Suicidal patient- assessment
Suicide can be defined as intentional self inflicted death
Suicide is a rare event Between 3.5 and 5 % of adults reported suicidal thoughts in the last year but only 0.5 % to 0.7 % actually made an attempt to end life ( US, UK date -BMJ 2017 ) In UK one in 5 adults has considered suicide at some time and one in 15 has attempted suicide Suicide prevention is a priority Approximately 6000 people take their own life each year in the UK ( NICE 2018 ) Patients would have sought help from health-care professions for eg ○ approximately 50 % of those who take their own lives will have seen a GP in the 3 months before death ○ 40 % in the month beforehand ○ around 20 % in the week before death National Confidential Inquiry into Suicide and Safety in Mental Health October 2018 Few points to note Report looks at data from 2004- 2014 Suicide rate follow different patterns between countries and varies also within each country Highest rate is in men in middle age Crisis services providing an alternative to hospital admissions are an established part of mental health services now ( CRHT- crisis resolution / home treatment teams ) Commonest suicide method is hanging , self poisoning the second most ( opiates being the most common drug ) Jumping from a height or in front of a train is the 3rd most common Economic factors are becoming more common as antecedents in patient suicides Certain risk factors have become more common – they include ○ isolation ○ economic adversity ○ alcohol and drug misuse ○ recent self harm
risk factors-Current or previous history of psychiatric disorders particularly ○ mood disorders ○ alcohol / substance misuse ○ post-traumatic stress disorder ○ personality disorders eg borderline PD , antisocial PD , Obsessive compulsive PD ○ psychotic disorders eg schizophrenia People with depressive disorder have the highest risk Attempted suicide – those who self- harm have a much greater risk of dying from suicide About 50 % of those who died of suicide had made at-least one previous attempt Persistent insomnia Demography More males commit suicide than females bimodal peak in men- early 20s and then 45 years single, separated or divorced living alone low socio-economic status Occupation higher among unemployed physicians are at higher risk than non-physicians Vets , pharmacists , farmers Co-morbidities eg malignancy , heart disease , COPD , chronic painful illnesses Epilepsy- particularly temporal lobe epilepsy Peptic ulcer and gastric ulcer disease Genetic – eg family history of suicide or self-harm Recent discharged from a psychiatric inpatient unit ( first 3 months in particular ) Exposure to suicidal behaviour of others either directly or via media Recent loss or other significant negative event Menstrual cycle ( phases with low oestrogen levels ) and women who suffer with pre-menstrual syndrome , pregnancy
Protective factors- Internal – for eg ability to cope with stress Skills in problem solving , coping and conflict resolution Cultural , spiritual and religious connections and beliefs Identification of future goals sense of belonging , sense of identity and good self esteem External – eg responsible for children ( particularly young children ), pets positive therapeutic relationships eg support via ongoing medical and mental health care relationships social support marriage acts as protective factor easy access to variety of clinical interventions and support for seeking help restricted access to highly lethal means of suicide eg firearms
Assessment –Assess face to face where ever possible Listen and show interest and support Pay attention to how patient behaves and what emotions they project onto you Directly question about suicide ( see examples ) Be non-judgmental Be empathetic – share your concern about their safety Do not make decisions for the patient Inform , discuss alternatives Involve the patient in decision making Speak to patients friends , relatives
Threatening to harm or end one’s life Seeking or access to means : seeking pills , weapons or other means Evidence or expression of a suicide plan Expressing ( writing or talking ) ideation about suicide wish to die or death Hopelessness Rage , anger , seeking revenge Acting reckless , engaging impulsively in high risky behaviour Expressing feelings of being trapped with no way out increasing or excessive substance misuse withdrawing from family friends or society Anxiety , agitation , abnormal sleep ( too much or too little ) Dramatic mood change Expresses no reason for living , no sense of purpose of life
Precipitating events –Major depressive episode Recent job loss Recent bereavement or separation / end of relationship Problem with law enforcement agencies eg imprisonment or threat of imprisonment Financial pressure eg DWP assessments Interpersonal problems – particularly humiliating social events School or work problems Unwanted pregnancy Recent life threatening diagnosis for eg cancer Social media / Games
These are some of the questions to assess if someone is at risk of committing suicide. Direct inquiry concerning suicidal ideation in patients with risk factors is associated with more effective treatment and management. Asking about suicide will not make patients more likely to harm themselves
In the past weeks have you wished you were dead ? In the past weeks have you felt that you or your family would be better off if you were dead ? Have you ever thought that life was not worth living ? Did you ever wish you could go to sleep and just not wake up ? Have you ever tried to kill yourself ? how/ when Have you done anything to prepare for ending life – eg writing a will ? Is there anything that would make life worth living ? What stops you from killing yourself ? Are the thoughts of ending your life becoming more intrusive and intense? Do you feel hopeless ? Are there any feelings of shame or guilt or worthlessness?
Risk factors are often divided into dynamic , static or stable Weighing up all these factors can be complex Attempts to produce algorithms to predict risk based on risk factors have not been successful Usually multiple risk factors contribute to suicide
Crisis team referral / advice – check transport Urgent psychiatric referral Primary care follow up Safety plan-Clear advice when/ how/ where to seek help Is the patient safe to go home ? Is mental health act assessment required ?
Negotiate a management plan and pay attention to documentation
References Risk and Protective factors for Suicide and Suicidal behaviour A Literature Review Revision notes in Psychiatry – Basant K Puri et al Hodder Education Suicide and suicide risk factors : A literature review Masango SM et al SA Fam Pract 2008 ; 50 (6) : 25-28 Exploring thoughts of suicide BMJ 2017 ; 356:j1128 Suicide Risk – A Guide for Primary Care and Mental Health Staff by Sarah Matthews and Roger Paxton Newcastle and North Tyneside and Northumberland Mental Health NHS Trust 2001 Assessment of suicide risk in people with depression Centre of Suicide Research , Department of Psychiatry , University of Oxford Suicide Risk Assessment Guide A Resource for Health Care Organizations Ontario Hospital Association National Confidential Inquiry into Suicide and Homicide by People with Mental Illness Annual report and 20-year review , October 2016 Suicide risk assessment and management by Dr Shahnaz Russ and Dr Andreas Russ May 2016 GP Online Evaluation and Treatment of the Suicidal Patient Am Fam Physician 2012 Mar 15;85(6) :602-605