Psychological medicine

Reading Time: 4 minutes

Suicide Assessment and Management

  • Always screen all psychiatric patients for suicide
  • Definitions:
    • Attempted suicide: self-inflicted harm intended to cause death
    • Parasuicide: Act intended to communicate distress not intended to cause death

Suicide History

  • Overview:
    • Establish and maintain rapport
    • Evaluate for:
      • Suicidal thinking
      • Suicidal intent
      • Suicidal plans
      • Future orientation
      • Relevant mental status: including mood, drugs/alcohol, labile, impulsiveness, insight, etc
    • Assessment of risk factors
  • Ideation questions:
    • Do you see a future for yourself?
    • Do you think a lot about death?
    • Have you ever considered harming yourself/wanted to end your life?
    • What specifically have you thought about this? When did you start thinking this way?
    • Have you talked to anyone about this?
    • Do you want to die – or do you want others to realise how bad things are for you?
    • Have you thought of a plan to kill yourself?
    • Do you have the means?
    • What has stopped you so far?
    • Have you thought about the effect your death would have on family and friends?
    • How do you feel about accepting help?
    • How does talking about this make you feel? 
    • If can‟t ask the question directly, then „what do you think about suicide‟, „what would you do if it got that bad‟, „how bad does it get… have you ever felt so bad that you wanted to end your life‟ 
    • Have you thought of hurting anyone else
  • Past Suicide attempt(s):
    • What did you do?
    • When did you start thinking about suicide?  Why did you think that?
    • When did you plan to do something? (ie was it impulsive or planned)
  • When did you start to action the plan?  What triggered that (what was the final straw)?
  • Did you leave a note/say goodbye/wind up your affairs?
  • What stopped you going through with it?
  • How did you get to be in hospital?
  • Are you surprised to be alive? (ie did they genuinely think it was going to kill them)
  • Has anything changed in the things that made you try?
  • What did you feel about getting help?

Assessment of Risk

  • Predisposing Risk Factors:
    • Present from birth or soon after:
      • Sex: Female more likely to try, male more likely to succeed
      • Genetic or congenital factors
      • Family History of suicide, psychiatric illness or substance abuse
      • Personality Traits (eg impulsiveness, perfectionism, hopelessness, low self esteem)
    • Risk Factors developed later in life:
      • Suicide Exposure 
      • Psychiatric diagnosis: depression, substance abuse (esp. age 40 – 60) and schizophrenia show strongest correlation
      • Other illness
      • Previous suicidal intents: include factors listed above, type and frequency of ideation, etc
      • Environmental factors: separated, living alone, elderly, isolated, unemployed
      • High risk situations: eg young males
  • Protective Factors: decrease risk:
    • Cognitive flexibility
    • Strong social supports
    • Hopefulness
    • Treatment of disorders
    • Responsibility for children
    • Are there other things that would stop them?
  • Precipitating Factors: short term risk factors:
    • Humiliating/precipitating life event: job loss, move, separation, death, interpersonal problems
    • Post partum
    • Recent discharge from a psychiatric hospital: a high risk time
    • Current mood: depression increases risk significantly 
  • Thoughts and expectations about the future. Very important to assessing overall risk. Is the future hopeless? If they have nothing to live for, suicide is easier 
  • Mental State: mood, psychosis (® impaired judgement, voices may tell them to do it, paranoia), 
  • judgement, impulsivity (be aware of effect of alcohol if person is sober when interviewed: when you drink, how do you feel afterwards)
  • Current plan: detail, lethality (not how lethal it actually would be, but what did patient think would happen), fantasies (eg have they thought about other‟s reactions to their death), expectations of outcome (eg do they want to be found?) Availability of method
  • High risk if:
    • Recent well planned attempt.  Remains fixed on wish to die or refuses treatment
    • Patient has had thoughts about suicide and intends to act on them
    • If the patient is uncooperative and the assessment was incomplete 
    • If the following are present: psych illness, significant stress, history of impulsivity or violence, family history of suicide

Influence of community standards and norms on suicide*

  • Individualism: you‟re a failure if you can‟t make it on your own
  • Copy cat syndrome 
  • Expectations of achievement ® individuals set high expectations and fail
  • Community encourages the use of weapons 
  • Community demeans the poor ® see themselves as unimportant
  • Community encourages external locus of control ® can‟t change anything Þ fatalism
  • Community encourages/condones suicide in certain circumstances:
  • People with certain conditions alienated, eg psych illness
  • Minority culture alienated by enforced dominance of the dominant group‟s beliefs and values 
  • (hegemony) ® alienation

Management of Current Suicide Risk *

  • For a high risk: emergency assessment (eg CAT team) followed by regular nursing assessment
  • For lower risk in a GP setting (UK source):
    • Straight away: 
      • Identify risk on notes in a way that won‟t be missed by you or other members of the team (eg note or sticker on summary sheet). Won‟t affect life insurance risk if insurance covers a mortgage or loan, or policy was taken out more than one year before. Suicide risk has no additional effect on premiums over and above the presence of depression 
      • Don‟t give prescriptions with repeats – get them to come back for each script. Allows better monitoring and limits the amount of medication they hold at any time
      • Ensure adequate symptom relief of physical symptoms 
      • Use a counselling approach: empathy, give feedback to clarify the patient‟s problems, provide advice if appropriate, etc
    • Further Actions: 
      • Plan the next few days: especially if a weekend, or they have poor social supports. Should be detailed, and given to the patient on paper to take home. Should include contact with other people and things the patient enjoys 
      • Ensure family member/responsible friend is available 
      • Encourage use of informal supports: whom can they talk to. If there is nobody, why do they feel like this? 
      • Use non-statutory Services: Lifeline, Youthline, Samaritans, community organisations, support groups, sports/hobby groups etc
      • Offer follow-up: opportunity to reassess patient, and provide further support 
      • Consider referral to specialist care: Community Psychiatric Nurse, social worker, psychiatrist, psychologist, CATT
  • Afterwards:
    • Liase with other professionals
    • Discuss with another team member to review your risk assessment and management plan 
    • Be aware of your own response: patients like these can cause considerable concern or evoke a strong emotional response