Suicide

Suicide Risk Factors – SAD PERSONS Scale

  • Sex (male)
  • Age >60, 15-24
  • Depression
  • Previous attempts – the best predictor of completed suicide (worst if in the past year)
  • Ethanol abuse
  • Rational thinking loss (delusions, hallucinations, hopelessness)
    • Mood disorders (depression > bipolar), anxiety disorders (esp panic disorder), schizophrenia, eating disorder)
  • Suicide in family (attempt/completion)
  • Organized plan
  • No spouse: widowed / divorced, alone, no children <18yo in the household (no support systems)
  • Serious illness, intractable pain

A score ≥ 6 req emergency psychiatric evaluation / Tx


Symptoms associated with suicide:

  • Hopelessness, anhedonia, insomnia
  • impaired concentration, psychomotor agitation
  • Severe anxiety, panic attacks

1. In any patient with mental illness (i.e., not only in depressed patients), actively inquire about suicidal ideation (e.g., ideas, thoughts, a specific plan).

Approach

Every Patient: “Have you had any thoughts of wanting to hurt/kill yourself?”
  • Ideation – “Do you have thought about ending your life?”
    • Passive – would rather not be alive but has no active plan for suicide
    • Active – “I think about killing myself”
  • Plan – “Do you have a plan as to how you would end your life?”
  • Intent – “You talk about wanting to die, but are you planning to do this?”
  • Past attempts – highest risk if previous attempt in past year
    • Ask about lethality, outcome, medical intervention

2 Given a suicidal patient, assess the degree of risk (e.g., thoughts, specific plans, access to means) in order to determine an appropriate intervention and follow-up plan (e.g., immediate hospitalization, including involuntary admission; outpatient follow-up; referral for counselling).

Assessment of Suicidal Ideation

  • Character: “Tell me what happened?”
  • Onset & Frequency & Duration of thoughts – “When did this start? How often do you have these thoughts?”
  • Intensity: “How severe are your SI now?”
  • Control over SI – ” Can you stop the thoughts or call someone for help?”
  • Lethality – “Do you want to end your life? Or get a ‘release’ from your emotional pain?”
  • Access to means – “How will you get a gun?” Which Bridge do you think you would go?”
  • Time and Place – “Have you picked a date and place?”
  • Provocative factors – “what makes you feel wore?”
  • Protective factors – “what keeps you alive?”
  • Final Arrangements – “Have you written a suicide note? Made a will? Give away belongings?”
  • Practised suicide or aborted attempts – “Have you put the gun to your head?”
  • Ambivalence – “There must be a part of you that wants to live – you came here for help?”

3 Manage low-risk patients as outpatients, but provide specific instructions for follow-up if suicidal ideation progresses/worsens (e.g., return to the emergency department [ED], call a crisis hotline, re-book an appointment).

Management

  • Proper documentation of the clinical encounter and rationale for management is essential
Higher Risk – hospitalized immediately
  • Patients with a plan, access to lethal means, recent social stressors, symptoms suggestive of a psychiatric disorder
  • Don’t leave pt alone, remove dangerous objects
  • If pt refuses to be hospitalized, complete form for involuntary admission
Lower Risk
  • Pt who are not actively suicidal, with no plan or access to lethal means
    • Manchester Self-Harm Rule – satisfy all criteria = low risk
      • No Hx of self-Harm & no use of BZD in current attempt
      • No prior & no current psychiatric Tx
  • Discuss protective factors & supports in their life, remind them of what they live for, promote survival skills
  • Make a safety plan – an agreement that they will
    • not harm themselves
    • avoid alcohol, drugs, and situations that may trigger SI
    • f/u with you at a designated time
    • contact a health care worker, call a crisis line or go to ED if they feel unsafe or if their sI return or intensity
Psych Related
  • Depression – hospitalize if severe of + psychotic features, otherwise out-pt SSRIs/SNRIs + good supports
  • EtOH – usually resolves with abstinence for a few days, if not, suspect depression
  • Personality disorders: Crisis intervention/confrontation, may or may not hospitazlie
  • Schizophrenia / psychosis: Hospitalization

4 In suicidal patients presenting at the emergency department with a suspected drug overdose, always screen for acetylsalicylic acid and acetaminophen overdoses, as these are common, dangerous, and frequently overlooked.

Assessment of Suicide Attempt

  • Setting – isolated vs other present
  • Planned vs impulsive attempt
    • Events associated: triggers / stressors
  • Intoxication
  • Medical attention – brought in by another person vs self
  • Time lag from suicide attempt to ER
  • Expectation of lethaliy, dying
  • Reaction to survival – guilt / remorse vs disappointment / self-blame

5 In trauma patients, consider attempted suicide as the precipitating cause.


References:

  • TN 2013 PS5-6
  • OSCE and Clinical Skills Handbook – second edition
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Posted in 90 Suicide, 99 Priority Topics, FM 99 priority topics, Psych

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