Regarding mental state examination (MSE), which ONE of the following statements is INCORRECT?
Answer: B: The MSE begins from the moment the clinician first observes a patient and not at the start of the formal interview. The observations of mental state are important and often more revealing than a small sample of behaviour observed during the interview. The main parts of MSE are:
Under the category of speech, suicidal and homicidal ideation and deliberate self-harm thoughts and acts may be included. The symptoms you observe can be confirmed by asking relevant questions. It is best to ask open-ended questions. Reaching a working diagnosis is an important outcome of the MSE.
Hallucination is a perception and it occurs in the absence of a sensory stimulus. Command hallucinations are often significant because they order patients to do things. These orders can vary from reminders about simple everyday tasks to dangerous acts of violence. The commands may be directed at the patient to harm themselves or others. A patient may or may not be able to resist these command hallucinations.
Affect is related to mood. Mood is described by the patient but affect is what is observed, for example, the patient might state that his/her mood is good, but you may observe that the patient’s face does not show much emotion or facial expression and it looks flat. There may be poor eye contact and diminished body language. This is described as flattened affect. This is more common in schizophrenia and more so if the illness is chronic.
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A 50-year-old female with no previous psychiatric history presents to the emergency department (ED) with symptoms of depression and some vague suicidal ideation. Further assessment reveals her low mood and a containable suicide risk.
Which ONE of the following is the MOST appropriate evidence-based treatment for this patient?
Answer: B: Evidence shows that one in four females suffers from depression at some time in their lives and most fall into the category of mild depression. This can be successfully treated via an outpatient clinic or the patient’s general practitioner. Diagnostic and statistical manual of mental disorders lV – text revision (DSM-IV TR) diagnostic criteria for a major depressive episode are given below and the patient must have a total of five symptoms for at least 2 weeks and one of the symptoms must be depressed mood or loss of interest:
Most of these presentations are triggered by stressful situations and it helps to enquire about such triggers. If the patient expresses any suicidal ideation, the detailed assessment of the suicidal risk is important. If this risk is appropriately judged to be containable, starting medication is not the first priority in the ED. If antidepressant medication is started in the ED, its effects and any adverse effects cannot be followed up by the clinician. Therefore the most important part of treatment planning that should be done in the ED is to identify a proper referral pathway.
Reference:
A 73-year-old man, whose wife died 6 months previously, presents with foot pain from diabetic neuropathy, poor sleep, lack of energy and increasing frustration about his inability to ‘keep his diabetes under control’. When being examined, he describes lack of interest in his usual activities, low appetite, and some significant weight loss (about 5 kg) over the past three months.
He denies feeling suicidal but feels no desire to continue living, and states that he is better off dead. All of the following statements are correct EXCEPT:
Answer: C: Late-life depression is an important presentation to the ED. Approximately 10% of adults 65 years of age or older presenting to primary care settings have clinically significant depression. It is often masked by other chronic medical conditions and if not proactively sought it could be missed and left untreated. Depression is often under-diagnosed in men and ethnic minorities. One reason for this is that depressive symptoms are considered as a normal part of ageing.
Depression is common in women, in patients with chronic medical conditions, patients reporting insomnia, and in patients who have experienced stressful life events such as loss of a spouse, functional decline or social isolation. These patients often present with other problems including worsening of their existing medical illnesses. In a scenario such as that described, it is important to differentiate depression from grief. Depressive symptoms last longer than normal grief. Persistence of major depressive symptoms in a patient who experienced a loss of a loved one more than 2 months previously should increase the suspicion for this diagnosis.
If untreated, late-life depression is associated with a poor quality of life, with poor social and physical functioning, poor adherence to treatment regimes, and worsening of the medical problems. This also increases morbidity and mortality in older people including from completed suicide. Evidence-based management strategies are:
Overall, depression in older people is a diagnosis which should actively be considered in patients who present to the ED with suggestive symptoms. These patients should be appropriately referred to psychiatry services for management and follow-up.
Which ONE of the following statements regarding risk factors for completed suicide is INCORRECT?
Answer: B: Approximately 2% of ED visits are due to patients with suicidal ideation. Suicidal attempts are at least 10 times more prevalent than completed suicide. One of the important factors for an emergency clinician to consider is that suicidal ideation is commonly associated with mental illness, and can successfully be treated with appropriate psychiatric interventions. In addition, many suicide attempts occur during an acute situational crisis, such as a personal loss. These acute crises are usually time-limited and may be resolvable or treatable.
Most people who attempt suicide have one or more risk factors. Individuals with the highest risk include those with psychiatric disorders, alcohol or substance abuse, adolescents, elderly and people suffering from certain chronic illnesses (e.g. chronic painful conditions, epilepsy, Huntington’s disease, cerebrovascular accident (CVA), multiple sclerosis, dementia or AIDS). There is a high risk for completing suicide among homosexual and bisexual men.
About 70–90% of individuals who completed suicide have DSM-IV TR diagnoses, mainly Axis I diagnoses. These Axis I diagnoses include depression (60–70% of people), schizophrenia (10%), substance abuse disorders and panic disorders. Other mental health diagnoses associated with completed suicide include BPD and antisocial personality disorder. Impulsivity is described as the common reason for increased completed suicide prevalence in these Axis II diagnoses. In schizophrenia, completed suicide is especially associated with the time of their first diagnosis, as well as after recovery from an exacerbation. When a patient first becomes aware of having this severe mental illness they tend to be highly vulnerable to take their life.
People with high intelligence have better coping strategies to deal with major stressors and therefore they are less likely to complete suicide than people who are less intelligent.
All of the following statements are true regarding suicidal risk assessment in the ED EXCEPT:
Answer: B: The SAD PERSONS is a quick and useful guide to detect suicidal risk in an acute setting such as the ED. This comprises:
This rough guideline covers many of the high-risk issues and can be easily used in a busy setting.
Patients should be assessed in a sympathetic but direct manner using ‘a graduated approach’. Assessing or estimating the suicidal risk of a patient is one of the most challenging clinical judgement situations. All information about risk factors gathered during interview with the patient and other sources should be applied to the patient’s clinical presentation and its severity. The risk factors are generally cumulative and worsen the overall risk; however, they should be evaluated against the presence of any protective factors (factors that mitigate the risk). These potential protective factors include:
Two of the most important predictors of suicide are current suicidal ideation and severity of previous suicidal attempts. This information gives valuable insights into the patient’s thinking and behaviours towards suicide. Some patients do not admit to suicidal ideation. However, one way the clinician could explore this is by enquiring about the patient’s future. Current suicidal ideation with clear and well-conceived plan increases risk. The information that should be gathered in suicidal risk assessment includes:
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