The Case

A 42-year-old man with history of posttraumatic stress disorder (PTSD), alcohol use disorder, and anxiety disorder, in a long-term stable relationship, was placed on 72-hour involuntary psychiatric hold and brought to the emergency department (ED) by police officers following a suicide attempt. The patient had been staying with his wife in a hotel, experiencing nightmares and depressive symptoms. His wife found him with a belt around his neck, wrapped around the clothes bar in the hotel room closet. He was apneic and cyanotic, with bruises on his neck, but he started breathing and became responsive after she released the belt and stimulated him.

En route to the hospital by police cruiser, the patient was confused and apparently struck the officer who was transporting him. In the ED, the patient was agitated and tried to escape his restraints; he was handcuffed to his bed, given an antipsychotic medication by injection, and placed on continuous observation. After initial evaluation, the ED staff decided to admit the patient for observation (still on involuntary psychiatric hold) due to gastrointestinal bleeding of unknown etiology. Given that the patient was not “cleared” for inpatient psychiatric care, he was not evaluated by behavioral health specialists. No inpatient beds were available at 0400 am, so he remained in the ED as a “boarder,” receiving periodic antipsychotic medications, and his wife and police escort left.

The next day, the patient remained in the ED awaiting an inpatient medical bed. His wife visited and found him to be confused and disoriented, with two guards assigned to observe him from outside the curtains of the ED treatment bay. However, less than an hour after his wife left the ED, she called to check his status and was informed that he had “slipped out somehow.” She was never otherwise notified or contacted by hospital or police personnel, and the hospital’s investigation of the incident was unrevealing. She drove around the area looking for him, and finally found him several hours later, walking in an abandoned lot, lost and disoriented, believing that he was at a restaurant. She tried to convince him to go back to the hospital, but he became agitated and refused to go, so she agreed to find a hotel and stay with him. As his alertness improved, he sobbed and described a desire to commit suicide.

Three days later, the patient again tried to hang himself, and his wife again called 911 for assistance. The responding police officers, aware of the previous incident when he struck another officer and eloped from the ED, arrested him. Agitated and fearful, he resisted arrest and was subdued with a taser and blows to the chest that caused several rib fractures. Due to staffing constraints, the jail was unable to provide emergency mental health services and allowed him to retain his shoelaces and other items that could be used for self-harm. He was released on bail and resumed outpatient psychiatric care. He was prescribed trazodone, sodium valproate, lorazepam, and sertraline, with periodic dose adjustments, but he remains extremely fearful of hospitals and health care organizations.

The Commentary

by James A. Bourgeois, OD, MD and Glen Xiong, MD

This patient was seen in the ED after a high-risk suicide attempt by hanging, followed by agitation and attempts to leave the ED while on an involuntary psychiatric commitment. Regrettably, the ED failed to adequately manage the patient's psychiatric illnesses and treated him as a “routine boarder” awaiting an inpatient bed, with insufficiently robust behavioral monitoring. After he eloped, further complications resulted when law enforcement personnel were inadequately trained to handle a psychiatric emergency, and when correctional mental health services were not available in a timely manner.

The standard of care for emergency management after a high-risk suicide attempt by hanging requires many elements. Hanging is one of the highest risk suicide methods. Beyond the obvious physiologic risks of the hanging, patients who have attempted self-hanging are at high risk for repeated high-lethality suicide attempts. The first urgent priority is medical evaluation of the neuropsychiatric consequences of the suicide attempt itself, which can include delirium from hypoxic injury in any hanging attempt. Despite any protestations to the contrary, self-hanging patients a priori need to be on high-risk suicide precautions with 24/7 monitoring. After initial medical stabilization is accomplished, assessment of arterial blood gas (ABG) and carboxyhemoglobin is needed in addition to the laboratory studies which are routine for other suicide attempt patients (e.g., metabolic panel, complete blood count [CBC], drug screen, alcohol level). Diagnostic imaging should be used to assess the neck soft tissues, cervical spine, and brain; computed tomography (CT) is typically readily available.¹

As with any case of asphyxiation, self-asphyxiation (e.g., smoke or carbon monoxide [CO] inhalation), patients are at risk of hippocampal damage, with varying degrees of impairment of orientation and/or recall memory, even if other cortical functions are preserved.^2,3 The psychiatry consultant would routinely complete a standard cognitive assessment, including standard cognitive instruments such as the Montreal Cognitive Assessment (MoCA)⁴ or the Mini Mental State Examination (MMSE)⁵ in addition to the standard diagnostic interview. Due to the high probability that the patient may have been under the influence of drugs and/or alcohol at the time of the hanging (leading to more impulsive behavior at the time of the hanging), the patient needs to be assessed both for substance use disorder(s) and commingled depressive, bipolar, neurocognitive, psychotic, trauma and stressor-related, anxiety, and adjustment disorders associated with sustained suicidal or psychotic symptoms, or “acute on chronic” exacerbated psychiatric symptoms associated with the suicide attempt. It is important to recall that amnestic symptoms and/or frank delirium due to hypoxia may be “additive” with the ongoing psychiatric symptoms that were associated with the suicide attempt and that the patient may be acutely medically unstable solely as a consequence of the hypoxic episode itself.

It was clinically illogical to withhold a psychiatric consultation because the patient had not yet been “medically cleared.” Indeed, inpatient psychiatry consultation-liaison teams routinely see patients admitted to the intensive care unit or other medical units, so that psychiatric care can be appropriately integrated into the patient’s other medical care. Following a high-risk suicide attempt, patient management must include suicide precautions irrespective of the patient’s medical condition. Patients with suicide attempts with resulting need for intensive care support need to be followed by the psychiatry consultation-liaison team while they are in the intensive care unit. After patients with high-risk suicide attempts are stabilized in the intensive care unit (ICU), they are referred for subsequent inpatient psychiatry admissions, even if the patient denies or minimizes suicidal ideation after medical resuscitation. Any patient on suicide precautions following a high-risk suicide attempt needs constant 1:1 observation (including while in the bathroom) pending psychiatric assessment.

Given his mental status when he was rediscovered after escape, and the history of hanging, he was at high risk of delirium (e.g., from hypoxia following hanging). It is possible that his reported “confusion” may be related to other psychiatric causes such as alcohol withdrawal or PTSD-related dissociation. It is also possible that he was overly sedated from high cumulative doses of antipsychotics received in the ED. Upon re-apprehension, he should have been returned to the ED immediately, been placed under an additional involuntary psychiatric hold, and received a full delirium work-up.

There is no doubt that he was at high risk for repeated suicidal and other acting out behaviors until given definitive psychiatric treatment. It is unfortunate that he was arrested by police officers and taken to the jail rather than escorted back to the ED, since he was most recently under involuntary psychiatric hold. This case illustrates the need to have mental health clinician integration in the 911 system. Mobile mental health crisis response teams have recently been designed to collaborate with police officers. Depending on local service structures, mobile crisis teams may have clinicians with master’s degrees such as licensed clinical social workers (LCSW) or licensed marriage and family therapists (LMFT) accompany law enforcement officers responding to acute crises to initiate mental health evaluation on scene. Police and mental health clinicians often will approach mental health crises together and collaboratively decide the best suitable methods to “de-escalate” citizens exhibiting mental health crisis. This approach is preferable to taking on a “physically aggressive” stance. The collaborative model can decrease the tendency to arrest citizens and encourage voluntary acceptance of mental health treatment or facilitate transport to local emergency rooms under involuntary detainments for psychiatric evaluation and disposition.

The patient’s unstable housing situation, fear of traditional health care systems treatments, often agitated state, and confrontations with the police appear to be compounded by alcohol use or withdrawal. Patients with alcohol use disorder with dependence are prone to alcohol withdrawal delirium, wherein the patient will manifest a hyperadrenergic state plus psychosis despite a measured alcohol level of 0. Common co-morbidities, including PTSD, psychotic disorder, or personality disorder, can also lead to a disorganized presentation, as can the use of non-alcohol substances of abuse. All of these complexities and co-morbidities support the need for comprehensive medical and psychiatric assessment and treatment for all patients with a disorganized and agitated presentation. The patient’s spouse also could use support from social services in the ED, and possible referral to community support groups.

Take Home Points

• Suicide attempts by hanging are de facto high-risk suicide attempts.
• Patients seen for evaluation after any strangulation need to be assessed for hypoxia-associated delirium and/or hippocampal damage or amnesia, which themselves may cause further mental status changes, in addition to the pre-morbid psychiatric illness(es).
• Patients with hanging may be unable to recall salient aspects of their recent history and may not thus recall their suicidal ideation or suicide attempt.
• Patients with medically serious suicide attempts are likely to need inpatient psychiatric hospitalization after emergency stabilization and management of delirium, despite statements of “no longer being suicidal.”
• Patients with serious suicide attempts also need full assessment for substance use disorders as these are often co-morbid; disinhibition due to substance intoxication or withdrawal increases risk of acting on suicidal impulses.

James Bourgeois, OD, MD
Professor of Psychiatry
Department of Psychiatry and Behavioral Sciences
UC Davis Health
jbourgeois@ucdavis.edu

Glen Xiong, MD
Clinical Professor of Psychiatry
Department of Psychiatry and Behavioral Sciences
UC Davis Health
gxiong@ucdavis.edu

References

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2. Bourgeois JA. Amnesia after carbon monoxide poisoning. Am J Psychiatry. 2000;157(11):1884-1885. [Free full text]
3. Mahmoud O, Mestour M, Loualidi M. Intoxication au monoxyde de carbone et amnésie antérograde [Carbon monoxide intoxication and anterograde amnesia]. Encephale. 2009;35(3):281-285. [Free full text]
4. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189-198. [Available at]
5. Nasreddine ZS, Phillips NA, Bédirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment [published correction appears in J Am Geriatr Soc. 2019 Sep;67(9):1991]. J Am Geriatr Soc. 2005;53(4):695-699. [Available at]