20.1 Mental state assessment

ABC of the MSE

A mental state examination (MSE) is analogous to the management of severe trauma. There is an initial risk assessment looking for immediately life-threatening risks to the patient or staff. The triage nurse and the treating doctor should then obtain a brief collateral history from the emergency services or carers and initial management is based on this assessment. Regardless of threat, all assessments should balance the safety of both patient and staff with privacy and dignity [7].

Assessment should be based on [12]:

 appearance and affect

 behaviour

 conversation

 drug and/or alcohol intoxication.

If the situation is relatively controlled, the formal mental health assessment should then take place. Further information is gathered from the community. A provisional assessment and management plan is developed in conjunction with the mental health team and appropriate disposition is arranged (Fig. 20.1.1).

Aims of mental health assessment

The aims of the formal mental health assessment are to determine the following:

Only if all of the above are answered, can management and appropriate disposition be considered.

The formal psychiatric interview

Introduction

The environment in which the mental state assessment is conducted is important. Behaviourally disturbed people tolerate noise poorly and have short concentration spans. The interview room should be quiet, private, make the patient feel safe and the interviewer should avoid all interruptions. These prerequisites are increasingly difficult to attain in current access-blocked environments.

The interviewer should sit at the same level as the patient and impart empathy. The voice should be quiet and calming. The interviewer should use non-judgemental language and open-ended questions [13,16]. It is important that the interviewer also feels safe and secure. If any risk is felt, the interviewer should have security or police present in the room or just outside. Depending on state legislation and hospital policy, the interviewer may request to have the patient searched. The interviewer should also note the nearest duress alarm and may choose to wear a personal alarm. The interviewer should sit within easy access of an exit and should never be boxed into a corner. If an interviewer begins to feel uncomfortable, there is always the option of leaving and returning to complete the assessment at a later stage. All threats, attempts and gestures suggestive of violence should be treated seriously.

First part of the interview: direct questioning

Basic demographic information

The formal interview has become less diagnosis focused and more problem based. Management is centred around the alleviation of symptoms and return to function. Thus, the psychiatric interview has become somewhat less structured.

It is wise to establish rapport with the patient by personal introduction and explaining the purpose of the interview. The interviewer can begin by asking a series of non-threatening questions, such as demographics. This information is often required as many mental health services rely on an appropriate post code to determine follow-up management.

These questions assist by building a profile of lifestyle, relationships and thought processes. Likelihood of success or failure of particular treatment modalities may be assisted by knowledge of previous hospital admissions, both general hospital and mental health (Table 20.1.6).

The process of obtaining a mental health assessment is different to that of a general medical assessment. In a general medical history, a series of questions is asked and the response is written. In a mental health assessment, responses are also interpreted. The interviewer is asked to form an opinion as to how thoughts are processed, based on observations. The interviewer is asked to interpret the patient’s thought patterns by what, and how, the patient tells the interviewer.

Presenting complaint

The patient is asked to recall the sequence of events prior to presentation to the ED. The interviewer should explore the circumstances of the behaviour, reasons for it, degree of planning or impulsivity and its context. Were drugs and alcohol involved? Was there a recent precipitating event? It is often useful to get the patient to recall the previous 48–72 hours leading up to the event.

This usually leads to questioning regarding current difficulties. The interviewer should explore the nature of current problems. They may be financial or legal problems, isolation, bereavement, impending or actual loss, or diagnosis of major illness. Have there been any recent changes and who are their usual support people? An exploration of significant relationships is important along with the depth and duration of these relationships. It is useful to explore the patient’s usual coping methods when under stress.

Mood and affect

There should be formal questioning regarding the patient’s mood (internal feelings) and whether it is in keeping with affect (external expression). The mood may be incongruent with affect, swing wildly between extremes (labile) or be inappropriate.

Usually mood is assessed by asking about the patient’s ability to cope with activities of daily living, such as eating, weight loss or gain, sleep disturbance (early morning wakening or trouble getting to sleep) and general hygiene. The patient’s ability to concentrate may also diminish with increasing mood disturbance, reflected by the ability to perform normal work duties.

This may lead to direct questioning regarding mood and thoughts of suicide. It is important to be direct in asking the patient about suicide and whether there is a formulated plan. A well thought out plan with clear means of carrying out threats is of great concern.

Delusions and hallucinations

Delusions and hallucinations are often personal and the patient may not want to disclose intimate thoughts and beliefs to the interviewer. Hallucinations may be auditory, visual, tactile, olfactory, somatic or gustatory. The context in which they occur should be explored. Hypnagogic (occurring just before sleep) and hypnopompic (occurring on wakening) hallucinations are more benign than others. Common themes for all types of hallucinations include suicide, persecution, religion, control, reference, grandeur or somatization.

Insight and judgement

Insight is the degree of understanding of what is happening and why. This may be:

It is important to determine the patient’s level of insight. This determines appropriate treatment and management, level of supervision required and the likelihood of compliance with treatment.

Second part of interview: observation

Key elements

The second part of the MSE can be more difficult to conceptualize. It relies on the interviewer actively observing the patient’s behaviour and conversation and interpreting thoughts. A summary is given in Table 20.1.7.

This part of the interview can be difficult to remember and different services have developed a multitude of acronyms for remembering the various elements of the remaining mental health assessment. Listed below are two.

ABC of Mental Health Assessment [12]:

GFCMA – ‘Got Four Clients on Monday Afternoon’ [13]:

Appearance, attitude and behaviour

This determines the patient’s ability to self-care. Table 20.1.8 lists features that may require particular attention. Attitude is important as it may indicate whether a patient is compliant with management and treatment. Abnormal posturing or repetitive behaviours should be noted. These may indicate increasing thought disturbance. With increasing aggression and agitation, there may be motor restlessness, pacing and hand wringing. Tension may escalate rapidly and steps should be taken early to diffuse the situation.

The interviewer should note the rate, volume and rhythmicity of speech. This can range from completely mute, through monosyllabic answers, to rapid, loud speech indicative of pressure of speech. The tone, inflection, content and structure of speech should be noted. The interviewer should determine if the speech is fluent, if the thoughts behind it are logical and whether it flows appropriately for the situation.

Thought disorder

This is speech that does not reach its goal, is not fluent and is interrupted often with many pauses or changes in direction. A list with explanations is given in Table 20.1.9.

Thought content

There are often recurrent themes in the speech of an acutely disturbed patient. These may revolve around suicide, persecution, control, reference, religion or somaticism (the extremes of which are nihilistic delusions – the belief that part of the self does not exist, is dead or decaying) or they may be grandiose in nature.

Perception

A patient may be actively hallucinating despite denying this on questioning. It is important to note if the patient’s eyes suddenly switch direction for no apparent reason or they appear to be listening to a voice. These movements are often quite subtle and easily missed if observation is not active.

Cognitive assessment and physical examination

A formal examination of cognitive function and a thorough physical examination complete the full psychiatric assessment. The interviewer should ensure that the patient does not have an acute confusional state secondary to a physical condition that may account for a behavioural problem.

A number of tools are available to assess cognitive functioning. These comprise assessments in orientation, concentration, memory, language, abstraction and judgement. An assessment of a patient’s cognitive functioning and intelligence may assist in deciding the best way to deal with problems.

Approximately 20% of mental health patients have a concurrent active medical disorder requiring treatment and possibly contributing to the acute behavioural disturbance [6]. Investigations depend on physical findings but may include creatine kinase, urine drug screen, electroencephalogram, computed tomography and lumbar puncture. Only after this can an emergency medicine practitioner plan the most appropriate management.

Conclusion

Although time consuming, a good mental health assessment is vital for the appropriate management and disposition of what is an increasingly large group of patients in the ED. If able to formulate an opinion on the risk assessments regarding suicide, violence and flight risk and the aims of the MSE, the emergency clinician will be able to present to mental health services a comprehensive picture of the patient.

The mental health professional is then able to administer mental health first aid [2], the principles of which are:

20.2 Distinguishing medical from psychiatric causes of mental disorder presentations

Investigations

Investigations should always be guided by clinical findings and must be tailored to each individual presentation. A combined Massachusetts Emergency Physician and Psychiatry Task Force in 2009 identified criteria for low medical risk. Patients must meet all criteria. The criteria were adults aged 15–55, no acute medical complaints, no new psychiatric or physical symptoms, no evidence of substance abuse pattern, normal vital signs, normal gait and speech with normal memory and concentration. Patients with low medical risk were not recommended for any routine testing in the ED as they are of very low yield.

First presentations and suspicion of a medical cause that needs to be confirmed or excluded are the major indications for emergency investigations. Baseline blood tests, such as full blood profile, blood sugar level, electrolytes, liver function tests, calcium and thyroid function tests, may at times detect clinically unsuspected problems. Examination and culture of urine and cerebrospinal fluid should be undertaken if occult infection is considered a possible cause. A urine drug screen may on occasion be the only way to confirm clinical suspicions of drug-related illness. Time delays for results, low specificity from cross-reactivity and uncertainty caused by drugs with long half-lives limit their usefulness. Newer drug-screening stat tests at the bedside may improve their usefulness in the ED. Mandatory brain computed tomography (CT) is not indicated, but the threshold for imaging in first presentations of altered mental state without obvious cause should be low. HIV and syphilis testing should be done on all patients with significant risk profile. Herpes encephalitis may not produce imaging changes but should be considered when fever, delirium or cognitive changes are present with sudden alterations in behaviour. Newer imaging modalities, such as magnetic resonance imaging, magnetic resonance spectroscopy, positron emission tomography and single-photon emission CT, continue as research tools but may have a role in the future. Electroencephalogram examination is rarely a current ED test for psychiatric patients.

Diagnostic formulation

Emergency physicians should suspect organic disease until proved otherwise. In particular, reversible medical causes of abnormal mental state should be sought. Proformas improve documentation and summation. Consideration of the factors in Table 20.2.5 may help to determine doubtful cases. There are few absolutes that distinguish organic from psychiatric patients. Use of the five-axis DSM-IV system improves the ability to look at the patient’s presentation in the context of total functioning. It also allows emergency physicians to communicate with psychiatric peers in the recognized language.

Some patients require periods of observation, re-examination and further investigations before a definitive answer is obtained. Intoxicated patients frequently are not assessable till sober. NEAT will pressure hospitals to look for safe disposition sites for this often difficult patient group. Interim care and disposition varies depending on presentation, prior history and facilities available. A common expectation of emergency physicians for patients referred to psychiatrists is to document that the patient is ‘medically cleared’. The assessment is known to be imprecise and difficult [1–4,7]. Better documentation is to state that the ED assessment has revealed no evidence of an emergent medical problem that would preclude admission to psychiatric care.

Conclusion

A thorough medical history, psychiatric history, collateral history, physical examination, mental state examination and judicious specific investigation will identify most patients likely to have an underlying physical cause for a mental disorder presentation. Omission of any of these steps may lead to missed medical diagnosis and incorrect disposition.

20.3 Deliberate self-harm/suicide

Epidemiology

In Australia, there were approximately 2300 deaths per year from suicide in 2010, with age-standardized rates of approximately 16.4 per 100 000 in males and 4.8 in females (Table 20.3.1) [4]. Suicide accounts for 1.6% of deaths in Australia. Suicide remains the leading cause of death among Australians between 15 and 34 years of age. Despite some decreases in suicide rate over the past decade, suicide remains a major external cause of death, accounting for more deaths than road traffic crashes [5].

Table 20.3.1

Suicide summary statistics, Australia, 2001–2010 [6]

Year of registration
Rate of suicide deaths (age standardized)	2001	2002	2003	2004	2005	2006	2007	2008	2009	2010
Male	20.3	18.8	17.8	16.8	16.5	15.8	16.3	17.2	16.0	16.4
Females	5.3	5.0	4.7	4.3	4.3	4.7	4.9	4.7	4.8	4.8
Persons	12.7	11.8	11.1	10.4	10.3	10.1	10.5	10.8	10.3	10.5
Rate ratio M:F	3.8	3.7	3.8	3.9	3.9	3.4	3.3	3.7	3.4	3.4
Suicide as % of total deaths	1.9	1.7	1.7	1.6	1.6	1.6	1.6	1.6	1.6	1.6
Suicide as percentage of all deaths from external causes	31.2	29.7	28.6	26.3	26.2	26.2	27.1	26.3	25.3	26.5

OECD Factbook 2009. [Internet homepage] [cited 2012, Nov 4].<http://www.oecd-ilibrary.org/economics/oecdfactbook-2009/suicide-rates_factbook-2009-graph162-en>

Across OECD (Organisation for Economic Cooperation and Development) countries, suicide rates were lowest in Greece, Mexico, Italy, the UK and Spain at less than 7 deaths per 100 000. They were highest in Hungary, Japan, Korea, Finland and Belgium at more than 19 deaths per 100 000 [6]. WHO estimates the low and middle income countries account for 84% of global suicides with India and China accounting for 49%. In these countries, rural young women are at an increased risk of suicide [7].

The trends involving completed suicide vary internationally, as well as subnationally, in addition to variance over time. Figure 20.3.1 shows this change over 62 years for New Zealand. Some inconsistencies across reporting systems should also be considered when interpreting suicide rates.

Hospital presentations for DSH are at least 10 times higher than suicide rates [4]. In the 2007 Australian National Survey of Mental Health, 0.3% of males and 0.5% of females reported they had made a suicide attempt in the previous 12 months. Most of these are not reported or are reported as accidents. Hence, unrecognized DSH is at least as frequent as that recognized. The same survey reported 1.9% of males and 2.7% of females experienced suicidal ideation within 12 months [8]. This rate may be as high as 25% in certain populations and age groups [9,10].

Patient characteristics

Demographic factors

Age

Suicide and DSH are rare in children under 12 years of age. Australian data suggest similar rates of suicide from the age of 20–50, with a peak at 40–44 years in males (27.7 per 100 000) and 45–49 years in females (7.6 per 100 000) [4]. There is another peak in the elderly, with suicide rates increasing with age from 65 years. This bimodal distribution is also evident from USA and New Zealand data, with males aged over 80 years having the highest age-specific rates of suicide.

The incidence of DSH increases throughout puberty, reaching a peak at 15–24 years of age and decreasing thereafter. The ratio of rates of DSH to suicide decreases markedly with age. DSH is uncommon in the elderly, who have a high ratio of successful to unsuccessful attempts [26].

Gender

In Australia, the overall rate ratio of M:F suicide is 3.4 in 2010 compared with 2.7 in New Zealand and 3.2 in the UK in the same year [27,28]. The rate for male DSH has been increasing in Western countries recently with the male to female ratio approximately 1:2. Females choose methods that are less likely to be fatal and may be more likely to present to hospital following DSH.

Employment

Unemployment increases the risk of DSH by 10–15 times, with the risk increasing with duration of unemployment. This may not be a cause or effect, but may be due to some underlying factor, such as psychiatric illness, personality disorder or substance abuse. There is a more pronounced increased in the risk factors of unemployment rate and lower socioeconomic status for young men in Australia [29].

Social and cultural factors

Suicide rates are higher in those who live alone or are in a lower social group, especially in urban areas characterized by social deprivation and overcrowding. Being single, separated, divorced or widowed increases the risk of suicide two- to threefold in the high- income countries [7]. In these countries, being partnered reinforced by children decreases the risk of suicidal behavior. In India and China, there is a reduced risk of suicide versus other causes of death in women widowed, divorced or separated compared with married women and men [7].

Recent data in Australian Aboriginal people report substantially higher suicide rates that commence at a lower age than in the non-Aboriginal population [4]. Suicide has become more common in recent years; in 2010 the percentage of deaths by suicide among Aboriginal and Torres Strait Islander people was 4.2% compared with non-indigenous Australians 1.6% (does not include states of Victoria, Tasmania and Australian Capital Territory data). It is of concern that the age-specific suicide rate for Aboriginal males aged 25–29 was 90.8 deaths per 100 000 in a combined 10-year period 2001–2010 [4]. A higher suicide rate is seen in indigenous groups of other developed countries, for example, in New Zealand, the age standardized rate was 16 per 100 000 in 2010 compared with a rate of 10.4 in the non-Maori population [28].

Suicide rates of migrants initially reflect rates in the country of origin and converge toward the Australian rate over time. Rural areas in Australia and New Zealand and remote areas in the UK have a higher rate than urban areas [4,28,30]. Incarceration is a risk factor for suicide; in any form of custody, the suicide rate is three times that of the general population [31].

Some social groups, such as doctors, dentists, musicians, lawyers and law-enforcement officers, are more prone to suicide [32]. Most adults (75%) with DSH have relationship problems with their partners and teenagers with their parents. A major argument or separation often precedes the act on a background of ongoing social difficulties or substance use.

Medical factors

There is an increased risk of suicidal ideation in people with chronic ill health, terminal illness or chronic pain and epilepsy. The majority of such patients have sought medical advice in the 6 months before suicide. Most patients with DSH have good health.

Psychiatric factors

There is a pre-existing psychiatric disorder in 90–100% of cases of suicide, with depression accounting for 66–80%, but this rate may be based on retrospective psychological autopsy and therefore be open to dispute. The lifetime rate of suicide among psychiatric inpatients is 3–12 times higher than in the general population and involves a greater proportion of more violent methods, such as jumping from buildings, hanging or jumping in front of vehicles. One-third of these episodes occur after self-discharge from hospital, with another third occurring during approved leave. The high-risk time is the first week of admission and during the first 3 months after discharge [33].

Psychiatric disorders are present in up to 60% of patients who commit DSH, but may be transient and secondary to acute psychosocial difficulties. Da Cruz et al. examined the cases of 286 individuals who died within 12 months of mental health contact in North West England; 43% of the sample attended the ED on at least one occasion and 12% of the sample attended an ED on more than three occasions and could be considered ‘frequent attenders’. Most frequent attenders had a history of self-harm (94%), 68% had a history of alcohol abuse, 63% were unemployed at the time of deaths and 49% had a history of drug abuse [34].

Affective disorders

The psychiatric diagnosis that carries the greatest risk of suicide is mood disorder, particularly major depressive disorder if associated with borderline personality disorder, anxiety or agitation [35]. Fifteen per cent of these high-risk patients commit suicide over a lifetime. Depression correlates well with the occurrence of suicidal desire and ideation, but may not be as strong a predictor of planning and preparation (intense thoughts, plans and capability) and, therefore, suicide completion [36]. Hopelessness is the most important factor associated with suicide completion and may be of greater importance than suicidal ideation or depression itself [36]. Depressed patients should, therefore, have their attitudes towards the future carefully assessed.

Substance abuse

Individuals with alcohol use disorders have an overall approximately 7% lifetime risk of dying by suicide, with women being at greater risk than men. Fifteen per cent of alcohol-dependent persons eventually commit suicide. The majority of these are also depressed. The risk is higher if associated with social isolation, poor physical health, unemployment and previous suicidal behaviour. The increased risk may be more pronounced in males aged below 35 years [37]. Young males dependent on heroin have 20 times the risk of the general population. Chronic alcohol dependence is uncommon in DSH, but alcohol intoxication is involved in 50–90% of suicide attempts. Wyder found that 65% of people presenting with deliberate self-harm in Australia were substance affected at the time [38]. Acute alcohol ingestion is found in approximately 35% of people who die by suicide and between 15 and 60% of people who die by suicide have been found on psychological autopsy to have lifetime alcohol-use disorders [39].

Schizophrenia

Up to 10% of people with schizophrenia die by suicide. Young adult males are at high risk, especially if there is associated depression with feelings of hopelessness, previous DSH or suicide attempts, unemployment or social isolation.

Personality disorders

Patients with cluster B personality disorders are at high risk of DSH and suicide, especially if associated with labile mood, impulsivity, alienation from peers and associated substance abuse. This may be due to precipitation of undesirable life events, predisposition to psychiatric and substance-abuse disorders and social isolation. Adjustment disorders are associated with 25% of adolescent suicide [23].

Frequent attenders

Frequent attenders to EDs (defined as greater than three presentations in a year) are also at high risk. This group has seven times the risk of the general population and rates of suicide similar to clinical psychiatric populations. This risk is particularly pronounced in patients who present with panic attacks, especially if associated with depressive symptoms.

Aetiology

No specific psychological or personality structure is associated with suicide and patients who commit suicide or DSH do so for many unrelated reasons. The precipitant may be a personal crisis or life change amplified by poor social support, substance abuse or psychiatric disorder. Intoxication may decrease inhibitions enough to allow an act to proceed. A study by Wyder interviewed 112 people following a deliberate self-harm attempt. She found that 51% had considered deliberate self-harm for 10 minutes or less, but of those who had been affected by alcohol that number jumped to 93% [40].

The most frequent methods of suicide in Australia are hanging, strangulation and suffocation, these modes being used in 56% of all suicide deaths in 2010 in Australia. Poisoning by drugs was used in 12% of suicide deaths in 2010, followed by poisoning by other methods including alcohol and motor vehicle exhaust (10%). Firearms accounted for 7% of suicide deaths in Australia in 2010, a rate which has declined from 20% a decade prior, possibly due to firearm restriction legislation [5]. Proportions due to each method vary according to region, residence, age and sex [1,41]. In the USA, firearms accounted for 57% of male and 32% of female suicide deaths. In trauma centres in the USA, stab wounds are a far more common method of deliberate self-harm than gunshot wounds and people (more often men) at the extremes of age are more likely to use firearms with fatal consequences [3]. In many developing countries, organophosphate or antimalarial poisoning and charcoal burning are more common methods of suicide [42]. One-third of patients with DSH express a wish to die, but most do so to communicate distress. DSH may serve many functions for the person. At its most simple, it serves an integrative function calming the person at a time of great distress. It may also be a way of mobilizing assistance for someone who is feeling overwhelmed by circumstances. Many patients threaten suicide or magnify being at risk of suicide to increase the likelihood of admission to hospital. These patients are more likely to be substance dependent, have personality diatheses (for example, marked borderline, antisocial or dependent traits or disorder) or homelessness and be unpartnered and in legal difficulty. However, these instances of goal directed behaviour should not be discounted and the behaviour should be taken seriously. A presentation to an ED is a declaration that the person is in a self-defined crisis for which they are using maladaptive coping measures.

Most cases of medically serious DSH are due to self-poisoning, with 90% associated with alcohol intoxication. The most common drugs are non-prescription analgesics and psychotropic drugs. Many overdoses are related to alcohol or illicit substance intoxication and may be accidental rather than deliberate, although this distinction is often difficult to ascertain. Self-injury may involve cutting of the skin in various sites about the body but may also involve self-inflicted cigarette burns, excoriation of the skin or hitting themselves or other objects. More violent forms of self-injury are less common and suggest serious suicidal intent. Bizarre self-mutilation may occur in psychotic patients who may not necessarily have an intention to die but are acting in accordance with delusional beliefs or in response to command hallucinations.

Assessment

A person who expresses suicidal ideation or engages in DSH is sending a distress signal that emergency physicians must acknowledge. Suicidality should also be assessed in patients with symptoms or signs of depression, unusual behavioural changes, substance abuse, psychiatric disorders, complainants of sexual violence [27] and those who present with injuries of questionable or inconsistent mechanism, such as self-inflicted lacerations and gunshot wounds or motor vehicle accidents involving one victim. Many would argue that assessment of suicidality should be a routine part of any ED assessment. A retrospective study by Da Cruz et al. found that 40% of persons who died by suicide had presented to the ED at least once during the year prior to their death [34]. Assessment in the emergency department ideally will contain elements that provide the person with the opportunity to discuss psychosocial aspects of their life. Within this discussion, it may be that suicidal ideation or thoughts of deliberate self-harm may be elicited. This may allow early referral to psychosocial supports thereby providing the person with holistic care to help address their needs.

Assessment requires a systematic, multidisciplinary approach involving prior staff education, appropriate triage, observation and restraint procedures (in the setting of imminent risk and the absence of less restrictive options) and a planned strategy for assessment followed by treatment and disposition. The priorities are to define the physical sequelae of the act, risk of further DSH behaviour, psychiatric diagnoses and acute psychosocial stressors. These aspects are those that can then be targeted for short-term interventions.

Triage

In a patient who has attempted DSH, initial management involves resuscitation, treatment of immediate life threats and preventing complications. The patient should be triaged according to the physical problem as well as current suicidality, agitation and aggressiveness and mental state. The mental health triage scale can be used for this purpose [43]. A triage score of 2 or 3 should be applied if patients are violent, actively suicidal, psychotic, distressed or at risk of leaving before full assessment can occur. Constant observation is required at this point and nursing staff, security or police may be needed. In Australia, a number of different triage scales can be used. There is some evidence that a mental health triage scale improves outcomes; however, the accuracy of the assessment can be limited by a number of environmental, staff and patient factors [44].

Medical assessment

The patient’s safety in the ED should be optimized by limiting availability of drugs, removing sharp implements, removing car keys, ropes, belts or sheets and securing nearby windows. Other concurrent and concealed methods of self-harm should be sought. This may be facilitated by changing into hospital gowns, whereby the patient is more easily identified if they abscond. In addition, other means to increase visibility, such as security cameras, high visibility cubicles or assigning a special nurse, should be considered. Assessment of the patient may be difficult, either due to a general medical cause or being unsettled from the precipitant of the act, or from not wanting to be in hospital or allow medical intervention. This may necessitate the therapeutic utilization of anxiolytic medication; the use of physical restraint may be considered if at high risk or unable to be fully assessed and wanting to self-discharge. This may be done under a duty of care to the patient or the local mental health act may be utilized in extreme situations. Emotional support of patient, friends and relatives is required during and after this phase, with clear explanation of the rationale and the procedures. Distinguishing medical from psychiatric causes of mental disorder presentations is discussed elsewhere in this book (see Chapter 20.2).

Suicide risk assessment

Initially, an assessment needs to be done in the ED so as to determine patient disposition, but a more comprehensive psychiatric assessment may need to wait until substance or anxiolytic medication effects wear off. Other sources of information need to be accessed since patient history can be unreliable or incomplete. Friends, family, local doctor, ambulance officers, helping agencies already involved and previous presentations documented in the medical record can all add useful information in order to advise an assessment. A therapeutic relationship should be formed and the clinician should be non-judgemental, non-threatening and clearly willing to help. A positive attitude has been shown to improve outcomes with this group of patients [45]. People presenting in crisis are hypersensitive to any negative transference. This may intensify the patient’s already low self-esteem, increasing future suicide potential and making a therapeutic relationship difficult to establish [46]. When managing a patient who may be suicidal, the suicidal ideation should be discussed openly. Expressions of self-harm carry individual meaning for each person. It is important, in a therapeutic relationship, to explore the meaning that this carries for the person and alternatives.

Risk factors may be divided into two main categories, namely static and dynamic. Static factors have been historically identified by Durkheim [47] who showed some, less socially integrated groups within society to be at greater risk of suicide than others. These static factors are enduring and in context of a person’s developmental history and social circumstances. Hence, being male, unemployed, single, poorly educated, from a lower socioeconomic group, with a history of mental disturbance and substance-use disorders would all place someone in a higher risk group.

Dynamic factors are the more fluid day-to-day factors that intensify the risk posed by the static factors. Flewett [48] divides these factors into internal and external factors. The internal factors include current feelings of abandonment, desperation, hopelessness, co-morbid depression, current drug use or physical illness. External factors are those of increased social dislocation, including homelessness, bereavement, intoxication, adverse life event, such as the recent loss of a job or relationship.

Definitive treatment and disposition

Following necessary medical treatment and suicide-risk stratification, disposition may involve involuntary or voluntary admission to a psychiatric or medical ward, short-term observation or discharge with appropriate follow up. Restraint and involuntary admission may be necessary for the high-risk patient who wishes to self-discharge. Approximately 30% of DSH patients are admitted for psychiatric inpatient care, but the factors involved in the decision for psychiatric hospitalization following DSH involve a complex evaluation of risk, potential for treatment and social supports [57].

Patients who are intoxicated with alcohol can be both behaviourally disinhibited and emotionally labile and, as discussed, are at higher risk of intentional self-injury. Short-term observation allows intoxication to resolve so that more comprehensive and longitudinal psychiatric assessment can take place. A short-term stay in hospital can also help resolution of many acute areas of conflict and make psychiatric evaluation more accurate. ED short-stay wards or psychiatric assessment and planning units are appropriate for these admissions, especially if a multidisciplinary team is available to review the patient and institute management and follow up.

Important elements of management involve addressing the modifiable elements of the precipitating problem, treatment of psychiatric illness and environmental interventions, such as family counselling, encouraging a support network and developing coping and problem-solving skills [58]. Adaptive solutions to the current crisis should be reinforced utilizing short-term solutions. Factors that should be addressed while patients are in hospital include referral to services to help address the dynamic risk issues, such as problems with relationships, employment, finances, housing, legal problems, social isolation, bereavement, alcohol and drug abuse and dependence. In this regard, social workers or mental health nurses are invaluable [59]. For greatest effect, these should be available after hours and on weekends since the majority of DSH presentations are after hours [60]. For repeat attenders who are often socially isolated, hospitalization should not be a substitute for social services, substance-abuse treatment and legal assistance, although admission may be necessary while appropriate supports are put in place [61].

Dispositional decisions need to be taken, weighing up the relative and potential iatrogenic harm generated by hospitalization and the now common legal mandate for treatment in a least restrictive environment. Discharge will be with referral to community agencies with responsibility for supporting the person in the community and, according to risk assessment, may include community mental health teams, GPs, non-government support agencies, etc. The aim of disposition is to minimize risk factors while empowering the person to develop more positive and capable coping styles for future crises.

Pharmacotherapy has been shown to be useful in addressing the debilitating symptoms of a major depressive disorder and, along with psychotherapy, can help the person regain their previous level of functioning. Once risk and disposition have been addressed, the pharmacotherapeutic management and ongoing assessment can be by the local medical officer, who can refer as necessary to mental health specialists. Pharmacotherapy involves the treatment of the underlying psychiatric disorder. Antidepressants decrease the risk of attempting suicide, although the lethality of suicide attempts is increased if tricyclic antidepressants are taken in overdose. Selective serotonin reuptake inhibitors and other newer classes of antidepressants (including SNRIs, NasSa, NRI, etc.) may have a more selective effect in decreasing suicidal behaviour and are less toxic in overdose than tricyclic antidepressants – the latter are no longer prescribed as first-line antidepressant medications by psychiatrists. These factors make the newer class of drugs an attractive choice for depressed patients who are suicidal.

Prevention

Comprehensive strategies for prevention of suicide have been or are being developed in Finland, Norway, Sweden, Australia and New Zealand [62]. Suicide prevention focuses on psychiatric, social and medical aspects and usually involves public education, media restrictions on reporting of suicide, school-based programmes with teacher education, training of doctors in detection and treatment of depression and other psychiatric disorders, alcohol and drug abuse information, enhanced access to the mental health system and supportive counselling after episodes of DSH. Decreasing the availability of lethal methods may involve legislative changes, such as more stringent gun control, restricting access to well-known jumping sites or changes to availability or packaging of tablets [63]. Overall, studies into the effectiveness of suicide-prevention strategies have shown inconsistent reductions in suicide rates following interventions [64]. Approaches to reduce DSH repetition have also shown disappointing results [65]. Improved recognition and treatment of mental illness, improved social services and drug and alcohol-support services may be of greater benefit than specific suicide-prevention strategies.