what happens to person who try commit suicide police maryland

• Journal List
• Prim Intendance Companion J Clin Psychiatry
• five.5(4); 2003
• PMC419387

Prim Intendance Companion J Clin Psychiatry. 2003; 5(4): 169–174.

Managing Suicide Attempts: Guidelines for the Principal Care Physician

Received 2003 May 2; Accepted 2003 Aug 4.

Abstract

The direction of patients who have fabricated suicide attempts is a responsibleness that frequently falls to the primary care physician. For this reason, it is important that the physician have a clear strategy for dealing with the suicidal patient in the part, infirmary, and emergency room. In the acute situation, the showtime priority is to stabilize the patient and ensure his or her medical safety. In one case this is accomplished, history and circumstances of the attempt tin can be assessed, along with likelihood of recurrence of the attempt. This article reviews guidelines for evaluating suicide chance. The importance of the patient-doc relationship is noted, particularly in regard to prevention of future suicide attempts. With a focused, thorough approach to the suicidal patient, which incorporates both medical and psychiatric considerations, the primary care physician tin amend the patient's astute situation and facilitate the coordination of care with appropriate psychiatric resource.

Primary care physicians are frequently called upon to evaluate and manage a patient who has attempted suicide. Services may be provided in the emergency department (ED) of the hospital immediately after the attempt or later in the role after the patient has been stabilized and is recovering. A comprehensive plan can aid the physician in both meeting the immediate, potentially life-threatening challenges of caring for the patient, equally well as providing the patient with needed back up and guidance in the follow-upward stage. An effective and collaborative patient-md relationship tin provide a mechanism to reduce the likelihood of some other suicide endeavor. Our goal in this article is to recognize the frequency and severity of suicide attempts in primary care patients and to offering guidelines for stabilization and safety, including possible interview strategies and procedures. Areas to explore in assessing the suicidal patient, especially risk factors for subsequent attempts, will be presented. Finally, some general issues in providing continuity care for a patient who has made a suicide attempt will also be addressed.

Groundwork: EXTENT AND Description OF THE PROBLEM

The incidence of suicide surpasses homicide and is the eighth leading cause of death in the United States. About 1% of full deaths are a result of suicide. Unsuccessful attempts outnumber completed suicides by a multiple of sixteen.¹ It has been estimated that the boilerplate number of suicide attempts in a family practice is 10 to xv yearly, although the family unit physician may exist aware of only 1 or 2.² Multiple attempts are more than likely to occur in the adolescent and young developed historic period groups. Frequently, the geriatric patient who commits suicide has not made previous attempts.³

Differentiation between a suicide endeavor and a parasuicide has been suggested.^four Parasuicide refers to an human activity of self-harm without the realistic expectation of death. These behaviors take also been referred to equally suicidal gestures and viewed as different from a "truthful attempt" in which there is a clear intent and expectation of death. However, gestures can also atomic number 82 to expiry when there are miscalculations or unexpected effects of the harmful beliefs. In addition, it is difficult and sometimes impossible to discern accurately the patient's intent. As a effect, parasuicides or gestures should be taken seriously and deserve the aforementioned intensive intervention equally unambiguous suicide attempts.

Managing the patient who has attempted suicide requires a comprehensive plan. The algorithm in Figure 1 describes an overall assessment and management strategy. The following sections detail the recommended steps.

Algorithm for the Management of Patients With a Recent Suicide Attempt

STABILIZATION AND SAFETY

Some suicidal patients present to the primary care physician with the main complaint of suicidal thoughts. Notwithstanding, more than often, patients come in for other complaints and are subsequently found to be suicidal post-obit thorough questioning virtually their thoughts of hurting or killing themselves. In either instance, the physician needs to gather information about the patient's intent, plan, support system, and past medical/psychiatric history. The patient should not be allowed to leave the function until the physician can thoroughly assess his or her status. A staff member should be assigned to stay with the patient while treatment arrangements are fabricated. If the patient is hostile or demands to get out, law enforcement should be chosen. However, if a patient is threatening to the clinician or office staff, heroic measures should not exist used to restrain the patient; instead, providing constabulary enforcement with a description of the patient's vehicle and direction of travel may be helpful.

Physician cognition of local mental health resources is necessary and so that the patient can exist directed to appropriate treatment. Some communities accept mental health crunch centers that take suicidal patients referred from physicians. Another option is to call emergency medical services for ambulance send to the nearest ED for evaluation. Suicidal patients cannot be discharged from the office alone. In unusual circumstances, if the patient is not intoxicated or impulsive and a reliable friend or family member is with the patient, that person can back-trail the patient to the ED or crisis middle, but it is safest for medical staff or law enforcement to aid with send.

During the initial meet with the patient who has attempted suicide, whether in the ED, office, or hospital room, the physician should focus first on the stabilization of the patient's medical condition. This includes the protocols for medical resuscitation such as Advanced Cardiac Life Support and vital sign stabilization. Signs and symptoms must exist evaluated carefully and should non automatically be attributed to a psychiatric origin. Intoxication and delirium should be ruled out. The patient must be sober before the formal suicide evaluation can take place.

A patient being evaluated in the ED should not be immune to go out prior to a full evaluation. If there is astute danger to the patient or others, so he or she should be restrained chemically or physically. The physician and medical staff must exist cognizant of their own safety. If the caregiver feels threatened by the suicidal patient, a security baby-sit should be present in the patient's room.^five

Information technology is important to ensure that the area where the patient is observed, both in the ED and every bit an inpatient if admitted, is safe and that there are no available ways for self-harm. This precaution is often overlooked when patients are admitted to intensive intendance units for observation, particularly if the patient is comatose when first admitted. All sharp objects, belts, drugs, and medical equipment should be isolated from the patient. The patient should be hands observable from the nurses' station and a guard should be assigned to lookout man the patient on a one-to-one basis. An attendant should back-trail the patient to all procedures and tests.

PATIENT HISTORY

After the patient is stabilized and his or her condom ensured, establishing a history becomes the next priority. To begin the interview, set up the appropriate environment. Ask family and friends to footstep out of the room, requesting to talk with them afterward.⁵ It is important to remain calm, nonjudgmental, and nonthreatening. Medical history should include review of current medications, by and recent substance use, history of seizures or head injuries, and HIV risk factors. Information should be gathered almost prior suicide attempts and psychiatric illnesses because both are associated with an increased risk of suicide.^three Those with bipolar disorder, depression complicated by comorbid anxiety disorders, and impulse control and substance abuse disorders, as well equally those with psychotic or delusional ideation, are at detail risk. Over 90% of persons who commit suicide accept diagnosable psychiatric affliction at the time of death, oftentimes depression, alcohol abuse, or both.⁶ Hopelessness, while often accompanying low, is an contained predictor of suicide and should be specifically probed.

Physicians should determine if a suicide note exists and, if so, make an effort to re-create it for inclusion in the medical record. Collateral data from paramedics, police, friends, and family are valuable and tin can provide clues to the timing and sequence of events.⁶ Information technology is of import to institute the temporal details, peculiarly in cases of ingestion or overdose. The length of time since ingestion tin can alter decisions regarding methods of treatment. Intendance must exist taken, however, since confidentiality laws require patients' permission to hash out health care information with others. The American Psychiatric Association has developed a "Position Statement on Confidentiality" that supports the breaching of confidentiality if necessary to protect the patient or the community from imminent danger.^{vii, 8}

The importance of confidentiality was underscored in the "Minimum Necessary" standard of the Wellness Insurance Portability and Accountability Act (HIPPA).⁹ Covered entities, such as physicians and hospitals, are required to review their privacy practices and enhance safeguards to protect patients' health information. Only the medical staff directly involved in the care of the patient should receive details or have access to the patient's health information. History of suicide attempts can be peculiarly sensitive, and if publicly known, tin have a profound impact on the patient's life.¹⁰ Of note, while HIPPA regulations and basic medical ethics prohibit the clinician from divulging patient health information, they do not prohibit a clinician from interviewing others and obtaining and recording information nearly the patient.

The use of basic interviewing techniques tin optimize the come across with the suicidal patient. This involves expressing empathic curiosity, active engagement, and morally nonjudgmental relatedness with the patient. Information technology can begin with a unproblematic question like "How tin I help yous today?" Listen carefully to the precise respond. The physician should try to sympathize what crunch would have prompted the patient to attempt suicide. For patients who are reluctant to be open up, focus should exist on the reason for that reluctance. Asking the uncomplicated question "Why now?" can oft atomic number 82 the interviewer direct to the precipitant of the crisis. Ask whom the patient would be leaving behind to proceeds the identity, human relationship, and significance of key people. Listen carefully to define the patient's emotional state and reiterate information technology for them, putting the problem in a broader context. For example, say, "You lot seem very sad about this, and information technology seems to you that at that place is no manner out."^{half dozen} Addressing the patient's sense of hopelessness may be an of import office of showtime to help them.

Although hopelessness is usually associated with depression, information technology tin occur in other diagnostic conditions every bit well and is frequently involved in suicide attempts.^eleven The patient cannot see how things will better and dreads continuing with things as they are. Death is seen equally an escape, a way to avoid a pain that volition never go away.¹² While empathizing with the patient'southward pain helps them feel more than trusting and understood, the physician tin can subtly brainstorm inculcating hope with a positive attitude, a conventionalities that the patient's circumstances and depression tin ameliorate and be treated successfully. The goal is for the patient to believe their situation and distress are appreciated, while at the same time perceive that the physician is confident that things can get improve.

The patient's problem solving and coping skills should be evaluated and stressors and back up systems identified. Knowledge of the patient'southward current and past prescription medications and access to drugs, alcohol, and firearms is vital. This information will be helpful in establishing an understanding of the surround that the patient may exist returning to upon discharge. For the boyish attempter, ask nigh changes in schoolhouse performance or omnipresence. It is assumed that the medico volition also obtain a detailed medical history for the patient, including comorbidities, allergies, and family history.

MENTAL STATUS AND PHYSICAL EXAMINATION

The concrete examination is a disquisitional chemical element in the evaluation of patients who have attempted suicide. This is an area where principal care physicians can greatly add to the care given the patient. Merely 17% of psychiatrists routinely perform physical examinations on their inpatients, and the rate for outpatients is even lower.¹³ Upwardly to fifty% of patients with psychiatric complaints have been found to harbor unrecognized medical illnesses that may have contributed to their mental deterioration.¹⁴

Throughout the initial encounter, the dr. will be collecting observational information about the patient'due south mental status. Was he able to spell his name when first asked? Did she remember the mean solar day of the week? Does she know where she is? Who brought him to the hospital/clinic? During the initial moments of the interview, these simple, directed questions should be asked to plant the patient's level of alacrity and orientation. The goal is to gain insight into the patient's mental status, including whatever indication that the patient is delusional, psychotic, or substance impaired. Findings from the mental condition exam⁶ can exist used to facilitate discussions with psychiatric consultants and will be valuable additions to the medical record.

The concrete test should be thorough and consummate. Special attention should be given to physical findings associated with chronic disease, alcoholism, and substance abuse.^fifteen Include observation of appearance, level of attention, affect, dress, grooming, and hygiene. Look for needle marks, unusual odors, or excoriations suggestive of past abuse or injury. Vital signs should be obtained from all patients; in antagonistic patients, wait until after they have calmed downwards. Observe interactions of the patient with family, friends, and hospital staff. Tests such every bit toxicology screens, electrolytes, complete blood cell count, blood glucose, liver function tests, and electrocardiography (ECG) are appropriate and should be obtained to establish any comorbid conditions.

The physician who is responsible for writing medical admission orders for the suicidal patient should take the following considerations into account in addition to the medical orders needed to stabilize the patient (e.g., activated charcoal, mannitol, ECG, routine labs). The patient should be placed on suicide precautions. In ane written report, half dozen out of 57 people who were inpatients or patients in a day infirmary committed suicide while in the hospital and iii of those half dozen patients were thought to exist improving based on chart notes.¹⁶ Consider the possibility of comorbid substance abuse. Monitor for delirium tremens and supplement folate and thiamin if the patient has neurologic deficits or is malnourished. Ancillary testing such as thyroid function tests, atomic number 82 levels, liver panel, serum osmolality, ammonia level, chest 10-ray, and lumbar puncture should be considered in patients with corresponding physical examination findings or in patients presenting with new onset of psychiatric symptoms.¹³

Patients presenting with overdose demand aggressive initial treatment and close monitoring for the showtime 12 to 24 hours. The patient may withhold, underestimate, or exist physically unable to requite authentic estimates of type or quantity of pills ingested. The medico should maintain a loftier index of suspicion for occult overdose and should be prepared to use reversal agents (i.e., naloxone in narcotic overdose, flumazenil in benzodiazepine ingestion) and gastrointestinal tract decontamination via emesis, gastric lavage, or activated charcoal with a cathartic.

Historically, ipecac has been used to induce emesis in cases of overdose; however, its employ is declining.¹⁷ Induced emesis can exist attempted simply in a fully alert patient who has not ingested a caustic, petroleum production, or antiemetic. Gastric lavage is performed using a large bore gastric tube (37°F [three°C] to 40°F [4°C]) inserted into the stomach and flushed with 200 mL of warmed water and aspirate suctioned. The procedure is repeated until the aspirate returns articulate fluid. Care must exist taken to ensure airway protection. In patients that practice not take a gag reflex, intubation must be considered. Activated charcoal tin exist given orally following lavage in a dose of 1 g/kg of patient trunk weight. To avoid constipation and increase gastrointestinal motility, charcoal is used in combination with the cathartic sorbitol in a dose titrated to achieve consistent loose stools.^xviii

Reliable knowledge of the agent(due south) for overdose may require specific antidotes that are outside the telescopic of this discussion. Help with management can be obtained from the chemist's shop staff in the infirmary and from poison control centers. The national number for poison command is 1-800-222-1222 and is available in the front pages of near telephone books and directories.

Finally, certificate the run across, including the assessment (based on the interview and the collateral information), differential diagnosis, working diagnosis, and treatment plan. The treatment plan should include evaluation by a psychiatrist, preferably while in the hospital. If the patient refuses to be evaluated or his insurance plan declines referral, and so the patient should be involuntarily hospitalized. Suicide is confronting the police force, and the police volition escort the patient to the psychiatric facility if necessary.¹⁹

If the patient is to be discharged, be sure to ask about and document the availability of firearms, potentially lethal medications, and other means of suicide. Handgun ownership in the Usa is estimated at 16% to 19% of the population. Handguns are commonly used in suicide, accounting for 62% of suicides among men and 39% among women. Therefore, steps must be taken to make guns inaccessible to the at-risk patient.²⁰ Ask a friend or family member to remove all firearms from the patient's home. Inform close contacts of the patient to remove all guns from other households attainable to the patient.

Establish a follow-up plan, including frequent shut contacts or visits during the days after the attempt.²¹ Follow-upwards is especially important for adolescents since they frequently echo attempts, and as many as l% of adolescents who have attempted suicide are not referred for follow-upwards at the time of emergency care.²² It is necessary to involve the patient's family unit and support organization. It is beneficial for a family member or close contact to monitor the patient and provide support post-obit the acute phase of the suicide attempt.

MANAGING CONTINUITY PATIENTS WHO HAVE ATTEMPTED SUICIDE

The master intendance dr. may not exist the one to immediately treat and stabilize the patient following the suicide endeavour. Nevertheless, responsibility may exist turned over to them at some point, and special considerations and guidelines will aid the principal care physician in the patient's intendance.

A close working relationship between the patient and doc will foster the patient's recovery and minimize the gamble of another suicide effort. Failure to adhere to belch recommendations is common in patients who have attempted suicide.⁴ This tendency may be reduced by a skilful therapeutic relationship with the primary care medico.²³ In particular, the md'southward knowledge over time not only of the patient's physical status but too of their psychosocial circumstances may alert the dr. to levels of patient stress and alarm signs. Because of the high incidence of chronic health bug in depressed and suicidal patients, especially among the elderly,²⁴ knowledge of the patient's attitudes and feelings most their affliction may exist very relevant.

Several studies have reported that betwixt 20% and 76% of patients who commit suicide accept seen their master intendance physician in the prior month.²⁵ Frequent monitoring of suicidal thoughts in loftier-risk patients, especially those who take made recent attempts, may reduce the number of completed suicides. Knowledge of high-take chances factors (Table ane)^{21–23, 26} volition make the chief care physician more constructive in identifying vulnerable patients.

Table 1.

High-Risk Factors in Assessing Suicide Chance

It has been suggested that "no-suicide" contracts may be helpful in managing suicidal patients.²⁷ Basically, this arroyo asks the patient to commit either verbally or in writing to not act on suicidal impulses but instead contact a source of assist, such as a suicide hotline or the primary intendance md, if they feel suicidal. This approach not only conveys the concern and regard of the primary care dr. but also gives the patient a concrete plan to follow when feeling in crisis and despondent. Understanding to a no-suicide contract does not ensure patient safety, just if the patient cannot agree to this contract, hospitalization should exist seriously considered. The potential for substance corruption, history of impulsive behavior, and social isolation all might limit the value of such contracting.

Close follow-up is important when treating a patient who has recently fabricated a suicide effort. While office visits will be the basic intervention, brief telephone calls can provide support contact and help identify if an urgent appointment needs to be scheduled. If hospital discharge planning did not include psychiatric referral, this should exist a priority. Prompt advice and coordination with the mental health professional person will promote efficient and effective intendance. Since many patients are yet averse to seeing a psychiatrist because of misconceptions and fear of stigma, encouragement and education from the primary care medico almost the importance of treatment volition make it more likely the patient will follow through on the referral.

Medication may play an of import role in the ongoing management of patients who take attempted suicide. The pharmacologic treatment depends on the underlying psychiatric diagnosis. Most clinicians choose a selective serotonin reuptake inhibitor equally starting time-line treatment of depressive disorders.²⁸ These medications are generally well tolerated and safety for use in the depressed patient and have been found to decrease suicidal ideation.²⁹ There are many choices available for depression, and a review of these medications is outside the scope of this article. Many excellent reviews of pharmacotherapy are available.²⁸ Patients who fail outset-line treatment or have other psychiatric disorders, such as bipolar disorder or schizophrenia, may do good from consultation with a psychiatrist.

It has been suggested that antidepressant medications may activate depressed individuals, thus increasing the risk of suicidal beliefs.³⁰ Close monitoring of the patient recently started on any antidepressant will help the master care medico assess whether suicidal risk has been increased as a result of activation effects from the medicine.

CONCLUSION

When evaluating a suicidal patient, first and foremost, keep the patient safe. Stabilize the presenting medical condition and treat any comorbid weather condition. Ask for collateral information from police, emergency medical staff, and whatsoever witnesses to the suicidal events. When the patient is able to participate in an interview, the physician should ask the question, "Why now?" and listen intently for any clues to the patient's electric current situation. Perform a thorough and detailed physical exam. Obtain a psychiatric consultation and/or contact the patient's existing md(s) and make certain a follow-up program is in identify. If the main care dr. sees the suicidal patient on a continuity basis, the therapeutic patient-md relationship as well as attention to suicidal risk factors and full general wellness status will be important. Finally, coordination with and support for specialized psychiatric care by the chief care physician is recommended.

Drug names: mannitol (Osmitrol), naloxone (Suboxone, Narcan, and others), flumazenil (Romazicon).

Acknowledgments

The authors admit valuable suggestions fabricated by Ronald McGinnis, M.D.; Angela Walter, M.D.; and Allan Wilke, Thou.D.

Pretest and Objectives

Instructions and Posttest

Registration and Evaluation

Footnotes

In the spirit of full disclosure and in compliance with all ACCME Essential Areas and Policies, the faculty for this CME activity were asked to complete a full disclosure argument. The information received is every bit follows: Drs. Carrigan and Lynch accept no significant commercial relationships to disclose relative to the presentation.

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Articles from Primary Care Companion to The Journal of Clinical Psychiatry are provided here courtesy of Physicians Postgraduate Press, Inc.

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