Behavioral Medicine II AY 2015-2016 • Suicide rates increases during economic recession and depressions

PSYCHIATRIC EMERGENCY
PPT (book based)/Lecturer Physician Suicides
• Physicians have elevated rates of suicide (female >male)
SUICIDE • More often by substance overdoses (because we have access) and
less often by firearms
• A primary emergency! • Commonly by:
• Derived from the Latin word, self-murder o Psychiatrists
• Fatal act that represents the person’s wish to die o Ophthalmologists
• Planned or upon impulse o Anesthesiologists
• Chronic suicides – death through alcohol and other substance
abuse and consciously poor adherence to medical regimens for Physical Health
addiction, obesity and hypertension • Previous medical care appears to be a positively correlated risk
• Impossible to predict precisely, but numerous clues can be seen indicator or suicide
• It is almost always a result of mental illness, usually depression • One third of all persons who commit suicide have had medical
attention within 6 months of death
• Amenable to psychological and pharmacological treatment
• Physical illness in estimated to be an important contribution factor
Epidemiology in about half of suicides
• 30,000 persons commit suicide/year • Factors associated with illness and contributing both suicides and
suicide attempts
• 60,000 suicide attempts
o Loss of mobility
o mas madali patayin ang sarili kaysa pumatay ng tao
o Disfigurement
• 20,000 homicide deaths
o Chronic, intractable pain
• 12.5 per 100,000
Suicide in Males (Philippines) Mental Illness
• Increased 0.23 to 3.59/100,000 • Important role of physicians/psychiatrists is to get them out of
• Between 1984 and 2005 the idea of committing suicide
• Incidence is similar in all age groups • About 95% of all person who commit or attempt suicide have a
Suicide in Females (Philippines) diagnosed mental disorder
• Increased from 0.12 to 1.09/100,000 o 80% depressive disorder
• Highest in females age 15 to 24 o 10% schizophrenia
o 5% dementia or delirium (unconscious act)
Suicide Risk Factors o 25% alcohol dependent and have dual diagnoses
• Suicide rates increase with age • Increased risk
• Older persons attempt suicide less often than younger persons, but o Delusional depression
are more often successful o History of impulsive behavior or violent acts
o Due to loss of family members or companion in life o Previous psychiatric hospitalization
• Suicide in men peak often after age 45, while women peak after • <30 years of age
age 55 o Diagnoses: substance abuse, antisocial PD
o Age group of depression o Stressors: separation, rejection, unemployment, legal
• Suicide rate is rising most rapidly among young persons troubles
o 15-24 years of age (male>female) • Age 30 and above
o 3rd leading cause of death in this age group o Diagnoses: mood and cognitive disorders
o Stressors: illness
Religion
• Suicide rates among Roman Catholic populations have been lower
that rates among protestants and Jews

Marital Status
• Marriage lessens the risk of suicide (magpakasal na tayo, meron na
tayo reason!! J)
o Increase (Forever alone)
§ Single, never married
§ Divorced
§ Widow or widower
§ Socially isolated
§ Family history of suicide
PSYCHIATRIC EMERGENCY

• Always find a way to ask of FH

• Ask for ideations of suicide

Occupation
• The higher the person’s social status, the greater the risk of suicide,
but a fall in social status also increases the risk
• High risk occupations:
o Physicians L huhu
o Law enforcement
o Dentists (how?) Previous Suicidal Behavior
o Artists • A past suicidal attempt is the best indicator that a patient is at
o Mechanics increased risk of suicide
o Lawyers • 40% of depressed patients who commit suicide have made a 1
o Insurance agents previous attempt  
• Suicide is higher among unemployed than among employed persons

 
 • The risk of second suicide attempt is highest within 3 months of the History, Signs and Symptoms of Suicidal Risk
first attempt • Previous attempt of fantasized suicide
• Patient having suicide intent • Anxiety, depression, exhaustion
o Male • Availability of means of suicide
o Older o Ask the family members to restrict them from items that the patient
o Single or separated can use to commit suicide
o Living alone o Tanggalin mo yung mga baril, bedsheet pagkagising nya
• Concern for effect of suicide on family members
o The patient does not care on how will the family be after he kills
Most Commonly Used Methods himself – BAD PROGNOSIS!!!
• Verbalized suicide ideation
ü Hanging (most common) • Preparation of a will, resignation after agitated depression
ü Shooting • Proximal life crisis, such as mourning or impending surgery or illness
ü Organophosphate poisoning of a family member
• Family history of suicide
Men commit suicide more than 4x as often as women: firearms, hanging, jumping • Pervasive pessimism of hopelessness
from high places
Suicide Prediction
Women are 4x more likely to attempt suicide than men: overdose of psychoactive
• High Risk characteristics
substances or a poison
o >45 years of age
o Male
The most common method of suicide is by hanging
o Alcohol dependence
o Violent behavior
Psychological Factors
o Previous suicidal behavior
o Previous psychiatric hospitalization
• Important to ask questions about suicidal feelings and behaviors
be asked
o Good history, ask about suicidal ideation and attempts
Etiology of Treatment
suicide • In patient vs Out patient
o Absence of social support
Sociological Biological o History of impulsivity
factors Factors o Suicidal plan of action (in patient)
§ If they refuse, ask the patient to sign consent and discuss
that they are risking the patient’s life when he is not
• Freud’s à Aggression turned inward supervised
• Menninger à inverted homicide, retroflex murder Approach
o Eto yung galit na galit sya sa asawa or parent nya, pero wala • The use of physical (strait jacket) and chemical restraint
syang magawa, especially who are chronically abused, so they o Neuroleptics
kill themselves L o Benzodiazepines
• Contemporary theories à fantasies, wish for revenge, power, o Antidepressants
control, punishment, atonement, escape, rebirth, reunion with dead, § Usually takes 10-14 days to take effect
overwhelming affect • The use of ECT (Electroconvulsive Therapy – BEST
o Suicide bomber believes in the idea of rebirth TREATMENT)
• Supportive psychotherapy
Sociological Factors • Follow-up
• Emile Durkenheim’s Theory • Family therapy
o Egoistic
§ Applies to those who are not strongly integrated into any Useful measures for the Treatment of Suicidal Inpatients
social group • Searching patients and their belongings upon arrival in the ward for
o Altruistic objects that could be used for suicide
§ Susceptible to suicide stemming from their excessive • Repeating the search at times of exacerbation of the suicidal
integration into a group ideation
• They feel that they should be together when they die • Treated in a locked ward where windows are shatterproof
(yung mga nandamay pa, palibhasa forever alone) • Patient’s room should be localized near the nurse station
o Anomic
PSYCHIATRIC EMERGENCY

§ A person whose integration into society is distributed so Principles in the Treatment of Depression
that they cannot follow customary norms of behavior • Pharmacotherapy
• ISIS!!! o Antidepressants
Biological Factors o Neuroleptics – for psychotic patients
• Diminished central serotonin à low concentration of 5-HIAA in CSF o Mood stabilizers
o SSRI for severe depression • Psychotherapy
• Other psychosocial therapy
Genetic Factors • Use of ECT
• Suicidal behavior tends to run in families
• In psychiatric patients, a family history of suicide increases the risk of
attempted suicide and that of completed suicide
• Twin and adoption studies
2
 

 
Preventive Measures for Dealing with a Suicidal Person Diagnostic Assessment
• Reducing the psychological pain by modifying the patient’s stressful
environment
Substance Related Disorders
• Enlisting the aid of the spouse, employer, or a friend • Alcohol, psychostimulants, benzodiazepines, opiates
• Building realistic support by recognizing that the patient may have a
General Medical Condition
legitimate compliant
• Offering alternative to suicide • Delirium, dementia, Seziures
o Marriage daw
Psychiatric Disorders
Psychotherapy in DEPRESSION • First episode psychosis, Schizophrenia, Mood disorders
• Wohlburg’s Classification
• Supportive
• Re-educative (e.g Cognitive therapy) Violent Behavior
• Reconstructive (e.g Psychodynamic theory) • Interview with a violent patient must attempt to ascertain the
• Interpersonal approach underlying cause of the violent behavior à cause determines
intervention
Electroconvulsive Therapy • Best predictors of violent behavior
INDICATIONS o Excessive alcohol intake
• Psychotic depression o History of violent acts
o History of childhood abuse
• Intense suicidal tendencies
§ They grow up as abuser themselves
• Catatonic
• Treatment failure with antidepressants Common Predictors of Dangerousness to others
• History of depression responsive to ECT • High degree of intent to harm
o Yung mga mahilig magdala ng baril. They don’t care if they hurt
AGGRESSION AND VIOLENCE somebody
• Presence of a victim
• Aggression and Violence à Complex interaction of Biologic, o If they think of someone as a weaker person than them, then
Psychotic, and Social Variables they can become aggressive (parang bully)
• Concrete plan
Report rate of Aggression in Psychiatric Emergency Service – 31% • Access to instruments
• Acute psychosis (majority) • History of loss of control
• Substance Abuse o ADHD – on times that they are very hyper, they cannot control
o On stimulants (plus alcohol) - they can develop hallucinations and themselves anymore
lack of impulse control • Chronic anger/hostility
• Childhood brutality
Prevalence Rate of Violence o Take note of school bullies, because often they grow up to be
• 8% with Schizophrenia (2% without mental illness) brutal as well
• 30% co-morbid substance abuse • Reckless driving
• 17.9%: mentally ill patients w/o substance-use diagnosis • Early loss of parent
o Ask for history of use. Make in thorough, because patients know • Lack of compassion
that these drugs can easily be excreted in the body, especially o “Okay lang yan, wala naman yang asawa, mamamatay din yan”
through the urine. So usually they stop taking the drug 24 hours
before drug test Violent Behavior Treatment
• 73%: mental illness and substance use • Hospitalization
• 24%: substance use with personality disorders (methamphetamine) • Benzodiazepines and/or antipsychotics
• Use of restraints (physical or chemical)
Disorders Associated with Aggression o Patients are so dangerous to themselves or others that
• Psychotic disorders: Schizophrenia they pose a severe threat that cannot be controlled in
• Mood disorders: Bipolar, MDD, substance induced any other way
• Intermittent explosive disorder o Temporarily to receive medication
• Personality disorders: paranoid, antisocial, borderline, narcissistic o For long periods if medication cannot be used
• Cognitive disorders: Delirium, Dementia
• Conduct disorders Expert Consensus Guidelines on Treatment of Behavioral Emergencies
• Mental retardation Verbal Intervention 76% - show that you are in control
• ADHD Voluntary Medication 65%
Show of Force 51%
PSYCHIATRIC EMERGENCY

Violence Risk Assessment Emergency Medication without Consent 45%

Demographic Male, young, poor, uneducated, unemployed, no Offer of food, Beverage 39%
supportive social network Physical Restraints 27%
Past History Early victimization, past violence, substance abuse, Locked Seclusion 23%
poor parental model
Unlocked Seclusion 21%
Diagnostic Organic brain syndrome, personality disorder,
psychosis, comorbidity with substance abuse
Clinical Features Command hallucinations, paranoid delusions and • Non-coercive Intervention (wag mong patulan kapag galit) à
suspiciousness, poor impulse control Verbal Approach à De-escalation technique (remain calm)à
Psychological Low tolerance for frustration, criticism and interpersonal Talk down intervention (pagusapan nyo kung ano ang
closeness, low self esteem, tendency toward projection problema)
and externalization, anger, irritability • Use of involuntary medications
o A drug used as a restraint is a medication used to control 3
behavior or to restrict the patient’s freedom of movement and “is  

 
 not a standard” treatment for the patient’s medical or psychiatric • Never forget if they are on AP medication. Best treatment is to remove
condition the offending agent
• Physical Restraint and Seclusion à primarily to protect patients • You can also give Dopamine Agonist – Levodopa (because the main
against injury to SELF or OTHERS because of behavioral or problem is dopamine antagonism)
emotional disorder • Non-specific changes in muscle biopsy or post mortem
o Protect yourself too. histopathologic studies
• Rapid Tranquilization • Once NMS is diagnoses and oral antipsychotic drugs are
↓ discontinued, NMS is self-limited in most cases
• Behavioral Control • The mean recovery time after drug discontinuation is in the range of 7
o Haloperidol (10-40 mg) to 10 days, with 63% risk of patients recovering within 1 week and
o Chlorpromazine (50-200 mg) nearly all within 30 days
o Diazepam • The duration of NMS episodes may be prolonged when long-acting
o Droperidol (10-20 mg) depot antipsychotics are implicated
• Residual catatonia and parkinsonism may persist for weeks after the
acute metabolic symptoms of NMS resolved
Typical Antipsychotics Atypical Antipsychotics
Treatment
• Haloperidol • Expert Consensus Guideline, APA 2002 • Supportive Therapy
• "Best evidence" • Oral Risperidone is as effective as • Pharmacologic Therapy
• 20 double blind studies Haloperidol (Currier, 2004 • Electroconvulsive therapy
(Allen, 2000) • Intramuscular Olanzapine 10-30 mg
• Presence of EPS (Baker, 2003) Antipsychotic Use after NMS
• Oral Olanzapine 20-40 mg (Baker, • Restarting antipsychotic treatment after resolution of NSM episode
2003) has been associated with an estimated likelihood of developing
NMS again as high as 30%
• Most patients who require antipsychotic treatment can be safely
treated, provided precautions are taken
NEUROLEPTIC MALIGNANT SYNDROME • At least 2 weeks should be allowed to lapse after recovery from
NMS before re-challenge
• An idiosyncratic, life-threatening complication of treatment with • Low-doses of low potency conventional antipsychotics or atypical
antipsychotic drugs that is characterized by fever, severe muscle antipsychotic should be titrated gradually after a test dose
rigidity and autonomic & mental status changes • Monitor for early signs of NMS
• Haloperidol, Chlorpromazine etc • Do not give the same drug
• Typical and Atypical AP can cause NMS • Supportive therapy
• An incidence of 0.01%-0.02% in the population – rare, although you • Similar to Malignant Hyperthermia (Succinylcholine)
should be familiar to recognize
• TREATMENT – remove the antipsychotic (AP) – typical or atypical ALCOHOL WITHDRAWAL & DELIRIUM TREMENS
• Secondary to dopamine antagonism
• Typically develops over a period of 24-72 hrs but may have a more Delirium Tremens
insidious evolution of symptoms • Appears within 2-3 to 7 days after cessation of alcohol intake –
• Risk of developing NMS sometimes after other withdrawal symptoms have resolved and
o 10-20 days after an oral neuroleptics are discontinued and even fluctuates in severity
longer when associated with depot forms of drugs • Life threatening
• Retrospective analyses suggest that alteration in mental status and • Signs and symptoms can last for 72 hours
other neurological signs precede systemic signs in more than 80% • Symptoms include
of cases of NMS o Altered mental status (mental dullness, disorientation,
• The initial progression of symptoms is usually insidious over days, confusion and hallucinations in the form of tactile –
occasional cases of NMS may have a fulminant onset within hours most commonly they have ants crawling on their skin)
after drug administration o Tremors - early
• About 16% of cases of NMS develop within 24 hours after initiation o Marked psychomotor agitation
of antipsychotic treatment, 66% within the 1st week, and virtually all o Loss of muscle coordination
cases within 30 days o Positional nystagmus
• Criteria for guidance in the diagnosis of NSM, the presence of 3 o Hypertension
major, or 2 major + 4 minor manifestations indicates high o Tachycardia, tachypnea
probability of the presence of NMS o High fever
o Diaphoresis
PSYCHIATRIC EMERGENCY
Category Manifestations
Major Fever, rigidity (lead pipe - may cause rhabdomyolysis), elevated TREATMENT: Supportive and Benzodiazepines (chlordiazepoxide).
Best treatment for DT is prevention
creatinine phosphokinase concentration
- High calorie, high-carbohydrate diet supplemented by
multivitamins is important 
Minor Tachycardia, abnormal arterial pressure, tachypnea, altered
- Physically restraining patients with DT is risky; they may
consciousness, diaphoresis (sweaty), leukocytosis
fight against the restraints to a dangerous level of exhaustion 
- Anorexia, vomiting, and diarrhea often occur during
*Renal failure is a strong predictor of mortality with a risk of approximately 50%*
withdrawal 
• Non-specific encephalopathy - Antipsychotic medications should be avoided because they
• Lumbar puncture is usually normal can reduce the seizure threshold in the patient 
• Cranial CT scan is normal
• Electroencephalography may demonstrate generalized slowing 4
consistent with metabolic encephalopathy