How to manage restlessness in a patient who has attempted hanging, potentially with underlying psychiatric conditions and possible substance abuse history?

Managing Restlessness in Post-Hanging Patients

Restlessness in a post-hanging patient requires immediate psychiatric hospitalization if the patient continues to express a desire to die, remains agitated or severely hopeless, cannot engage in safety planning, or lacks adequate support—this is non-negotiable given that hanging represents a high-lethality suicide attempt method that strongly predicts completed suicide. 1, 2

Immediate Medical Stabilization

Before addressing psychiatric restlessness, ensure the patient is medically stable:

• Assess airway patency, breathing adequacy, and circulatory status immediately, as hanging causes vascular compromise leading to cerebral edema rather than primarily asphyxia 1
• Monitor for aspiration pneumonia, neurologic deficits, and delayed respiratory complications, which can develop even in initially conscious patients 3, 4, 5
• Aggressive resuscitation should be initiated regardless of initial presentation, as severe neurologic deficits are often reversible and initial findings correlate poorly with eventual outcome 3, 6, 5

Psychiatric Risk Stratification

Patients who attempt hanging are at extremely high risk for completed suicide based on the following factors:

• Hanging is classified as an "unusual method" (not ingestion or superficial cutting), which predicts further suicide attempts and ultimate death by suicide 2, 1
• Medically serious attempts by unusual methods require the most intensive intervention 1
• Male gender, ages 16-19, represents the highest risk demographic 2, 7

Managing Acute Restlessness

When the patient exhibits restlessness, agitation, or behavioral dyscontrol:

• Establish a therapeutic relationship immediately to prevent aggressive outbursts and facilitate processing of the traumatic event 2
• Assess the mental state systematically: Look for depressed mood, manic/hypomanic symptoms, severe anxiety, irritability, agitation, psychosis, or substance intoxication 2
• If less restrictive options fail or cannot be safely applied, seclusion and restraint may be required to prevent dangerous behavior to self or others 2

Restraint Safety Protocols (If Necessary)

If physical restraint becomes necessary for severe agitation:

• Never use restraints that cause airway obstruction (choke holds, covering face with towels) 2
• With prone restraints, ensure the airway is unobstructed and lungs are not restricted by excessive back pressure—40% of restraint deaths involve asphyxiation from excess weight on a prone patient's back 2
• Continuous observation is mandatory for all restrained patients, as lack of monitoring contributed to 40% of restraint-related deaths 2
• A licensed independent practitioner must conduct face-to-face evaluation within 1 hour of restraint initiation 2

Chemical Restraint Considerations

For pharmacological management of severe agitation:

• Offer oral medication before parenteral administration whenever possible 2
• Oral medication must be given sitting up or standing to avoid aspiration 2
• Consider the patient's medical and psychiatric history, including concurrent medications before ordering chemical restraint 2
• Olanzapine carries specific warnings about suicide risk and requires close supervision of high-risk patients, with prescriptions written for the smallest quantity consistent with good management 8

Mandatory Psychiatric Assessment

Arrange immediate mental health professional evaluation during the current medical visit with options including:

• Psychiatric hospitalization (likely the safest course for high-risk patients) 1
• Emergency department psychiatric transfer 1
• Same-day psychiatric appointment (only if lower risk criteria met) 1

Do not discharge without psychiatric evaluation if the patient exhibits: persistent desire to die, depression with mania/hypomania/mixed states, substance abuse, irritability, agitation, threatening violence, delusions, or hallucinations 2

Comprehensive Risk Factor Screening

During evaluation, systematically assess:

• Mood disorders, anxiety disorders, or substance abuse—primary risk factors for suicide attempts 1
• History of physical or sexual abuse—present in 15-20% of suicide attempters and increases risk independently 1
• Comorbid substance abuse with depression—dramatically increases suicide risk 9, 7
• Family history of suicide, recent psychiatric hospitalization, impulsivity 2

Safety Planning Before Any Discharge

If discharge is being considered (only after psychiatric clearance):

Conduct a comprehensive safety planning discussion that includes:

• Identification of warning signs and triggers for recurrent suicidal ideation 2, 1
• Specific coping strategies the patient can use if suicidal thoughts return 2, 1
• Healthy distraction activities 2, 1
• Names and contact information of responsible social supports 2, 1
• Professional support contacts and emergency services information 2, 1

Lethal Means Restriction (Critical Component)

Counsel explicitly on means restriction—many suicide attempts are impulsive (24% occur within 0-5 minutes of decision) 2:

• Remove all firearms from the home—adolescents can access even locked guns, and firearms have an 85% case-fatality rate versus 2% for ingestions 2, 1
• Lock up all medications (prescription and over-the-counter) 2, 1
• Secure knives and other sharp objects 2
• Address access to means in homes of friends or family 2

Follow-Up Care Coordination

• Maintain contact with the patient even after psychiatric referral to enhance continuity and treatment adherence 1
• Ensure frequent monitoring, especially during initial treatment phases—greatest risk of reattempting is in the months after initial attempt 2, 1
• Consider evidence-based psychotherapy: cognitive behavioral therapy (CBT) or dialectical behavior therapy (DBT) 1, 7

Common Pitfalls to Avoid

• Never rely on "no-suicide contracts" alone—patients may not be in a mental state to accept or understand them, and they do not prevent subsequent suicides 2
• Do not underestimate impulsivity—many attempts occur within minutes of the decision 9
• Never discharge based solely on improved presentation—initial clinical status correlates poorly with suicide risk 5
• Do not prescribe benzodiazepines or phenobarbital to suicidal patients, as these reduce self-control 9