Suicide and self-harm Flashcards
Spectrum of Qs to ask for suicidality
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Future:
- How do you feel about the future?
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Hopelessness:
- Have you ever thought life was not worth living?
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Self-harm:
- Have you ever had thoughts of harming yourself? Have you acted on them?
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Passive suicidality:
- Have you ever gone to bed and wished you didn’t wake up?
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Active suicidal ideation:
- Have you ever thought of ending your own life?
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Method:
- Have you thought about how you would do it?
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Preparation:
- Have you made any preparations (e.g. suicide note)
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Attempt:
- Have you ever tried to take your own life?
Questions to ask about self-harm
- Method
- Frequency
- Citcumstances
- Emotion before/after
Principles of risk management (all risks)
- Documentation incl crisis plan and specifying of roles
- Short-term treatment: incl. pharmacology
- Long-term psychosocial intervention
- Supervision and monitoring: By whom, how often, early warning signs
- Re-assessment date
Static risk factors for suicide
Demographic: Male, elderly, impulsivity/self control
Medical Hx: Concurrent physical illness, any mental disorder, recent hospital discharge
Past suicidal/self-harm behaviour ( 1/3 of completed suicides have >=1 previous attempt)
Social: Exposure to suicide (family/friends), recent bereavement, Hx of abuse
Protective factors
Dynamic risk factors for suicide
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Social stressors/precipitants:
- Financial/employment issues
- Social isolation, lives alone
- Single, widowed, divorced
-
Psychiatric:
- Recent/present suicidal behaviour
- Mental state: hopelessness, relapse, agitation
- Substance abuse
- Psychotic symptoms (e.g. command hallucinations
-
Practical:
- Access to means
- Intent
- Final preparations
- Anniversaries
- Engagement with services
Order of risk of suicide for psychiatric disorders
Depression + Anorexia
>
Primary psychosis
>
Neuroses + anxiety disorders
Completed suicide in 24months following self-harm
1%, highest in first few weeks following initial act
Protective factors for suicide
Family support
Children at home
Strong religious faith
Problem-solving skills
Sense of responsibility
Risk factors about the act of self-harm that require assessment
- Perceived lethality
- Impulsivity/advance planning
- Preparations
- Discovery
- Actions following act
- Comparison to previous acts
Assessment of mental state following suicide attempt
- Attitude to survival
- Mood: current affective state + symptoms of depression (MDD screening essential)
- Screen for: Substance use disorder, psychotic symptoms, bipolar symptoms, borderline PD (hospital admission unhelpful)
- Past medical/psychiatric Hx
- Recent live events/triggers
- ID goals from patient + work towards them: What’s important to you? What do you value?
Questions that should be addressed following assessment of suicide attempt
- Ongoing suicidal intent?
- Psychiatric/physical illness?
- Social stressors?
Evidence for ongoing suicidal intent following suicide attempt
- Hoplessness
- Ambivalence/disappointment about survival
- Continued stated wish to die
- Clear lethal intent of attempt
Management of patient following self-harm
- Treat medical illness - routine bloods, drug levels, ?activated charcoal 50mg for paracetamol/NSAIDs, ED referral
- Thorough assessment + MSE when patient is in full consciousness
- Consider admission to inpatient psychiatric ward if:
- Ongoing suicidal intent
- Serious mental illness (e.g. first presentation of psychosis)
- Need for further assessment to clarify diagnosis
- Referral to specialist services for mental health (GP for moderate depression, turning point for substance misuse, etc…)
- i.e. identifying available resources
- Referral to self-help services: E.g. Samaritans, Papyrus, Survivors of bereavement by suicide
- Liaising with services for social issues (e.g. school, social work, abuse counselling)
- Contingency plans for any foreseeable changes
1-year prognosis for self-harm presenting to hospital
20% repeated self-harm presentation
1% completed suicide in 24 mo
Demographics for self-harm
15-24 (20% prevalence)
2/3 of self-harm <35yo
More common in females
Joiner’s aetiological factors for suicide/self-harm
Thwarted belonging
Perceived burdensomness
Acquired capability
Factors contributing to thwarted belonging
Social isolation
Unemployment
Recent bereavement
Relationship breakdown
Factors contributing to perceived burdensomeness
Major depressive disorder
Physical illness
Substance use disorder
“They’d be better off without me”
Factors contributing to acquired capability
Hx of abuse/self-harm
Access to means
Contagion effect
Psychiatric disorder
Distinction between risk status and risk state in suicide
Risk status: Relative to specific population (e.g. general, outpatient, inpatient), informed by more static risk factors
Risk state: Relative to patient’s baseline, informed by more dynamic risk factors (has it changed over past week/month/several months?)
Steps for creating management plans from suicide risk assessment
- Identify available resources: In collaboration with patient, ideally >=2 –> put in place with management plan
- Social support, self-help resources
- Family + friends
- GP
- Identify foreseeable changes: Acute changes that could precipitate increase/decrease in risk state. Put together contingency plan
- Previous stressors/triggers
- Challenging transitions (e.g. discharge)
Treatment for delayed presentation of paracetamol OD
>8h later –> N-acetylcysteine
