Coming Face to Face with Seriously Ill and Suicidal Clients

In March, the International Association of Eating Disorders Professionals (iaedp) celebrated its 25th anniversary with a full program of preconference seminars, sessions, keynote presentations, and hands-on workshops. More than 300 professionals attended the symposium, “Behind Closed doors: Face to Face with the Client,” March 11-14, at the Walt Disney Swan Resort in Orlando, FL. Two presentations offered treatment strategies for very ill and suicidal patients.

Managing Very Ill Patients

Drs. Phillip S. Mehler and Jennifer L. Gaudiani of the Denver Health A.C.U.T.E. Center for Eating Disorders, Denver, CO, tackled serious treatment challenges in their presentation, “Becoming More Comfortable Taking Care of the Sickest Patients with Anorexia and Bulimia.” The authors’ treatment center is a 5-bed inpatient unit that treats severely ill patients with anorexia nervosa (AN) and bulimia nervosa (BN). The Center only accepts AN patients who weigh less than 70% of ideal body weight or patients with BN who have severe edema or electrolyte problems.

The clinicians began by stressing that AN results in the highest death rate of any psychiatric disease. Deaths from AN are 5.6 times greater than in the general population, and a third of these deaths are due to cardiac complications. According to Drs. Mehler and Gaudiani, medical complications of BN are directly correlated with the mode and frequency of purging, while in patients with AN they are a direct result of semistarvation and weight loss. Patients with BN face a host of problems, including metabolic, renal, gastrointestinal, cardiac, endocrine, and pulmonary-mediastinal complications. Those with AN often have serious metabolic, gastrointestinal, cardiac, endocrine, and hematologic problems, along with electrolyte dysfunction.

When Should Patients Be Hospitalized?

Drs. Mehler and Gaudiani gave the following guidelines for hospitalizing patients with AN: (1) Seek inpatient care if the patient is below 75% of ideal body weight (IBW), and medical hospitalization when he or she is less than 70% of IBW. (2) Patients should be hospitalized if they have severe organ dysfunction, including cardiac, gastrointestinal, liver, endocrine, electrolyte, and hematologic problems. (3) Worsening weight loss with severely restricted caloric intake, making refeeding complications more likely, is another indication for hospitalization. The goal is to start weight restoration, avoiding and treating refeeding complications.

Among bulimic patients, medical problems are caused by the mode and frequency of purging. Severe fluid and electrolyte shifts can be life-threatening. And, for patients with a history of severe edema, difficult diuretic detoxification, or severe hypokalemia should be managed in a hospital staffed with clinicians experienced in the treatment of people with eating disorders.

The Challenges of Osteoporosis

One example of a challenging endocrine problem in patients with AN is osteoporosis, the Denver clinicians said. The osteoporosis associated with AN is extremely severe and not readily treatable nor reversible. Although it occurs early in life, estrogen replacement therapy does not prevent or treat reduced bone density. Normalized weight is the best indicator of bone density. According to the clinicians, early detection is key because exercise does not protect against bone loss. The duration of amenorrhea and extent of lean body mass are the best predictors of bone density, and it is well to remember that the patient may never fully recover. DEXA should be used as a routine screening device for all anorectic patients who have been amenorrheic longer than 6 months.

Therapy includes weight restoration with resumption of menses, and use of calcium supplements (1200 to 1500 mg/day with vitamin D). Drs. Mehler and Gaudini also noted the importance of measuring 25 (OH) vitamin D levels in these patients. They added that four trials of estrogen therapy showed no benefit on bone mineral density. One positive area may be use of bisphosphonates in patients with AN, but there are some concerns as well; neonates born to mothers who received bisphosphonates show decreased bone weight and incomplete ossification. Other complications of bisphosphonates are that their use does not result in normal bone formation and the bone that is produced may actually be weaker than normal bone. No data for calcitonin or fluoride are yet available, they added.

Dealing with the Refeeding Syndrome

According to the two clinicians, another challenge is the refeeding syndrome, which can be deadly. Phosphorus is the key electrolyte level to watch, they said. The glucose load in food stimulates exuberant insulin release, which shifts phosphate and potassium into the cells, causing serum levels of both to drop sharply. Newly synthesized tissues incorporate phosphorus, potassium, and magnesium, causing serum levels of both to drop sharply. Newly synthesized tissues incorporate phosphorus, potassium, and magnesium, which further depletes serum levels. The main fall in serum phosphorus levels occurs 2 to 3 days after refeeding is started and low levels might last 1 to 2 weeks. Greater than expected amounts of phosphorus repletion may be required, during which time serum phosphorus levels should be monitored daily.

How can you prevent the refeeding syndrome? The speakers advised that a little nutrition support is good, while too much may be lethal—start low, and go slow on calories, paying attention to sodium levels as well, they said.

Managing the Suicidal Patient

Kevin Wandler, MD, Chief Medical Officer at Remuda Ranch, Wickenburg, AZ, told the audience that every 16.6 minutes an American commits suicide, and that suicide is the second leading cause of death for people 20 to 24 years of age. Furthermore, knowledge of suicidal intention and risk of suicide is very important for those treating clients with eating disorders because 50% of psychiatrists face the risk that a patient of theirs will commit suicide during their career, and 20% of psychologists will lose a patient to suicide. When Sullivan conducted a meta-analysis of 42 studies of 178 deaths in 3,006 eating disorders patients, it was learned that 54% died from the complications of eating disorders; 27% from suicide; and 18% from unknown causes. In another study, by Pompili et al., suicide was found to be the major cause of death among individuals with AN, challenging the belief that starvation is the primary cause of death in these patients.

Dr. Wandler pointed out that the challenge for clinicians is predicting which patient with suicidal ideation will go on to harm himself or herself. He noted that even with a thorough suicide assessment, no amount of diligence on the part of the clinician treating such patients can take away another individual’s ability to choose to commit suicide. There are warning signs, however. Psychosocial factors that increase risk for suicide include: recent lack of social support, unemployment, drop in socioeconomic status, poor relationship with family, and domestic partner violence. Childhood trauma, including sexual and physical abuse also increases the risk. He advises considering genetic and familial risk factors, including a family history of suicide (especially in first-degree relatives) and a family history of mental illness, including substance use disorders. Physical illness can also increase the risk, of brain and spinal cord injury, pain syndromes, and diseases of the nervous system.

Factors that can help mitigate the risk include having a sense of responsibility to the family, children in the home, life satisfaction, positive coping skills, positive problem-solving skills and a positive therapeutic relationship.

In Dr. Wandler’s view, in comparison to cognitive behavioral therapy and pharmacology, where improvement rates (reduction of depressive symptoms by half) or remission is very low, dialectical behavioral therapy (DBT) has been very successful. In one study, use of DBT reduced suicide attempts by half, compared with other types of psychotherapy available in the community. DBT teaches life-management skills, he said, and can bring conflicts into awareness, helping patients to make conscious decisions rather than acting out of habit or automatically. He added that more effective compromises are available because the patient sees what he or she is “giving up” in order to “get.”

When Should the Suicidal Patient Be Admitted?

Indications that a patient should be admitted for treatment include the following: (1) when he or she has made a suicide attempt or aborted suicide attempt; (2) if the patient is psychotic, the attempt was violent, premeditated, or near-lethal; (3) if the patient took precautions to avoid rescue or being discovered; (4) if he or she has a persistent plan and or intent, and (5) if distress is increased or the patient regrets surviving the suicide attempt. Additional factors that increase risk are: male gender, age older than 45 years, especially if there has been a new onset of psychiatric illness or suicidal thinking, and if the patient is severely agitated, refuses help, or needs further workup in a structured setting.

Outpatient treatment may be more beneficial than hospitalization in cases where the patient has chronic suicidal ideation and/or self-injury but no prior medically serious attempts at suicide, and where a safe and supportive loving setting is available and outpatient care is ongoing. Dr. Wandler said that suicide contracts are largely useless and only make a clinician feel better. Also, there is a risk that the clinician may become too comfortable, stop listening to the patient, and may overlook warning signs.

“It is our responsibility to conduct and document a reasonable suicide assessment,” he said, but added, “We are not expected to predict suicide and to prevent it.” Instead, Dr. Wandler added, clinicians are expected to identify elevated risks of suicide, and when such risk is identified, they are expected to take reasonable professional steps to reduce the risk and to protect the patient.

Finally, he said, the reality is that some patients will commit suicide, and patients with eating disorders are at high risk. Every patient should be assessed, he said, and it is important to document the assessment, interventions, and recommendations.