Suicidal Patients

Introduction

The patient must be approached in an empathetic manner. The physician must remain calm and uncritical. Questions about suicide should not be asked before establishing some degrees of rapport. It is a good practice to proceed from a very general to more specific issues. The patient must be given sufficient privacy so that he/she can talk to the physician alone.

Evaluation

The cardinal rule is that all threats have to be taken seriously. It is wise to question about ideas or wishes or plans of suicide when such a doubt arises. It is a misconception that talking about suicide may result in giving ideas to the patient or may hasten the process. Indeed, truly suicidal patients are relieved to be asked about it.

Considerations Evaluation involves the following considerations:

1. Was the method chosen for suicidal attempt a dangerous one?
2. Did the patient believe that the method would work?
3. The chances of the patient likely to be discovered in the process?
4. Does the patient feel relieved of being saved?
5. Whether the attempt is planned or impulsive?
6. Was the patient trying to get a message across or did the patient just want to die?
7. Whether there is any change in life situations that led up to the attempt?

Once the suicidal attempt is made:

1. At least a short hospital stay is indicated
2. Patients who have serious psychiatric disorder necessitate admission in a centre where psychiatric help is available
3. If severely depressed, may require very active treatment and most of the time electroconvulsive therapy.
4. Psychotic patients may require admission in a locked unit.
5. If the medical or surgical problem is serious following an attempt, the patient should be admitted in general hospital where psychiatric consultation has to be obtained.

Violent Patient

Technique of Evaluation and Management

The violent patients brought belong to mainly three categories:

i. Mentally ill

ii. Neurologically ill or other organic disorders

iii. Intoxicated or in a withdrawal phase. No interview should be conducted with weapons present in the room or with objects that could possibly be used as weapons. Interviewing room should not be in a secluded area and the examiner and the patient should be positioned in such a way that they have access to the door.

While interviewing:

• Show concern
• Try to develop rapport
• Assure the patient that, you will do whatever you can to help him/her
• With paranoid patient, never take up an attitude of confrontation but present as if you and the patient are facing the problem together.

Situations which carry increased risk of violence i. Paranoid patient ii. The patient with command hallucination ordering violence iii. Intoxicated with alcohol or drugs iv. Organic syndromes v. Manic patients when they are irritable.

Clues to impending violence: Speech that is loud and threatening, increased tension, hyperactivity, slamming doors or knocking over furniture are all pointers to impending violence Acutely Violent Patient

Needs physical restraint: 1. Restraint must be performed by at least 5 individuals, each individual taking a limb and one taking the head. 2. This has to be done with the patient’s attention diverted and the restraint applied. Leather restraints are safest and should be checked periodically. 3. The reason for the restraint should be calmly explained to the patient and the restraint should never be removed without the presence of adequate staff. 4. Parenteral sedative should be immediately given if the patient is struggling.

Drugs

1. If the patient is only moderately violent, he can be given 2 mg lorazepam or 5-10 mg diazepam. If necessary, repeat administration after 30 minutes; or
2. By IV injections haloperidol 5-20 mg diluted in 10 ml of distilled water slow IV (if needed same dose of drugs can be repeated after 2 hours).
3. If there is history of addiction, one of the phenothiazines (Chlorpromazine 25 mg-50 mg) can be given. To avoid the risk of postural hypotension and also in older individuals, haloperidol (5 mg) could be given; especially so in psychotic individuals. Dosage determination in the psychotics should be in the light of his previous requirement. Parenteral administration may be resorted to when the patient refuses oral medication and also in dire emergencies when the patient is acutely violent. Once the crisis situation is successfully managed, further treatment depends on the underlying condition. If there are repeated episodes of violence, the psychotic condition or organic condition needs careful treatment; and if necessary, the patient has to be hospitalized in a psychiatric hospital.