ASSESSMENT OF SUICIDAL PATIENTS

DR SALMAN KAREEM1ST YR POST GRADUATE RESIDENTDEPARTMENT OF PSYCHIATRY

Definition

Suicidal behaviour – conceptualized as a continous ranging from suicidal ideation and communication to suicidal attempts and complete suicide.

Suicidal process – developmental process which leads to suicidal ideation, suicidal communication, self destructive behaviour in some even to suicide and consequence to survivors

Deliberate self harm – as a non fatal act whether physical injury , drug overdosage or poisoning carried out in the knowledge, it is potentially harmful, and in case of drug dosage that the amount taken was excessive.

SUICIDE: A MULTI-FACTORIAL EVENT

Neurobiology

Severe MedicalIllness

Impulsiveness

Access To Weapons

Hopelessness

Life Stressors

Family History

SuicidalBehavior

Personality Disorder/Traits

Psychiatric IllnessCo-morbidity

Psychodynamics/Psychological Vulnerability

Substance Use/Abuse

Suicide

etiology

Sociological factor Durkheim’s theory – Emile Durkheim divided into

3 social categories Egoistic – those who are not socially integrated into

any social group. Altruistic – society which can exert a strong inflence

on an individual’s decision to sacrifice his or her own life.

Anomic – applies to person whose integration into society is disturbed so that they cant follow customary norms of behavior.

Fatalistic – result of strict rules in society which have proved decisive for the destiny of an individual.

Psychological factor

Freud’s theory ( mourning and melancholia)

Meninger’s theory – suicide as an inverted homicide because of patient’s anger towards another person. Believed that suicide could be understood

through the interplay of three internal wishes:

• Wish to kill• Wish to be killed• Wish to die

Biological factor

Diminished central serotonin plays an important role in suicide behaviour.

Decreased concentration of serotonin metabolite in lumbar CSF is associated with suicidal behaviour.

FAMILY HISTORY/GENETICS

Relatives of suicidal subjects have a four-fold increased risk compared to relatives of non-suicidal subjects.

Twin studies indicate a higher concordance of suicidal behavior between identical rather than fraternal twins.

Adoption studies: a greater risk of suicide among biologic rather than adoptive relatives.

Suicide appears to be an independent, inheritable risk factor.

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RISK FACTORS

Demographic male; widowed, divorced, single; increases with age; white; homosexuals.

Psychosocial lack of social support; unemployment; drop in socio-economic status; firearm access

Psychiatric psychiatric diagnosis; co morbidity

Physical Illness malignant neoplasms; HIV/AIDS; peptic ulcer disease; hemodialysis; systemic lupus erthematosis; pain syndromes; functional impairment; diseases of nervous system

Psychological Dimensions

hopelessness; psychic pain/anxiety; psychological turmoil; decreased self-esteem; fragile narcissism & perfectionism

Behavioral Dimensions

impulsivity; aggression; severe anxiety; panic attacks; agitation; intoxication; prior suicide attempt; borderline personality

Cognitive Dimensions

thought constriction; polarized thinking

Childhood Trauma sexual/physical abuse; neglect; parental loss

Genetic & Familial family history of suicide, mental illness, or abuse

Clinical Factors Severe anxiety and/or agitation Anorexia Nervosa Bipolar Disorder

Bipolar II Mixed state Depressive phase of illness

Depression Severe Anhedonia or hopelessness Anxiety, agitation, or panic Aggression or impulsivity Delusional thinking Global or partial insomnia Recent sense of peace/well-being Co-morbid alcohol abuse/dependence

• Dysthymia• Post Partum Depression• Alcohol/Substance Abuse/Dependence• Co-morbid Axis I Disorder• Mixed Drug Abuse Obsessive-Compulsive Disorder

• Schizophrenia• Paranoid or Undifferentiated Type• Depressive State• Command Hallucinations• More than a high school education• Less than 40 years old

• Personality Disorders• Cluster B or Cluster C• Co-morbid depression• Co-morbid alcohol abuse/dependence

• Epilepsy• Temporal lobe epilepsy

• Chronic Pain• More than one psychiatric diagnosis• Currently psychotic• Unstable or poor therapeutic relationship

Cognitive Features that Contribute to Risk Loss of executive function Thought constriction (tunnel vision) Polarized thinking Closed-mindedness Inability to adapt to a dependent role

AFFECTIVE DISORDERS AND SUICIDE

High-Risk Profile:• Suicide occurs early in the

course of illness• Psychic anxiety or panic

symptoms• Moderate alcohol abuse• First episode of suicidality • Hospitalized for affective

disorder secondary to suicidality• Risk for men is four times as

high as for women except in bipolar disorder where women are equally at risk.

SCHIZOPHRENIA AND SUICIDE

High-Risk Profile: Previous suicide attempt(s)

Significant depressive symptoms - hopelessness

Male gender

First decade of illness – (however, rate remains elevated throughout lifetime)

Poor premorbid functioning

Current substance abuse

Poor current work and social functioning

Recent hospital discharge

Suicide occurs later in the course of the illness with communications of suicidal intent lasting several years

In completed suicides, men have higher rates of alcohol abuse, women have higher rates of drug abuse

Increased number of substances used, rather than the type of substance appears to be important

Most have co morbid psychiatric disorders, females have Borderline Personality Disorder

High Risk Profile: Recent or impending interpersonal loss Co morbid depression

ALCOHOL / SUBSTANCE ABUSE AND SUICIDE

PERSONALITY DISORDERS AND SUICIDE

Borderline Personality Disorder Lifetime rate of suicide - 8.5% With alcohol problems -19% With alcohol problems and major affective disorder -38% A co morbid condition in over 30% of the suicides. Nearly 75% of patients with borderline personality

disorder have made at least one suicide attempt in their lives.

Antisocial Personality disorder Suicide associated with narcissistic injury / impulsivity.

Areas to Evaluate in Suicide AssessmentPsychiatric

IllnessesComorbidity, Affective Disorders, Alcohol / Substance Abuse, Schizophrenia, Cluster B Personality disorders.

History Prior suicide attempts, aborted attempts or self harm; Medical diagnoses, Family history of suicide / attempts / mental illness

Individual strengths / vulnerabilities

Coping skills; personality traits; past responses to stress; capacity for reality testing; tolerance of psychological pain

Psychosocial situation

Acute and chronic stressors; changes in status; quality of support; religious beliefs

Suicidality and Symptoms

Past and present suicidal ideation, plans, behaviors, intent; methods; hopelessness, anhedonia, anxiety symptoms; reasons for living; associated substance use; homicidal ideation

Evaluation of suicidal patient Complete psychiatric history Thorough examination of patient’s

mental status Inquiry about depressive symptoms Suicidal thoughts, intents, plans and

attempts.

Inpatient versus outpatient treatment Indications for hospitalization

Patient is psychotic. Violent , near lethal or pre meditated act. Precaution was taken to avoid rescue or

discovery. Distress is increased or patient regrets

surviving Limited family and social support. Current impulsive behavior, severe agitation ,

poor judgment and refusal to help. Specific plan with high lethality and high

suicidal intent.

Admission may be necessary Psychosis Major psychiatric disorder Past attempts if medically serious Possible contributing medical condition Lack of response or inability to cooperate

with partial hospital or outpatient department

ECT or medical trial Limited family /social support, including

lack of stable living situation.

Lesser risk/ outpatient Suicidality is reaction to precipitating

events particularly if the patient’s view of situation has changed.

Plan/method has low lethality. Patient has stable and supportive living

situation

Useful measures for managing a depressed suicidal inpatient include searching the patient's belongings and person on arrival on the unit for objects that might be used for suicide, and repeating the search at times of exacerbation of suicidal ideation.

Ideally, the suicidal depressed inpatient should be managed on a locked unit with shatterproof windows, and the patient's room should be located near the nursing station to maximize observation by the nursing staff.

DETERMINE TREATMENT SETTING AND PLAN

Attend to issue of patient’s safety.

Assess treatment plan/setting/alliance.

Somatic treatment modalities:

ECT – used to treat acute suicidal behavior Benzodiazepines – may reduce risk by treating anxiety Antidepressants Lithium, Anticonvulsants Antipsychotics, recent study on Clozapine

Psychotherapeutic intervention – widely viewed as helpful for suicidal patients.

Provide education to patient and family.

Monitor psychiatric status and response to treatment.

Reassess for safety and suicide risk frequently.

SOMATIC TREATMENTS

ECT Evidence for short-term reduction of suicide, but not long-term.

Benzodiazepines May reduce risk by treating anxiety

Antidepressants A mainstay treatment of suicidal patients with depressive illness / symptoms.

Lithium Lithium has a demonstrated anti-suicide effect.

Antipsychotics Evidence for Clozapine reducing suicidality in schizophrenia and schizo-affective disorders.

Psychotherapy

Regardless of theoretical basis, key element is a positive and sustaining therapeutic relationship

Recommended (primarily from clinical consensus) To target issues

Denial of symptoms Lack of insight

To manage high risk symptoms Hopelessness Anxiety

Effective treatment in high risk diagnoses Depression Personality disorders (use of Dialectical Behaviour

Therapy)

Problem solving – Brief problem solving therapy shows reduction of repetition of self harm episodes.

Goals to reduce suicide

1. Promote awareness that suicide is a public health problem that is preventable

2. Develop broad based support for suicide prevention

3. Develop and implement strategies to reduce the stigma associated with being a consumer of mental health , substance abuse , and suicide prevention services.

4. Develop and implement suicide prevention programs.

5. Promote efforts to reduce access to lethal means and methods of self-harm. 6. Implement training for recognition of at-

risk behavior and delivery of effective treatment. 7. Develop and promote effective clinical

and professional practices.

8. Improve access to, and community and

linkages with, mental health and substance

abuse services. 9. Improve reporting and portrayals

of suicidal behavior, mental illness , and

substance abuse in the entertainment and

news media 10. Promote and support research on

suicide and suicide prevention.

11. Improve and expand surveillance systems.

The end