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HanneleHeilä

A Patient at Risk of Suicide

Essentials

  • Suicide is often an ending to a long process and the consequence of a lifelong accumulation of risk factors, an absence of protecting factors and, finally, the presence of precipitating factors.
  • In most cases of suicide (over 90%) the person has a previous history of mental health problems, usually mood disorders or substance abuse.
  • Suicides can be prevented by the assessment of both short-term and long-term suicide risk in those belonging to the risk groups.
  • The possibility of suicidal ideation and behaviour must always be explored in a depressed patient.
  • If the patient harbours suicidal thoughts, establish the degree of suicidal intent (plans, timing).
  • Ensure that the treatment of a suicidal patient is sufficiently protective and do not prescribe large amounts of medicines at any one time.

Prevalence

  • Transient suicidal ideation is fairly common (in about 10% of the general population, see e.g. http://pubmed.ncbi.nlm.nih.gov/18245022/).
  • Self-harm (self-inflicted cuts) and other behaviours suggestive of suicidal intentions are fairly common among adolescents in western countries (5-9%). If this is accompanied with a strong wish to die the person's suicide risk is increased.
  • About 1-5% of the population has attempted suicide. Attempts are more common among young adults than in older individuals, and more than half of the attempts occur while intoxicated.
  • The suicide rates among adolescents in relation to all suicides have been on the increase in the 2000's.

Risk factors

Factors which increase long-term suicide risk

  • Social risk factors (male gender, living alone, low income, unemployed)
  • Suicide of a close relative or friend (a risk factor particularly among the young)
  • Previous self-destructive behaviour, suicide ideation
  • Mental health problems (mood disorders, substance dependence, unstable and antisocial personality disorder, psychoses)
  • Serious physical disease, pain
  • Genetic or familial predisposition
  • Tendency to impulsive-aggressive behaviour
  • In men severe mental symptoms in childhood (anxiety, behavioural symptoms)

Immediate or short-term suicide risk

  • Suicide attempt during the past 12 months
  • Negative life events: especially divorce/separation, experiences of loss and events leading to strong feelings of shame or guilt; especially in adolescents arguments and disappointments as triggering factors behind self-destructive behaviour Risk of Suicide in Adolescence
  • Psychological risk factors: hopelessness, negative life expectations, general dissatisfaction with life, impulsivity
  • Severely symptomatic psychiatric disorder
    • The risk of suicide is very high around a hospital admission for psychiatric treatment, at the start of the treatment and during the first month after discharge.
    • Depression
      • Psychotic depression, feelings of guilt, nihilistic and somatic delusions
      • Agitation, anxiety, panic attacks
    • Bipolar disorder
      • Mixed states
    • Schizophrenia
      • Early years of the illness
      • Frequent hospitalisations, severe form of disease
    • Uncontrolled substance abuse (young individuals in particular)

Diagnostic assessment

  • Suicidal behaviour should be actively discussed and always tackled with the patient.
  • Suicidality is not a disease, but a mode of behaviour. The best understanding can be achieved through viewing the patient's overall psychosocial situation, for example by establishing how the patient experiences life in relation to his/her physical diseases and symptoms.
  • Questions relating to possible suicidality and the patient's wish to die will often flow naturally
    • after the patient's overall situation has been discussed; a patient with pain could be asked how he/she experiences the pain, for instance;
    • if the patient expresses negative feelings and experiences relating to, for instance, his/her physical disease.
  • How to ask questions?
  • However, the patient may deny any suicidal ideation if he/she has already made a firm decision about the matter.
    • In Finland, of the people who committed suicide in 1987-88, 40-60% had sought medical help during the last month of their life, 18% actually during the last day of their life due to problems associated with their general health, but only very few had communicated any suicidal ideation.

Management and evaluation in immediate suicide risk

  • The background of a suicide attempt is clarified with open questions. Always ask whether the patient has any earlier suicide attempts, whether the attempt was associated with a wish to die and what was the lethality of the method used in the attempt. The aforementioned questionnaires can be used to assist in the investigation of self-destructive behaviour.
  • The psychiatric evaluation of patient who has attempted suicide must be led by a specialist in psychiatry or by a physician with special expertise in psychiatry. An adolescent who has attempted suicide must always be evaluated within specialized care.
  • Consult psychiatric specialist services and, based on the consultation, proceed with a referral to emergency care if
    • the patient exhibits suicidal behaviour (ideation, attempts) associated with a psychiatric disorder
    • a suicidal patient (ideation, attempts) has no social network to offer support.
  • Psychiatric hospitalisation is often indicated when a suicidal patient
    • cannot control his/her self-destructive impulses and shows
      • psychotic thoughts
      • impulsive behaviour
      • intermittent uncontrolled substance abuse
      • strong self-destructive inclination.
    • is openly psychotic
    • is very distressed or agitated or shows severe hopelessness
    • is covering up or denying the suicide intent (e.g. after a planned suicide attempt).
  • The patient can be referred to a hospital for observation, with the view of possibly subsequently committing him/her to involuntary psychiatric treatment, if there is suspicion of a mental illness and risk of suicide; for a young person a suspicion of a severe mental disorder is sufficient for a referral.
  • Family members should be informed of the hospital admission unless explicitly forbidden by the patient.
  • If referral for psychiatric care is not indicated based on sufficient psychiatric evaluation, the patient must be given instructions on whom and how he/she can contact if self-destructive thoughts should become active.

Psychological management Psychosocial Interventions for Self-Harm in Adults

  • Explore the reasons behind the patient's wish to die (emotional distress, problems with life?).
  • It is important to relieve the feelings of hopelessness. Emphasise the irreversibility of death and that it is not a solution to problems or feelings of distress.
  • Relate the suicide ideation with the emotional distress: depression is often accompanied by a feeling of hopelessness and a wish to die, and these will improve as the depressive symptoms are relieved.
  • Explain how and in what timescale medication, and other treatment modalities, can ease the patient's distress.
  • Explore factors in the patient's life that can act as protective factors against suicide: including close family members and the effect of the possible suicide on their lives.

Points to consider during treatment

  • The full therapeutic benefit of antipsychotics and antidepressants is not reached until about a week after the treatment is started. Benzodiazepines relieve anxiety quickly.
  • When the symptoms of a person suffering from depression are alleviated, also self-destructive thinking decreases and the risk of being self-destructive reduces. Starting antidepressant drug therapy may sometimes increase self-destructive thoughts, and a close follow-up of pharmacotherapy is necessary in the initial phase.
  • Prescribe only small amounts of medicines at any one time.
  • Tell the patient how to get in touch and obtain crisis assistance 24 hours a day.
  • Attempt to find out whether the patient has specific equipment at home necessary for committing suicide (other medication, a weapon etc.)
  • Identify the patient's social network (a support person) and aim at creating a safety net within health care, as well as an action plan for emergency situations. Involving the family of the self-destructive individual in the evaluation and management improves the prognosis. A safety plan may be developed http://www.kaypahoito.fi/xmedia/hoi/hoi50122b.pdf.
  • Support the patient's abstinence from substances of abuse, since these predispose to self-destructive behaviour.

Treatment intervention for a person who attempted suicide

  • Guidelines for the treatment of a self-destructive patient have been crafted for example in the United States and the UK. In Finland the national suicide prevention project recommended that each patient that has attempted suicide should undergo a psychiatric or psychosocial evaluation and afterward this he/she should have the possibility to have at least one appointment of acute nature to address the crisis.
  • An active therapeutic approach that reaches for the patient is needed to make the patient who attempted suicide to commit to treatment. It is important to be in contact with the patient and to allow him/her to take contact even after the active treatment has ended. An agreement can be made with the patient that allows him/her to contact the treating unit without new referral for a period of e.g. 3 months, should his/her condition worsen again.

Suicide prevention (long-term suicide risk)

  • The most important aspect of prevention is the appropriate treatment of an underlying psychiatric disorder. In as many as 80% of completed suicides, the treatment of the psychiatric disorder has been insufficient.
    • In follow-up studies lithium used for bipolar disorder and clozapine used for schizophrenia seem to have a decreasing effect on self-destructiveness.
  • Scientific evidence exists on education programmes: depression recognition and appropriate treatment by general practitioners reduced local suicide rates during the follow-up period.
  • Various psychotherapies and interventions have been developed for the treatment of a patient who is self-destructive or has attempted suicide; relevant research has been published particularly in journals oriented toward dialectic and cognitive methods.

    References

    • Temes CM, Frankenburg FR, Fitzmaurice GM ym. Deaths by Suicide and Other Causes Among Patients With Borderline Personality Disorder and Personality-Disordered Comparison Subjects Over 24 Years of Prospective Follow-Up. J Clin Psychiatry 2019;80 [PubMed]
    • Gysin-Maillart A, Schwab S, Soravia L et al. A Novel Brief Therapy for Patients Who Attempt Suicide: A 24-months Follow-Up Randomized Controlled Study of the Attempted Suicide Short Intervention Program (ASSIP). PLoS Med 2016;13(3):e1001968. [PubMed]
    • Turecki G, Brent DA. Suicide and suicidal behaviour. Lancet 2016;387(10024):1227-39. [PubMed]
    • Self-harm: longer-term management. NICE guidelines (CG133), November 2011 http://www.nice.org.uk/guidance/cg133/resources/guidance-selfharm-longerterm-management-pdf
    • Sourander A, Klomek AB, Niemelä S et al. Childhood predictors of completed and severe suicide attempts: findings from the Finnish 1981 Birth Cohort Study. Arch Gen Psychiatry 2009;66(4):398-406. [PubMed]
    • Linehan MM, Comtois KA, Murray AM et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry 2006;63(7):757-66. [PubMed]