Today is an important topic within emergency psychiatry. We will be discussing suicide and this will include an introduction, risk factors, the suicide risk assessment, and how to manage/treat the suicidal patient.
Today's Content Level: All Levels (Beginner, Intermediate, Advanced)
Let's start off with some basic definitions 1:
Suicide-> death caused by self-directed injurious behavior with intent to die as a result of the behavior.
Suicide Attempt-> non-fatal, self-directed, potentially injurious behavior with intent to die as a result of the behavior. A suicide attempt might not result in injury.
Suicidal Ideation (SI) -> refers to thinking about, considering, or planning suicide.
•According to the Centers for Disease Control and Prevention (CDC) in 2018 suicide was the 10th leading cause of death overall in the United States, claiming the lives of over 48,000 people. It is the 14th leading cause of death globally. 2
•In the US the most common means of suicide are firearms > suffocation/hanging > poisoning/overdose.
•Risk factors for suicide are commonly broken down into static factors (can't be modified), modifiable factors (possible area for intervention), and protective factors. The following list of risk factors is compiled from data drawn from the CDC, NIH (National Institutes of Health), and VA/DOD (Veteran Affairs / Department of Defense).
Static Risk Factors
History of suicide attempt/plan/ideation/intent
History of self-directed violence or self-injury
Family history of suicide
Psychiatric disorders (increased risk if multiple)
CNS Disease, pain syndrome, terminal illness, and/or functional Impairment
Lack of social supports
Caucasian or Native American
Male, elderly, and/or adolescent
Living in rural setting
History of childhood sexual or physical abuse
Modifiable Risk Factors
Active psychiatric symptoms (psychological pain, stress, agitation, hopelessness, self-hate, impulsivity, aggression, psychosis, command hallucinations, insomnia)
Post-hospitalization (increased risk in period after discharge)
Current suicidal ideation
Social connectedness / positive social support
Sense of responsibility to family
Positive relationship with outpatient providers
Coping skills, problem-solving, and flexibility
Reality testing is intact
Specific additional factors noted by patient ("reasons to live")
•The suicide risk assessment is something that all mental health providers will be required to do on a regular basis. Whether we are seeing a patient in the emergency room with suicidal thoughts or seeing our patients in the clinic it is important to develop an approach to assess this risk. Below you will find my personal approach and I have used ideas from CAMS (Collaborative Assessment and Management of Suicidality), the VA/DOD clinical practice guideline, “Suicidal Behavior and the Three I’s” by John Chiles, “Interpersonal Theory of Suicide” by Thomas Joiner, the NIMH Brief Suicide Assessment Guide, and my personal experiences seeing patients in the emergency department.
SUICIDE RISK ASSESSMENT
Over the last 2 weeks have you had thoughts that you would be better off dead, or of hurting yourself?
Past Attempts/Behaviors (how/why/when? Did you receive tx?)
Identify The Real Problem
What is the problem? (sadness, guilt, anxiety, grief, fear, loneliness, boredom, shame, anger, trauma, pain, mental pain, harassment, bullying, debt, legal issues…)
Symptoms (depression, anxiety, impulsivity, hopeless, anhedonia, isolation, irritability, substance/alcohol, sleep, appetite, shame, hallucinations, paranoia, pain, other concerns)
Social stressors (school/work functioning, bullying, suicide contagion, significant loss, relationship problems, burden to others, legal/financial issues)
Intent to Live / Die
I wish to live to the following extent (1-10)
I wish to die to the following extent (1-10)
Reasons for dying
Reasons for living
Tell me what you envision for your life in 1, 5, and 10 years from now
To what extent is the problem seen as Intolerable, Inescapable, Interminable
What is Your Social Support?
Support circles (family, friends, command, work)
Do you have a sense of belonging?
View yourself as a burden?
Get Collateral Information
If possible speak with family, friends, co-workers, outpatient providers, etc...
Use the least restrictive means necessary to ensure safety. When in doubt, err on the side of caution.
Depending on their acuity and level of risk consider -> admission to inpatient unit vs partial hospitalization program vs intensive outpatient vs regular outpatient.
If elevated acute risk do not leave patient alone (place 1:1 order).
Notify family / outpatient providers and set up resources.
If you are NOT admitting them to the hospital then make a thorough "safety plan".
Make Safety Plan
*use CAMS or NIMH brief assessment or CSSR-S or other evidence-based resource*
Acknowledge that suicidality is one of several options for dealing with problems and mental pain but that other options may work more effectively: “Let’s take a look at them.” Your approach should be collaborative, not confrontational.
Our first priority is keeping you safe. Let’s work together to develop a safety plan for when you are having thoughts of suicide
Identify their personal warning signs. Scaled plan. 1= I’m good. 5= Thoughts of self-harm, S/I. 7= Racing thoughts, isolation. 10= Specific plans with rehearsal, preparations.
Example of scaled plan…. If ___ (10) then ___ (go to ED). If ___ (7) then ___ (call/talk to family/friend/outpatient doc). If ___ (5) then ___ (exercise, meditate, read, talk to family/friend).
Scheduled follow-up / tx
Provide resources / contacts / professionals to contact / suicide hotline
Restricting/securing lethal means (remove firearms, lock excess medications)
Remove psychosocial stressors as feasible. Have someone contact them for safety.
Although it is frequently done, there is no evidence that having the patient "contract for safety" reduces risk.
Do you think you need help to keep yourself safe?
TREATMENT OPTIONS FOR SUICIDALITY
•The focus of this lesson is to help provide a framework for the assessment of the suicidal patient. At this point we will provide a brief overview of treatment options that have evidence in reduction of suicide.
Cognitive Behavioral Therapy (CBT) and Dialectic Behavioral Therapy (DBT) focused on reducing suicidal cognitions and behaviors have modest evidence for effectiveness. 3
Problem-Solving Therapy based interventions also have been shown to be helpful. This is a form of cognitive–behavioral intervention geared to improve an individual's ability to cope with stressful life experiences. 4
The basic task in therapy is to destabilize your patient’s belief that mental pain is inescapable (show that the problem can be solved), interminable (show that the negative feeling will end), and intolerable (show your patient that he or she can stand negative feelings). Ideally, this can lead the patient to once again feel hope regarding their situation.
Suicidal behavior increases mental pain and creates new problems producing more mental pain. At the same time, acknowledge that suicidal feelings are a valid and understandable response to this pain.
Stress that suicide is a permanent solution to what is most often a temporary problem. Acknowledge that such behavior is one of several options for dealing with problems and mental pain but that other options may well work more effectively.
Avoid power struggles over behavior. Your value comes from offering effective solutions to life’s problems and showing that mental pain can be accepted in a way that allows life to have meaning and be enjoyed. Identify specific skill sets that can be developed through structured behavioral training— mindfulness and acceptance skills, detachment skills, problem- solving skills, and self-compassion skills.
This is a topic that could easily be an entire post by itself, but briefly the interventions that have strong evidence for reduction of suicide are lithium, ketamine, clozapine (in patients with psychosis), and electroconvulsive therapy (ECT).
Pharmacologic treatment should be focused on treating any underlying psychiatric condition.
Much has been said on this topic, but there is no clear evidence that antidepressants increase the risk of suicidality. There is limited data that suggest a mild increased risk just after starting medication in young adults and this has been attributed to the activation of goal-directed behavior associated with the treatment of depression. Keep in mind, however, that that is a clear risk that depression itself significantly increase risk of suicidality and this may be mitigated with appropriate treatment with antidepressants.
Crisis Response Plan (CRP) is a brief intervention designed to reduce suicidal behaviors. Includes techniques of stress reduction, distraction, reasons for living, and identifying social supports and contact information for support of crisis (hotlines, mental health clinicians, etc...). 6
"Means Reduction" such as removing firearms from the home and locking up excess medication is effective. 7
I put a lot of work into this lesson, so I hope you found it helpful. The suicide risk assessment is a critical part of what we do as mental health professionals even though it is difficult and hard to truly assess their risk. It is often the first step to start helping these patients on the path to recovery. Feel free to comment below if there are other helpful tips or resources you'd like the other readers to see.
Resources for today's post include Pocket Psychiatry and the articles referenced in the lesson.
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