Suicide and self-harm

Question 1

Spectrum of Qs to ask for suicidality

Answer 1

• Future:
  
  • How do you feel about the future?
• Hopelessness:
  
  • ​Have you ever thought life was not worth living?
• Self-harm:
  
  • ​Have you ever had thoughts of harming yourself? Have you acted on them?
• Passive suicidality:
  
  • Have you ever gone to bed and wished you didn’t wake up?
• Active suicidal ideation:
  
  • Have you ever thought of ending your own life?
• Method:
  
  • Have you thought about how you would do it?
• Preparation:
  
  • Have you made any preparations (e.g. suicide note)
• Attempt:
  
  • Have you ever tried to take your own life?

Question 2

Questions to ask about self-harm

Answer 2

• Method
• Frequency
• Citcumstances
• Emotion before/after

Question 3

Principles of risk management (all risks)

Answer 3

1. Documentation incl crisis plan and specifying of roles
2. Short-term treatment: incl. pharmacology
3. Long-term psychosocial intervention
4. Supervision and monitoring: By whom, how often, early warning signs
5. Re-assessment date

Question 4

Static risk factors for suicide

Answer 4

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

Question 5

Dynamic risk factors for suicide

Answer 5

• 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

Question 6

Order of risk of suicide for psychiatric disorders

Answer 6

Depression + Anorexia

>

Primary psychosis

>

Neuroses + anxiety disorders

Question 7

Completed suicide in 24months following self-harm

Answer 7

1%, highest in first few weeks following initial act

Question 8

Protective factors for suicide

Answer 8

Family support

Children at home

Strong religious faith

Problem-solving skills

Sense of responsibility

Question 9

Risk factors about the act of self-harm that require assessment

Answer 9

1. Perceived lethality
2. Impulsivity/advance planning
3. Preparations
4. Discovery
5. Actions following act
6. Comparison to previous acts

Question 10

Assessment of mental state following suicide attempt

Answer 10

1. Attitude to survival
2. Mood: current affective state + symptoms of depression (MDD screening essential)
3. Screen for: Substance use disorder, psychotic symptoms, bipolar symptoms, borderline PD (hospital admission unhelpful)
4. Past medical/psychiatric Hx
5. Recent live events/triggers
6. ID goals from patient + work towards them: What’s important to you? What do you value?

Question 11

Questions that should be addressed following assessment of suicide attempt

Answer 11

1. Ongoing suicidal intent?
2. Psychiatric/physical illness?
3. Social stressors?

Question 12

Evidence for ongoing suicidal intent following suicide attempt

Answer 12

• Hoplessness
• Ambivalence/disappointment about survival
• Continued stated wish to die
• Clear lethal intent of attempt

Question 13

Management of patient following self-harm

Answer 13

1. Treat medical illness - routine bloods, drug levels, ?activated charcoal 50mg for paracetamol/NSAIDs, ED referral
2. Thorough assessment + MSE when patient is in full consciousness
3. Consider admission to inpatient psychiatric ward if:
   
   1. Ongoing suicidal intent
   2. Serious mental illness (e.g. first presentation of psychosis)
   3. Need for further assessment to clarify diagnosis
4. Referral to specialist services for mental health (GP for moderate depression, turning point for substance misuse, etc…)
   
   1. i.e. identifying available resources
5. Referral to self-help services: E.g. Samaritans, Papyrus, Survivors of bereavement by suicide
6. Liaising with services for social issues (e.g. school, social work, abuse counselling)
7. Contingency plans for any foreseeable changes

Question 14

1-year prognosis for self-harm presenting to hospital

Answer 14

20% repeated self-harm presentation

1% completed suicide in 24 mo

Question 15

Demographics for self-harm

Answer 15

15-24 (20% prevalence)

2/3 of self-harm <35yo

More common in females

Question 16

Joiner’s aetiological factors for suicide/self-harm

Answer 16

Thwarted belonging

Perceived burdensomness

Acquired capability

Question 17

Factors contributing to thwarted belonging

Answer 17

Social isolation

Unemployment

Recent bereavement

Relationship breakdown

Question 18

Factors contributing to perceived burdensomeness

Answer 18

Major depressive disorder

Physical illness

Substance use disorder

“They’d be better off without me”

Question 19

Factors contributing to acquired capability

Answer 19

Hx of abuse/self-harm

Access to means

Contagion effect

Psychiatric disorder

Question 20

Distinction between risk status and risk state in suicide

Answer 20

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?)

Question 21

Steps for creating management plans from suicide risk assessment

Answer 21

1. Identify available resources: In collaboration with patient, ideally >=2 –> put in place with management plan
   
   1. Social support, self-help resources
   2. Family + friends
   3. GP
2. Identify foreseeable changes: Acute changes that could precipitate increase/decrease in risk state. Put together contingency plan
   
   1. Previous stressors/triggers
   2. Challenging transitions (e.g. discharge)

Question 22

Treatment for delayed presentation of paracetamol OD

Answer 22

>8h later –> N-acetylcysteine