Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Suicide

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Suicide - Key Features

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).

Assessment of Suicidal Ideation
Onset and frequency of thoughts – “When did this start? How often do you have these thoughts?”
Control over suicidal ideation – “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 to?”
Time and place – “Have you picked a date and place? Is it in an isolated location?”
Provocative factors – “What makes you feel worse (e.g. being alone)?”
Protective factors – “What keeps you alive (e.g. friends, family, pets, faith, therapist)?”
• Final arrangements – “Have you written a suicide note? Made a will? Given away your belongings?”
Practiced suicide or aborted attempts – “Have you put the gun to your head? Held the medication in your hand? Stood at the bridge?”
Ambivalence – “There must be a part of you that wants to live – you came here for help.”

- >90% of patients who attempt suicide have a major psychiatric disorder
- 95% of patients who commit suicide have a psychiatric diagnosis

Canadian Task force on Preventative Health Care (1994)
- poor evidence (expert opinion alone) to include or exclude routine evaluation of suicide risk in the periodic health examination
- physicians should remain alert to the possibility of suicide in high-risk patients
- routinely evaluate the risk of suicide, particularly if there is evidence of:

- psychiatric disorder (especially psychosis)
- depression
- substance abuse
- if the patient lives alone
- recently attempted suicide
- family member has committed suicide

- special attention paid to young Native and Aboriginal males

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).

- Prior history of attempted suicide = strongest single factor predictive of suicide

SAD PERSONS
- Sex (male)
- Age (>60 y.o.)
- Depression
- Previous attempts
- Ethanol abuse
- Rational thinking loss (delusions, hallucinations, hopelessness)
- Suicide in family
- Organized plan
- No spouse (no support systems)
- Serious illness / intractable pain

- Scoring Guide (based on total number of risk factors present)

- 0-2 : consider sending home with family
- 3-4 : close follow-up, consider hospitalization
- 5-6 : strongly consider hospitalization
- 7-10 : hospitalize


- Suicide contracts = unreliable

Clinical Presentation
- symptoms associated with suicide

- hopelessness
- anhedonia
- insomnia
- severe anxiety
- impaired concentration
- psychomotor agitation
- panic attacks


In Elderly Patients
- personality disorders, rigid personality styles
- non-adaptive coping strategies
- functional decline

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 of the Suicidal Individual
- reducing immediate risk

- involve a family member or person close to patient, if allowed
- ask about availability of lethal means (e.g., firearms, medications) and make inaccessible
- increase the frequency of contact with the patient; communicate a commitment to help
- begin aggressive treatment of psychiatric disorders or substance abuse

- managing underlying factors

- referral to counseling
- engagement of community, religious, and family supports
- CBT
- treatment of depression (e.g., SSRI) / bipolar disorder (e.g., lithium)

- monitoring and follow-up

- risk fluctuates, should be reassessed frequently
- determine if there have been changes, especially a reemergence of precipitating events, adverse life circumstances, or mental disorders
- assure that previously suicidal patients are actively engaged in ongoing care for any mental disorders
- continue to receive treatment for prevention of relapse or recurrence of depression, bipolar disorder, anxiety disorders, psychosis, or other conditions
- for those with a history of alcohol or substance abuse, monitoring and assisting the patient in remaining in programs that promote adequate control
- days and initial weeks following discharge from psychiatric hospitalization are a time of increased risk
- particularly if patients perceive that they have lost a therapeutic support system
- high risk for non-adherence to medication regimens


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.

- Other common Rx’s

- TCAs
- benzodiazepines
- CCBs
- Β-blockers


- Urine toxicology screen and blood alcohol level are the two most commonly required tests for patients transferred/admitted to psychiatric facilities from the ED

- Serum levels for other Rx may include:

- Mood stabilizers
- Lithium
- Valproic acid
- Antiepileptic
- Phenytoin
- Carbamazepine
- Phenobarbital
- Digoxin
- Cyclosporine (for transplant patients)
- INR (in patients taking Coumadin)


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

Study Guide

Suicide

Resources

Canadian Task Force on Preventative Health Care www.canadiantaskforce.ca/