Psychiatricemergency• DIFINITION:- It is a condition where patients has a disturbances of thought, affect and psychomotor activity leading to a threat to his existence (suicide) or threat to other people in the environment (homicide) with himself.
Common Psychiatric emergencies1. Suicidal threat2. Violent/aggressive behaviour/excitement3. Panic attacks eg snake4. Hysterical attacks5. Transient situational disturbances eg. Earth quake6. Epileptic furor7. Drug toxicity8. Victims of disaster9. Rape victim10. grief
DEFINITION’SSuicide:-• It is a type of deliberate self-harm.• It is defined as an international human act of killing one self.Suicidal client:-The person who is more proneto kill himself & had one ormore suicidal attempt
• Attempted suicide:- person try to kill own self but not succeed. More by women • Completed suicide:- person kill own self successfully. More by men.
Suicidal tendencies in psychiatric ward1. Major depression:- Suicide is a major depressive episode is due to-• Persistent sadness• Pessimistic cognition to past, present & future• Delusion of guilt• Helplessness , hopelessness & worthlessness• Derogatory voices urging him to take his life.
•Risk of suicide more when acutephase is passed & psychomotorretardation has improved b,cozpatients have more energy.
2.schizophrenia• Because of hallucination & delusion schizophrenic patients see suicide as areasonable alternative.
3.mania:-• Result of grandiose ideation.• Patient may believe he is a great person or wish to prove his supernatural powers.• Because of this he may carry out some dangerous activity that can cost him his life.• Eg. Jesus, lord Krishna,• superman
4.Drug or alcohol abuse• Suicide among alcoholics can be due to depression in the withdrawal phase. • Loss of friends, family, self respect, status & a general realisation of that aspect can cause the individual to with to die.
5.Personality disorder:-• Individual with histrionic & borderline traits may occasionally attempt suicide.• But their success rate is low.
6.Organic condition:-• Delirium & dementia due to changes of mood like anxiety & depression may attempt suicide.
2.Physical disorders:- patients with incurable or painfulphysical disorder like cancer & AIDS Severe pain BURN
3. PSYCHOSOCIAL FACTOR• Failure in examination • Loss of loved object • DEATH OF LOVED REALATIVE
• Dowry harassment • Marital problemsIsolation & alienation of society • Financial & occupational problems
1.AGE:-• Male above 40 yrs of age• Female >55yrs of age2. sex:-• Men have greater risk of completed suicide• Women have higher rate of attempted suicide• Suicide is 3 time more common in men than women• Successful suicide number about 70% men & 30% women
CONTD….3. Marital status:-• Twice in single person than of married person• Being unmarried, divorced, widowed or separated have 5-6 time more risk.
4.Socioeconomic status:-• Acc to SADOCK & SADOCK “highest & lowest class individual have high rate than middle class• Occupation related suicide is higher among artists, law enforcement officers, lawyer & insurance agents.• health-related occupations higher (dentists, doctors, nurses, social workers) especially high in women physicians
• History of childhood trauma or abuse, or of being bullied• Family history of death by suicide• Being unemployed• Retired Occupation
1.Education:-A.Individual and Public Awareness:-•Primary risk factor for suicide ispsychiatric illness as aware about it.•Teach depression is treatable so noneed to take stress or think deeply.•Try to deestimate the illness.•Destigmatize treatment•Encourage health seeking behavior &continuation of treatment.
B. Professional Awareness:-• Healthcare professional – physician, pediatrician, nurse practiceners etc.• Mental health professional – Psychologist, social workers etc.• Primary & secondary school staff – Principle, teacher, counselors, nurses• College & university resource staff – Counselors, student health services, student residence services
Contd…..• Gatekeepers• Religious leader ,• police,• fire departments,• armed services.
2.Screening:-•Identify At Risk Individuals•Identify the patient who have high prone mentaldisease R/T suicide•Identify the “WARNING SIGNS OF SUICIDE’’
Warning signs of suicide:-• Suicidal threat• Writing farewell letters• Giving away treasured articles• Making a will• Closing bank account• Appearing peaceful happy after a period of depression• Refusing to eat /drink• Refusing to maintain personal hygiene
3. MEANS RESTRICTIONS:-• Fire alarm safety• Construction of barriers of jumping sites• Detoxification of domestic gas• Restriction on pesticides• Reduce lethality or toxicity of prescription – Use lower toxicity antidepressants• Restrict sales of lethal hypnotics e.g. barbiturates
4.Mediaa)Media Guidelines•Encourage implementation ofresponsible media guidelines forreporting on suicide.
b) Media Considerations Consider how suicide is portrayed in the media TV Movies Advertisements The Internet danger Suicide chat rooms Instructions on methods Solicitations for suicide pacts.
Antidepressants Adequate prescription treatment and monitoring Only 20% of medicated depressed patients are adequately treated with antidepressants – possibly due to: Side effects I.Lack of improvement II.High anxiety not treated III.Fear of drug dependency IV.Didnt combine with psychotherapy V.Dose not high enough VI.Didnt add adjunct therapy such as lithium or other medication(s) VII.Didnt explore all options including: ECT or other somatic treatment
Psychotherapy:-• Specifically designed to treat depression• Relatively short term(10-16 WKS)• Structured – It should be step by step treatment instructions that any other therapist can easily follow• E.g. – Cognitive behaviour therapy(CBT) – Interpersonal therapy (IPT) – Dialectical behaviour therapy (DBT)• Implement teaching of these techniques
Initial approach during emergency:-• warm, direct & concerned.• Quick evaluation to identify the condition• Care on the basis of seriousness is essential• Emergency staff should have basics knowledge of handling psychiatric emergency.
• Medico legal cases need to be registered separately & informed to concerned officers Security should be adequate to control violent & dangerous patients
• Findings should be recorded in emergency file.• Patient condition & plans of management should be explained in simple language to patient & family members
1. monitoring the patient safety need• Take all suicidal threats or attempts seriously & notify to psychiatrist.• Remove toxic agent like drugs/alcohol• Donot leave medication tray within patient reach.• Make sure that daily medication swallowed.• Remove sharp instrument
• Contd…• Remove straps & clothing like belts, necktie etc.• Do not allow the patient to bolt his door on the inside.• Make sure somebody accompanies him to the bathroom• Constant observation & should not be alone• Good vigilance especially morning hours• Spend time to him, talk to him & allow him to ventilate his feelings.
Contd….• Encourage him to talk about his suicidal plans/method• If suicidal tendencies are very severe, sedation should be given.• Enhancing self-esteem of the patients by focusing on his strengths & positive qualities than weakness.
2.Mangement of attempted suicide in the IPD• Assess for vitals, check airway• If pulse weak start IV fluids• Turn patient head & neck to one side to prevent regurgitation & swallowing of vomitus.• Emergency measures to be instituted in case of self-inflicted injuries.
3.Management of shock:-• Transfer the patient to medical centre immediately• It there is no evidence of life leave the body in the same position/room in which it was found.• Patient has attempted suicide By jumping, do not leave the body in a place which is visible to other patient af the ward.• Inform authorities, record the incident accurately
• Contact local guardian & inform them• Hand over the patient properties to the concerned authorities/relatives.• Senior staff should discuss with all staff about passive lapse & preventive measure that need to be undertaken.