Suicide Risk screening

So how do you ask about suicide? 

• THOUGHTS
• THREATS
• PLANNING
• PREVIOUS ATTEMPT (deliberate self harm)

1. Have you had thoughts about taking your life?  (1)
   1. And were they frequent and were they intrusive?
   2. To get quality of thoughts
2. Threats to others (2)
   1. telling others thoughts like “I will kill myself or …. Happens”
   2. How many times
   3. context
3. Plans (3)
   1. Knowing doses, methods
   2. What sorts of plans have you made? Any definite plans 
4. Self harm or self injure or risky behaviour (4)
   1.  may not necessarily be suicidal but even if there is no intent of suicide it is still important 
   2. Cutters are often not suicidal
5. Previous attempt (5)
   1. Best predictor of future attempts
   2. Did they expect and want to die?
   3. What was the level of lethality? (how serious were they) 
   4. What was the level of intent?  Anyone else in family committed suicide?

1. RISK FACTORS

• Suicidal behavior: history of prior suicide attempts, aborted suicide attempts, or self-injurious behavior
•  Current/past psychiatric disorders: especially mood disorders, psychotic disorders, alcohol/substance abuse, ADHD, TBI, PTSD, Cluster B personality disorders, conduct disorders (antisocial behavior, aggression, impulsivity) Co-morbidity and recent onset of illness increase risk
• Key symptoms: anhedonia, impulsivity, hopelessness, anxiety/panic, global insomnia, command hallucinations
• Family history: of suicide, attempts, or Axis 1 psychiatric disorders requiring hospitalization
• Precipitants/Stressors/Interpersonal: triggering events leading to humiliation, shame, or despair (e.g, loss of relationship, financial or health status—real or anticipated). Ongoing medical illness (esp. CNS disorders, pain). Intoxication. Family turmoil/chaos. History of physical or sexual abuse. Social isolation
• Change in treatment: discharge from psychiatric hospital, provider or treatment change
• Chronic medical illness (esp. CNS disorders, pain).
• istory of or current abuse or neglect.
• Access to firearms

2. PROTECTIVE FACTORS Protective factors, even if present, may not counteract significant acute risk

• Internal: ability to cope with stress, religious beliefs, frustration tolerance
• External: responsibility to children or beloved pets, positive therapeutic relationships, social supports

3. SUICIDE INQUIRY Specific questioning about thoughts, plans, behaviors, intent

• Ideation: frequency, intensity, duration—in last 48 hours, past month, and worst ever
• Plan: timing, location, lethality, availability, preparatory acts
• Behaviors: past attempts, aborted attempts, rehearsals (tying noose, loading gun) vs. non-suicidal self injurious actions
• Intent: extent to which the patient (1) expects to carry out the plan and (2) believes the plan/act to be lethal vs. self-injurious.

Explore ambivalence: reasons to die vs. reasons to live

• For Youths: ask parent/guardian about evidence of suicidal thoughts, plans, or behaviors, and changes in mood, behaviors, or disposition
• Homicide Inquiry: when indicated, esp. in character disordered or paranoid males dealing with loss or humiliation. Inquire in four areas listed above

RISK LEVEL/INTERVENTION

• Assessment of risk level is based on clinical judgment, after completing steps 1–3
• Reassess as patient or environmental circumstances change

RISK FACTORS FOR SUICIDE: “SADPERSONS”

• S – sex, male>female
• A – age, adolescent & elderly 
• D – depression or hopelessness
• P – previous self harm
• E – excessive alcohol or drug abuse
• R – rationality loss
• S – separated, widowed, divorced
• O – organised or serious planned attempt (ie suicide note written, will changed)
• N – no social supports (no close/reliable family, friends or siblings)
• S – stated future intention to self harm 

If have untreated depression 🡪 10-15% risk of suicide

If have psychosis 🡪 15% risk of suicide 🡪 risk is greatest once they are discharged, the delusions settle & then they get some insight as to what they’ve done & how they’ve become so isolated, etc. 

Patient Safety Plan Template

Step 1. Warning signs (thoughts, images, mood, situation, behavior) that a crisis may be

developing:

1. _________________________________________________________________________________________

2. _________________________________________________________________________________________

3. _________________________________________________________________________________________

Step 2. Internal coping strategies – things I can do to take my mind off my problems

without contacting another person (relaxation technique, physical activity):

1. _________________________________________________________________________________________

2. _________________________________________________________________________________________

3. _________________________________________________________________________________________

Step 3. People and social settings that provide distraction:

1. Name ________________________________________ Phone ____________________________________

2. Name ________________________________________ Phone ____________________________________

3. Place _________________________________________ 

4. Place _________________________________________

Step 4. People whom I can ask for help:

1. Name ________________________________________ Phone ____________________________________

2. Name ________________________________________ Phone ____________________________________

3. Name ________________________________________ Phone____________________________________

Step 5. Professionals or agencies I can contact during a crisis:

1. Clinician Name _________________________________ Phone ____________________________________

Clinician pager or emergency contact # ______________________________________________________

2. Clinician Name _________________________________ Phone ____________________________________

Clinician pager or emergency contact # ______________________________________________________

3. Local Urgent Care services _________________________________________________________________

Urgent Care services address _______________________________________________________________

Urgent Care services phone ________________________________________________________________

4. Suicide Prevention Lifeline Phone: 1-800-273-TALK (8255)

Step 6. Making the environment safe:

1. _______________________________________________________________________________________

2. _______________________________________________________________________________________

FORMULATION

• concise summary of your assessment of the patient
• Used to communicate information in clinical notes, letters & when presenting a case in ward rounds or exams
• Begins with brief description of the patient (eg Mrs Smith is a 38 yo married housewife with 3 children, presenting with a 6/12 Hx of panic attacks)
• It then progresses through the Hx, MSE & physical exam (summarising the important points of the case)
• Not necessary to repeat every detail but important negative findings must be included such as no family history of mental illness, no suicidal ideation, no psychotic symptoms, etc. 
• The formulation ends with a discussion of the DDx including the arguments for & against the various possibilities, the relevant aetiological factors, investigations & immediate short & long-term management plans

• Try to discuss the 4 P’s
  • Predisposing
  • Precipitating
  • Perpetuating
  • Protective

Differential Diagnosis

1. ‘functional’ mental illness – psychiatric illness without a ‘physical’ cause
2. organic mental illness – physical disorders causing ψ Sx & include neurological, metabolic, endocrine, iatrogenic, drug & alcohol including withdrawal syndromes. (commonly UTI, thyroid, hyperCa²⁺, seizure disorder)
3. personality disorder – may be the 1° Dx or occur concurrently with another disorder
4. mental retardation – may result in presentation with emotional or behavioural abnormalities. Both functional & organic mental illness are more common in people with mental retardation. 
5. medical disorder – coincident medical disorder which, although not directly causing the mental illness, may have an impact on its presentation & response to treatment 

Management 

 = 5 principles

1. Safety (broadly)
   1. Consider use/implementation of MHA
   2. suicidality/ homicidality 
   3. Safety to self, others, children, elderly, finances, reputation
   4. ? duty to intervene & prevent damage

2. Therapeutic alliance
   1. Core issue is TRUST
   2. Can be VIP for the patient – you may be the only one who ‘listens’ to them

3. Diagnostic clarification
   1. To refine the DDx
      1. Collateral Hx (family, friends, GP, old notes, etc)
      2. Serial observation of MSE
      3. Investigations
         1. Bloods – FBC, U&E, ESR, B12, folate, Ca/Mg/Phos 
         2. Urine drug screen, MSU/MCS for UTI, catecholamines for phaeochromocytoma 
         3. serology – HBV, HCV, HIV (neurotrophic virus!), syphilis (don’t forget consent because if +ve, will need to refer for contact tracing) 
         4. levels of mood stabilisers (lithium, carbamazepine, valproate) & clozapine 
         5. weight & WHR (metabolic syndrome with antipsychotics)
         6. AutoAB in atypical depression (SLE)
         7. fasting lipids & sugar because atypicals can cause problems
      4. Radiology (CT/MRI brain with contrast)
      5. EEG (esp. for later in life or atypical presentations)
      6. Other – detailed neuropsychiatric review, OT for ADLs, physio for unstable gait, etc

4. Symptom reduction using bio-ψ-social model

	BIO	PSYCHO	SOCIAL
SHORT TERM	medicationECT	supportive psychotherapy CBT Psychodynamic therapy	accommodation income support vocational rehabilitation  Centrelink
LONG TERM

5. Assess decision making capacity

• are they able to give valid informed consent? 
• Substitute decision making 🡪 next of kin, adult guardian (last resort)
• Power of attorney act (PAA 1998) – can have AHD 
• Guardianship & administration act (GAA 2000) – can have appointed guardians by tribunal  
• Note that the MHA can only be used for treatment of mental illness!