Stephen C. Schoonover

Introduction: The Practice of Pharmacotherapy

Experimentation with drugs that alter mood, thinking, or perception represents a timeless human enterprise. Although largely aimed at the relief of suffering, the utilization of various pharmacological agents also reflects different cultural, religious, and political ideologies. Frequently, the implementation of effective pharmacological treatments depends more on social issues, economic considerations, and serendipity than on clinical factors. A historical account of both the discovery and introduction of psychoactive drugs in the United States highlights these patterns.

Bipolar Affective Disorder and Recurrent Unipolar Depression

Lithium (Lithonate®, Lithane®, Eskalith®, and others), a naturally occurring salt, has been used for various medical purposes since the 1800s. Initially, it was given to patients who suffered from urinary calculi and gout. Later, it was combined with bromides and used as a sedative. In 1949, Cade observed that lithium calmed agitated psychotic patients: ten manic patients responded, six schizophrenic and chronically depressed psychotic patients did not, and one patient’s symptoms reappeared after lithium was stopped.1 During this same period, lithium was introduced in the United States as a salt substitute for cardiac patients, but it caused numerous toxic reactions and several deaths. Thus, even with the emergence of convincing evidence that lithium was safe and effective in manic-depressive illness, it was not accepted in the United States until 1970.

General Principles of Pharmacologic Management in the Emergency Setting

In the emergency setting, the clinician must make decisions rapidly, often on the basis of limited historical data and without the advantages of an extended diagnostic evaluation. The patient may require containment of his behavior and immediate relief of his distress before he has established a working relationship with the clinician or before the underlying psychiatric disorder is defined. Therefore, the use of psychoactive drugs must be carefully tailored to the special requirements of the individual, the situation, and the setting.

Intensive Care for Suicidal Patients

Despite the difficulties assessing which patients are dangerous and in need of immediate protection, many forms of intensive psychiatric care are effective for treating the acutely self-destructive individual. In any case, the issue of physical safety must not distract the clinician from focusing on the nature of the patient’s internal life, the meaning of the suicide attempt, and the availability of environmental supports. In addition to understanding patient’s dilemma, the caretaker should know the assets and limitations of various treatments. Therefore, this chapter describes a general approach toward the intensive interventions with the suicidal individual which takes into account both the characteristics of the patient and the care settings. The entire range of closely supervised treatment modalities is described with a particular focus on the methods employed in an inpatient milieu.

Emergency Presentations Related to Psychiatric Medication

Patients commonly use the emergency room because of various adverse effects from psychiatric medication. Among the most common are those related to the use of lithium, antipsychotic agents, and other psychiatric drugs with anticholinergic effects. This section describes the clinical manifestations and management of these drug effects. Agents used to treat medical disorders that also may cause behavioral effects are primarily described in the chapters on anxiety, depression, and acute psychoses.

Introduction: The Extent of the Problem

Suicide is the ninth leading cause of death in the United States and currently accounts for 60 to 70 fatalities per day. Its rate has increased slightly since the turn of the century and is now approximately 12.7 per 100,000 population.1 Many more people attempt suicide than succeed. In recent years the number of attempts, especially by drug overdosage, has climbed to epidemic proportions and has led to a rise in the number of associated medical admissions. The reported ratio of eight attempts to one completed suicide is significantly underestimated.2 In addition, countless people seriously contemplate the act without carrying it out. Many of these individuals require professional help. Taken together, the entire range of suicidal feelings, thoughts, and behaviors constitutes a major health care problem and reflects the untold suffering of large numbers of people.

Pharmacotherapy of the Suicidal Patient

Medication is frequently an adjunct to crisis therapies and initially may be the primary treatment method. The choice of a regimen depends on the identification of a drug-responsive syndrome (see Chart I) and on the evaluation of possible risks from medical conditions, side effects, potential abuse, and other medications. If suicidal symptoms interfere with adequate cooperation in psychotherapy the clinician should administer medication early in treatment. Intense confusion, feelings of helplessness and despair, and preoccupation with internal cues may predominate the patient’s awareness, particularly in individuals with major affective disorders or schizophrenialike psychoses. These characteristics may significantly limit the usefulness of ego supportive approaches, that encourage cooperation and rapport with the clinician, reestablishment of previously effective social attachments, and the mobilization of cognitive defenses. Frequently, patients with affective and psychotic disorders improve only after therapeutic doses of medication are administered for several weeks. The sedative, antianxiety, and neuroleptic properties of antipsychotic agents and the cyclic antidepressants, however, provide more immediate relief.