Table 27–5 depicts a case of suspected self-poisoning from the starting point of prehospital care through the completion of a comprehensive assessment and treatment planning.
TABLE 27–5.Case Presentation: Suspected Self-Poisoning ||Download (.pdf) TABLE 27–5. Case Presentation: Suspected Self-Poisoning
|Case ||Evolution ||Disposition |
|Patient course ||Patient found in the community unresponsive ||Patient monitored in the emergency department; vital signs stable; still unresponsive ||Patient lethargic but cooperative; answers simple questions ||Patient fully awake and alert ||Evaluation complete |
|Treatment course ||Prehospital ||Triage medical assessment ||Observation and monitoring ||Formal psychiatric evaluation ||Treatment planning |
|Physician course || |
Search for prescription drugs, drug paraphernalia
Assessment of cardiac and respiratory function
Orogastric lavage (?)
Activated charcoal (?)
Diagnostic testing (blood studies, electrocardiography, urine toxicology)
Contact collateral sources for history
Focused psychiatric assessment:
immediate suicide risk
Comprehensive psychiatric assessment:
Initial Psychiatric Management
In any case of suspected self-poisoning, a thorough psychiatric assessment is warranted. It can be helpful to call a psychiatric consult immediately after medical stabilization, even if the patient is unable to communicate, since important information such as pill bottles, ambulance reports, and the ability to call the patient’s family and outside providers may be lost if the consult is delayed. Although not required for an ED assessment unless clinically indicated, it should be helpful for the psychiatrist if urine toxicology and blood alcohol concentration is obtained as early as possible.
An early, focused assessment is necessary to ascertain elopement risk and decisional capacity. Subacute residual central nervous system (CNS) effects of ingestions, such as confusion, fatigue, and fear, can dispose patients to wander or elope. The patient should be searched for weapons, pills, and other potentially toxic materials to prevent additional self-harm or ingestion in the hospital. Given that the patient’s intentions remain unclear at this point, the question of unintentional versus intentional exposure to a xenobiotic cannot be completely resolved. For this reason, a high level of supervision should be maintained, and a patient should not be allowed to leave or be left unattended until an adequate assessment of the patient’s mental status is completed. Depending on the architecture and organization of the ED and its personnel, it may be sufficient to place the patient in an open area in the direct line of sight of the medical staff. If such an arrangement is not possible, or if the patient is agitated and disruptive, it may be necessary to separate the patient from the general population. Under these circumstances, an individual aide should be assigned to observe the patient on a one-to-one basis. Safe physical and/or chemical restraints may be necessary to prevent further injury to both the patient and the staff.
At a relatively early point in the patient’s course, when the patient can be cooperative, a more detailed psychiatric assessment is critical to address specific clinical concerns. Both history-taking and collateral contacts can help to establish the patient’s preingestion mental status and baseline, as it may be difficult in an initial, time-limited assessment to differentiate a xenobiotic-induced delirium from mental illness and therefore ensure that any delirium has fully resolved. The determination that the patient is stable is not solely established on the basis of blood concentrations of a xenobiotic or ancillary medical tests, but rather when the emergency physician or medical toxicologist with an understanding of toxicokinetics and toxicodynamics deems it appropriate.66 Although a thorough psychiatric examination is not possible until an altered mental status has cleared, it is reasonable to have the psychiatrist involved earlier for the above-mentioned reasons.
The physician should not unequivocally attribute altered mental status to poisoning or toxicity until the signs of altered consciousness have resolved and cognitive functions have returned to normal. Until that time, other toxic-metabolic and structural conditions that might coexist with, or masquerade as, toxicity cannot be excluded. If the patient’s cognitive functioning is impaired by xenobiotics, then critical historical details may be unreliable.33 It should be understood that much of what the patient reports may be ephemeral, caused by the predictable temporary and reversible effects on mood of these xenobiotics.14 However, any patient utterances about intended overdose or self-harm should be documented in the record, since it is important information to consider if the patient becomes guarded and evasive after returning to baseline mental status.
In addition to routine laboratory studies, such as complete blood count, electrolytes, renal function, and liver function tests, psychiatrists usually request thyroid function tests, B12, folate, HIV testing, and syphilis immunoglobulin G antibody or RPR; abnormalities in these laboratory values can be associated with medical disorders producing psychiatric manifestations that would affect management and disposition. However, these laboratory tests have proven to be low yield when obtained routinely and without clinical suspicion, and are not necessary as part of the ED work-up.80
Special Issues of Capacity in Suspected Self-Poisonings.
Patients may request to be discharged, refuse care, or become aggressive. Aggression may arise from lingering effects of ingestion or withdrawal, severe anxiety, fear, anger at the loss of autonomy, or the discomfort associated with unpleasant procedures.86 Although patients may respond to verbal limit-setting and repeated explanations of their care, they may also require pharmacologic or physical restraint and involuntary treatment. Patients are not allowed to make poor health care decisions if their ability to weigh the risks and benefits of the proposed care is limited by cognitive deficits or mental illness. In the setting of toxicity, appropriate care may be provided under the doctrine of implied consent.
The emergency exception to the doctrine of informed consent may also apply in circumstances where self-injury is suspected. The emergency exception permits forcible detention, restraint, medication over objection, and necessary medical care until psychiatric assessment can be accomplished. This includes collecting information from collateral sources without the patient’s consent. After the management of the immediate medical emergency and resolution of toxicity, suspected self-injury is sufficient evidence of impaired decisional capacity for the emergency physician to hold a patient for further psychiatric assessment. The emergency physician should document the patient’s objections in the medical record and indicate the basis for the determination of diminished capacity.
After the intentionally self-poisoned patient is stabilized, there may be a need for a more thorough assessment of decisional capacity. Psychiatric consultation is appropriate at this stage to help document the degree of impairment, determine the etiology, and predict the likely course.
Immediate Risk of Self-Harm.
After these safety considerations are addressed, the aim of the focused psychiatric assessment moves toward a determination of immediate suicide risk. This examination should answer the following questions: What is the patient’s attitude toward lifesaving care? What are the patient’s current wishes with regard to living or dying? What are the patient’s thoughts about his or her rescue and likely recovery?
These questions can only be answered in the course of a frank discussion between the patient and the emergency physician. The physician should not be concerned about “provoking” further self-injurious impulses by having this vital discussion; many patients will be relieved that the health care professional is speaking directly about their distress.
Reliability and Confidentiality.
Mention should be made here about the difficult issues of reliability and confidentiality with regard to gathering history. Evasiveness, lack of detail, inconsistency, and improbability may lead to an unreliable history. It is appropriate to confront the patient with the implausible aspects of this history and offer an opportunity for the patient to rethink the history. This is often successful, although subsequent reports are, of course, equally suspect.
The most important step from the standpoint of both clinical care and risk management is to locate other sources of information to clarify the patient’s situation. A careful review of any previous medical and psychiatric records is critical. Any pattern to a patient’s presentations such as increasing frequency, more aggravated behavior, or disheveled appearance should be noted.
Collateral contacts are another important source of information, although the level of involvement, sophistication, and reliability of the collateral contacts must also be taken into account. In the interest of providing necessary medical and psychiatric care for a patient in an emergent situation, the ED staff is legally permitted to solicit information from collateral contacts without the patient’s consent. However, an effort should be made to obtain consent for any broader discussion of the patient’s situation with family, friends, or other physicians. The patient may express concern about the ED staff contacting a family member or counselor. Any information to be imparted to third parties can be discussed in advance with the patient. The patient may restrict consent to receiving information only and may withhold consent to impart certain information. More caution is indicated in contacting an employer. Although disclosing information about the patient without the patient’s consent is a breach of confidentiality, a physician may do so in the interest of protecting the patient (Chap. 141).5
Comprehensive Psychiatric Assessment
The goal of comprehensive psychiatric assessment is to: (1) characterize the nature of the attempt and any ongoing suicidal ideation that might be present, (2) explore risk factors for another suicide attempt, and (3) formulate a diagnostic impression. These three elements help to determine the level of risk and guide immediate treatment and disposition planning.110
The best understanding of suicide at this time is that it results from intrinsic vulnerability factors interacting with external circumstances, which can be termed the “stress vulnerability.” Intrinsic vulnerability may be conferred by a variety of traits such as impulsivity or conditions such as depression, anxiety, low self-esteem, low self-efficacy, loneliness, and hopelessness. External factors include stressful life events, access to lethal means, and a host of other factors, positive and negative. Poor interpersonal problem-solving skills and a perceived lack of problem-solving ability also appear to increase risk.40
Assessing Suicide Attempts and Suicidal Ideation.
The core of the suicide risk assessment is a detailed discussion of the patient’s suicide attempt and any ongoing suicidal thoughts and urges. It is important to establish rapport and introduce these topics in an appropriate context in order to improve the patient’s candor. This evaluation requires significant time and skillful interviewing, for which there is no substitute. This approach will enhance both the therapeutic quality of the interview and its reliability.
The clinician should explore the exact details of the attempt, including precipitating factors that may have begun days or weeks prior to the actual act. It is critical to determine the level of actual and intended lethality, along with the seriousness of the intent. Why did the patient make an attempt on that day or time? Understanding the patient’s thought process can help to gauge the extent of impulsivity versus planning involved in the attempt. Signs of premeditation and planning are concerning, such as organizing one’s affairs (giving away possessions, ensuring a will is updated) or writing goodbye letters (such as a phone call, internet posting or text message). It is crucial to determine if the patient expected to be found, and if any effort was made to notify someone about the impending attempt such as a phone call, internet posting, or text message. How was the patient discovered, and by whom? A patient who overdoses alone in a hotel room is very different from someone who overdoses in the bedroom while the family is at home. Current feelings about surviving should also be assessed: Is the patient relieved or upset to be alive? Is there currently active or passive suicidal ideation? How forthcoming does the patient appear to be when discussing this? Other important information includes prior suicide attempts and their lethality and circumstances, the frequency and duration of suicidal ideation in the past, prior psychiatric treatment, prior and current medication trials, and a detailed substance abuse history. Psychological factors such as reactivity to positive and negative external events and subjective distress are also important to explore. The social history should focus on interpersonal conflict, stressors within romantic or family relationships, and employment or financial concerns. Current support systems or lack thereof are important to note, as are feelings of isolation and abandonment, which can all be contributing factors.67
The communication of suicidal ideas either directly or indirectly should not be misconstrued as a “cry for help” and hence evidence of lower risk. Communication is probably related to the degree of preoccupation with morbid thoughts and to personality characteristics that dispose individuals to revealing their thoughts to various degrees.74 In psychological autopsy studies, approximately 50% to 70% of those who completed suicides gave some warning of their intention, and 30% to 40% disclosed a direct and specific intent to kill themselves.10,91
The goal of assessing suicide risk factors is to identify factors that may increase or decrease the level of suicide risk in a particular patient, which will enable the clinician to develop a plan that addresses the modifiable factors. For example, hopelessness is one such modifiable risk factor, which would likely improve with time and treatment; when risk factors such as hopelessness can be modified on the inpatient psychiatric ward, an inpatient admission is warranted to help decrease the risk of suicide. Unfortunately, to date no study has ever identified one specific risk factor or set of risk factors as specifically predictive of suicide or other suicidal behavior; therefore, the assessment is ultimately based on clinical judgment. Despite the lack of such predictive factors for suicide, there is a large body of evidence on the multiple risk factors that contribute to suicide risk, and a growing body of evidence on protective factors (Tables 27–3 and 27–4). Knowledge of this evidence is critical to informing the clinical determination of suicide risk.
Risk factors are additive, with suicide risk increasing with the number of risk factors that are present, but certain risk factors interact synergistically to increase suicide risk. The combined risk of concomitant depression and alcohol intoxication may be greater than the sum of the risk associated with each in isolation. Certain risk factors, such as a recent suicide attempt associated with a high degree of lethality or the presence of a suicide note, should be considered serious on its own, regardless of whether other risk factors are present.34
A number of avenues of inquiry suggest that violent suicide attempts are associated with a persistent deficiency in brain serotonin concentrations. Impulsive types of aggression and impulsive suicidal behavior have been linked to serotonergic dysfunction in prefrontal cortical regions of the brain.36 This deficiency has been measured in the postmortem brains and spinal fluid of suicide victims and survivors of violent attempts as compared to nonviolent attempts and to other patients. Hopelessness has also received a significant amount of study as a potential predictor of suicide; unfortunately, it appears to have a high sensitivity but a low specificity.13 However, identifying hopelessness does provide for an intervention.
While much is known about the risk of suicide for various groups over time, little can be said with certainty about an individual patient at a particular point in time. The risk of suicide increases 50 to 100 times within the first 12 months after an episode of self-harm as compared to the general population risk. About one-half of all people who commit suicide have a history of self-harm, and this increases to 60% in juveniles.6 Unfortunately, there is no “typical” suicidal patient or clinically useful test or rating scale at this time. Albeit, while one investigator was able to prospectively identify almost all of those who ultimately died by suicide (97% sensitivity), the investigator overpredicted suicide by almost one-half (56% specificity).88 However, there is also no patient in distress for whom the risk of suicide is so remote that it need not be considered.
Ultimately, most persons belonging to a high-risk group do not commit suicide, and some individuals with no apparent risk factors do. Many risk factors are not modifiable. This type of information, then, weighs most heavily in the assessment in the absence of other more specific data, early in the hospital course, or in the case of the uncooperative or hostile patient. The best foundation for treatment planning and clinical decision making is direct examination and clinical diagnosis.43
Psychiatric Illness and Suicide.
One major consideration in suicide risk assessment is the occurrence of severe mental illness. Suicide risk for individuals with severe mental illness is 20 to 40 times higher than it is for the general population.75 Psychological autopsy studies, which focus historically on the decedent’s intentions and mental state prior to death, have consistently revealed major psychiatric illness to be a factor in suicide and present in 93% of adult suicides.68,75,89,92 This is also true of those who make medically serious suicide attempts.13,68 In particular, prospective cohort studies and retrospective case control investigations have revealed clinical depression and bipolar disorder to dramatically increase suicide risk.60,74,109 For mood disorders, factors correlated with current suicidality include current depression, severe anxiety, anhedonia, panic, insomnia, ambivalence, and acute alcohol abuse.74
After mood disorders, chronic alcoholism is the most commonly reported disorder and is present in approximately 20% of cases. Moreover, alcoholic patients who also experience episodes of depression are at a higher risk for suicide than patients who present with either disorder separately. There are considerable data that other types of substance use such as heroin, cocaine, or polydrug use also increase the risk of suicidality when psychiatric illness is present, and this seems to be especially true in depressive or dysphoric mood disorders (unipolar, bipolar II, and mixed types of bipolar I disorders).15,108 As a result, any assessment conducted on a patient with a substance use history must include an examination of symptoms of major depression or bipolar illness.47,111
Patients with schizophrenia are at risk for suicide at rates comparable to major depression and are 20 times more likely to attempt suicide than the general population.106 Approximately 50% of patients with schizophrenia will attempt suicide and 13% of schizophrenic patients will successfully complete suicide.17,106 Additionally, between 5% and 18% of patients with severe borderline personality disorder (especially those patients with comorbid depression) ultimately kill themselves.52,68,102
The ability to treat psychiatric disorders such as mood disorders, schizophrenia, borderline personality disorder, and alcoholism suggests that most suicides are preventable. Indeed, a suicide prevention program designed for general practitioners in Sweden demonstrated evidence for prevention based on the detection and treatment of depression.90 The Centers for Disease Control and Prevention reported that psychiatric problems in US EDs represented approximately 3% of mental illness visits, which is significantly lower than the national psychiatric rate of 20% to 28%.27 This suggests that significant psychiatric underdiagnosis is occurring in the ED. Consequently, emergency physicians must enhance the comprehensive nature of their psychiatric screening to identify suicidality and concomitant mental disorders in patients presenting with self-injury.
Following a comprehensive psychiatric assessment, the next step is deciding on treatment alternatives. Any patient who has made a suicide attempt must be considered to be at risk for another attempt and some further intervention is warranted. The risk of a subsequent lethal attempt is approximately 1% per year over the first 10 years. The risk is highest during the first year. Suicide is most commonly a symptom of an underlying disease process, so the goal is to diagnose and treat the underlying disease in the setting that is the least restrictive while also ensuring safety for the patient. The treatment alternatives available will depend on the psychiatric sophistication of staff available to the ED at any given time. This section describes the commonly used interventions in the ED; they can be employed singly or in combination.
Psychotropic medications can be used acutely in the treatment of severe anxiety or psychosis; however, in the case of antidepressants, several weeks are required for therapeutic effect, so their immediate use is not indicated in the ED. However, if the patient is to be discharged to the community with follow-up, it is reasonable for a psychiatrist to start an antidepressant in the ED setting. There are concerns about prescribing medications with relatively high potential for lethality in overdose, such as the TCAs and nonselective monoamine oxidase inhibitors, to persons who have recently attempted suicide. Medications for medical illnesses, such as insulin, should also be considered for risk of overdose. However, newer antidepressants, particularly the SSRIs, can be used as first-line drugs for treatment of most depressions and are relatively safe in overdose.
In 2007, the US Food and Drug Administration (FDA) ordered that all antidepressants should include a black box warning stating that there is an increased risk of suicidality in children, adolescents, and adults younger than 24 years of age. This risk was not increased in adults 25 to 64 years of age, and was actually decreased in adults older than 65 years of age. Further studies have confirmed this age-related difference.18,101Proposed explanations include an ascertainment bias, activation and/or akathisia as an adverse event in the first few weeks, or increased energy resulting in increased ability to carry out suicidal plans. Nonetheless, the FDA and other authors emphasize that untreated depression also carries a risk of suicide, and treatment options should be carefully weighed with regard to their risks and benefits. Therefore, the initiation of antidepressant therapy by the nonpsychiatric physician is not recommended unless a tight linkage can be made between discharge and immediate (within days) aftercare by either a community outreach team or a crisis clinic.
Patients with depressive disorders may suffer from significant anxiety, as may patients with overwhelming situational stressors such as job loss, new financial hardship, bereavement, or divorce. The prescription of a short course (days to weeks) of a benzodiazepine may provide significant relief to the patient in crisis. Yet again, close psychiatric follow-up is essential.
After the patient’s immediate symptoms have been treated in the ED, the next treatment decision is determining the setting in which further treatment may safely be provided. Not all patients with suicidal ideation or even significant attempts necessarily require hospitalization, and there is still a substantial stigma attached to psychiatric hospitalization. In general, hospitalization should be used if less restrictive measures cannot ensure the patient’s safety. If significant doubt exists about the safety of outpatient treatment, then the patient should be observed in the ED for further evaluation, admitted to a general hospital with close nursing supervision, or admitted to a psychiatric unit. “Holding beds,” now available in some larger psychiatric EDs, are ideal for this purpose. Some localities may also have crisis outreach services that follow the patient after discharge from the ED and can provide appropriate monitoring and continuity of care.
Patients most likely to respond to interventions in the ED are individuals who have been stable, until recently but now, as a result of some external event, may find their way of life threatened. This acute change results in a painful state of anxiety and the mobilization of some combination of adaptive and maladaptive coping strategies. Finally, a second event, the precipitant, intensifies the anxiety to the point that the patient cannot tolerate the instability and is thrown into crisis. The patient then feels desperate and may be completely immobilized or vulnerable to various strong impulses including the impulse to run away, strike out at someone else, or kill him or herself. Reality testing is preserved, and no major psychiatric syndrome is present. The patient accurately perceives his or her situation, understands that the current reaction is a psychological problem, and is highly motivated to obtain help. The crisis may last for a matter of hours or weeks prior to the ED presentation and will ultimately resolve. Such patients respond well to crisis intervention and may actually undergo some positive development in the course of treatment.
By contrast, patients whose condition has been deteriorating for some time in the absence of significant stressors, and who appear on examination to be suffering from severe depressive symptoms, are unlikely to benefit rapidly from supportive techniques. If such patients present with suicidal ideation or attempts, it will be difficult, although not impossible, to manage them outside the hospital.
Outpatient settings have the advantage of maintaining the patient’s functioning as much as possible. Work and childcare responsibilities, financial obligations, and social relationships are not disrupted. Unnecessary regression is halted. The patient can assume more responsibility for his or her outcome, and independence helps preserve self-esteem. These individuals remain closer to and more engaged with the people and situations with whom and with which they must learn to cope. Their morale may be rapidly improved by the combination of support, planning, and modest early treatment successes.
However, in some cases, these same factors may be disadvantageous. Routine tasks may seem overwhelming. High levels of conflict may render major relationships at least temporarily unworkable. Inpatient settings offer the advantage of respite, high levels of structure, more intensive professional and peer support, constant supervision, and, usually, more rapid pharmacologic and psychosocial intervention.
The choice of inpatient or outpatient setting will depend on the balance of strengths and weaknesses of the patient, the involvement and competence of family or friends, the availability of a therapist in the community, and the ongoing stresses in the patient’s life. This decision is best made by a psychiatrist. Because a psychiatrist is not always present in many facilities, a trained mental health professional should optimally be on call to every ED. This may be a psychiatric social worker, nurse clinician, or psychologist. When such services are not available, it is appropriate to detain patients in the ED until a practitioner with specific competence is available or to transfer the patient to another facility for evaluation. Every U.S. state has laws that provide for the involuntary commitment of the mentally ill under circumstances that vary from state to state (Chap. 141). Any acute, deliberately self-injurious behavior would generally qualify. Chronic, repetitive dangerous behavior that is not deliberate, such as frequent unintentional opioid, alcohol, sedative-hypnotic, or illicit “recreational” psychoactive drug overdoses, warrants careful evaluation. In the absence of psychiatric illness, involuntary treatment is usually not necessary, but should be considered carefully if a patient appears unable to achieve self-care. The practitioner should be familiar with the criteria for commitment and the classes of health care professionals so empowered under state law.
There are other treatment interventions that can be provided in the emergency setting, including crisis intervention, substance abuse counseling, and family therapy. A single session in the ED may be sufficient to defuse a crisis or to spur the drug-abusing patient to seek help. Alternatively, the intervention may be initiated in the ED and continued as an outpatient.
Crisis intervention is a brief, highly focused therapy that seeks to deconstruct how a crisis occurred, with the intent of examining the patient’s role. Often, patients have distorted perceptions of the crisis, and a gentle “correction” of catastrophic thinking can be extremely helpful. The crisis is presented to the patient as an unfortunate and perhaps tragic experience that the patient can overcome. Ideally, the patient should have a relief of symptoms and learn how crises may be avoided in the future. This insight intervention will likely fail for patients with severe depression because of the presence of profound hopelessness. It is most successful for patients who give a history of high functioning just prior to the crisis.
Interestingly, sustained contact with patients via letters, postcards, or telephone calls can reduce suicidal behavior in the months after their presentation. A toxicology service in Australia found that a “postcard intervention” significantly reduced the rate of repeated self-poisoning by patients who presented to their ED for self-poisoning.21 The postcard was mailed to patients in a sealed envelope eight times over the 12 months after their initial presentation, and simply stated: “It has been a short time since you were here, and we hope things are going well for you. If you wish to drop us a note we would be happy to hear from you. Best wishes.” Although the proportion of patients who self-poisoned again did not differ in the experimental versus control group, the total number of self-poisoning episodes were halved for the experimental group on follow-up 24 months later.21Follow-up data at 5 years indicated that this benefit was sustained, and that psychiatric admissions were reduced by one-third.20 Other studies examining letter-writing or postcard interventions in various clinical settings have also shown some benefit when examining rates of attempted or completed suicide or psychiatric emergency department visits.63,71,84 Given that such interventions do not require many resources and are quite cost effective, they appear promising.
“Contracting for safety” was a popular technique in the past, and consists of patients being asked whether they can remain safe and agree not to engage in self-harm. However, there are no empirical data to show that it is effective, and in court cases it has not been protective in terms of liability for the clinician. It is not recognized as part of the standard of care for the suicidal patient, and if anything, it seems to provide the clinician with a false sense of security. Its use is not recommended except as a technique to engage in a larger discussion of a safety plan that delineates scenarios the patient might face after leaving the hospital, and possible coping strategies.53