Suicide risk assessment and management

Question 1

if a patients discloses they ‘took some pills’ what specific questions do you want to ask?

Answer 1

1. what tablets did you take?
2. how many tablets did you take?
3. where were you when you took the tablets?
4. where did you get the tablets?

Question 2

what antidepressant class is most likely to cause lethality than the others?

Answer 2

tricyclic antidepressants

Question 3

perceived vs potential lethality ?

Answer 3

potential and perceived lethality are not always the same. 10 paracetamol tablets = potential high but perceived may be low

Question 4

question to ask in determining the patients perceived lethality of the act (ie taking pills) ?

Answer 4

what did you think would happen when you took the pills?

Question 5

questions about concealing actions?

Answer 5

did you do anything not to be found ?

Question 6

questions to ask regarding final acts ?

Answer 6

1. was there anything else you did
2. was there anything else you did before taking tablets - for example people make sure they have things in order or completed before
3. did you do anything else - did you leave a note
4. did you drink any alcohol before taking the tablets ?
5. . anything else you did before taking tablets?

Question 7

what is the relevance of a previous suicidal attempt?

Answer 7

1. one or more prior suicide attempts is a risk factor for completed suicide
2. 18-38% of suicide completers had previously attempted suicide

Question 8

information needed to determine ‘seriousness of the suicide’ attempt

Answer 8

1. perceived lethality
2. degree of pre-planning
3. efforts to conceal actions
4. potential lethality
   - level of medical intervention required
   - probability of irreversible damage
   - degree of impaired consciousness

Question 9

how can risk factors for suicide be broadly classified ?

Answer 9

1. static/stable risk factors
2. dynamic risk factors

Question 10

what are static risk factors for suicide and what are stable risk factors for suicide ?

Answer 10

1. static = fixed historical risk factors (history of previous suicide attempt, serious previous suicide attempt)
2. stable = long term risk factors that are likely to endure for many years but are fixed (e.g personality disorder - ameniable to treatment but not in the short term

Question 11

what is the importance of static/ stable risk factors?

Answer 11

give an indication of propensity for suicide but are not the focus of acute risk management

Question 12

what is the importance of dynamic risk factors?

Answer 12

1. condition or circumstances that elevate risk in the short term
2. fluctuate in duration and intensity and inform acute risk management

Question 13

suicidal ideation is an important .. risk factor

Answer 13

dynamic

Question 14

define suicidal ideation ?

Answer 14

thinking about or formulating plans for suicide

Question 15

what are examples of dynamic risk factors for suicide

Answer 15

1. hopelessness
2. suicidal ideation, communication and intent
3. psychosocial stress (e.g financial problems and what happened to lead to them, relationship breakdown)
4. substance ie alcohol use
5. psychological symptoms (depression, anxiety and psychosis)

Question 16

psychosocial stressors do … significantly contribute to the risk of suicide on their own. However, they are …. . When combined they can act as …. or …. for suicidal behaviour

Answer 16

not
cumulative
triggers/precipitants

Question 17

there is a strong association between …. and … . Alcohol has been shown to be associated with … of all suicides . alcohol use at the time of suicidal ideation may increase the possibility of … , …. and …. , increasing the liklihood of a potentially lethal outcome. Alcohol is also a …

Answer 17

• alcohol use and suicidal behaviour
• 1/2
• poor judgment, lack of control and mood changes
• depressant

Question 18

what psychological symptoms are associated with increased risk of suicide?

Answer 18

• certain symptoms, irrespective of diagnosis are important risk factors for suicide
  1. depression
  2. anxiety
• panic, agitation, anxious ruminations
• akathisia (usually an extrapyramidal side effect of antipsychotic is said to be an anxiety state)
  3. psychotic symptoms
• especially command auditory hallucinations
• delusions of passivity/ control

Question 19

association between mental illness and suicide. as many as … out of 10 individuals who die by suicide suffer from a mental disorder at the time of their death. virtually all mental disorder are associated with …. risk of suicide. a history of mental disorder is a …. risk factor for suicide. it suggests a greater propensity for suicide in the future (usually by virtue of illness recurrence or relapse). generally suicide risk is highest at the … of treatment and diminishes thereafter. when the course of illness is … , maximum risk occurs at the beginning of the … phase and in the first … months after in patient discharge

Answer 19

• 9
• increased
• background
• beginning
• episodic
• acute
• 3

Question 20

with regard to schizophrenia and suicide, between … and … % of individuals with schizophrenia die from suicide. Those at most risk include … (4)

Answer 20

1. 10-15%
2. male gender
3. younger age (initial stages of illness)
4. co-morbid mood symptoms
5. non-compliance with treatment

Question 21

with regard to affective disorder and suicide, more than … of clinically depressed patients have suicidal thoughts. the lifetime risk of suicide is significantly elevated in major affective disorders. traditionally a figure of around … % is quoted, but more recent studies indicate much lower rates of … %. No conclusive difference have been drawn between unipolar and bipolar patients with regard to life-time risk of suicide. Those most at risk include … (2)

Answer 21

1. half
2. 16%
3. 6%
4. severe depressive symptoms and co-morbidity with substance misuse disorder and personality disorders

Question 22

with regard to anxiety disorder and suicide, there is a risk of suicide in anxiety disorders although … occuring co-morbidly are probably greater significance. Panic disorder has …. been shown as an independent risk factor. It may however … the risk when occuring co-morbidly with other mental disorders such as substance misue disorders and personality disorders

Answer 22

1. anxiety symptoms
2. not
   3.

Question 23

with regard to suicide and family history of suicide, suicide is a … for suicide. studies indicate that there is an increased risk of both … and … suicide amongst those with relative who has a history of suicidal behaviour. the majority of patients with a family history of suicide also have a history of … . However, even when controlling for …. there appears to be a familial transmission of suicidality

Answer 23

1. risk factor
2. attempted
3. completed
4. affective disorders
5. mental disorders

Question 24

background risk factors for suicide

Answer 24

1. gender - higher rates in men compared to womens
   - male gender is a significant risk factor
2. age
   - in general suicide rates increase with age but suicide is not the most common cause of death among the elderly. two age groups have been identified with increased suicide risk. (a) 15 to 30 years and (b) over 65 years of age
   - risk for suicide after age 60 is associated with retirement, social isolation, declining health and other losses
3. history of suicide attempts
4. seriousness of past suicide attempts
5. family history of suicide
6. history of mental health disorder
7. family history of mental health disorder
8. previous hospitalization

Question 25

with regard to previous hospitalization and suicide, the frequency of admission to hospital was associated with … . the recurrence of severe mental disorders such as severe depression, which is associated with … is believed to contribute to the cumulative risk of suicide

Answer 25

1. suicidality
2. hospitalization

Question 26

overall risk factor for suicide

Answer 26

other background risks: history of a substance misuse disorder, childhood adversity

Question 27

with regard to childhood adversity and suicide, familial violence and bereavments (particularly of family members) are … for later suicide. Studies of youth suicide indicate that … , … and … were all associated with suicidal behaviour

Answer 27

1. risk factors
2. negative parenting
3. sexual abuse
   physical abuse

Question 28

with regard to substance misuse disorder and suicide, studies have found that substance abuse is … in frequency to … as a risk factor for completed suicide. the risk of suicide in substance abusers increases dramatically with the addition of other risk factors in particularly … disorder

Answer 28

1. second
2. depression
3. co-morbid depressive disorder

Question 29

with regard to suicide and personality disorder, the diagnosis of personality disorder is associated with a suicide risk … times the expected values. The risk is probably greater if the serious underestimate of the prevalence of personality disorder in studies is taken into account. The diagnosis of personality disorder is associated with other risk factors, notably …. and …. . the main categories of personality disorders associated with suicidal behaviour are ….. and … disorder.

Answer 29

1. 7
2. affective disorders
3. substance misuse
4. borderline personality disorder
5. anti-social personality disorder

Question 30

with regard to suicide and problem solving difficulties, suicidal patients often experience significant difficulties with … . suicidal patients may attempt to solve problems … . They may be less likely to generate … solutions to problems and have difficulty managing … problems . The combination of increased negative life events and reduced problem solving ability may further increase risk of suicide.

Answer 30

1. problem solving
2. passively (e.g let problems ‘sort themselves out’)
3. alternative
4. interpersonal

Question 31

with regard to suicide and psychiatric admission and discharge, for a considerable number of patients admission to a psychiatric hospital is psychologically … . Studies revealed that in the general population the strongest risk factor for suicide is … leading to hospital admission with the risk of suicide being especially high during … and in the … year after discharge. there are three critical time periods where suicide risk is elevated for psychiatric patients. these are (3)

Answer 31

1. traumatic
2. mental illness
3. admission
4. 1 year
5. the period immediately after admission to psychiatric hospital
6. the period of discharge planning
7. the period following discharge

Question 32

with regard of ongoing means of access and risk of suicide, in suicidal behaviours the methods use are, in part, associated with their …. the national confidential inquiry in the UK found that three methods of suicide together accounted for almost … of suicides in the general population; …. , ….. and ….. . younger men tend use to more …. methods of suicide such as …. . in contrast women tend to die as a result of …

Answer 32

1. ease of access
2. 3/4
3. hanging
4. self poisoning (overdose)
5. carbon monoxide poisoning (using car exhaust fumes)
6. violent
7. overdose

Question 33

with regard to treatment adherence and suicide risk, studies have found that of suicides in contact with mental health services in the 12 months before death, over … of the community sample had a failed … contact before suicide. poor adherence to treatment encompasses (3)

Answer 33

1. 1/4
2. poor continuity of care
3. poor adherence or response to drug treatment
4. poor engagement with and response to psychosocial interventions

Question 34

risk factors for suicide

Answer 34

these are all of them

Question 35

how is risk formulation done?

Answer 35

group dynamic risk factors under distinct heading based upon whether they are biological, psychological or social in nature

Question 36

what are examples of biological risk factors for suicide ? (dynamic)

Answer 36

1. depressed mood
2. disturbed sleep
3. poor appetite
4. psychotic symptoms
   - these are known to be associated with cerebral serotonergic, noradrenergic and dopaminergic abnormalities and are thus responsive to biological treatments such as antidepressants and antipsychotics

Question 37

what are psychological risk factors for suicide ? (dynamic)

Answer 37

hopelessness, suicidal ideation, communication and intent are dynamic risk factors (and alos psychological symptoms associated with depressive illness) which may be considered as psychological in nature or etiology. they are therefore appropriately grouped under the heading ‘psychological’ risk factors. problem solving deficits can also be considered as psychological in nature or etiology

Question 38

social risk factors for suicide

Answer 38

cumulative psychosocial stresses (including financial problems, recent job and a relationship breakup), substance misuse, ongoing access to means of suicide, and recent admission or discharge may be considered social risk factors

Question 39

admitting a patient to hospital is an appropriate strategy to manage which of the following suicide risk factors ?

Answer 39

ongoing suicidal communication and intent. psychiatric admission and discharge is in itself a risk factor for suicide. it should therefore be used only as a risk management strategy when there is ongoing communication of suicidal ideation and intent. admission should be offered to contain the risk in this case.

Question 40

determining the etiology of poor treatment adherence is essential in planning risk management. poor treatment adherence may be related to … (3)

Answer 40

1. side effects from treatment (biological)
2. impaired insight (psychological)
3. stigman (social)

Question 41

if side effects may be the cause of poor adherence how should this be managed?

Answer 41

discuss side effects of current drug treatment with the patient, with collaborative decision making regarding evidence based tolerable drug treatment options if warranted

Question 42

in address stigma as a cause of poor adherence to treatment how should this be addressed?

Answer 42

1. address concerns in relation to disclosure of illness to others, including family and friends
2. involve family, friends, work colleagues if appropriate in discussion about diagnosis and overcoming obstacles
3. link the patient with a member of the MDT to provide information on access to services available including contact telephone numbers for emergencies and clinic opening times

Question 43

how should impaired insight be addressed if this is the cause of poor adherence to treatment ?

Answer 43

1. consider evidence based psychological interventions for improving insight including cognitive behavioural therapy

Question 44

which drug treatments have been suggested to have specific anti-suicidal effects

Answer 44

1. clozapine
2. lithium

Question 45

with regard to lithium and protective effect of lithium, there is a growing body of evidence that lithium has a protective effect. the potential benefits of treatment are however …. to some extent by the negative effects if treatment is … . …. leads to sharply elevated risk of suicide. Lithium has strong evidence base for treatment of manic episodes and prophylaxis of depressive and manic episodes in bipolar disorder. it also has evidence for use as an adjunctive in ….

Answer 45

1. offset
2. discontinued
3. abrupt discontinuation
4. treatment resistant depression

Question 46

with regard to clozapine and protection against suicide, clozapine treatment has been associated with decreased risk of suicide in …

Answer 46

schizophrenia

Question 47

what are protective factors for suicide ?

Answer 47

1. close family
2. supportive peer relationships
3. supportive professional relationships (established counsellor/ psychotherapist