Treatment of patients at risk for suicide should be chosen based on their underlying mental illness and the manifestation of suicidal behaviors. 51 For example, chronic suicidal behaviors should be treated with interventions based on psychotherapy, whereas acute suicidal behaviors should be treated with more aggressive interventions (i.e., increased frequency of therapy and/or psychopharmacologic medications). Partial hospitalization programs (PHPs) and intensive outpatient programs (IOPs) are structured mental health treatment programs that are a step down from 24-hour care in an inpatient hospital. The main difference between PHPs and IOPs is the length of time. Partial hospitalization programs are at least four hours a day and at least five days a week; IOPs are a few hours per day and a few days per week. Patients who have an elevated risk of suicide that is not imminent but require aggressive treatment would benefit from these programs. 51 Partial Hospitalization and Intensive Outpatient Care Inpatient Hospitalization Any patient at imminent risk for suicide, including a recent suicide attempt, should be referred to psychiatric inpatient hospitalization. Inpatient care offers medically supervised care in a hospital setting 24 hours a day, seven days a week, and an average stay for a patient usually ranges from 48 hours to ten days. 4 The goal of inpatient hospitalization is to conduct an evaluation, initiate therapy and/or medications, and stabilize the patient until they are safe and eligible for a lower level of care. 2 Factors that can place a patient at high risk of suicide include 2 : • Suicide attempt with a highly lethal method (firearm or hanging). • Suicide attempt that includes steps to avoid detection. • Ongoing moderate-severe suicidal ideation or disappointment that a suicide attempt was not successful. • Inability or reluctance to honestly discuss the suicide attempt and what precipitated it. • Inability or reluctance to openly discuss safety planning. • Lack of alternative interventions for monitoring and treatment. • Agitation. • Hopelessness. • Impulsivity. • Poor social support. • Psychiatric disorders: anxiety disorders, bipolar disorder, personality disorder, PTSD, psychotic disorders, and substance use disorders. If a patient cannot be immediately hospitalized in a psychiatric inpatient unit, they should be kept in a room where all sources of potential harm are removed, and a staff member should be providing constant supervision. 2 Patients identified
with suicidal thoughts and behaviors in most clinical settings are assigned a dedicated “safety attendant” to watch them. This intervention often decreases the need for restraints for most patients. The use of family members is highly discouraged because family members may connive with patients to make plans to leave against medical advice or violate a legal hold, or if they see a patient leaving, they may not try to stop them. 53 Security staff may be necessary if the patient insists on leaving. 2 Mechanical and chemical restraints should be used judiciously in suicidal patients. The use of restraints should be minimized when possible. However, the use of restraints may be essential and potentially lifesaving for situations wherein the patient is combative or otherwise uncooperative. All restrained patients must be assessed per hospital protocol. Often, documentation of the neurovascular status of the restrained patient must be performed. Finally, a re-evaluation of the need for restraints should be performed per hospital protocol. 51 If the patient needs to be transferred to a hospital on a psychiatric hold, an ambulance should be used, and the paramedics should be aware of the suicide risk. 2 Involuntary Hospitalization If a patient refuses to be hospitalized despite being a risk to themselves or others, involuntary hospitalization may be necessary. The process of committing a patient to hospitalization varies from state to state in the U.S. 2 If a patient is admitted involuntarily, they maintain autonomy to consent for treatment. The only medications that can be administered without consent are those that are required to stabilize the patient during a behavioral crisis. If other medications are deemed necessary, a clinician must obtain court-ordered treatment. 2 Transition from Inpatient to Outpatient Care and Continuity of Care In the U.S., one out of seven people (or 14%) who died by suicide had contact with inpatient mental health services in the year before their death (National Action Alliance for Suicide Prevention, 2019). The transition from inpatient to outpatient behavioral care is a critical time for patients who are at risk for suicide. In the month after a patient is discharged from inpatient care, the suicide death rate is 300 times higher (in the first week) and 200 times higher (in the first month) than the general population. The suicide risk remains high for up to three months, and sometimes up to a year, after discharge. 4 The following evidence-based recommendations guide care for an individual with elevated suicide risk during the transition from inpatient to outpatient care 4 : • Work as a collaborative team. Both inpatient and outpatient teams should work as a unified team and employ a patient-centered approach that involves the providers, the patient, and the family. This collaboration can help patients navigate the gap between care settings.
•
Cultivate human connection. Encourage contact between the outpatient provider and the patient prior to discharge. Make use of certified peer specialists and others who have lived experiences to support both the patient and the family. Build bridges. Establish and follow protocols to triage appointments and arrange for rapid referrals for patients. Write formal agreements between inpatient and outpatient provider organizations to clarify their roles, responsibilities, and commitments to rapid referrals. Develop strategies for narrowing the gap in the care transition. Lastly, maintain good communication between organizations to provide optimal patient care.
•
Recommendations for Inpatient Providers Due to the nature of increased suicide risk following an inpatient discharge, it is crucial that patients receive an outpatient appointment or other mental health services as soon as possible after discharge. Prior to discharge, inpatient providers should do the following 4 : 1. Develop relationships, protocols, and procedures for safe and rapid referrals. •
Begin discharge planning upon admission. Discharge planning begins within 24 hours of admission and sets an expectation that hospitalization is a brief period of treatment, and that post- discharge care will be needed. Develop collaborative protocols. Work with outpatient organizations to ensure a safe and rapid referral post- discharge. Negotiate a memorandum of un- derstanding (MOU) or memorandum of agreement (MOA). Partner with an outpatient organization and write a formal agreement detailing care coordi- nation expectations. These partnerships are the key to developing a smooth transfer with minimal barriers.
•
•
• Electronically deliver copies of essential records. Send the following information to the outpatient provider: current course of illness and treatment; transition/discharge plans; treatment plans; medication list; crisis/safety plan; release of information; and emergency contacts list. Send the records at the time of discharge. 2. Involve family members and other supports. • Encourage family participation. Family members and other individuals (relatives, spouses, partners, friends) can provide a source of support for the patient upon discharge. Providing education to these supports can increase the efficacy of the support network for the patient.
52
Powered by FlippingBook