2. Introduction
Suicide appears to occur when a mental Disorder is present,
Intent develops and Means become available.
The majority of those who commit suicide have told
someone beforehand of their thought; two thirds have seen
their GP in the previous month.
A quarter are psychiatric outpatient at the time of death, half
of them will have seen a psychiatrist in the previous week.
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3. General Approach to Intervention
Conduct a thorough assessment to identify disorder, intent
and risk factors.
Take steps to mitigate or eliminate identified risk factors and
means.
Strengthen barriers to suicide and its means.
Treat the associated disorder.
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4. When Should Suicide Assessment be Conducted?
• First assessment on any patient with a mental illness or
substance abuse diagnosis.
• When a patient experiences sadness, low mood, recent loss
or hopelessness, and at each subsequent session as long as the
patient remains at risk.
• Any time a patient has any other identified potential risk
factors.
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5. Dimensions of Assessing Suicide?
Elicitation of suicidal ideation
Identification of risk factors for suicide.
Weighing of risk factors.
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6. Overview of ideation assessment.
• Be sensitive to the different cultural views regarding suicide
• At minimum, ask directly for presence and nature of suicidal
thoughts, including frequency, intensity, circumstances &
characteristics.
• Determine if there is current intent or a plan
• Ask for plan details, including rehearsals
• Assess availability and lethality of means
• Determine if there's a history of thoughts, wishes, impulses or attempts
• Assess attitude, beliefs and values about suicide
• Determine if anything is different this time that will raise or lower risk
• Determine if patient shared ideation with anyone
• Identify any support person who might be helpful in reducing the risk.
NB:Available assessment tools, such as the Scale for Suicide Ideation (SSI) or Beck
Scale for Suicide Ideation (BSS)
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7. Assessing Suicidal Ideation 1
• The assessment of suicidal ideation proceeds along a gradient, from least to most severe, with
a specific line of inquiry as part of the assessment of mental status:
• Beginning with general questions about how patient sees the future, the meaning and worth of
life, and any consideration of self-harm.
• The interviewer should ask whether thoughts of death or suicide have occurred; if so,
how often, how persistently and with what intensity?
• Are they fleeting, periodic or constant? Are they increasing, decreasing or
remaining constant?
• Do they occur under specific circumstances?
• Thoughts should be characterized as passive (e.g.,“I would be better off dead”) or active
(e.g.,“Sometimes, when I am driving my car, I get the impulse to drive into other cars.”)
• Any thoughts noted should then be elaborated upon using the patient’s own language.
Specifically, what are the thoughts content?
• The patient should be asked whether there is current intent /impulse, and if so, is there a
plan?
• Details of the plan (method, time and place) should be reviewed and documented in the
clinical record.
• The patient should be asked about whether any rehearsal (mental or through action) has
taken place and whether there have been any attempts made thus far.
• Past history of similar thoughts, wishes, impulses, plans or attempts should be obtained.
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8. Assessing Suicidal Ideation 2
• The patient with a plan should be asked about the availability of means
and/or whether there is a plan/intent to obtain any means (e.g., plan to
purchase a gun).
• As part of the evaluation, the interviewer should determine the patient’s
attitude toward suicide, which may range from acceptance of its inevitability
or desirability (ego syntonic) to ambivalence or rejection (ego dystonic).
• The patient should be asked about barriers to suicide.
• What are the reasons for living and those for dying?
• What has prevented the patient from carrying out the act, or
• How has s/he managed to evade the act of suicide thus far?
• Is there anything different now or anticipated to be different in the near future?
• Has the suicidal ideation been shared with anyone else besides the
therapist?
• Who has been or could be helpful in managing the ideation?
• This will allow for the involvement of family and/or significant others.
who can can assist in obtaining data about the patient and provide containment
and feedback during treatment, as part of the safety plan, but such
collaboration should be with the patient’s permission.
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9. Suicide Risk Scale:
Sex: men kill selves 3x more frequently than women.
Age: greater risk among 19 yrs or younger, and 45 yrs or older.
Depressed: 30x more than non-depressed.
Previous attempters: 64x that of general population.
Ethanol abuser: about 15% of alcoholics commit suicide.
RationalThinking loss: psychosis, mania, depression or OBS.
Social support lacking: especially a recent loss of support.
Organised plan: either directly or indirectly communicated.
No spouse: single, divorced, widowed or separated.
Sickness: severe, chronic or debilitating illness.
Scoring: One Point is scored for each factor present –
0-2 allow home with follow up
3-6 consider hospitalisation depending on confidence in follow-up.
7-10 suggests either hospitalisation or commitment.
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10. Other Identified Risk Factors:
Patients are at greater risk for suicide if they:
Have had psychiatric hospitalization within the past year
• Have had a recent or impending loss
• Have a history of impulsive or self destructive behavior
• Have committed violence in the past year
• Have access to guns
• Have a family history of suicide
• Are socially isolated
• Have a chronic, terminal or painful medical disorder
• Are newly diagnosed with serious medical problems
• Are male age 65 or older
• Have lost a child either to suicide or in early childhood
• Have a history of physical or sexual abuse in childhood.
Top High risk Diagnosis for completed suicides
Depression, especially with psychic anxiety, agitation and/or significant insomnia
Bipolar disorder
Alcohol and substance use disorders
Schizophrenia
Borderline personality disorder.
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11. Assessment following an attempt
After an act of para-suicide, it important to determine the degree of suicidal intent
existing at the time:
What is the explanation for the attempt in terms of likely reason(s) and goal(s)?.
Does patient intent to die now?
What problems confront the patient?
Is there psychiatric disorder and if so how relevant is it to the attempt
What are the patient’s coping resources and support?
What kind of help might be appropriate, and is the patient willing to accept such
help?
A high degree of suicide intent is indicated by the following:
Planning beforehand
Precaution taken to avoid discovery
No attempt made to seek help afterwards
A dangerous method was used: shooting, drowning, hanging.
There was a final act: will, suicide note.
Extensive premeditation
Admission of suicidal intent
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12. Documentation of assessment.
The clinical record should reflect that the
• suicide risk assessment has taken place,
• what the findings are, and
• what intervention plans are in place to contain, manage or
mitigate the identified suicidal risk.
• The ideation and risk, along with the positive and negative
findings, should be noted in the clinical record, either in the
mental status exam section or in a clinical note.
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13. Management guidelines
If there is serious risk, patient should be admitted, compulsorily if need be
A good rapport should be established between patient and staff:
So that patient will be able to articulate and express his or her feelings and suicidal
thoughts.
• A strong therapeutic alliance could enhance engagement between clinician and
patient thus enabling clinical interventions to reduce suicidal risk.
Any potentially lethal implement (e.g sharp objects and belts), should be removed.
Patient may need to be observed continuously and nursed in pyjamas (without a
cord) or a nightdress throughout the day.
Any psychiatric disorder should be treated appropriately.
The presence of pervasive anxiety with depression, thought disorder with persecutory
delusions and/or command hallucinations with schizophrenia should alert the
clinician to the need for rapid symptom reduction and containment whether or not
suicidal ideation is acknowledged.
For a severe depressive episode ECT may be required as this will act faster than
antidepressant treatment.
Address any abuse of substances, in order to restore the patient to normal restraint
and inhibition. .
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14. Maintenance Treatment Strategies
• Address the abuse of substances in order to restore the patient to normal restraint and
inhibition.
• Assist with the strengthening of social resources through active involvement of
family/significant others in containment and Strengthen barriers and reasons for not
committing suicide.
• Maintenance treatment anxiety or agitation associated with depression and/or thought
disorder, if present.
• Assist the patient in planning and taking steps to stabilize job and family situations that are
in jeopardy.
• Identify and address dangerous behavior that may represent suicidal intent.
• Make lethality an acknowledged and targeted issue.
• There are evidences supporting the efficacy of specific psychotherapies for suicidal
patients, such as cognitive-behavioral therapy (CBT), interpersonal psychotherapy (IPT)
and dialectical behavioral therapy (DBT). It is, however, generally acknowledged that most
forms of psychotherapy may be useful, providing the therapist develops a strong
therapeutic alliance with the patient and conveys a sense of optimism and activity.
• Inform and involve the patient’s primary care physician and other clinicians to increase
coordination of care across settings.
• Employ family intervention to enhance effective family problem-solving and conflict
resolution.
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15. Disposal from Emergency room after suicide attempt
• RELEASE FROM EMERGENCY DEPARTMENTWITH
FOLLOW-UP RECOMMENDATIONS MAY BE POSSIBLE
• After a suicide attempt or in the presence of suicidal ideation / plan when:
• Suicidality is a reaction to precipitating events (e.g., exam failure,
relationship difficulties), particularly if the patient’s view of the situation
has changed since coming to emergency department
• Plan / method and intent have low lethality
• Patient has stable and supportive living situation
• Patient is able to cooperate with recommendations for follow-up, with
therapist contacted, if possible, if patient is currently in treatment
• OUTPATIENTTREATMENT MAY BE MORE BENEFICIAL
THAN HOSPITALIZATION
• Patient has chronic suicidal ideation and/or self-injury without prior
medically serious attempts, if a safe and supportive living situation is
available and outpatient psychiatric care is ongoing
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