Suicide assessment and management guidelines


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Suicide assessment and management guidelines

  1. 1. Jayesh patidarSuicide Assessment andManagement
  2. 2. IntroductionSuicide appears to occur when a mental Disorder is present,Intent develops and Means become available. The majority of those who commit suicide have toldsomeone beforehand of their thought; two thirds have seentheir GP in the previous month. A quarter are psychiatric outpatient at the time of death, halfof them will have seen a psychiatrist in the previous
  3. 3. General Approach to Intervention Conduct a thorough assessment to identify disorder, intentand risk factors. Take steps to mitigate or eliminate identified risk factors andmeans. Strengthen barriers to suicide and its means. Treat the associated
  4. 4. When Should Suicide Assessment be Conducted?• First assessment on any patient with a mental illness orsubstance abuse diagnosis.• When a patient experiences sadness, low mood, recent lossor hopelessness, and at each subsequent session as long as thepatient remains at risk.• Any time a patient has any other identified potential
  5. 5. Dimensions of Assessing Suicide? Elicitation of suicidal ideation Identification of risk factors for suicide. Weighing of risk
  6. 6. Overview of ideation assessment.• Be sensitive to the different cultural views regarding suicide• At minimum, ask directly for presence and nature of suicidalthoughts, including frequency, intensity, circumstances &characteristics.• Determine if there is current intent or a plan• Ask for plan details, including rehearsals• Assess availability and lethality of means• Determine if theres a history of thoughts, wishes, impulses or attempts• Assess attitude, beliefs and values about suicide• Determine if anything is different this time that will raise or lower risk• Determine if patient shared ideation with anyone• Identify any support person who might be helpful in reducing the risk.NB:Available assessment tools, such as the Scale for Suicide Ideation (SSI) or BeckScale for Suicide Ideation (BSS)
  7. 7. Assessing Suicidal Ideation 1• The assessment of suicidal ideation proceeds along a gradient, from least to most severe, witha specific line of inquiry as part of the assessment of mental status:• Beginning with general questions about how patient sees the future, the meaning and worth oflife, and any consideration of self-harm.• The interviewer should ask whether thoughts of death or suicide have occurred; if so,how often, how persistently and with what intensity?• Are they fleeting, periodic or constant? Are they increasing, decreasing orremaining constant?• Do they occur under specific circumstances?• Thoughts should be characterized as passive (e.g.,“I would be better off dead”) or active(e.g.,“Sometimes, when I am driving my car, I get the impulse to drive into other cars.”)• Any thoughts noted should then be elaborated upon using the patient’s own language.Specifically, what are the thoughts content?• The patient should be asked whether there is current intent /impulse, and if so, is there aplan?• Details of the plan (method, time and place) should be reviewed and documented in theclinical record.• The patient should be asked about whether any rehearsal (mental or through action) hastaken place and whether there have been any attempts made thus far.• Past history of similar thoughts, wishes, impulses, plans or attempts should be
  8. 8. Assessing Suicidal Ideation 2• The patient with a plan should be asked about the availability of meansand/or whether there is a plan/intent to obtain any means (e.g., plan topurchase a gun).• As part of the evaluation, the interviewer should determine the patient’sattitude toward suicide, which may range from acceptance of its inevitabilityor desirability (ego syntonic) to ambivalence or rejection (ego dystonic).• The patient should be asked about barriers to suicide.• What are the reasons for living and those for dying?• What has prevented the patient from carrying out the act, or• How has s/he managed to evade the act of suicide thus far?• Is there anything different now or anticipated to be different in the near future?• Has the suicidal ideation been shared with anyone else besides thetherapist?• Who has been or could be helpful in managing the ideation?• This will allow for the involvement of family and/or significant others.who can can assist in obtaining data about the patient and provide containmentand feedback during treatment, as part of the safety plan, but suchcollaboration should be with the patient’s
  9. 9. Suicide Risk Scale: Sex: men kill selves 3x more frequently than women. Age: greater risk among 19 yrs or younger, and 45 yrs or older. Depressed: 30x more than non-depressed. Previous attempters: 64x that of general population. Ethanol abuser: about 15% of alcoholics commit suicide. RationalThinking loss: psychosis, mania, depression or OBS. Social support lacking: especially a recent loss of support. Organised plan: either directly or indirectly communicated. No spouse: single, divorced, widowed or separated. Sickness: severe, chronic or debilitating illness.Scoring: One Point is scored for each factor present –0-2 allow home with follow up3-6 consider hospitalisation depending on confidence in follow-up.7-10 suggests either hospitalisation or
  10. 10. Other Identified Risk Factors:Patients are at greater risk for suicide if they: Have had psychiatric hospitalization within the past year• Have had a recent or impending loss• Have a history of impulsive or self destructive behavior• Have committed violence in the past year• Have access to guns• Have a family history of suicide• Are socially isolated• Have a chronic, terminal or painful medical disorder• Are newly diagnosed with serious medical problems• Are male age 65 or older• Have lost a child either to suicide or in early childhood• Have a history of physical or sexual abuse in childhood. Top High risk Diagnosis for completed suicides Depression, especially with psychic anxiety, agitation and/or significant insomnia Bipolar disorder Alcohol and substance use disorders Schizophrenia Borderline personality
  11. 11. Assessment following an attempt After an act of para-suicide, it important to determine the degree of suicidal intentexisting at the time: What is the explanation for the attempt in terms of likely reason(s) and goal(s)?. Does patient intent to die now? What problems confront the patient? Is there psychiatric disorder and if so how relevant is it to the attempt What are the patient’s coping resources and support? What kind of help might be appropriate, and is the patient willing to accept suchhelp? A high degree of suicide intent is indicated by the following: Planning beforehand Precaution taken to avoid discovery No attempt made to seek help afterwards A dangerous method was used: shooting, drowning, hanging. There was a final act: will, suicide note. Extensive premeditation Admission of suicidal
  12. 12. Documentation of assessment. The clinical record should reflect that the• suicide risk assessment has taken place,• what the findings are, and• what intervention plans are in place to contain, manage ormitigate the identified suicidal risk.• The ideation and risk, along with the positive and negativefindings, should be noted in the clinical record, either in themental status exam section or in a clinical
  13. 13. Management guidelines If there is serious risk, patient should be admitted, compulsorily if need be A good rapport should be established between patient and staff: So that patient will be able to articulate and express his or her feelings and suicidalthoughts.• A strong therapeutic alliance could enhance engagement between clinician andpatient thus enabling clinical interventions to reduce suicidal risk. Any potentially lethal implement (e.g sharp objects and belts), should be removed. Patient may need to be observed continuously and nursed in pyjamas (without acord) or a nightdress throughout the day. Any psychiatric disorder should be treated appropriately. The presence of pervasive anxiety with depression, thought disorder with persecutorydelusions and/or command hallucinations with schizophrenia should alert theclinician to the need for rapid symptom reduction and containment whether or notsuicidal ideation is acknowledged. For a severe depressive episode ECT may be required as this will act faster thanantidepressant treatment. Address any abuse of substances, in order to restore the patient to normal restraintand inhibition.
  14. 14. Maintenance Treatment Strategies• Address the abuse of substances in order to restore the patient to normal restraint andinhibition.• Assist with the strengthening of social resources through active involvement offamily/significant others in containment and Strengthen barriers and reasons for notcommitting suicide.• Maintenance treatment anxiety or agitation associated with depression and/or thoughtdisorder, if present.• Assist the patient in planning and taking steps to stabilize job and family situations that arein jeopardy.• Identify and address dangerous behavior that may represent suicidal intent.• Make lethality an acknowledged and targeted issue.• There are evidences supporting the efficacy of specific psychotherapies for suicidalpatients, such as cognitive-behavioral therapy (CBT), interpersonal psychotherapy (IPT)and dialectical behavioral therapy (DBT). It is, however, generally acknowledged that mostforms of psychotherapy may be useful, providing the therapist develops a strongtherapeutic alliance with the patient and conveys a sense of optimism and activity.• Inform and involve the patient’s primary care physician and other clinicians to increasecoordination of care across settings.• Employ family intervention to enhance effective family problem-solving and
  15. 15. Disposal from Emergency room after suicide attempt• RELEASE FROM EMERGENCY DEPARTMENTWITHFOLLOW-UP RECOMMENDATIONS MAY BE POSSIBLE• After a suicide attempt or in the presence of suicidal ideation / plan when:• Suicidality is a reaction to precipitating events (e.g., exam failure,relationship difficulties), particularly if the patient’s view of the situationhas changed since coming to emergency department• Plan / method and intent have low lethality• Patient has stable and supportive living situation• Patient is able to cooperate with recommendations for follow-up, withtherapist contacted, if possible, if patient is currently in treatment• OUTPATIENTTREATMENT MAY BE MORE BENEFICIALTHAN HOSPITALIZATION• Patient has chronic suicidal ideation and/or self-injury without priormedically serious attempts, if a safe and supportive living situation isavailable and outpatient psychiatric care is
  16. 16. Thank