended that family members provide the direct supervision because of a possibility of collaboration between family and patient to leave the hospital. In this event, or even before coming into the hospital, all law enforcement has the right to bring into custody any patient at risk of harming self or others.
A 25 year old male is brought to the emergency department by his family, with a complaint of feeling depressed for the past week. In obtaining the history, which of the following statements regarding this patient would support a diagnosis of major depression? A. The patient has no history of medical illness B. The patient has a history of Crohn's disease C. There is no family history of depression D. The screening mnemonic in SAD CAGES is negative
The answer is B. In SAD CAGES is a screening mnemonic for symptoms, not causes, of major depression. Depression is more common in patients with history of other medical illnesses, some of which may actually cause depressive symptoms. As compared with major depression, dysthymic disorder is a more chronic, and less severe, form of depressive illness.
Which of the following psychiatric disorders is associated with the greatest increased risk of committing suicide? A. schizophrenia B. panic disorder C. major depression D. post-traumatic stress disorder (PTSD)
The answer is B. Most people who commit suicide suffer from either alcoholism or a diagnosable psychiatric illness. 15-20% of people with major depression and 10% of people with schizophrenia will commit suicide. Up to 40% of people with panic disorder will attempt suicide at some point in their lives. PTSD also carries an increased risk.
A 22 year-old man, recently released from hospital with a newly diagnosed psychiatric disorder, was found dead at his home from an overdose of medications prescribed by his doctor. Of the following drugs, which one (taken in isolation), would be most likely to be associated with fatal outcomes in an overdose scenario? A. fluoxetine B. lithium C. amitriptyline D. lorazepam
The answer is C. Antidepressant overdose is the most common cause of suicide by ingestion. Cyclic antidepressants are associated with a higher potential for lethality than other antidepressant medications. Often during the early stages of recovery from major depression, patients may have a "mobilization of energy" which allows them to act on their suicidal thoughts, for which they previously lacked the energy.
When using the "SAD PERSONS" scale to determine suicide risk, which factor conveys the least amount of points? A. stated future intent B. depression or hopelessness C. separated, divorced or widowed D. rational thinking loss
The answer is C. Being separated, divorced or widowed is an important but less significant factor in determining suicide risk and so is assigned 1 point on the suicide scale. All the others are high-risk factors and are each assigned 2 points on the suicide scale. A score of 6 or more has a sensitivity of 94% and a specificity of 71% compared with formal psychiatric evaluation to identify the need for hospitalization in patients who present immediately after a suicide attempt.
A 42 year old male with end stage liver disease due to chronic hepatitis C infection arrives to the emergency department in stable condition after an unsuccessful suicide attempt by bilateral wrist laceration. He reports no history of depression or psychiatric disorder. Aside from his liver disease, for which he takes interferon alpha and ribavirin, he reports that he is in good health and takes no other medications. Which of the following factors increased this patient's risk of new-onset suicidal ideation? A. chronic hepatitis C infection B. end-stage liver disease C. interferon alfa therapy D. ribavirin therapy
The answer is C. Interferon alfa, an important cytokine in the early immune response to viral infection, has both antiproliferative and antiviral properties. It is the only therapy approved by the Food and Drug Administration for hepatitis C infection. Interferon alfa has been associated with high rates of central nervous system side effects, including anhedonia, fatigue, anorexia, impaired concentration, sleep disturbance, and suicidal ideation. Clinicians should always look up the side effects of their patients' medications, especially unfamiliar drugs. This can both expedite diagnosis of drug-induced complications and prevent them with appropriate pretreatment. Pretreatment with a selective serotonin reuptake inhibitor appears to be an effective strategy to minimize depression induced by interferon alfa. Chronic hepatitis C infection and end-stage liver disease can both be difficult diseases to live with, however, these conditions are not known to significantly increase a patients' risk for new suicidal ideation. Depression is not a known side effect of ribavirin treatment. Although males have a higher percentage of successful suicide attempt than females, females have a much higher incidence of suicide attempt and ideation than males overall.
Which clinical scenario is use of chemical restraint indicated? A. Patient is uncooperative with the history B. Patient's remarks are felt to warrant negative reinforcement C. Patient's behaviors and actions pose an imminent harm to self D. Patient is responding to verbal tactics, but requires multiple attempts
The answer is C. Physical and chemical restraints should only be used when verbal tactics have failed and when the patient is an immediate threat to himself, others or the integrity of the emergency department. From a medico-legal standpoint, clear documentation is very important when a decision is made to apply restraints. Answers A, C, D, and E are all valid reasons for physical or chemical restraints.
Toxicological screening is indicated in which patient with suicidal ideation? A. Patient who threatens to cut both wrists with a knife B. Patient who ingested unknown amount ibuprofen 48 hours earlier C. Patient who ingested a "bottle" of tylenol D. Patient who takes lithium for bipolar affective disorder
The answer is C. Routine toxicological screening is unnecessary in the evaluation of suicidal patients in whom there are no clinical indications for such testing. With the exception of acetaminophen, essentially all patients with dangerous overdoses and poisoning will demonstrate clinical signs within several hours of ingestion. History, physical examination, and risk determination of suicide, however, is part of the routine evaluation of the suicidal patient
Suicide risk is increased in this patient population: A. Patients who have not been involuntarily committed B. Patients who directly questioned about suicide C. Patients who are elderly and Caucasian D. Patient who takes lithium for bipolar affective disorder
The answer is C. TRoutine toxicological screening is unnecessary in the evaluation of suicidal patients in whom there are no clinical indications for such testing. With the exception of acetaminophen, essentially all patients with dangerous overdoses and poisoning will demonstrate clinical signs within several hours of ingestion. History, physical examination, and risk determination of suicide, however, is part of the routine evaluation of the suicidal patient.
Suicide rates are consistent with the average population in this population: A. Females with breast implants B. Men with AIDS C. African-American males D. Presence of underlying panic disorder
The answer is C. The epidemiology of suicide varies according to age, gender and race. Overall, men have higher rates of completed suicide and women have greater numbers of suicide attempts. Suicide risk among men shows a bimodal distribution with increased risk between the ages of 15 and 24 and after age 65. Suicide risk among women peaks after age 60. People who suffer from a chronic disease such as AIDS are at increased risk for committing suicide. The dramatic increase in suicide rates among adolescents is thought to be due to changing demographics and greater access to firearms. Underlying psychiatric illness increases a person's risk of suicide. Major depression, bipolar, borderline personality disorder, schizophrenia, and panic disorder are all associated with increased suicide rates. Of note, One study demonstrated that 40% of people who suffer from panic attacks would attempt suicide at some point in their lives. Studies have demonstrated that the presence of breast implants portends a higher risk of suicide.
