Adolescents in Crisis: When to Admit for Self-Harm or Aggressive Behavior: Assess Suicide Risk, Family Support, Other Factors When Considering Hospitalization

Article excerpt

Ms. R, age 17, has a history of major depression, obsessive-compulsive disorder, and self-harm through superficial cutting of her arms and inguinal region. She reports that 10 days ago she ingested 7 times her prescribed fluoxetine dosage of 20 mg/d and aripiprazole dosage of 2 mg/d because she no longer wanted to feel emotional pain. She did not tell anyone she did this or seek medical attention.

Ms. R complains of chronic difficulties with her stepfather, who she describes as alcoholic. She feels her depression is worsening and support from her mother has deteriorated. Ms. R's parents say they are trying to respond to their daughter, but she will not talk with them and some nights she does not return home. Ms. R admits to staying overnight in local mall parking lots to be alone. Her psychiatrist recommends acute inpatient care for Ms. R's safety.

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Admitting an adolescent such as Ms. R to a psychiatric inpatient facility may be necessary to address a crisis. Interdependent links among the patient, family and support network complicate the determination of whether an adolescent requires inpatient care. To make the best decision, a psychiatrist needs to understand the youth's difficulties within family, school, and community.

Who needs inpatient care?

Inpatient treatment remains an important part of the continuum of care for adolescent psychiatric treatment. (1) Inpatient treatment typically is reserved for patients whose psychiatric disorder impairs multiple areas of functioning or poses a significant danger to self or others and for whom less-restrictive treatment resources are not appropriate or available. (2) The number of psychiatric hospitalizations for adolescents is increasing, although lengths of stay are decreasing. (3), (4)

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Psychiatric inpatient care is appropriate for patients who require 24-hour nursing care and psychiatric monitoring to stabilize symptoms when they are in acute crisis and have a high risk of harm, and for initiation of treatments required for stabilization and integration into a less-restrictive setting. (5) The decision to admit an adolescent rests on:

* the clinician's ability to evaluate the risk of harm and functional status

* how much support the family and/or caregivers can provide

* the clinician's knowledge of treatment resources available to the adolescent and family. (6)

Exploring suicide risk

Understanding potential lethality of suicidal thought and intent is complex and requires assessing suicidal behavior, the patient's past and current intent, the risk of engaging in or repeating a suicide act, the underlying diagnosis, and protective factors. To quantify imminent suicide risk, directly address suicidality when interviewing an adolescent, progressing from past thoughts to current intent, plan, and ability to carry out such a plan (Table 1). (7)

Table 1

Suggested questions for assessing adolescent suicidality

Have you had thoughts of hurting yourself?

Have you ever tried to hurt yourself?

Have you ever wished you were not alive?

Have you had thoughts of taking your life?

Have you done things that are so dangerous that you knew you might get hurt or die?

Have you ever tried to kill yourself?

Have you had recent thoughts of killing yourself?

Do you have a plan to kill yourself?

Are the methods to kill yourself available to you?

Do you have access to guns?

Source: Adapted from reference 7

Planning and lethality. Also examine the patient's degree of planning for a suicide attempt, efforts to avoid discovery and rescue, and his or her perceived lethality of a suicide attempt or plan. Patients who develop a coherent plan that would successfully avoid discovery clearly are at highest risk. …