Day # 84: Review Quiz -> Emergency Psychiatry

Today will be our first review quiz for the emergency psychiatry theme. Take a few minutes and check your retention.

1) Which of the following is not a protective factor against the risk of suicide attempts and completion of suicide?

a) Living in a rural setting

b) Pregnancy

c) Religious beliefs

d) Dependent children

2) Which of the following landmark case outlines laws in regards to our "duty to protect" all known or suspected potential victims of violence.

a) O'Connor v. Donaldson

b) Sell v. United States

c) Tarasoff v. Regents of University of California

d) Rogers v. Commissioner of Department of Mental Health

3) Which of the following would not be a recommended verbal de-escalation technique for an agitated patient?

a) Use calm / nonthreatening / reassuring tone

b) Offer friendly gestures such as hot coffee or tea

c) Ask directly about agitation/violence

d) Offer choices when possible even offering medications to help them stay calm

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ANSWERS

Question 1:

From day #81

Answer: a

Living in a rural setting is a risk factor for suicide (not a protective factor).

Explanation:

Risk factors for suicide are commonly broken down into static factors (can't be modified), modifiable factors (possible area for intervention), and protective factors. The following list of risk factors is compiled from data drawn from the CDC, NIH (National Institutes of Health), and VA/DOD (Veteran Affairs / Department of Defense).

Static Risk Factors

• History of suicide attempt/plan/ideation/intent

• History of self-directed violence or self-injury

• Family history of suicide

• Psychiatric disorders (increased risk if multiple)

• CNS Disease, pain syndrome, terminal illness, and/or functional Impairment

• Single/divorced/separated/widowed

• No children

• Lack of social supports

• Caucasian or Native American

• Male, elderly, and/or adolescent

• Living in rural setting

• History of childhood sexual or physical abuse

• LGBTQ identification

Modifiable Risk Factors

• Active psychiatric symptoms (psychological pain, stress, agitation, hopelessness, self-hate, impulsivity, aggression, psychosis, command hallucinations, insomnia)

• Acute stressors

• Substance use

• Living alone

• Homelessness

• Post-hospitalization (increased risk in period after discharge)

• Current suicidal ideation

Protective Factors

• Social connectedness / positive social support

• Dependent children

• Sense of responsibility to family

• Pregnancy

• Positive relationship with outpatient providers

• Coping skills, problem-solving, and flexibility

• Religious beliefs

• Reality testing is intact

• Meaningful employment

• Specific additional factors noted by patient ("reasons to live")

Question 2:

From day #82

Answer: c

•Tarasoff v. Regents of University of California = duty to protect/warn

Explanation:

According to the Tarasoff reporting laws we have a "duty to protect" all known or suspected potential and readily identifiable victims. The specific implementation of this law varies by state (always verify with your local guidance), but in general includes ethical permission to breach confidentiality in order to protect the patient or the identified victim(s).

If you assess a patient and deem them to be dangerous to others then consider the following possible interventions:

• Consider hospitalization, particularly if the danger is related to serious mental illness.

• Consider notification of law enforcement authorities.

• Consider notification of the identifiable victim(s) via telephone, in-person, mailed letter, etc.

• Consider notification of other individuals who could reasonably prevent the tragedy (example: boss of a company identified as a target).

• Consider verifying removal of firearm or other weapons.

• DOCUMENT all attempts to contact the above individuals including all efforts to mitigate risk.

• Other interventions aimed at treating/mitigating dynamic risk factors: psychotherapy, medication changes, substance use treatment, etc.

•O'Connor v. Donaldson = mental illness alone is not sufficient to warrant an involuntary hold.

•Sell v. United States = the government may involuntarily administer antipsychotic medications to a mentally ill criminal defendant in order to render him competent to stand trial, "but only if the treatment is medically appropriate, is substantially unlikely to have side effects that may undermine the fairness of the trial and, taking account of less intrusive alternatives, is necessary significantly to further important governmental trial-related interests."

•Rogers v. Commissioner of Department of Mental Health = right to refuse treatment.

Question 3:

From day #83

Answer: b

Offering friendly gestures can be an effective way to build trust, however don't provide anything that could be used as a weapon such as hot beverages.

Explanation:

Attempt the following verbal de-escalation techniques:

• Approach: use a calm/nonthreatening tone. Be honest, straightforward, and in control. Use concise and simple language. Advanced terms are hard for an agitated person to understand. Use active listening. Provide reassurance that the patient is safe from harm.

• Avoid appearance of threat: avoid prolonged eye contact, posturing, and direct confrontation. Also do no move suddenly, stand too close to the patient, or approach the patient from behind.

• Build trust: friendly gestures can be helpful. Examples include offering a snack or something to drink (not a hot beverage), a soft chair or blanket, pain relief, or nicotine replacement therapy.

• Ask directly about agitation/violence: politely address their feelings. "You look upset. Do you feel like hurting someone?" Give supportive statements about doing a good job keeping these feelings under control.

• Set clear limits: calmly inform them with statements such as "I can help you with your problem but I cannot allow you to continue threatening the staff". This is important but can go either way (some patient are aware of impulse control problem and will welcome limit setting whereas in other cases this may be viewed as confrontational).

• Offer choices when possible: try to understand what the patient wants. Patients feel empowered if they have some choice in certain matters.

• Offer medications: you can ask the patient if they would like medication to help them to stay calm. If you deem a medication necessary you can even give the patient options and ask them their preference (both type and route). Providing an oral medication may avoid physical restraints.

CONCLUSION

Nice work. You are halfway through the emergency psychiatry theme. If you want to see all of the weekly quizzes you can see them here. Next lesson we will cover the pharmacological management of agitation.