1) The document outlines the approach to assessing and treating patients with suicidal tendencies. It discusses conducting a thorough psychiatric evaluation, specifically inquiring about suicidal thoughts and plans, establishing a diagnosis, estimating suicide risk, and considering different treatment settings and therapies. 2) The psychiatric evaluation involves assessing the patient's history, mental state, and direct questions about suicidal ideation and behaviors to identify risk factors. Tools like the SSI and C-SSRS can also help assess suicide risk. 3) Treatment may involve medications like antidepressants, lithium, antipsychotics and ECT as well as psychotherapies like CBT to target underlying issues and reduce suicide risk. Constant monitoring of high-risk patients is important

1. APPROACH TO A PATIENT
WITH SUICIDAL TENDENCY
ABHIMANYU SINGH
JUNIOR RESIDENT

2. OVERVIEW
• Core of the suicide assessment is the
psychiatric evaluation
• Patients history, current circumstances,
mental state and direct questioning about
suicidal thinking and behaviors are asked

3. • This evaluation also involves identifying
specific factors that may increase or decrease
the potential risk for suicide or other suicidal
behaviors

4. This evaluation is important in addressing:
 Patient’s immediate safety
 Determining the appropriate treatment
setting
 Developing a multiaxial differential diagnosis
that will further guide the planning of
treatment

5. CONDUCT A THOROUGH PSYCHIATRIC
EVALUATION
Core element. It involves:
1. Identify specific psychiatric signs and symptoms
2. Assess past suicidal behavior, including intent of
self-injurious acts
3. Review past treatment history and treatment
relationships

6. 4. Identify family history of suicide, mental
illness, and dysfunction
5. Identify current psychosocial situation and
nature of crisis
6. Appreciate psychological strengths and
vulnerabilities of the individual patient

7. 1. Identify specific psychiatric signs and
symptoms
• Assess mood, anhedonia, hopelessness,
anxiety (level of symptoms/panic attacks),
agitation, global insomnia, fearfulness,
aggression, violence toward others, and
impulsiveness

8. 2. Assess past suicidal behavior, including
intent of self-injurious acts
• Obtain details about the precipitants, timing,
intent, consequences as well as the potential
lethality of the attempt

9. Also, assess patient’s thoughts about the
attempt which includes:
• Ones own perception of the chosen method’s
lethality
• Ambivalence toward living, visualization of
death,
• Degree of premeditation
• Persistence of suicidal ideation, and reaction
to the attempt

10. 3. Review past treatment history and treatment
relationships
• It can help in identifying medically serious
suicide attempts
• Also, about the status of past or current
medical diagnoses that may be associated
with augmented suicide risk.

11. 4. Identify family history of suicide, mental
illness, and dysfunction
• Includes details of family conflict or
separation, parental legal trouble, family
substance use, domestic violence, and
physical and/or sexual abuse
• As, many aspects of family dysfunction might
linked to self-destructive behaviors

12. 5. Identify current psychosocial situation and
nature of crisis
• Detect any financial or legal difficulties,
interpersonal conflicts or losses, stress related
to housing problems, job loss, educational
failure
• Their understanding also helps in mobilizing
external supports, which can have a protective
influence on suicide risk.

13. 6. Appreciate psychological strengths and
vulnerabilities of the individual patient
• May include factors as coping skills,
personality traits, thinking style, and
developmental and psychological needs.

14. SPECIFICALLY INQUIRE ABOUT
SUICIDAL THOUGHTS, PLANS, AND
BEHAVIORS
• It is essential as, the more an individual has
thought about suicide, has made specific
plans for suicide, and intends to act on those
plans, the greater will be the risk

15. 1. Elicit the presence or absence of suicidal
ideation (one of essential component )
• At enquiry, it is important to focus on the
nature, frequency, extent, timing of suicidal
thoughts and to understand the
interpersonal, situational, and symptomatic
context in which they are occurring

16. • Often helpful to begin with questions that
address the patient’s feelings about living
• E.g.-“How does life seem to you at this
point?” or “Have you ever felt that life was not
worth living?” or “Did you ever wish you could
go to sleep and just not wake up?”

17. • If the patient’s response reflects
dissatisfaction with life or a desire to escape
it, then more specific questions about
whether the patient has had thoughts of
death or suicide are asked

18. • Even if the patient initially denies of thoughts
of death, then consider asking additional
questions
• Examples might include asking about plans
for the future or about recent acts or thoughts
of self-harm.

19. 2. Elicit the presence or absence of a suicide
plan
• If suicidal ideation is present, then detailed
information about specific plans for suicide
and any steps that have been taken toward
enacting those plans

20. • Some suicidal acts can occur impulsively with
little or no planning, more detailed plans are
generally associated with a greater suicide risk

21. • If the patient reports that he or she is unlikely
to act on the suicidal thoughts, factors are
contributing to that expectation, as such
questioning can identify protective factors.

22. • Whether or not a plan is present, if a patient
has acknowledged suicidal ideation, there
should be a specific inquiry about the
presence or absence of various means of
suicide including firearm in the home or
workplace

25. 3. Assess the degree of suicidality, including
suicidal intent and lethality of plan
• Regardless of whether the patient has
developed a suicide plan, the patient’s level of
suicidal intent should be explored
• In general, the greater and clearer the intent,
the higher the risk for suicide will be.

26. • Suicidal intent reflects the intensity of a
patient’s wish to die and can be assessed by
determining the patient’s motivation for
suicide as well as the seriousness and extent
of his or her aim to die, including any
associated behaviors or planning for suicide.

27. • The lethality of the plan can be ascertained
through questions about the method, the
patient’s knowledge and skill concerning its
use, and the absence of intervening persons
or protective circumstances

28. ESTABLISH A MULTIAXIAL DIAGNOSIS
• Studies have shown that more than 90% of
individuals who die by suicide satisfy the
criteria for one or more psychiatric disorders.
• Hence, look whether a patient has a primary
axis I or axis II diagnosis.

29. • Identification of physical illness (axis III) is
essential since such diagnoses may also be
associated with an increased risk of suicide
• Also crucial in determining suicide risk is the
recognition of psychosocial stressors (axis IV),
which may be either acute or chronic

30. • It is crucial to consider the perceived
importance and meaning of the life event for
the individual patient
• As the final component of the multiaxial
diagnosis, the patient’s baseline and current
levels of functioning are important to assess
(axis V).

31. ESTIMATE SUICIDE RISK
The goal is to identify factors:
• That may increase or decrease a patient’s level
of suicide risk
• To estimate an overall level of suicide risk, and
• To develop a treatment plan that addresses
patient safety and modifiable contributors to
suicide risk.

36. TOOLS FOR SUICIDE ASSESMENT
• Scales for suicidal ideation (SSI)
• Columbia-suicide severity rating scale (C-SSRS)
• Sad persons scale
• Becks suicidal intent scale

37. • The estimation of suicide risk, at the
culmination of the suicide assessment, is the
essential clinical judgment, since no study has
identified one specific risk factor or set of risk
factors as specifically predictive of suicide or
other suicidal behavior

38. TREATMENT SETTINGS

41. GENERAL CONSIDERATIONS
• Strict vigilance of the suicidal patient
• Every possible means related to suicide should
be out of the reach to the patient
• Medication must be monitored and given by
family members
• Empathic listening, encouragement, support
should be provided to the patient

42. GENERAL CONSIDERATIONS
• Involvement of the family is important
• Psychoeducation to the patient and their
family is important

43. GENERAL CONSIDERATIONS
• Psychoeducate that psychiatric disorders are
real illnesses
• Effective treatments are both necessary and
available may be crucial for patients who
attribute their illness to a moral defect

44. GENERAL CONSIDERATIONS
• Psychoeducate about the role of psychosocial
stressors and other disruptions in precipitating
or exacerbating suicidality or symptoms of
psychiatric disorders

45. GENERAL CONSIDERATIONS
• Education regarding available treatment
options will help patients make informed
decisions, anticipate side effects, and adhere
to treatments.
• Patients also need to be advised that
improvement is not linear and that recovery
may be uneven.

46. GENERAL CONSIDERATIONS
• Some family members, particularly those of
patients with BPD, mistakenly view suicide
attempts as “manipulative” or “attention-
seeking” behaviors.
• Help family members learn ways to respond in
a helpful and positive manner when the
patient is experiencing a suicidal crisis.

47. TREATMENT
SOMATIC THERAPIES
• Antidepressants
• Lithium
• Antipsychotics
• Mood-stabilizing agents
• Sedative-anxiolytics
• ECT
PSYCHOTHERAPY

48. ANTI-DEPRESSANTS
• Mainstay of the treatment of patients
suffering from anxiety and depressive illness
• Nontricyclic, non-MAOI antidepressants are
relatively safe
• Although the tricyclic antidepressants and
MAOIs are much more toxic in overdose, but
useful in patients not responding to SSRI

49. • Encouragement to life and monitor especially
closely in the initial days of treatment
• During initial, partial recovery, it is possible
that suicidal impulses as well as the energy to
act on them may increase
• Patients should be forewarned of this and
likely delay in treatment effects.

50. LITHIUM
• Strong and consistent evidence that it helps in
major reductions in risk of both suicide and
suicide attempts

51. MOOD STABILIZING AGENTS
• No established evidence of a reduced risk of
suicidal behavior with any other “mood-
stabilizing” anticonvulsants

52. ANTIPSYCHOTIC AGENTS
• the antipsychotic medications have been the
mainstay of somatic treatment for suicidal
patients with psychotic disorders.

53. ANTI-ANXIETY MEDICATIONS
• Since anxiety is a significant and modifiable
risk factor for suicide, utilization of antianxiety
agents may have the potential to decrease this
risk.

54. ELECTROCONVULSIVE THERAPY(ECT)
• ECT is used to treat patients who are acutely
suicidal, considered for patients for whom a
delay in treatment response is considered life-
threatening
• Efficacy of ECT is best established in patients
with severe depressive illness, manic or mixed
episodes of bipolar disorder, schizoaffective
disorder, or schizophrenia

55. PSYCHOTHERAPIES
• In addition to medications and ECT,
psychotherapies play a central role in the
management of suicidal behavior in clinical
practice

56. • Cognitive behavior therapy, dialectical
behavioral therapy, psychodynamic therapy,
and interpersonal psychotherapy have been
found effective in clinical trials for the
treatment of various disorders

57. • By targeting deficits in specific skills, such as
emotional regulation, impulse control, anger
management, and interpersonal
assertiveness, these therapies helps in
reducing suicide attempts

58. THANK YOU