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
- Manchester Self-Harm Rule – satisfy all criteria = low risk
- 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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