suspicions to Ella’s mother. However, Ella’s mother did not understand the severity of her daughter’s concerns, which was a particular hindrance in securing the right help for Ella. Given her mother’s resistance to the situation, the counselor could have tried to contact Ella’s father to convey the immediacy of Ella’s needs. Education regarding lethal means is imperative for all involved. Limiting or reducing Ella’s access to lethal means (i.e., Tylenol in this case) could have effectively prevented her death by suicide. This restriction to access may have resulted in her using a substitute or delaying the attempt. Either the substitution or delay would have provided time to pass and potentially the crisis to pass, which would have resulted in an unsuccessful attempt or no attempt at all.
Self-Assessment Quiz Question #3 Based on the information provided regarding lethal means, who does not need education to raise awareness of Ella’s risk for suicide? a. Educators. b. Mother. c. The school counselor. d. Lay gatekeeper. Case study discussion Managing suicidal ideations can be challenging, especially in children whose parents are dismissive of the warning signs in their children. The counselor, in this case, reacted appropriately by promptly reporting her findings and
TREATMENT AND MANAGEMENT OF SUICIDE
Levels of care Outpatient treatment
Transition from inpatient to outpatient care and continuity of care 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, when compared to the general population, the suicide death rate is 300 times higher in the first week and 200 times higher in the first month (National Action Alliance for Suicide Prevention, 2019). The suicide risk remains high for up to three months, and sometimes up to a year, after discharge (National Action Alliance for Suicide Prevention, 2019). Recommendations for outpatient providers Before discharge from the inpatient setting, the provider should connect with the patient to build a therapeutic alliance (National Action Alliance for Suicide Prevention, 2019). This predischarge contact triples the odds of a patient engaging in outpatient services posthospitalization (National Action Alliance for Suicide Prevention, 2019). The following are steps an outpatient provider should follow prior to their patient being discharged (National Action Alliance for Suicide Prevention, 2019): 1. Develop relationships, protocols, and procedures that allow for safe and rapid referrals . ○ Establish relationships through effective communication. Cultivate a relationship with inpatient facilities to ensure smooth transitions for future patients. ○ Establish policies and procedures . Review policies and procedures for referral acceptance and triage appointments. A patient’s heightened risk for suicide in the first week after discharge prioritizes them for an intake appointment. ○ Accept shared responsibility . Work with the inpatient facility, the patient, and their family to coordinate a safe and effective care transition. ○ Negotiate a memorandum of understanding (MOU) or memorandum of agreement (MOA). Work with inpatient facilities to ensure timely communication and promote the release of records for care continuity. ○ Obtain copies of essential documents . Obtain releases of information, transition plan, treatment plans, medications, and collaborative crisis/safety plan. ○ Arrange a conference call. Schedule a call with the inpatient providers in order to gather as much information as possible prior to your patient intake.
The appropriateness of outpatient treatment is contingent on a thorough assessment of a patient endorsing suicidality to include current stressors in a safety plan. Patients who are discharged from the inpatient setting must have an appropriate outpatient follow-up with mental health providers (Kazim, 2017). Follow-up should be set up as soon as possible, within a few days of discharge. Given that compliance with follow-up appointments may be low, having family members help patients comply should be encouraged. Partial hospitalization and intensive outpatient care 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 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 (Kazim, 2017). 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, 7 days a week, and an average stay for a patient usually ranges from 48 hours to 10 days (National Action Alliance for Suicide Prevention, 2019). 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 (Schreiber & Culpepper, 2021). 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. (Schreiber & Culpepper, 2021). If a patient is admitted involuntarily, they maintain autonomy to consent to treatment (Schreiber & Culpepper, 2021). The only medications that can be administered without consent are those that are required to stabilize the patient during a behavioral crisis (Schreiber & Culpepper, 2021). If other medications are deemed necessary, a clinician must obtain court-ordered treatment (Schreiber & Culpepper, 2021).
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