What is the emergency room treatment for a patient with ethanol (EtOH) abuse, a history of schizophrenia, and suicidal ideations?

From the Guidelines

For a patient presenting to the ER with alcohol abuse, schizophrenia history, and suicidal ideations, immediate stabilization and comprehensive assessment are essential, with a focus on reducing morbidity, mortality, and improving quality of life. The patient's safety should be ensured through constant observation and removal of potentially harmful objects. A thorough evaluation including vital signs, blood alcohol level, comprehensive metabolic panel, and toxicology screening should be conducted. For alcohol withdrawal, the CIWA-Ar protocol with benzodiazepines such as lorazepam 1-2mg IV/PO every 1-4 hours as needed should be implemented 1.

Assessment of schizophrenia symptoms is crucial, and antipsychotic medications should be continued if previously prescribed, such as risperidone 2-6mg daily or olanzapine 5-20mg daily, as recommended by the American Psychiatric Association practice guideline for the treatment of patients with schizophrenia 1. For acute psychosis, haloperidol 2-5mg IM/PO with potential addition of benzodiazepines may be considered.

Given the patient's history of suicidal ideations, a detailed suicide risk assessment using standardized tools should be performed, and appropriate precautions based on risk level should be implemented, considering the guidelines for assessment and management of patients at risk for suicide 1. Thiamine 100mg IV/IM and folate supplementation are important to prevent Wernicke's encephalopathy. After stabilization, arranging psychiatric consultation for medication adjustment and developing a comprehensive discharge plan including substance abuse treatment, outpatient psychiatric follow-up, and connection to community support services is essential.

This multifaceted approach addresses the interrelated issues of alcohol abuse, schizophrenia, and suicidal ideation, which often exacerbate each other and require simultaneous treatment. The use of clozapine may be considered for patients with schizophrenia whose risk for suicide attempts or suicide remains substantial despite other treatments, as suggested by the American Psychiatric Association practice guideline 1. Cognitive behavioral therapy (CBT) may also be beneficial in reducing suicidal ideation and behavior, as supported by evidence from studies on assessment and management of patients at risk for suicide 1.

Key considerations in the management of this patient include:

• Ensuring patient safety and stabilization
• Comprehensive assessment and management of alcohol withdrawal, schizophrenia, and suicidal ideations
• Use of evidence-based treatments, including antipsychotic medications and CBT
• Development of a comprehensive discharge plan with connection to community support services
• Consideration of clozapine for patients with substantial risk for suicide attempts or suicide despite other treatments.

From the Research

ER Treatment for EtOH Abuse with History of Schizophrenia and Suicidal Ideations

• The treatment of alcohol withdrawal syndrome is crucial in patients with a history of schizophrenia and suicidal ideations. According to 2, benzodiazepines are considered the gold standard for treating alcohol withdrawal syndrome, with other medications such as anticonvulsants and adrenergic drugs also being used.
• In patients presenting to the emergency department with suicidal ideation and a blood alcohol level (BAL) ≥80 mg/dl, it is common practice to wait until the BAL is <80 mg/dl to evaluate patient safety. A study by 3 found that among patients presenting with suicidal ideation and a concurrent BAL ≥80 mg/dl, 69% no longer reported suicidal ideation when their BAL was <80 mg/dl.
• Alcohol use is a significant risk factor for suicide-related outcomes in people with a diagnosis of schizophrenia. A systematic review and meta-analysis by 4 found that alcohol use was associated with suicide, attempted suicide, and suicidal ideation in individuals with schizophrenia.
• The relationship between alcohol use and suicide has been established in various studies. A meta-analysis by 5 found that the risk ratio between alcohol use and suicide was 1.65, indicating that alcohol use is a significant risk factor for suicide.
• Benzodiazepines are commonly used to treat alcohol withdrawal syndrome, but they also have a potential for addiction and withdrawal symptoms. A study by 6 highlighted the dangers of benzodiazepine use and the need for careful tapering of the medication to avoid withdrawal symptoms.

Considerations for Treatment

• When treating patients with a history of schizophrenia and suicidal ideations, it is essential to consider the potential risks and benefits of medication use, including benzodiazepines.
• A comprehensive treatment plan should include supportive care, vitamin supplementation, and monitoring of symptoms to ensure effective management of alcohol withdrawal syndrome.
• Clinicians should routinely inquire about alcohol use in mental health services to focus preventative treatment efforts, as highlighted by 4.