For a patient who survives a recent suicide attempt, the emergency department usually is the first stop for assessment and triage. If the patient is medically cleared, ideally a psychiatrist, but sometimes another mental health professional, evaluates the patient and decides whether psychiatric inpatient or outpatient management is the appropriate disposition. It is important for psychiatrists to form their own judgment about whether patients are truly medically stable enough for transfer out of the medical setting because countertransference to suicidal states frequently causes nonpsychiatric physicians to minimize the role of medical contributions and prematurely “clear” patients. For a patient with self-induced injuries severe enough to require additional medical or surgical care, admission follows, and a psychiatrist is consulted. Patients who are admitted to medical-surgical beds after suicide attempts represent a particularly dangerous subset of suicidal patients. Considering data from all of New Zealand’s public hospitals, Conner et al. showed that individuals hospitalized with self-induced injuries have a relative risk of 105.4 for suicide within the next year and a relative risk of 175.7 for additional self-injury hospitalizations, compared with the New Zealand general population.
Divergent conditions such as delirium, psychosis, personality disorder, and intoxication and withdrawal syndromes have in common the impulsivity that must be anticipated and managed in medical settings. Withdrawal — particularly from alcohol or sedative-hypnotics — epitomizes impulsivity syndromes that can be deadly and must be recognized and aggressively managed with detoxification protocols. In the absence of a suitably equipped psychiatric unit, the psychiatrist will need to arrange medical admission.
In addition to trying to make the environment safe, egress must be controlled. In the general medical hospital, patients should be prevented access to open stairwells, roofs, and balconies, and all windows should be secured. In a classic study of the dangers of hospitalizing impulsive patients in an unsecured environment, Reich and Kelly () described 17 medical inpatients who attempted suicide while on the medical and surgical wards at Peter Bent Brigham Hospital between 1967 and 1973 and survived. They judged 15 of the 17 patients to have mental disorders, but the cardinal characteristics of depression and hopelessness were not present in this sample. “All…were impulsive acts, none of the patients gave warnings, left notes, expressed suicidal thoughts or appeared to be seriously depressed”. The investigators considered most of these 17 attempts to be reactions motivated by anger at perceived loss of emotional support, usually from staff. They attributed this underlying impaired impulse control to personality disorders in 8 of the patients, to psychosis in 7, and to delirium in 3.
When a suicidal or an impulsive patient is too medically ill to be cared for on a locked general psychiatry unit, a medical-psychiatry unit — if a hospital has one — is the ideal disposition for such a patient. In the absence of such a specialty unit, medical intensive care units are more likely to provide one-to-one nursing care, although critical care physicians may argue that such observation in the absence of need for critical care is an inappropriate use of their service.
Ms. C, a 22-year-old woman addicted to crack cocaine, developed severe cardiomyopathy after the birth of her third child. Four months later, no longer able to climb the two flights of stairs to her apartment without becoming short of breath, she was admitted to the hospital with congestive heart failure. A toxicology screen was positive for alcohol and cocaine.
After she arrived on the medical floor, Ms. C curled up in a fetal position and refused to speak to her nurse until she was found lighting a cigarette while receiving oxygen. When the nurse attempted to stop her, Ms. C began cursing and shrieked that if she were not allowed to smoke, she would overdose on digitalis she had hidden in the room.
Ms. C refused to submit to a room search. The psychiatric consultant recommended that security be called so that Ms. C could not leave before he could perform an emergency evaluation. Ms. C had to be placed in leather restraints when she assaulted the officers. After speaking with the psychiatrist, Ms. C agreed to take medication (5 mg of haloperidol and 1 mg of lorazepam). She then consented to a search of her belongings. A bottle of 50 digitalis tablets was found in her suitcase. Because of her threats and impulsivity, the psychiatrist recommended constant observation with sitters.
As Ms. C’s case shows, the first task in the medical setting is ensuring the patient’s safety. A safe environment must be created and maintained until the patient is stable enough for psychiatric transfer.
Patients who are most intent on suicide, as well as those who are most impulsive and unpredictable, may attempt suicide in the hospital. The patient’s room must be secured — that is, anything that patients could potentially use to injure themselves must be removed. Luggage and possessions should be searched with a suspicious eye and a morbid imagination. Staff must ferret out sharp objects, lighters, belts, caches of pills — anything that could inflict damage in either an impulsive or a carefully planned way. Objects that are being brought into the room must be regarded as potential hazards (e.g., the phlebotomist’s needles, the pop-tops from soft drink cans, the custodian’s disinfectants). The rooms of the general medical hospital lack many of the safeguards that are routine on inpatient psychiatric units, such as locked unit entrances and collapsible shower heads, curtain rods, and light fixtures. Normally, in the former, scissors and a variety of paraphernalia that can be “creatively” used for self-harm are easily accessible. The culture on medical inpatient units also differs from that on psychiatric units. On medical units, staff do not usually consider elopement a risk; they assume that patients are fundamentally compliant and that they will press their call buttons when they need help.
Early reports focused on jumping as a means of suicide in medically hospitalized patients, a usually lethal method regardless of whether the patient actually intends to die. In the most recent study, White and colleagues identified impulsivity and agitation in many of the 12 patients who jumped from an Australian general hospital during a 12-year period. Five had been noted to be delirious on the day of the jump, 7 were dyspneic, and 10 were in pain. Ten of the 12 had two of these factors, and 1 had all three factors.
Modern hospitals are deliberately built without open stairwells and without windows that open or break easily; however, many older buildings remain in service, indicating the persistent need for corrective precautions. The in-patient suicide rate in a New York hospital dropped fivefold during the first 11 years after the hospital secured the windows and implemented educational programs encouraging staff members to pay closer attention to disruption in the doctor-patient relationship.
Shah and Ganesvaran found that one-third of 103 suicides committed by psychiatric inpatients at their hospital involved patients away on pass, and another one-third involved patients away from the hospital without permission. Methods readily available near the hospital include jumping in front of vehicles, leaping from buildings or bridges, and drowning in nearby bodies of water. Although these authors studied psychiatric inpatients, the same dangers exist with patients on medical units. Passes are rarely given from contemporary medical units, but elopements are all too common, with resultant ready access to potentially lethal means of suicide.
Constant observation by a one-to-one sitter is indicated for patients judged at high risk for impulsive self-harm. This may require compromising patients’ privacy. Patients permitted to use the bathroom unobserved have been known to hang or cut themselves behind the closed door. A moment of privacy granted to the patient out of misplaced civility, or a few minutes of inattention or absence by the sitter, may be all the time a suicidal person needs to execute a suicide plan. All staff guarding suicidal patients should know how to summon security personnel as reinforcements when they perceive that they have lost control of the patient or the situation. In an era of cost cutting, the consultant may feel pressure to limit the use of constant observation. Economizing on sitters could mean the life of a suicidal patient. On the other hand, staff anxiety may lead to overuse, initiating one-to-one sitters for every patient who has expressed any suicidal thoughts. In addition to wasting resources, overuse of sitters may desensitize them to the constant awareness needed for their role. The decision to use constant observation should be made on clinical grounds. Prudent risk management supports avoiding under- and overuse of one-to-one sitters.
After the environment is secured, the medical psychiatrist should search for reversible contributors to the impulsive state, including delirium (“Delirium”), medical illness or medications that may be contributing to mood (“Depression”), anxiety (“Anxiety Disorders”), and psychotic disorders (“Mania, Catatonia, and Psychosis”).
Agitation and active suicide attempts in the hospital often require chemical restraints and, rarely, physical restraints. Neuroleptics should be used in patients with delirium or psychosis, and neuroleptics and/or benzodiazepines should be given to other agitated, anxious patients. Physical restraints may be required if other measures prove inadequate. In some cases, emergent electroconvulsive therapy may be necessary (“Electroconvulsive Therapy”).
Selections from the book: “Textbook of Psychosomatic Medicine”, 2005.