A basic approach to a suicidal patient With Dr Joanne Ferguson, Staff Specialist Psychiatry and Addiction Medicine, Royal Prince Alfred Hospital Introduction Talking about suicide is regarded as one of the most stressful conversations that staff can have with patients. Patients who have expressed suicidality or thoughts of self harm to staff are often quite ambivalent and express fear and a sense of powerlessness about these thoughts, however they are often open to discussion. As a junior doctor you shouldn t be afraid to talk with patients about this. Case 1 - You are asked to review a patient on the ward who has told nursing staff he is having suicidal thoughts 1. What is your approach to the assessment of this patient? Assessing risk of suicide o The general consensus within the field is that there is no reliable way to predict suicide, nor does an assessment provide an accurate reflection on a patients risk for any prolonged period of time, and thus suicidality needs to be constantly reassessed o There are some warning signs and risk factors to help estimate risk Lower risk - e.g. occasional fleeting thoughts that life is too hard and they would be better off dead versus a patient who feels life is definitely not worth living and they would much rather be dead with plans of how to end their life Warning signs: things that may be predictive of suicide in the near future Planning to die, writing a note, selling business, sorting out finances Risk factors are associated with increased risk of suicide over the longer term Previously attempted suicide, social isolation, abused or neglected in childhood At risk mental status: depression, hopelessness, despair, agitation, shame, guilt, anger, psychosis including hallucinations and delusions Alcohol or drug intoxication or withdrawal Financial/legal difficulties including significant social losses 2. Assessment Need to assess details, lethality and any preparations of planning - as any degree of planning would require a much more acute response o Protective factors help balance the risk of suicide but do not mitigate it has to be the patient s identified protective factors not ones we think and should include: o Family support, love for family and children, ability to problem solve, coping strategies, cultural, social, spiritual and religious connections
Often people will be reassured when you talk with them about their resilience s and strengths o The assessment of suicide risk is based on identifying warning signs, risk and protective factors ISSUE HIGH RISK MEDIUM RISK LOW RISK At risk mental status - Depressed - Psychotic - Hopelessness, despair - Guilt, shame, anger, agitation - impulsivity Suicide attempt or suicidal thoughts - Intentionality - Lethality - Access to means - Previous suicide attempts Substance disorder - Current misuse of alcohol and other drugs Corroborative History - Family, carers - Medical records - Other service providers/sources Strengths and Supports (coping and connectedness) - Expressed communication - Availability of supports - Willingness/capacity of support persons - Safety of person and others Reflective practice - Level and quality of - Changeability of risk level - Assessment confidence in risk level E.g. Severe depression Command hallucinations or delusions about dying Preoccupied with hopelessness, despair, feelings of worthlessness Severe anger, hostility E.g. Continual/specific thoughts Evidence of clear intention An attempt with high lethality (ever) Current substance intoxication, abuse or dependence E.g. Unable to access information, unable to verify information, or there is a conflicting account of events to that those of the person at risk E.g. Patient is refusing help Lack of supportive relationships/hostile relationships Not available or unwilling/unable to help Low assessment confidence or high changeability or no rapport, poor E.g. Moderate depression Some sadness Some symptoms of psychosis Some feelings of hopelessness Moderate anger, hostility E.g. Frequent thoughts Multiple attempts of low lethality Repeated threats Risk of substance intoxication, abuse or dependence E.g. Access to some information Some doubts to plausibility of person s account of events E.g. Patient is ambivalent Moderate connectedness, few relationships Available but unwilling/unable to help consistently E.g. Nil or mild depression, sadness No psychotic symptoms Feels hopeful about the future None/mild anger, hostility E.g. Nil or vague thoughts No recent attempt or 1 attempt of low lethality and low intentionality Nil or infrequent use of substances E.g. Able to access information / verify information and account of events of person at risk (logic, plausibility) E.g. Patient is accepting help Therapeutic alliance forming Highly connected/good relationships and supports Willing and able to help consistently High assessment confidence/low changeability Good rapport, No (foreseeable) risk: Following comprehensive suicide risk assessment, there is no evidence of current risk to the person. No thoughts of suicide or history of attempts, has a good social support network (Suicide Risk Assessment and Management Protocols Community Mental Health Service NSW Department of Health, September 2004)
One of the challenges is there are no tests that can determine risk, thus the assessment is largely based on the history and is an estimate: o One thing that does help the assessment is transference that is a constellation of information that comes across from the patient to the medical practitioner, gut feelings and associated mood feelings. These are often subtle signs, often ignored, however the skills can be developed and are widely useful. Certain underlying disorders that are associated with suicidal thoughts or ideation need to be considered o Up to 90% of people who die by suicide suffer from a diagnosable mental disorder usually depression/acute stress reaction(conwell et al.) Psychosis Schizophrenia: 15% will suicide, about half of people with schizophrenia have attempted suicide Bipolar: 5-10% suicide Serious substance disorder: 10% suicide Severe personality disorder of the borderline type have significant ongoing suicidal ideation and many have made attempts on their life Any combination of the above will increase the risk Not a persistent feeling or thought 3. What is your approach in this patient? Gather information: o Nursing staff: on how things are, if there is a change in behaviour or mood o Organise a private/quiet place to see the patient You shouldn t be afraid of approaching someone unless the patient is hiding a weapon or there is some concern they are feeling hostile or frightened in that situation you approach the patient with other staff members and avoid private areas History: o A good opening question: have there ever been times when life is just too hard, when the suffering they have been experiencing is just too much to go on with o Need to know how risky the patient is right now Somethings to ask staff over the phone before coming to see the patient: The background of the patient Have they ever attempted suicide before? Are they threatening to do anything immediately? Is this something I need to come up for immediately? Are they currently safe? o Determine risk factors, warning signs and protective factors o Any current history of mental health conditions Examination: o General physical examination looking for signs of injury or self-harm o Examine surroundings for potential harm risks/dangerous objects
4. Management of a suicidal patient Assessing the level of intervention required depends on many factors o Severity of illness o Degree of impulsivity o Degree of insight o Safety in current setting o Supports available o Ability and willingness of patient to engage How quickly you escalate the management response depends on your assessment of how immediate the risk is o High risk: ensure safe and secure environment, re-assess within hours, ensure plans are in place in case the situation escalates, including one to one nursing or transfer to a secure unit like Mental Health o Medium risk: needs monitoring and re-assessment within 24-48 hours however you should also have plans in place in case of escalation o Low risk: review as determined by acuity and services. Provided with information on 24 hour access to suitable care Escalating to a senior colleague or Mental health service o Give a good history to your colleague o Indicate: this a significant current risk o Need to work out how to make the patient safe Special, private room, psych admission o Always have a low threshold for escalating and asking for help o Resources for junior doctors when facing such a patient Your best resources are colleagues Asking senior colleagues over the phone Speak with nursing staff Formal risk assessment: Forms available (Psychiatric Registrars can direct you to these) Online resources and education SANE Australia 5. Take home messages It can be a challenging area A difficult area to talk about with people Completed suicide of a patient is one of the most difficult things doctors have to face Talk to colleagues and friends, speak to Employee Assistance Program or supports When asked to assess someone, this is not something to be afraid of but something to take seriously, ask for help and have a low threshold for escalating and referring to a Psychiatric Registrars Reference: Suicide prevention and recovery guide: A resource for mental health professionals 2 nd Edition SANE Australia, 2014
Suicide Risk Assessment and Management Protocols Community Mental Health Service NSW Department of Health, September 2004 Conwell Y, Duberstein PR, Cox C, Herrmann JH, Forbes NT, Caine ED. Relationships of age and axis I diagnosis in victims of completed suicide: a psychological autopsy study. American Journal of Psychiatry. 1996; 153: 1001-1008