"Chronic Versus Acute Suicide Risk" "Because patients with depressive disorders present with a wide range of symptoms and severities in a constantly changing environment of stresses and supports, their suicide risk may fluctuate over the course of illness from a chronic high risk state of severity requiring long-term preventive treatment to an acute high risk state requiring some form of immediate clinical intervention. Thus, assessment of acute suicide risk can be viewed as a process that must be repeated depending on the patient's clinical situation. The suicide assessment process should lead to a decision as to whether the patient is at a chronic high risk of suicide, acute high risk of suicide, or no increased risk of suicide at this time." Fawcett J, p.257, Textbook of Suicide Assessment and Management, American Psychiatric Publishing, February, 2006
Most of these facts are taken from psychological autopsy reports.
Robins, E 1981: 50% to spouses, 40% to coworkers Reuneson, B, Suicide Life Threat Beh 1992
It is estimated that there are 25 attempted suicides for each death by suicide. (Ratio implies 730,000 suicide attempts annually in USA).
In a study investigating the potential risk of screening for mental health problems, high school students were randomly assigned to 2 groups, one who received a survey with suicide questions (experimental group) and one who did not (control group). Distress levels after the survey were no different between the two groups. Two days later both groups were measured again with the same survey that included the suicidal questions. There were no differences in the report of suicidal ideation in the exposed or unexposed groups. "High- risk students" (defined as those with depression symptoms, substance use problems, or any previous suicide attempts) in the experimental group were neither more suicidal or distressed than "high-risk youth" in the control group: on the contrary, depressed students and previous suicide attempters in the experimental group appeared less distressed and suicidal than high-risk youths in the control group. Gould et al, JAMA (2006).
After psychiatric hospitalization for depression, the days immediately following discharge are the highest risk for suicide and it diminishes gradually over the year. Fawcett et al, Am J Psychiatry, 1990 Hoyer et al, J Affect Disord, 2004 Qin and Nordentoft, Arch Gen Psychiatry, 2005
Although it is true that suicide as an outcome is highest in the first years of an illness like Major Depression (Isometsa et al, 1994, Angst, 2004 and 2005), it still can occur every time the patient has a recurring depression. Those who are the most suicidal and complete suicide while depressed are removed from the pool of potential suicides, so the frequency of the event goes down. Still, it happens.
From studies, although their can be triggering events before a suicide in a person with depression, the most important issue is to identify the depressive disorder and get adequate and aggressive treatment. In patients with a diagnosis of chronic alcoholism who commit suicide (usually later in their illnesses) acute interpersonal losses play a more important role. Murphy G, Suicide in Alcoholism, Oxford Press, 1992. Use of alcohol (or drugs) can play a role in suicide, because of the disinhibition it causes.
1972-1990 (18 years) Month Average Percent January 75.27 97.4 February 76.66 99.3 March 79.83 103.3 April 80.12 103.7 May 79.45 102.9 June 78.49 101.6 July 78.52 101.6 August 78.30 101.4 September 77.50 100.3 October 76.03 98.4 November 75.00 97.1 December 71.63 92.8 Accurate to the decimal places shown.
These are only a few of the screening instruments. They are usually short, simple questions that unveil depression, alcohol or substance use, and other disorders like anorexia or bulimia. With the first, it is used in high schools, after parental consent and on a day when a counselor is present to refer those in highest distress to appropriate care. With the second, it is done anonymously over a website and can only be used if there is an appropriate counselor available to respond. The others are general depression screening usually done at health centers or designated health care sites around the country on a specific day. October is Depression and Mental Health Month. *Dr. Douglas Jacobs, Associate Clinical Professor of Psychiatry at Harvard Medical School founded and is the Executive Director of Screening for Mental Health, Inc. and founded and directs National Depression Screening Day. Since 1991, the program has provided free nationwide depression screenings each October during Mental Illness Awareness Week. Many mental health web sites, like DBSA or NAMI also have screening instruments for individuals to take to see if they had suffering from specific disorders. The most frequently used screening instrument to recognize depression is the PHQ-9 (online). It will be part of a large New York City campaign in the summer of 2006 to identify and treat people with depression.
Psychiatricemergency• DIFINITION:- It is a condition where patients has a disturbances of thought, affect and psychomotor activity leading to a threat to his existence (suicide) or threat to other people in the environment (homicide) with himself.
Common Psychiatric emergencies1. Suicidal threat2. Violent/aggressive behaviour/excitement3. Panic attacks eg snake4. Hysterical attacks5. Transient situational disturbances eg. Earth quake6. Epileptic furor7. Drug toxicity8. Victims of disaster9. Rape victim10. grief
DEFINITION’SSuicide:-• It is a type of deliberate self-harm.• It is defined as an international human act of killing one self.Suicidal client:-The person who is more proneto kill himself & had one ormore suicidal attempt
• Attempted suicide:- person try to kill own self but not succeed. More by women • Completed suicide:- person kill own self successfully. More by men.
Suicidal tendencies in psychiatric ward1. Major depression:- Suicide is a major depressive episode is due to-• Persistent sadness• Pessimistic cognition to past, present & future• Delusion of guilt• Helplessness , hopelessness & worthlessness• Derogatory voices urging him to take his life.
•Risk of suicide more when acutephase is passed & psychomotorretardation has improved b,cozpatients have more energy.
2.schizophrenia• Because of hallucination & delusion schizophrenic patients see suicide as areasonable alternative.
3.mania:-• Result of grandiose ideation.• Patient may believe he is a great person or wish to prove his supernatural powers.• Because of this he may carry out some dangerous activity that can cost him his life.• Eg. Jesus, lord Krishna,• superman
4.Drug or alcohol abuse• Suicide among alcoholics can be due to depression in the withdrawal phase. • Loss of friends, family, self respect, status & a general realisation of that aspect can cause the individual to with to die.
5.Personality disorder:-• Individual with histrionic & borderline traits may occasionally attempt suicide.• But their success rate is low.
6.Organic condition:-• Delirium & dementia due to changes of mood like anxiety & depression may attempt suicide.
2.Physical disorders:- patients with incurable or painfulphysical disorder like cancer & AIDS Severe pain BURN
3. PSYCHOSOCIAL FACTOR• Failure in examination • Loss of loved object • DEATH OF LOVED REALATIVE
• Dowry harassment • Marital problemsIsolation & alienation of society • Financial & occupational problems
1.AGE:-• Male above 40 yrs of age• Female >55yrs of age2. sex:-• Men have greater risk of completed suicide• Women have higher rate of attempted suicide• Suicide is 3 time more common in men than women• Successful suicide number about 70% men & 30% women
CONTD….3. Marital status:-• Twice in single person than of married person• Being unmarried, divorced, widowed or separated have 5-6 time more risk.
4.Socioeconomic status:-• Acc to SADOCK & SADOCK “highest & lowest class individual have high rate than middle class• Occupation related suicide is higher among artists, law enforcement officers, lawyer & insurance agents.• health-related occupations higher (dentists, doctors, nurses, social workers) especially high in women physicians
• History of childhood trauma or abuse, or of being bullied• Family history of death by suicide• Being unemployed• Retired Occupation
1.Education:-A.Individual and Public Awareness:-•Primary risk factor for suicide ispsychiatric illness as aware about it.•Teach depression is treatable so noneed to take stress or think deeply.•Try to deestimate the illness.•Destigmatize treatment•Encourage health seeking behavior &continuation of treatment.
B. Professional Awareness:-• Healthcare professional – physician, pediatrician, nurse practiceners etc.• Mental health professional – Psychologist, social workers etc.• Primary & secondary school staff – Principle, teacher, counselors, nurses• College & university resource staff – Counselors, student health services, student residence services
Contd…..• Gatekeepers• Religious leader ,• police,• fire departments,• armed services.
2.Screening:-•Identify At Risk Individuals•Identify the patient who have high prone mentaldisease R/T suicide•Identify the “WARNING SIGNS OF SUICIDE’’
Warning signs of suicide:-• Suicidal threat• Writing farewell letters• Giving away treasured articles• Making a will• Closing bank account• Appearing peaceful happy after a period of depression• Refusing to eat /drink• Refusing to maintain personal hygiene
3. MEANS RESTRICTIONS:-• Fire alarm safety• Construction of barriers of jumping sites• Detoxification of domestic gas• Restriction on pesticides• Reduce lethality or toxicity of prescription – Use lower toxicity antidepressants• Restrict sales of lethal hypnotics e.g. barbiturates
4.Mediaa)Media Guidelines•Encourage implementation ofresponsible media guidelines forreporting on suicide.
b) Media Considerations Consider how suicide is portrayed in the media TV Movies Advertisements The Internet danger Suicide chat rooms Instructions on methods Solicitations for suicide pacts.
Antidepressants Adequate prescription treatment and monitoring Only 20% of medicated depressed patients are adequately treated with antidepressants – possibly due to: Side effects I.Lack of improvement II.High anxiety not treated III.Fear of drug dependency IV.Didnt combine with psychotherapy V.Dose not high enough VI.Didnt add adjunct therapy such as lithium or other medication(s) VII.Didnt explore all options including: ECT or other somatic treatment
Psychotherapy:-• Specifically designed to treat depression• Relatively short term(10-16 WKS)• Structured – It should be step by step treatment instructions that any other therapist can easily follow• E.g. – Cognitive behaviour therapy(CBT) – Interpersonal therapy (IPT) – Dialectical behaviour therapy (DBT)• Implement teaching of these techniques
Initial approach during emergency:-• warm, direct & concerned.• Quick evaluation to identify the condition• Care on the basis of seriousness is essential• Emergency staff should have basics knowledge of handling psychiatric emergency.
• Medico legal cases need to be registered separately & informed to concerned officers Security should be adequate to control violent & dangerous patients
• Findings should be recorded in emergency file.• Patient condition & plans of management should be explained in simple language to patient & family members
1. monitoring the patient safety need• Take all suicidal threats or attempts seriously & notify to psychiatrist.• Remove toxic agent like drugs/alcohol• Donot leave medication tray within patient reach.• Make sure that daily medication swallowed.• Remove sharp instrument
• Contd…• Remove straps & clothing like belts, necktie etc.• Do not allow the patient to bolt his door on the inside.• Make sure somebody accompanies him to the bathroom• Constant observation & should not be alone• Good vigilance especially morning hours• Spend time to him, talk to him & allow him to ventilate his feelings.
Contd….• Encourage him to talk about his suicidal plans/method• If suicidal tendencies are very severe, sedation should be given.• Enhancing self-esteem of the patients by focusing on his strengths & positive qualities than weakness.
2.Mangement of attempted suicide in the IPD• Assess for vitals, check airway• If pulse weak start IV fluids• Turn patient head & neck to one side to prevent regurgitation & swallowing of vomitus.• Emergency measures to be instituted in case of self-inflicted injuries.
3.Management of shock:-• Transfer the patient to medical centre immediately• It there is no evidence of life leave the body in the same position/room in which it was found.• Patient has attempted suicide By jumping, do not leave the body in a place which is visible to other patient af the ward.• Inform authorities, record the incident accurately
• Contact local guardian & inform them• Hand over the patient properties to the concerned authorities/relatives.• Senior staff should discuss with all staff about passive lapse & preventive measure that need to be undertaken.