Suicidality: Assessment & Management

Transcription

1 Suicidality: Assessment & Management Dr Larkin Feeney Consultant Psychiatrist Cluain Mhuire Community Mental Health Service ICGP Spring Study Sessions IMI 12/04/12

2 CSO latest suicide statistics 2009 record % up on suicides (386 men) Increase in suicide among males ,966 self-harm presentations to EDs in % female, 50%<30

3 Ireland s response Reports, NOSP, limited service improvements, voluntary groups... HSE Clinical Programme for the Management of Self Harm presenting to Emergency Departments

4 Preliminary thoughts Should we be talking about suicide? Too much talk about talking Language confusing

5 Cause of Suicide? Complex & multifaceted Not just a health issue Can be just mental illness or no mental illness Commonly: Susceptibility + Stress + Precipitating incident + Intoxication event

6 Ireland Methods CSO OTHER 5% GUN 8% POISON 17% DROWNING 20% HANGING 50% Access is an issue

7 Preventing suicide Population based strategies Anti poverty, pro social-inclusion measures Reduce access to means Reduce alcohol/drug availability Education, training, anti-stigma measures Lithium in the water supply? Develop services for high risk groups Mental illness, self-harm, substance misuse Elderly, certain occupations Marginalised, bereaved Prisoners, asylum seekers Individuals

8 Role of the GP Support population based measures Explore suicide risk where appropriate Identify individuals at high risk Identify addressable risk factors Help manage addressable risk factors Help families and others to deal with the consequences of a suicide

9 How to ask about suicide How bad does it get? Do you ever wish it was all over? Have you thought about suicide? How close have you come? How would you do it? Have you made any preparations? When might you do it?

10 Assessing risk Remember that many who die by suicide have very few risk factors Need to find out what is happening in the person s life to have caused them to contemplate suicide Need to get a sense of what they are like normally Need to explore level of intent Need to examine individual risk factors Need to explore what can be done to alleviate the current situation

11 Following self-harm? Chronological account of the day before (event by event) Circumstances of formation of intent Reason suicide attempt failed Note or final acts Took precautions to avoid discovery Attitude to survival ambivalence? Healthy scepticism in both directions!

12 Risk Factors Static Previous parasuicides Male gender No partner Unemployment or certain professions History of childhood abuse Family history of suicide Personality factors Impulsivity, risk taking behaviour Poor problem solving skills Antisocial behaviour, hostility to others Self-isolating

13 Risk Factors - Dynamic Mental illness Alcohol or drug addiction Recent psych admission/discharge Poor social supports Poverty /debt Bereavement/ Relationship difficulties/ Shame/ Humiliation Work stresses /bullying Poor physical health Access to means Recent suicide of person known to them or in a media personality Prison/ sex-offence / fraud

14 Mental State Examination Mood hopeless/guilty/failure/sleep/weight Psychosis bizarre ideas/hallucinations Agitation hostility, aggression Withdrawal silence preoccupation Suicidal thinking/planning The patient makes you feel uneasy

15 What to do once risk identified? Do they need psychiatric admission? High intent, psychiatrically ill If not do they need urgent psychiatric assessment Unclear intent,?psychiatrically ill Can they be managed in primary care? Intent not imminent, addressable precipitants & stressors, identifiable supports

16 Managing risk in primary care 1 Tell patient that you will try to help Early reassessment Plan for what to do if risk increases Plan for addressing dynamic risk factors Alcohol/drugs/mental illness/access to means/ pain/social factors etc.

17 Managing risk in primary care 2 Use resilience factors Job/ family/ relationships/ interests/ spirituality Involve family or others in plan Give information Counselling/Support groups/samaritans

18 What can be done in secondary care? Management of major mental illness Crisis admission to safer environment in situations of high risk Little evidence of effectiveness in the absence of major mental illness Coordinated multidisciplinary input Specific programmes in some centres for emotionally unstable (borderline) personality disorder dialectical behavioural therapy (DBT)

19 If Patient is high risk & mentally ill but will not see a psychiatrist Seek advice Involve family You may need to consider involuntary admission

20 Antidepressants and suicide? Controversial and emotive Best advice is to be cautious and to advise regarding possible risks

21 After a suicide Assisting the bereaved Console ( Help prevent contagion Addressing your own response

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