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Treatment of severe anxiety. In the emergency department, 1-2 mg of Ativan is a very good standard. Some people like to use Herbal Xanax. But I think Ativan is a really good standard. When you are choosing a benzodiazepine I like … another reason Ativan is a good choice as a sort of standard benzodiazepine to use is, one, it’s clean so it has no active metabolites. You can use it in all three forms, IM, PO or IV. You can use it in the elderly.
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The suicidal patient. About 30,000 suicides annually in the U.S. Suicide is very impulsive. That’s why people with substance abuse are at particular risk for suicide because they get drunk – I’ve seen it over and over. You work in an ER or you do consulting as a psychiatrist in an ER, over and over. The person comes in, the police are called. They take the gun away from them because the wife called the police. They had the gun to their head. You see them at 9 o’clock in the morning back. “I’m fine, I’m fine. There’s no problem. I’m not suicidal. I don’t’ know what the hell I was doing, I don’t even remember it. I just want to go home. And no, I’m not depressed.” You see this over and over. For some people, alcohol is like a suicide potion. So what happens is, if the people are around other people or someone can get the gun away from them, they are fine. But if they are alone in the middle of the night and all they have is that six-pack of beer and that shotgun, then it’s a very lethal combination. And, guys like guns. Men use more lethal attempts. Women, you’ll see a lot more of these subacute attempts.
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Risk factors for suicide: the older you get, the more you are at risk for suicide. Elderly males have the highest rate of suicide.
Management of the suicidal patient: somebody comes into the ER or your office and they are talking about suicide, what do you do? Number one, try to assess the seriousness of the risk. Does it seem real? And there’s no science to this. The more you do it, obviously if you are a mental health crisis worker, every night you are on call you see two of these people and you get better at assessing the risk. Nobody can predict who is going to kill themselves in the near future.
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A lot of people who kill themselves really are a mystery. They will have a freezer and a refrigerator full of food, they will have recently renewed all their magazine subscriptions. It’s really a mystery and I think one of the answers to that mystery is what I said before; suicide is very very impulsive. A lot of times people will have the idea in their head, and there are people who think about it every day or every other day of their lives, but sometimes it’s the right hour, they have the right means, they have the gun, it’s the middle of the night – and if it were the middle of the day and they were at the mall there would be no problem – but they are alone in the middle of the night and suddenly they get that, “I know what I have to do.” It’s kind of like that phone call that you know you have to make but you dread making it and then suddenly it’s like, “Okay, fine. I’ve got to get this out of the way. I’ve got to make this phone call.”
Violent patients. There’s two kinds of really violent patients. There’s one where they are agitated secondary to confusion, and the other where they are just kind of sociopathic and criminal. Number one: assess and treat the medical issues above. Use Haldol and lorazepam like we talked about. Antipsychotics like Haldol can cause dystonia. What’s dystonia? It’s that twisting of the neck, rolling of the eyes, sticking out of the tongue.
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