Suicide

Chapter - 24

IntroductionSuicide is a complex human behavior. There is no one reason why an individual chooses to end his or her life.Suicide has been defined as an act with a fatal outcome that is deliberately initiated and performed by the person in the knowledge and expectation of its fatal out comeEpidemiology• Attempted : Completed = 20:1• M:F =3:1 for completed; 1:4 for attempts Risk Factors:• Epidemiologic Factors:

age: increases after age 14, second most common cause of death for ages 15-24; higher rates in persons> 65yrs

sex: male race/ethnic background: white or native Canadians on reserves

marital status: widowed/ divorced living situation: alone, on children < 18 yrs old in the household

other: stressful life events; access to firearms

• psychiatric disordersmood disorders (15% lifetime risk in depression; higher in bipolar)

Anxiety disorders (especially panic disorder)

Schizophrenia (10-15% risk)Eating disorders (5% lifetime risk)

Adjustment disordersConduct disordersPersonality disorders

•Past historyPrior suicide attemptFamily history of suicide attempt/completion

Clinical Presentation• Symptoms associated with suicide:

Hopelessness‘Anhedonia InsomniaSevere anxiety Impaired concentrationPsychomotor agitationPanic attacks

ApproachEvery patient: “Have you had any thoughts of wanting to hurt/kill yourself?”

Ideation- “Do you have thoughts about ending your life, committing suicide?”

Passive- “Would rather not be alive but has no active plan for suicide?”

e.g. “I’d rather not wake up.” “I would not mind if a car hit me”

Active e.g. “I think about killing myself”

Plan: “Do you have a plan as to how you would end your life?”

Intent- “You talk about wanting to die, but are you planning to do this?” “What has stopped you from ending your life?”

Past attempts- Highest risk if previous attempt in past year

Ask about lethality, outcome, medical intervention

Assessment of Suicidal Ideation• onset and frequency of thoughts- “When did this start? How often do you have these thoughts?”• control over suicidal ideation- “Can you stop the thoughts or call someone for help?”• lethality- “Do you want to end your life? Or get a ‘release’ from your emotional pain?”• access to means- “How will you get a gun?” “Which bridge do you think you would go to?”• time and place- “Have you picked a date and place? Is it an isolated location?”

• provocative factors- “What keeps you alive (e.g. 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 put the gun to your head? Held the medications in your head? Stood at the bridge?”• ambivalence- “There must be a part of you that wants to live….you came here for help”Assessment of Suicide Attempt• setting- isolated vs. others present, chance of discovery• planned vs. impulsive attempt, triggers/stressors• intoxication• medical attention- brought in by another person vs. brought in by self or ER

• time lag from suicide attempt or ER arrival• expectation of lethality, dying• reaction to survival- guilt/ remorse vs. disappointment// self-blameManagement• higher risk

patients with a plan, access to lethal means, recent social stressors, and symptoms suggestive of a psychiatric disorder should be hospitalized immediately

donot leave patient alone, remove potentially dangerous objects from room

if patient refuses to hospitalized, complete form for involuntary admission

• lower risk patients who are not suicidal, with no 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- an agreement that will not harm themselves, avoid alcohol, drugs, and situations that may trigger suicidal thoughts, follow-up with you at a designated time, and 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

depression: hospitalize if severe or if psychotic figures are present; otherwise outpatient treatment with good supports and SSRIs and SNRIs

alcohol-related: usually resolves with abstinence for a few days, if not suspect depression

personality disorders: crisis intervention/ confrontation, may or may not hospitalize

schizophrenia/ psychosis: hospitalization

parasuicide/ self- mutilation: long-term psychotherapy with brief crisis intervention when necessary

proper documentation of the clinical encounter and rationale for management is essential

The End