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

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Symptoms associated with suicide:

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

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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).

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?”

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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

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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

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

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References:

• TN 2013 PS5-6
• OSCE and Clinical Skills Handbook – second edition