3. Suicide

Question 1

How to approach suicide? (4)

Answer 1

• ask every patient: i.e. “Have you had any thoughts of wanting to harm or kill yourself?”
• classify ideation
  
  • passive ideation (“death wish”): would rather not be alive but has no active plan for suicide
    
    • i.e. “I’d rather not wake up” or “I would not mind if a car hit me”
  • active ideation
    
    • i.e. “I think about killing myself ”
• assess risk
• assess suicidal ideation

Question 2

How to assess the risk of suicide? (3)

Answer 2

• plan: “Do you have a plan as to how you would end your life?”
• intent: “Do you think you would actually carry out this plan?” “If not, why not?”
• past attempts: number, lethality, outcome, medical intervention, while intoxicated?, precipitants

Question 3

How to assess suicidal ideation? (12)

Answer 3

• onset and frequency of thoughts: “When did this start?” or “How often do you have these thoughts?”
• control over suicidal ideation: “How do you cope when you have these thoughts?” “Could you call someone for help?”
• intention: “Do you want to end your life?” or “Do you wish to kill yourself?”
• intended lethality: “What do you think would happen if you actually took those pills?”
• access to means: “How will you get a gun?” or “Which bridge do you think you would go to?”
• time and place: “Have you picked a date and place? Is it in an isolated location?”
• provocative factors: “What makes you feel worse (i.e. being alone)?”
• protective factors: “What keeps you alive (i.e. friends, family, pets, faith, therapist)?”
• final arrangements: “Have you written a suicide note? Made a will? Given away your belongings?”
• practiced suicide or aborted attempts: “Have you ever put the gun to your head?” “Held the medications in your hand?” “Stood at the bridge?”
• ambivalence: “I wonder if there is a part of you that wants to live, given that you came here for help?”
• determine level of risk and develop treatment/safety plan

Question 4

Describe: Assessment of Suicide Attempt (8)

Answer 4

• setting (isolated vs. others present/chance of discovery)
• planned vs. impulsive attempt, triggers/stressors
• substance use/intoxication
• medical attention (brought in by another person vs. brought in by self to ED)
• time lag from suicide attempt to ED arrival
• expectation of lethality, dying
• reaction to survival (guilt/remorse vs. disappointment/self-blame)
• evidence of escalation in potential lethal means

Question 5

Describe epidemiology: Suicide (2)

Answer 5

• attempted: completed = 20:1 (100:1 in younger persons; 4:1 in older persons)
• M:F = 1:4 for attempts, 3:1 for completed

Question 6

Name suicide risk factors (26)

Answer 6

• epidemiologic factors
  
  • age: increases after age 14, second most common cause of death for ages 15-24, highest rates of completion in persons >75 yr
  • sex: male
  • race/ethnic background: white or Indigenous Canadians
  • marital status: widowed/divorced
  • living situation: alone; no children <18 yr old in the household
  • other: stressful life events, or access to firearms
• psychiatric factors
  
  • past suicide attempt(s)
  • eating disorders
  • bipolar disorder
  • major depression
  • mixed drug abuse
  • panic disorder
  • schizophrenia
  • personality disorder
  • alcohol abuse
• psychosocial factors
  
  • recent, severe stressful life event
• psychiatric disorders
  
  • mood disorders (15% lifetime risk in depression; higher in bipolar)
  • anxiety disorders (especially panic disorder)
  • schizophrenia (10-15% risk)
  • substance abuse (especially alcohol – 15% lifetime risk)
  • eating disorders (5% lifetime risk)
  • adjustment disorder
  • conduct disorder
  • personality disorders (borderline, antisocial)
• past history
  
  • prior suicide attempt
  • family history of suicide attempt/completion

Question 7

Name Suicide Risk Factors SAD PERSONS

Answer 7

SAD PERSONS

• Sex (male)
• Age >60 yr old
• Depression
• Previous attempts
• Ethanol abuse
• Rational thinking loss (delusions, hallucinations, hopelessness)
• Suicide in family
• Organized plan
• No spouse (no support systems)
• Serious illness, intractable pain

Question 8

Name symptoms associated with suicide (6)

Answer 8

• hopelessness
• anhedonia
• insomnia
• severe anxiety
• impaired concentration
• psychomotor agitation

Question 9

Describe management of suicide (8)

Answer 9

• proper documentation of the clinical encounter and rationale for management is essential
• higher risk (patients with a plan and intention to act, have access to lethal means, recent social stressors, and symptoms suggestive of a psychiatric disorder)
  
  • hospitalization to be strongly considered
  • do not leave patient alone; remove potentially dangerous objects from room
  • if patient refuses to be hospitalized, complete form for involuntary admission (Form 1) and must give patient Form 30 to notify them of their admission
• lower risk (patients who are not actively suicidal, with no active plan or access to lethal means)
  
  • discuss protective factors and supports in their life, remind them of what they live for, promote survival skills that helped them through previous suicide attempts
  • make a safety plan that could include an agreement that they will:
    
    • not harm themselves
    • avoid alcohol, drugs, and situations that may trigger suicidal thoughts
    • follow-up with you at a designated time
    • contact a health care worker, call a crisis line, or go to an emergency department if they feel unsafe or if their suicidal feelings return or intensify
• patients with depression: consider hospitalization if symptoms severe or if psychotic features are present; otherwise outpatient treatment with good supports and SSRIs/SNRIs
• patients with alcohol- or substance-related issues: suicidality usually resolves with abstinence for a few days; if not, suspect depression
• patients with personality disorders: crisis intervention, may or may not hospitalize
• patients with schizophrenia/psychosis: hospitalization might be necessary
• patients with parasuicidal behaviours/self-mutilation: long-term psychotherapy with brief crisis intervention when necessary