Death - Trier Cathedral

Foreword

In this entry I proceed to talk about those patients that, while consulting in an ambulatory consult, have clear symptoms that put them at risk for themselves or others. The challenge in this scenarios stems from the impredictability of the situation and the lack of protocols or strategies that are already present in a psychiatric emergency ward.

This topic has a special importance given that acute, urgent exacerbations of previously diagnosed patients can present themselves in the private practice of the psychiatrist (or the psychologist, given the case) and in multiple occasions the patient himself may not consider his situation an emergency at all (like in a case of psychosis).

The suicidal patient

According to statistics, 30 – 40% of primary care patients manifest symptoms compatible with depression, suicidal ideation is an extreme clinical feature and completed suicide is a real risk, and regrettably, a frequent event in some populations.

Risk factors and basic epidemiology

Risk evaluation is out of the scope of this article (it is assumed that the mental health professional has more than enough knowledge regarding that aspect) nonetheless it is important to mention that in current practice the top risk factor is a previous suicidal attempt (up to 38 times higher when compared to the general population), and that other risk factors that should alert the professional are: concurrent psychiatric disease (predominantly affective disorders), a previous highly lethal attempt and an explicit intention (even more so if there is a structured plan).

Screening

Suicide risk screening is an important practice to take into account, and in some scenarios it can be erroneously omitted (as in long term psychotherapeutic treatments), yet, then main recommendation is to screen for suicidal ideation in the following situations, regardless of the current state of the therapy: history of depression, anxiety and substance abuse (mainly alcohol). Asking for suicidal ideation must be done in a brief, specific and clear fashion, and ideally should be done midway through the interview in order to give some time for a therapeutic alliance to be established, while at the same time for the question itself to not to be perceived as intrusive. It is important to note that one should not fear to make a direct question regarding the matter, as it will not influence the patient to develop such ideation, and omitting the question may exclude a valuable therapeutic intervention given that the patient presents him or herself with a high risk.

Managing the suicidal patient in the ambulatory setting

In case of a patient with manifest suicidal ideation during the interview, several scenarios can be present: exclusive death thoughts without a suicidal intention, to be willing to die without a specific suicidal intention; suicidal intention without a plan, and finally suicidal intention with a specific plan.

The Death of Chatterton - Painting by Henry Wallis
The Death of Chatterton – Painting by Henry Wallis

Death thoughts and death wishes

Even if suicidal risk is higher in this population as when compared with those who don’t, the frequency of this finding in the population is so high that in case of an indiscriminate hospitalization, It would induce a collapse in mental health services around the world, this is why regarding the management of an isolated suicidal thoughts and death wishes (clearly differentiated from other situations), the focus is predominantly preventive. In these cases, prevention should be aimed to an indicated level (unlike a universal or selective level of prevention).

According to current evidence, the most effective strategies are: psychoeducation, management of the underlying mental illness and specific intervention of risk factors.

Psychoeducation: The aim of psychoeducation is to inform the patient in a clear manner about its diagnosis, natural history and prognosis, as well as an ample set of measures like; medication adherence, contingency management in case of suicidal exacerbation, frequency of clinical interventions, measures directed at strengthening the social and family network, and the therapeutic objectives to be intervened.

As expected, this aspect of patient care is to be performed in any and all possible clinical conditions (even those unrelated to mental health care), but acquires a very important role in the prevention of the escalation to a suicide attempt, as well as allowing the patient to feel empowered ans self sufficient, which is a perception that can be significantly compromised in presence of a full blown thanatical ideation, more so in the context of a chronic affective disorder with a poor response to treatment.

Management of an underlying psychiatric illness: regarding the management of an underlying psychiatric illness, it is important to remember that suicidal ideation and a death wish are not illnesses in themselves, but behaviors and thoughts derived from a preexisting clinical condition and that may be exacerbated by social, environmental and even pharmacological and clinical factors (as an example we can mention depressive symptoms associated to efavirenz).

Conclusion

In this writing which I hope will be useful in the ambulatory care of the mentally ill patient I reference a practical framework with the most common situations (in my experience), and in a next post I plan to continue talking about those patients that have an explicit suicidal ideation (with or without plan), that in my opinion carry an ostensibly higher risk and that will require quicker and more specific neasures for an optimal intervention that, if successful, may save the patient life.

I would like to give my thanks to the Movement for Global Mental Health, whose efforts towards the humanization of mental health services and the involvement of families and the general public are worthy of praise.

References

  • Carvalho, A. F., & McIntyre, R. S. (2017). Mental disorders in primary care: a guide to their evaluation and management. Oxford: Oxford University Press.
  • Riba, M. B., & Ravindranath, D. (2010). Clinical manual of emergency psychiatry. Washington, DC: American Psychiatric Publishing

  • Maloy, K. (2016). A cases-based approach to emergency psychiatry. Oxford: Oxford University Press.

  • Simon, A. B., New, A. S., & Goodman, W. K. (2017). Mount Sinai expert guides. Chichester, West Sussex, UK: John Wiley & Sons, Ltd.

  • Sadock, B. J., Sadock, V. A., Ruiz, P., & Kaplan, H. I. (2009). Kaplan & Sadocks comprehensive textbook of psychiatry. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

  • Ghaemi, S. N. (2008). Mood disorders: a practical guide. Philadelphia, Pa.: Wolters Kluwer.

  • McCarron, R. M., Xiong, G. L., & Bourgeois, J. (2009). Lippincotts primary care psychiatry: for primary care clinicians and trainees, medical specialists, neurologists, emergency medical professionals, mental health providers, and trainees. Philadelphia: Lippincott Williams & Wilkins.

  • Byrne, P., & Rosen, A. (2014). Early intervention in psychiatry: EI of nearly everything for better mental health. Chichester, West Sussex, UK: John Wiley and Sons Inc.

  • Beer, M. D., Pereira, S. M., & Paton, C. (2008). Psychiatric intensive care. Cambridge: Cambridge University Press.

  • Simon, R. I. (2011). Preventing patient suicide: clinical assessment and management. Washington, DC: American Psychiatric Publishing.

Medico especialista en Adicciones, UCLAM // Estudiante en Fellow en Demencias, Asociación Psiquiátrica Argentina

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