Bruna Varalli-Claypool, MHS, PA-CAssociate Professor

University of OklahomaPhysician Associate Program

Review the SAD PERSONS scale

Evaluate the case presented

Review the Involuntary commitment process

Identify the components of Medical Clearance

Differentiate the metropolitan vs rural Emergency Department PA’s role in the Involuntary commitment process

Present the patients disposition to the audience

A 78 year old male complains of appetite loss and weakness. While you are interviewing him in your 2 bed Rural Oklahoma Emergency Department, he starts to cry and tell you that his wife of 57 years died last month. On closer questioning, he admits that he has a pistol in the closet table and has thought about putting it in his mouth and pulling the trigger. You offer the patient psychiatric hospitalization, but he refuses.

1. ask why he does not wish to be hospitalized

2. involuntarily commit him using restraint as necessary

3. physically or chemically restrain him until a psychiatrist can evaluate him

4. start an anti-depressant medication and discharge him

5. start antipsychotic medication and discharge him

The SAD PERSONS scale

◦ an acronym based on 10 suicide risk factors

◦ has found widespread acceptance in assessing the likelihood of a suicide attempt

◦ It also has been adapted for use with children.

Major risk factor omitted from the scale is the availability of a lethal means for suicide◦ Firearm◦ stockpiled medication◦ or other potentially lethal item

In particular, where firearm ownership levels are higher, a disproportionately higher number of people die from suicide

Oklahoma

SAD PERSONS can be modified to

SAD PERSONAS to remedy this omission◦ with the second ‘A’ representing

◦ Availability of lethal means

This modification reminds the clinician to ask about lethal means when assessing suicidality. If lethal means are available, the clinician can then take whatever action is reasonably indicated to reduce the likelihood of a suicide.

SAD PERSONS scale

S – Sex: 1 if male; 0 if female; (more females attempt, more males succeed)

A – Age: 1 if < 20 or > 44

D – Depression: 1 if depression is present

P – Previous attempt: 1 if present

E –Ethanol abuse: 1 if present

R – Rational thinking loss: 1 if present

S – Social Supports Lacking: 1 if present

O – Organized Plan: 1 if plan is made and lethal

N – No Spouse: 1 if divorced, widowed, separated, or single

S – Sickness: 1 if chronic, debilitating, and severe

Guidelines for action with the SAD PERSONS scale

Total points Proposed clinical action

0 to 2 Send home with follow-up

3 to 4 Close follow-up; consider hospitalization

5 to 6Strongly consider hospitalization, depending on confidence in the follow-up arrangement

7 to 10 Hospitalize or commit

Consider these two patients:

A man who is depressed and has an organized plan to shoot himself with his handgun…How many points?

an elderly widower who has dementia and is physically ill…How many points?

Both men would score a 4

◦ Risk of suicide would be substantially greater in the first case

◦ Suicide risk factors are qualitative—not quantitative

◦ Should be considered within the overall context of the clinical presentation

Elderly male with a recent loss◦ High risk for suicide

May ultimately require commitment◦ Significant danger to himself

Depressed patients◦ Reluctant to accept hospitalization

◦ Fear or anger

Patient reluctant to accept hospitalization◦ Provider should attempt to

Identify and address the specific reason

Family or friends may help convince patient◦ To accept psychiatric care

If patient still refuses…begin the

Involuntary commitment “72 hour hold” Emergency Order of Detention (EOD)

Begins with Medical Clearance◦ Must assess an organic cause

CBC

CMP

UA

UDS (urine drug screen)

BA (blood alcohol)

TSH

Other labs and imaging as PMH dictates

Everything comes back “normal”

Now what do you do?

Your job is to fill out the paperwork◦ To detain the patient against their will

For 72 hours

Until a judge makes a decision

◦ You as a PA do not EOD anyone This is a legal proceeding

This paperwork process is totally dependent on your location◦ Metropolitan Oklahoma

◦ Rural Oklahoma

Metropolitan Oklahoma◦ The patients chart

◦ The medical history and physical exam

◦ And possibly a third party statement

If family, friends, law enforcement not present

MAT (Mental Health Assessment Team)◦ Fills out other forms

◦ Contacts facility to see if they’ll accept patient

◦ Makes transportation arrangements

◦ One phone call and they handle it all…

No such thing as MAT

It’s all you and your ED staff◦ Patient chart

◦ Mental Health provider statement

◦ History and Physical exam

◦ Contacting facility to accept patient

◦ Arranging transport

“72 hour hold” CAN NOT be transported by

POV (privately operated vehicle)

Must go by law enforcement

Which law enforcement entity transports?

Our patient has presented to a Rural ED

Unaccompanied by law enforcement

Unaccompanied by friends or family

No past medical history

Takes no daily medication

Walk thru…Involuntary Hold Process◦ http://digitalprairie.ok.gov/cdm/ref/collection/stg

ovpub/id/2426