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Assessment of suici dl al patients
 

Assessment of suici dl al patients

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    Assessment of suici dl al patients Assessment of suici dl al patients Presentation Transcript

    • ASSESSMENT OF SUICIDAL PATIENTS DR SALMAN KAREEM 1STYR POST GRADUATE RESIDENT DEPARTMENTOF 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 Medical Illness Impulsiveness Access To Weapons Hopelessness Life Stressors Family History Suicidal Behavior Personality Disorder/Traits Psychiatric Illness Co-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. (
    • 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/SubstanceAbuse/Dependence • Co-morbid Axis I Disorder • Mixed Drug Abuse Obsessive-Compulsive Disorder • Schizophrenia • Paranoid or UndifferentiatedType • 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.
    • SCHIZOPHRENIAAND 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 Assessment Psychiatric Illnesses Comorbidity, 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