How do you manage a patient at high risk of suicide and self-harm who requests a prescription for lorazepam (Ativan), then presents to the emergency department (ED), informs a psychiatrist nurse that you discontinued their lorazepam, and subsequently notifies a medical body about your decision?

From the Guidelines

In managing a high-risk suicidal patient requesting lorazepam, I would first conduct a comprehensive suicide risk assessment and avoid prescribing benzodiazepines due to their potential for misuse and overdose risk, as supported by the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines 1. This approach is crucial because benzodiazepines can worsen suicidal ideation and provide a dangerous means for overdose in high-risk patients.

Key Considerations

• The patient's high risk of suicide and self-harm necessitates immediate referral to the emergency department for psychiatric evaluation, rather than prescribing lorazepam.
• A comprehensive suicide risk assessment is essential to identify the patient's specific needs and develop an appropriate treatment plan.
• The use of crisis response plans, problem-solving therapy, and other interventions, such as periodic caring communications, can be effective in reducing suicide risk, as demonstrated by studies 1.

Management Approach

• Refer the patient to the emergency department for psychiatric evaluation, ensuring that the patient receives immediate attention and care.
• Develop a crisis response plan in collaboration with the patient, incorporating components such as semi-structured interviews, unstructured conversations, and identification of social support and crisis resources.
• Consider alternative treatments, such as problem-solving therapy or cognitive-behavioral therapy, to address the patient's underlying mental health needs.
• Maintain professional communication with all parties involved, including the psychiatric team, to ensure that the patient receives comprehensive and coordinated care.

Response to Regulatory Complaints

• Provide complete medical records demonstrating the assessment process, high suicide risk identified, and decision to prioritize patient safety through emergency psychiatric care.
• Explain the rationale for avoiding benzodiazepine prescription and the potential risks associated with their use in high-risk patients.
• Emphasize the importance of prioritizing patient safety and adhering to the medical principle of "first, do no harm" in the management of high-risk suicidal patients.

From the FDA Drug Label

The use of benzodiazepines, including lorazepam, exposes users to risks of abuse, misuse, and addiction, which can lead to overdose or death The continued use of benzodiazepines, including lorazepam may lead to clinically significant physical dependence. Abrupt discontinuation or rapid dosage reduction of lorazepam after continued use may precipitate acute withdrawal reactions, which can be life-threatening To reduce the risk of withdrawal reactions, use a gradual taper to discontinue lorazepam or reduce the dosage

Management of a patient at high risk of suicide and self-harm who requests a prescription for lorazepam and then discontinues it:

• Assess the patient's risk for abuse, misuse, and addiction before prescribing lorazepam 2
• Monitor the patient frequently for signs and symptoms of respiratory depression and sedation, especially when used with opioids 2
• Use a gradual taper to discontinue lorazepam or reduce the dosage to minimize the risk of withdrawal reactions 2
• Inform patients about the signs and symptoms of benzodiazepine abuse, misuse, and addiction, and the risks of dependence and withdrawal 2
• Consider alternative treatment options for patients at high risk of suicide and self-harm, as benzodiazepines may not be the best choice due to the risk of abuse, misuse, and addiction.
• Key considerations include:
  • Risk of abuse, misuse, and addiction: The patient's history of requesting lorazepam and then discontinuing it may indicate a risk of abuse, misuse, or addiction.
  • Risk of withdrawal reactions: The patient's decision to discontinue lorazepam abruptly may precipitate acute withdrawal reactions, which can be life-threatening.
  • Risk of suicide and self-harm: The patient's history of being at high risk of suicide and self-harm requires careful consideration of the potential risks and benefits of prescribing lorazepam.

From the Research

Managing a Patient at High Risk of Suicide and Self-Harm

• The patient's request for a prescription for lorazepam (Ativan) and subsequent presentation to the emergency department (ED) after discontinuing the medication requires careful assessment and management 3, 4.
• A thorough risk assessment should be performed, taking into account factors such as intent, plan, and means, as well as availability of social support, previous attempts, and presence of comorbid psychiatric illness or substance misuse 5, 6.
• The patient's notification of a medical body about the decision to discontinue lorazepam should be addressed in a transparent and professional manner, with documentation of the reasoning behind the decision and the patient's response 4.

Assessment and Management of Suicidal Patients

• Patients at high risk of suicide and self-harm require enhanced care, including inpatient or outpatient follow-up care, a list of local support resources, and self-help material 3.
• Therapeutic risk management involves augmenting clinical risk assessment with structured instruments, stratifying risk in terms of severity and temporality, and developing and documenting a safety plan 4.
• Patients' experiences of engagement with healthcare services following a high-risk self-harm presentation to hospital are critical, with positive experiences including supportive and compassionate relationships and timely and comprehensive follow-up care 7.

Key Considerations

• The decision to hospitalize patients at imminent risk for suicide requires careful assessment of risk factors, including sociodemographic, psychiatric, general medical, and mental status considerations 5.
• Proper assessment, monitoring, and treatment of patients at imminent risk for suicide can save lives, and family physicians need evidence-based resources to address this growing clinical concern 6.
• Care plans for patients with chronic suicidal ideation should include ensuring patient safety and medical stabilization, activating support networks, and initiating therapy for psychiatric diseases 6.