Suicidal statements in a delirious patient

[Psychferlyfe3000]

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This situation keeps arising where I will have a patient on my program's CL service that, while delirious, will make a suicidal statement. What extra considerations do you take into account when the patient is delirious? Attendings on my service seem to discount these suicidal statements, but I sometimes I wonder if that would be like discounting an intoxicated patient's suicidal statement, which we generally take quite seriously. Just because there is a reversable factor that is causing disinhibition, does not mean the statement should be taken less seriously, no?

 

[Crayola227]

This situation keeps arising where I will have a patient on my program's CL service that, while delirious, will make a suicidal statement. What extra considerations do you take into account when the patient is delirious? Attendings on my service seem to discount these suicidal statements, but I sometimes I wonder if that would be like discounting an intoxicated patient's suicidal statement, which we generally take quite seriously. Just because there is a reversable factor that is causing disinhibition, does not mean the statement should be taken less seriously, no?

Isn't one thing you account for, besides just intent to carry out a plan, but the means?

And with delirium it seems it would be difficult for a patient to have a realistic plan, remember a plan, and also access and implement the means in the hospital? I mean, a lot of these patients forget what they say 5 secs after they say it. Doesn't seem like a winning recipe for getting yourself dead inpt. I imagine there is a minimum amount of executive function needed to harm yourself on purpose (not saying a ton, but some), and maybe just not seeing it in these patients. Executive function is often really, really lacking in delirium. The issue with executive functioning is basically the defining feature of delirium.

So maybe they just if figure the the delirum itself is causing SI, that it's also, well not a protective factor but certainly a likely inpediment to achieving much on the threat.

I would also be more interested to know if they are expressing SI during more lucid intervals, if there are any to really speak of.

 

[ObsequiousAplomb]

I think that the SI is just a component of what you're talking about here.

Delirious patients should have close monitoring irrespective of suicidal statements. Someone should be there to reorient them when they become active and particularly confused. They should have someone to help keep them comfortably in bed and to avoid them hurting themselves accidentally in their delirious state. I would be much more worried about them attempting to get out of bed and falling than them successfully intentionally killing themselves. When they are not acutely delirious, it would be a good idea to mention some of the troubling statements they had said in their confusion, in a non-aggressive manner.

As to acutely intoxicated people making statements like that - I still am not entirely sure what you mean. I have almost never seen a patient admitted to inpatient psychiatry because they said something like that while intoxicated in the ER but then recanted the statement after some observation and they had sobered up. In the few instances I have, I wasn't really sure what the purpose of the admission was other than someone misunderstanding medicolegal risks.

And as to any reversible condition - is that not what is done with depression? 1. Patient is depressed and suicidal. 2. Depression treatment is started (but not ECT or anything that has actually been shown in trials to meaningfully address suicidality). 3. Patient recants the suicidal statements. 4. Patient is discharged.

Suicidal due to psychotic belief system. 1. Antipsychotic other than clozapine is started (even though it's the only antipsychotic that meaningfully reduces suicidal behavior, usually avoided due to providers suffering from clozaphobia). 2. Patient may or may not report lessened psychotic symptoms, but does report fewer suicidal statements. 3. Patient is discharged.

Suicidal related to BPD. 1. Patient is counseled in ED briefly. 2. Admission is not offered. 3. Patient is returned to the community.

I see those three examples as really more or less the same thing as treating the underlying condition for the delirium under appropriate risk-stratified monitoring followed by rapid discharge.

I've only ever once seen someone admitted for longer than a week for suicidal statements. A week of Zoloft or Prozac or Zyprexa or Seroquel is incredibly unlikely to have any meaningful impact on suicide risk. But it's apparently what everyone thinks is taking it seriously.

 

[clausewitz2]

I think that the SI is just a component of what you're talking about here.

Delirious patients should have close monitoring irrespective of suicidal statements. Someone should be there to reorient them when they become active and particularly confused. They should have someone to help keep them comfortably in bed and to avoid them hurting themselves accidentally in their delirious state. I would be much more worried about them attempting to get out of bed and falling than them successfully intentionally killing themselves. When they are not acutely delirious, it would be a good idea to mention some of the troubling statements they had said in their confusion, in a non-aggressive manner.

As to acutely intoxicated people making statements like that - I still am not entirely sure what you mean. I have almost never seen a patient admitted to inpatient psychiatry because they said something like that while intoxicated in the ER but then recanted the statement after some observation and they had sobered up. In the few instances I have, I wasn't really sure what the purpose of the admission was other than someone misunderstanding medicolegal risks.

And as to any reversible condition - is that not what is done with depression? 1. Patient is depressed and suicidal. 2. Depression treatment is started (but not ECT or anything that has actually been shown in trials to meaningfully address suicidality). 3. Patient recants the suicidal statements. 4. Patient is discharged.

Suicidal due to psychotic belief system. 1. Antipsychotic other than clozapine is started. 2. Patient may or may not report lessened psychotic symptoms, but does report fewer suicidal statements. 3. Patient is discharged.

Suicidal related to BPD. 1. Patient is counseled in ED briefly. 2. Admission is not offered. 3. Patient is returned to the community.

I see those three examples as really more or less the same thing as treating the underlying condition for the delirium under appropriate risk-stratified monitoring followed by rapid discharge.

I've only ever once seen someone admitted for longer than a week for suicidal statements. A week of Zoloft or Prozac or Zyprexa or Seroquel is incredibly unlikely to have any meaningful impact on suicide risk. But it's apparently what everyone thinks is taking it seriously.

I think the point is more that if someone genuinely delirious is making suicidal statements, it is not clear how much the verbal behavior they are producing corresponds to anything resembling theirs intentions, plans, or indeed the actual semantic content of their thoughts.

I don't read too much into the fact that a delirious person informs me that they will need a new first-class ticket because there are too many gorillas on the airplane and i think the same goes to some extent. I would be surprised if empirically there is much correlation between a truly delirious person making statements like this while delirious and any violence/injury when compared to delirious people who don't make such statements.

EDIT: I reread your post and realized I miscontrued what you were saying and that we might actually be in agreement.

 

[ObsequiousAplomb]

I think the point is more that if someone genuinely delirious is making suicidal statements, it is not clear how much the verbal behavior they are producing corresponds to anything resembling theirs intentions, plans, or indeed the actual semantic content of their thoughts.

I don't read too much into the fact that a delirious person informs me that they will need a new first-class ticket because there are too many gorillas on the airplane and i think the same goes to some extent. I would be surprised if empirically there is much correlation between a truly delirious person making statements like this while delirious and any violence/injury when compared to delirious people who don't make such statements.

EDIT: I reread your post and realized I miscontrued what you were saying and that we might actually be in agreement.

Yep, we agree. No matter what the patient says, the sitter can probably respond "that's nice dear" in a grandmotherly way and the patient will calm down and have no recollection 10 seconds later.

 

[deleted1100659]

This situation keeps arising where I will have a patient on my program's CL service that, while delirious, will make a suicidal statement. What extra considerations do you take into account when the patient is delirious? Attendings on my service seem to discount these suicidal statements, but I sometimes I wonder if that would be like discounting an intoxicated patient's suicidal statement, which we generally take quite seriously. Just because there is a reversable factor that is causing disinhibition, does not mean the statement should be taken less seriously, no?

if they have delirium then there should be some form of monitoring in place- its the same context as someone who is acutely psychotic, you wouldn't just have them sit on the hospital bed, leave the room to the door open and not do some form of obs- they lack capacity to leave AMA if they are delirious so they aren't going anywhere.

If you're worried about suicide then a thorough assessment once the medical condition causing delirium has improved, with collateral information would be ideal. Patients that were severely intoxicated, I would let them sober up a bit, and likely they're hanging out in the ER anyways at that point. Again, if you're intoxicated or delirious you lack capacity to check yourself out and a thorough assessment can be done with a clearer mental status

 

[whopper]

Anyone delirious-their comments can't be taken at full value in every instance. Agree with all of the above. Make sure they're safe until they're out of delirium, then re-evaluate them.

Don't do what Peter Griffin does.

 

[calvnandhobbs68]

I've only ever once seen someone admitted for longer than a week for suicidal statements. A week of Zoloft or Prozac or Zyprexa or Seroquel is incredibly unlikely to have any meaningful impact on suicide risk. But it's apparently what everyone thinks is taking it seriously.

100%

This is why I always hated most admissions for just SI. Combine 1) Our terrible lack of positive predictive value for predicting short term suicide risk + 2) Lack of any data for meaningful intervention that actually short term suicide risk is reduced from an acute inpatient stay= what exactly are we doing here?

If we got rid of liability around suicide, we'd probably cut admissions for SI by at least 50% and I'd bet see very little meaningful difference in overall suicide rates.

 

[comp1]

I think maybe the OP is trying to rephrase in vino veritas. Well...sometimes. Most people who are suicidal when drunk are just suicidal when drunk. I bet an even smaller portion of patients who are "suicidal" when delirious from something else are still suicidal when not delirious. I'm honestly not even sure what suicidal when delirious means, really. They mumble something incoherent about wanting to die? Treat the underlying medical condition.

 

[Nudexta]

There was a malpractice case that I read a couple of years ago for a patient who was delirious and ended up killing themself by jumping from a window in the hospital although the psychiatrist was consulted for something else.

 

[Crayola227]

I think maybe the OP is trying to rephrase in vino veritas. Well...sometimes. Most people who are suicidal when drunk are just suicidal when drunk. I bet an even smaller portion of patients who are "suicidal" when delirious from something else are still suicidal when not delirious. I'm honestly not even sure what suicidal when delirious means, really. They mumble something incoherent about wanting to die? Treat the underlying medical condition.

yeah, I think it's kind of important to keep in mind that while delirium and intoxication are both in the umbrella of causes of AMS, that doesn't necessarily mean they are the same w/r/t suicide risk. And while both are associated with disinhibition, that the disinhibition seen may not represent the same levels of risk for suicide attempt or completion.

I know it comes up all the time, that suicide is often an impulsive behavior. And certainly the disinhibition of drug intoxication like alcohol is a major risk factor for completed suicide. We always talk about the male gunowner that lives alone, drinks, and blows his head off or hangs himself. But recognizing that this may not be the same disinhibition as you see in delirium, and may not pose the same risk. We talk all the time that assessing SI is actually a fairly complicated thing that requires considering not only the state of the patient but the rest of the context of the situation, like location for one.

I also want to point out as I did above, why "just suicidal when drunk" may not in fact actually be that much safer or less likely to complete than your chronically depressed pt with chronic SI yet never drinks.

 

[Mad Jack]

This situation keeps arising where I will have a patient on my program's CL service that, while delirious, will make a suicidal statement. What extra considerations do you take into account when the patient is delirious? Attendings on my service seem to discount these suicidal statements, but I sometimes I wonder if that would be like discounting an intoxicated patient's suicidal statement, which we generally take quite seriously. Just because there is a reversable factor that is causing disinhibition, does not mean the statement should be taken less seriously, no?

Depends on the situation. Generally they'll buy themselves a sitter and reassessment once stable anywhere I've been

 

[Candidate2017]

I don't read too much into the fact that a delirious person informs me that they will need a new first-class ticket because there are too many gorillas on the airplane

Hmm, given the current state of air travel, they may not be delirious.

 

[Merovinge]

Suicidal due to psychotic belief system. 1. Antipsychotic other than clozapine is started (even though it's the only antipsychotic that meaningfully reduces suicidal behavior, usually avoided due to providers suffering from clozaphobia).

Not sure what % is clozaphobia vs REMSphobia

 

[ObsequiousAplomb]

Not sure what % is clozaphobia vs REMSphobia

Many days I wonder if Eli Lilly or Alkermes are the real reason clozapine is hamstrung by those absurd REMS.