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Alcohol Intoxication And Suicide Risk In The Emergency Department

Patients with depression are at significantly increased risk of alcohol abuse and dependence. Data suggests that this relationship is bidirectional. Depressive illness often fosters hopelessness, social isolation, and dysphoria, all of which can lead to the use of alcohol. Conversely, the impact of alcohol on mood is generally in the direction of worsening depression. Furthermore, alcohol has the general effect of disinhibition of brain function, which may lead to worsening suicidal thoughts and decreased ability to control suicidal behavior. As a result, alcohol abuse is a major lifetime risk factor for completed suicide.29 In addition, individuals who make suicide attempts or present with suicidal ideation are more likely to be acutely intoxicated.

Such patients often present to the ED intoxicated or under the influence of alcohol, which can make it a challenge to evaluate their intentions to harm themselves or others. Patients may endorse suicidal ideation or a wish to harm others while intoxicated but may deny such thoughts or intentions when sober. This change in verbalized intent may impact disposition, which explains why many mental health providers will insist that the patient be “sober” before they do an assessment. Thus, the emergency clinician and consulting mental health providers are faced with a paradox. Population-based studies clearly indicate that such patients have an increased lifetime risk of death due to suicide. However, there are no data to support that patients who are no longer suicidal when intoxication clears are at increased acute safety risk. Therefore, the decision whether to seek psychiatric hospitalization for these patients is a difficult one. Emergency clinicians are advised to develop a consistent but thoughtful approach to the assessment of intoxicated suicidal patients, which should involve the following concepts:

  • It is prudent to allow the patient to achieve a reasonable level of sobriety before completing the evaluation. Sober individuals are more likely to be organized in their thinking and more accurate in their assessment of their own safety.
  • Guidelines for establishing when the patient has achieved an effective level of sobriety should be based on clinical assessment and not blood alcohol levels. Chronically alcohol-dependent individuals may be sober despite significant blood alcohol level.
  • When possible, consultation with a psychiatrist or qualified mental health provider is indicated.
  • Patients in active withdrawal should be aggressively treated throughout their stay in the ED.
  • The clinical assessment should evaluate for comorbid mood disorders, severity of alcohol and other substance dependence, history of prior suicide attempts, and recent serious psychosocial changes in the patient’s life.
  • Strength of social supports and/or ongoing outpatient treatment should be assessed, and family and treaters should be involved in the emergency care and decision-making when possible.

Once an assessment is completed, it is often more apparent whether acute safety concerns are present. Patients who are truly suicidal will typically reveal this during assessment, even when sober. For patients without evidence of acute ongoing safety risk, acute but voluntary treatments may still be indicated. This may include outpatient substance abuse treatment, referral to a detoxification center, day treatment, or combined substance abuse/ psychiatric hospital unit (often known as “dual diagnosis unit”). Efforts should be made to identify the level of care the patient is motivated to participate in rather than attempting to coerce treatment. Again, involving people with an established relationship with the patient in this process, such as family and outpatient treaters, may increase the likelihood of patient participation in treatment.

The 2006 ACEP/American Association of Emergency Psychiatrists guidelines support this type of approach, recommending a personalized approach to intoxicated psychiatric patients.94,95 The guideline emphasized evaluating the patient’s cognitive abilities rather than the specific blood alcohol level as the guiding factor in deciding whether emergency clinicians should pursue a formal psychiatric assessment. Future research in this area may explore the correlation of blood alcohol with decision- making capability, but currently it is recommended to evaluate patients as a function of their individual presentation as well as a period of observation for intoxicated patients with psychiatric symptoms to evaluate for possible resolution of psychiatric symptoms as the patient sobers.

Serotonin Reuptake Inhibitors And Suicidality/Age Interaction

Recent changes in specific types of medications or a new medication may be associated with suicidal ideation. In particular, SSRIs have been noted in several case studies to be associated with an increased risk of suicidal behavior either with the commencement of the medication or a change in dosage.96 A metaanalysis by Barbui et al found that the use of SSRIs was associated with a reduced risk of suicide in adults with depression but an increased risk among adolescents.97 The underlying process for this potential interaction is unknown, but if the presence of suicidal ideation is abrupt and novel to the patient’s clinical presentation, such a medication change may warrant further exploration and discussion with the prescribing physician.

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Last Modified: 12/12/2017
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