SUICIDE AND OTHER

PSYCHIATRIC EMERGENCIES
Presented by; Sophia Faisal Suleiman, Mbabazi
Eric, Masereka Ronald, Omwenge John

Tutor; Dr. Birungi

 Topic outline
• Definition of psychiatric emergencies • Definition of suicide
• Epidemiology of psychiatric • Definition of terms related to
emergencies suicidal ideation and behavior
• Types of psychiatric emergencies • Epidemiology of suicide
• Examples of psychiatric emergencies • Risk factors for suicide
• Emergency psychiatric evaluation • DSM 5 Proposed Criteria for
• General strategy in evaluating the Suicidal Behavior Disorder
patient
• History, Signs, and Symptoms of
• Screening laboratory tests
Suicidal Risk
• Decision-making algorithm for
• Management
psychiatric emergencies.
• Common Misconceptions about
• The S.A.F.E.S.T. Approach to
violent or agitated patients
Suicide
• Treatment of psychiatric • References
emergencies
 Definition of psychiatric emergencies

• A psychiatric emergency is any disturbance in

thoughts, feelings, or actions for which
immediate therapeutic intervention is
necessary.
• It causes sudden distress to the individual (or
to significant others) and/or sudden disability,
thus requiring immediate management.
 Epidemiology
• Psychiatric emergency rooms are used equally by men
and women and more by single than by married
persons.
• About 20 percent of these patients are suicidal, and
about 10 percent are violent.
• The most common diagnoses are mood disorders
(including depressive disorders and manic episodes),
schizophrenia, and alcohol dependence.
• About 40 percent of all patients seen in psychiatric
emergency rooms require hospitalization.
Epidemiology of CMNDs in Uganda
“Prevalence of all CMNDs in 2016 was 160/10,000 persons.
Prevalence of all CMNDs was similar between males
(150/10,000) and females (160/10,000). People aged 5-59
years were the most affected (860/10,000). Epilepsy was the
commonest disorder (76/10,000), followed by bipolar
affective disorder (24/10,000). Northern Uganda accounted
for the largest prevalence of epilepsy (100/10,000) while
central Uganda had the highest prevalence of bipolar
(62/10,000), schizophrenia (26/10,000), depression
(18/10,000), and HIV-related psychosis (11/10,000). On
average, CMNDs increased by 9% annually from 2012-2016.”
Research Square, 2020
 Types of psychiatric emergencies
1. A new psychiatric disorder with an acute onset.
2. A chronic psychiatric disorder with a relapse.
3. An organic psychiatric disorder.
4. An abnormal response to a stressful situation.
5. Iatrogenic emergencies.
i. Side effects or toxicity of psychotropic medication( s).
ii. Psychiatric symptomatology as a side effect or toxicity of other
medication(s).
6. Alcohol or drug dependence.
i. Withdrawal syndrome.
ii. Intoxication or overdose.
iii. Complications.
7. Deliberate harm to self or others.
Causes of Psychiatric emergencies
 Organic Causes of Psychiatric Emergencies
• Dementia
• Delirium
• Drug Intoxication and Withdrawal
• Infection
• Endocrine and Metabolic Disorders
• Neurologic Disorders
• Cardiopulmonary Disease
Causes of Psychiatric emergencies Cont’d

 Functional Causes for Psychiatric Emergencies

• Cognitive (Thought) Disorders: Schizophrenia
• Affective (Mood) Disorders such as Depression
and Manic States
• Borderline Personality Disorder
• Somatoform disorders and hysterical states
• Psychogenic fugue
 Emergency psychiatric evaluation
• The primary goal of an emergency psychiatric
evaluation is the timely assessment of the
patient in crisis.
• The physician must make an initial diagnosis,
identify the precipitating factors and
immediate needs, and begin treatment or
refer the patient to the most appropriate
treatment setting.
 Emergency psychiatric evaluation Cont’d

The cornerstone of the emergency room evaluation

includes the standard psychiatric interview consisting
of;
• a history
• a mental status examination,
• and, when appropriate and depending on the rules
of the emergency room, a full physical examination
and ancillary tests.
 Emergency psychiatric evaluation Cont’d
• The emergency room psychiatrist, however, must be
ready to introduce modifications as needed such as
structuring the interview with a rambling manic patient,
medicating or restraining an agitated patient, or forgo the
usual rules of confidentiality to assess an adolescent’s risk
of suicide.
• In general, any strategy introduced in the emergency
room to accomplish the goal of assessing the patient is
considered consistent with good clinical practice as long
as the rationale for the strategy is documented in the
medical record.
 Emergency psychiatric evaluation Cont’d
• An initial assessment of the patient’s total biopsychosocial
needs is optimal, but the patient’s emergency status, other
patients waiting to be seen, and the constraints of the
emergency room setting often make such a full assessment a
moot point. At a minimum, the emergency evaluation should
address the following questions before any disposition is
decided on:
1. Is it safe for the patient to be in the emergency room?
2. Is the problem organic, functional, or a combination?
3. Is the patient psychotic?
4. Is the patient suicidal or homicidal?
5. To what degree is the patient capable of self-care?
General strategy in evaluating the patient
 Screening laboratory tests
 The following studies may be helpful in the evaluation of
patients presenting with psych emergencies if the history and
physical suggests an organic cause:
• Electrolyte panel with glucose
• Pulse oximetry
• Toxicology screen (blood and urine)
• Blood ethanol level
• Liver function tests
• Computed tomography (CT) scan of the head
• Electrocardiogram (ECG)
• Thyroid function tests
Decision-making algorithm for psychiatric emergencies.
 The S.A.F.E.S.T. Approach to
violent or agitated patients
• Spacing —Maintain distance from the patient. Allow both the
patient and you to have equal access to the door. Do not touch a
violent person.
• Appearance —Maintain empathetic professional detachment. Use
one primary contact person to build rapport. Have security staff
available as a show of strength.
• Focus —Watch the patient’s hands. Watch for potential weapons.
Watch for escalating agitation.
• Exchange —Delay by calm, continuous talking is crucial to permit
de-escalation of the situation. Avoid punitive or judgmental
statements. Use good listening skills. Target the current problem or
situation in order to find face-saving alternatives for resolution and
to elicit the patient’s cooperation with treatment.
 The S.A.F.E.S.T. Approach to
violent or agitated patients Cont’d
• Stabilization —If necessary, use three stabilization
techniques to get control of the situation:
1. Physical restraint
2. Sedation
3. Chemical restraint.
• Treatment —Once the patient is more
manageable, initiate treatment based on the
patient’s symptoms. The patient may refuse
treatment and may need to receive treatment
involuntarily in order to ensure his or her safety.
 Treatment of emergencies
• Psychotherapy- all attempts are made to help patients’ self
esteem.
• Pharmacotherapy- The major indications for the use of
psychotropic medication in an emergency room include violent
or assaultive behavior, massive anxiety or panic, and
extrapyramidal reactions, such as dystonia and akathisia as
adverse effects of psychiatric drugs. Laryngospasm is a rare
form of dystonia, and psychiatrists should be prepared to
maintain an open airway with intubation if necessary.
• Restraints - are used when patients are so dangerous to
themselves or others that they pose a severe threat that
cannot be controlled in any other way.
• Disposition- Patient may be admitted or discharged or
managed in an extended-observation setting
 Definition of suicide
• Suicide is a type of deliberate self-harm (DSH)
and is defined as a human act of self-inten
tioned and self-inflicted cessation (death).
• Suicide is derived from the Latin word for
“self-murder.”
Definition of terms related to suicidal
ideation and behavior
 Definition of terms related to suicidal
ideation and behavior Contd
• An attempted suicide is an unsuccessful suicidal act
with a nonfatal outcome. It is believed that 2-10% of
all persons who attempt suicide, eventually complete
suicide in the next 10 years.
• A suicidal gesture, on the other hand, is an attempted
suicide where the person performing the action never
intends to die by the act. How ever, some of these
persons may accidentally die during the act.
• Attempted suicide is more common in women while
completed suicide is 2-4 times more common in men.
 Epidemiology
• There are over 35,000 deaths per year (approximately 100 per
day) in the United States attributed to suicide. This is in
contrast to approximately 20,000 deaths annually from
homicide. It is estimated that there is a 25 to 1 ratio between
suicide attempts and completed suicides.
• Although significant shifts were seen in the suicide death rates
for certain subpopulations during the past century (e.g.,
increase adolescent and decreased elderly rates), the rate
remains fairly constant, averaging about 12 per 100,000
through the20th century and into the first decade of the 21st
century.
• Suicide is currently ranked the tenth overall cause of death in
the United States
 Epidemiology Contd
According to the World Health Organization-
Global Health Observatory Data Repository, in
2016 in Uganda;
• Suicide mortality rate- 9.9/ 100,000
• Suicide mortality rate, male per 100,000 male
population- 10.7
• Suicide mortality rate, female per 100,000
female population- 9.1
 Risk factors for suicide
• Gender- Men commit suicide more than four times as
often as women, regardless of age or race.
• Age
• Race- Suicide rates among white men and women are
approximately two to three times as high as for African
American men and women across the life cycle
• Religion- Historically, Protestants and Jews in the United
States have had higher suicide rates than Catholics.
Muslims have much lower rates.
• Marital status- Marriage lessens the risk of suicide
significantly, especially if there are children in the home
 Risk factors for suicide Cont’d
• Occupation- Suicide is higher among the unemployed
than among employed persons.
• Mental illness- Almost 95 percent of all persons who
commit or attempt suicide have a diagnosed mental
disorder. Depressive disorders account for 80 percent
of this figure, schizophrenia accounts for 10 percent,
and dementia or delirium for 5 percent. Among all
persons with mental disorders, 25 percent are also
alcohol dependent and have dual diagnoses. Persons
with delusional depression are at highest risk of
suicide.
 Risk factors for suicide Cont’d
• Severe, disabling, painful or untreatable
physical illness
• Recent serious loss or major stressful life
event
• Social isolation
• Previous suicidal behaviour
• Alcohol or drug dependence
 DSM 5 Proposed Criteria for
Suicidal Behavior Disorder
A. Within the last 2 4 months, the individual has made a suicide attempt. Note: A
suicide attempt is a self-initiated sequence of behaviors by an individual who,
at the time of initiation, expected that the set of actions would lead to his or
her own death . The ''time of initiation" is the time when a behavior took
place that involved applying the method . )
B. The act does not meet criteria for non suicidal self-injury-that is , it does not
involve self-injury directed to the surface of the body undertaken to induce
relief from a negative feeling/cogn itive state or to achieve a positive mood
state.
C. The diagnosis is not applied to suicidal ideation or to preparatory acts.
D. The act was not initiated during a state of delirium or confusion.
E. The act was not undertaken solely for a political or religious objective.
Specify if:
• Current: Not more than 1 2 months since the last attempt.
• In early remission: 1 2-24 months since the last attempt.
History, Signs, and Symptoms of Suicidal Risk
 Management
Once suicide is committed, it is obviously no longer treatable.
Some important steps for preventing suicide include:
• Take all the suicidal threats, gestures and/or attempts
seriously and notify a psychiatrist or a mental health
professional.
• Psychiatrist (or a mental health professional) should quantify
the seriousness of the situation (a proper risk assessment)
and take remedial precautionary measures.
• i. Inspect physical surroundings and remove all means of
committing suicide, such as sharp objects, ropes, drugs, fi
rearms, etc. Also, search the patient thoroughly.
• ii. Surveillance, depending on the severity of risk.
 Management Contd
• Acute psychiatric emergency interview.
• Counselling and guidance
i. to deal with the desire to attempt suicide.
ii. to deal with on-going life stressors, and teaching coping
skills and interpersonal skills.
• Treatment of the psychiatric disorder(s) with medication,
psychotherapy and/or ECT. ECT is the treatment of choice for
patients with major depression with suicidal risk. It should
also be used for the treatment of suicidal risk associated
with psychotic disorders. Follow-up care is very important to
prevent future suicidal attempts or suicide.
 Common Misconceptions about Suicide
(Modified after Shneidman and Farberow, 1961)
 References
• Sadock, B., Sadock, V. and Ruiz, P., 2015. Kaplan & Sadock's
synopsis of psychiatry. 11th ed. Philadelphia: Lippincott Williams &
Wilkins.
• Keith, C. and L., R., 2011. CURRENT Diagnosis and Treatment
Emergency Medicine, Seventh Edition. McGraw Hill Professional.
• Ahuja, N., 2010. A Short Textbook of Psychiatry. Jaypee Brothers
Medical Publishers.
• Research Square. 2020. Prevalence and trends of common mental
and neurological disorders in Uganda, 2012- 2016: analysis of
national surveillance data | Research Square. [ONLINE] Available
at: https://www.researchsquare.com/article/rs-17580/v1.
[Accessed 01 March 2021].