Transcript Suicide

Safety (suicide and
aggression) assessment
and management
Fahad Alosaimi MD
Psychiatry and psychosomatic
medicine consultant
Associate professor
KSU, Riyadh
Suicide assessment:
Patient was brought to emergency with paracetamol
overdose.
• How to assess suicidal Patient?
• How to manage suicidal Patient?
Definitions
• Suicide: intentional self-inflicted death
• Suicidal ideation: thoughts of killing oneself
(i.e., serving as the agent of one’s death)
• Suicidal act: intentional self-injury (can have
varying degrees of lethal intent)
• Deliberate self-harm or parasuicide: An act
of self-damage carried out with destructive
intent but without the will to finish one’s
life.
Epidemiology
• Suicidal behaviors are the most common
psychiatric emergency
• The 11th leading cause of death in U.S.
• About 30,000 suicides annually in U.S.
• Over 90% of suicide victims have a
diagnosable psychiatric disorder—over half
have a depressive disorder
Scott Stroup, 2004
Depression and History of Attempted Suicide as Risk Factors for
Heart Disease Mortality in Young Individuals.
Depression and History of Attempted
Suicide as Risk Factors for Heart Disease
Mortality in Young Individuals.
Shah, Amit; Veledar, Emir; Hong, Yuling;
MD, PhD; Bremner, J; Vaccarino, Viola; MD,
PhD
Archives of General Psychiatry.
68(11):1135-1142, November 2011.
DOI: 10.1001/archgenpsychiatry.2011.125
Figure 2. Populationattributable risk of ischemic
heart disease mortality due to
depression and a history of
attempted suicide and
traditional risk factors. Risk is
based on hazard ratios in a
multivariate model that
included depression/attempted
suicide, age, race/ethnicity,
smoking, hypertension,
hyperlipidemia, diabetes
mellitus, and obesity.
Copyright 2011 by the American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions
Apply to Government Use. American Medical Association, 515 N. State St, Chicago, IL 60610.
2
Attempts vs. Completions
• Ratio of attempts to completions may be as
high as 25:1
• Women more likely to attempt suicide
• Men more likely to complete suicide
• Men use more lethal means
Psychiatric disorders are
the primary underlying risk factors
• Major depression
• Bipolar disorder
• Schizophrenia
• Substance use disorders
• Personality disorders: borderline,
antisocial
• Panic disorder
Highly important underlying risk
factors
•History of previous attempts
•Depression
•Alcohol or drug abuse
Other underlying risk factors
• History of psychiatric hospitalization
• Chronic medical illness(serious, painful or
disfiguring)
• Family history of suicide
• History of childhood abuse (physical, verbal,
or sexual)
• Impulsiveness
Underlying sociodemographic
risk factors
• Social isolation:
-Living alone
-Not currently married (never married,
separated, divorced, or widowed)
• Unemployment
• Male gender
• Increased age
• Certain occupations: police officers,
physicians
Biological Factors
• Serotonin abnormalities
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decreased CSF 5-HIAA
increased 5-HT2A receptors
linked with impulsivity and aggression
PET: abnormal metabolism in prefrontal cortex
• Genetics
• familial association beyond risk for specific diagnoses
Precipitating (proximal) Risk
Factors
• Intoxication especially with Alcohol
• Stressful life events:
-loss of job
-death of a loved one
-divorce
-migration
-incarceration
• Is suicide contagious?!!
• Role of media?!!
Most common methods of
completed suicide
Men
Women
1. Firearms (61%)
• Presence of a gun in the home
increases risk of suicide 5X
• Readily accessible firearms facilitate
lethal impulsive acts and leave little
chance for rescue
2.
Hanging
1. Firearms (37%)
2. Self-poisoning
Psychological factors/theories
• Hopelessness, despair
• Freud: aggression turned inward
• Escape from rage
• Guilt; self-punishment or atonement
• Rebirth or reunion fantasies
• Control over a relationship
• Revenge
Religion and Suicide
• Lower rates among Muslims, Jews and Catholics,
presumably due to religious prohibition
• Lower rates in predominately Catholic countries,
but this is not consistent
• Religious affiliation is apparently less important
than religious involvement and participation in
affecting risk of suicide
• No major studies about suicide in Islamic countries
Suicide and Schizophrenia (I)
• 33-50% with schizophrenia will attempt suicide
• Approximately 10% with schizophrenia die by
suicide
• Gender: equal attempt ratio, more men die by
suicide
• Isolation (single, living alone, unemployed)
• Substance abuse
• Akathisia
Suicide and Schizophrenia (II)
• Periods of increased risk:
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Highest risk in first 10 years of illness
When depression
When hopeless
After resolution of an acute psychotic exacerbation
Days, weeks, months after hospitalization
• Persons with more “insight” thought to be at
higher risk of suicide
Suicide among physicians
• Rate higher than general population, particularly for women
doctors (same rate in male, female MDs)
• Unrecognized and untreated depression a common theme
• Physician help-seeking highly suboptimal:
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1/3 of physicians have no regular doctor
Low rates of seeking help for depression
Professional attitudes discourage admission of health vulnerabilities
Concerns about confidentiality, licensing, privileges, medical
insurance, malpractice insurance
• When seek help often quite ill
Figure. Proportionate Mortality Ratio for
White, Male Physicians vs. White, Male
Professionals, 1984-1995
Center et al, JAMA, June 18, 2003
Profile of a Physician at High
Risk for Suicide
• Sex: Male or female
• Age: 45 Years or older (woman); 50 years or older (man)
• Race: White
• Marital status: Divorced, separated, single, or currently having marital
disruption
• Risk factors: Depression, alcohol or other drug abuse, workaholic, excessive
risk taking (especially high-stakes gambler, thrill seeker)
• Medical status: Psychiatric symptoms or history (especially depression,
anxiety), physical symptoms (chronic pain, chronic debilitating illness)
• Professional: Change in status—threats to status, autonomy, security,
financial stability, recent losses, increased work demands
• Access to means: Access to legal medications, access to firearms
Center et al, JAMA, June 18, 2003
Assessment of suicidality
• Ask about suicidality in every initial
psychiatric assessment
• Asking about suicidality does not suggest it
• Do not dismiss someone’s suicidal
comments
• Spectrum of suicidality: passive thoughts,
plan, intent, attempt
• Intent is not always communicated
• No absolute predictive test or criteria
When assessing suicide risk,
consider:
• Pervasiveness of thoughts
• Plan
• Lethality of plan/attempt
• Availability of lethal means
• Likelihood of rescue
Markers of increased suicide risk
• Preparations for death: Settling affairs, giving away
personal items, writing a note
• Sudden change of mood
• Lack of future plans
• Recent loss
• Symptoms: Insomnia, hopelessness, severe anxiety,
extreme restlessness or agitation
The chronological assessment of suicide
events (CASE)
1. The presenting suicide ideation and behaviors.
2. Recent suicide ideation and behaviors over the
preceding 8 weeks
3. Past suicide ideation and behaviors
4. Immediate suicide ideation and future suicide
plans
(Shea, 2002)
Assessment of the suicide
• The present attempt:
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Situation
Mean
Suicidal note
Planning
MSE
• Past History:
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Past attempts
Past psychiatric disorder
Medical disease
Present factors
Living status
Social support
Suicide risk categories (Psychosomatic
medicine, Amos, 2010)
SAD PERSONS Scale
Management of suicidal patients
• Determine treatment setting: Inpatient or
outpatient
• Caution regarding use of “contracts for safety”
• Better to use (commitment to treatment
statement) (Rudd,2006)
• Medications
• Limit availability of firearms, lethal drugs, other
means
• Access to crisis services needed
• Therapy
Management of suicide
• Immediate:
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Admission: psychiatric vs. medical wards
Instructions to nurses
Management of medical problems
Involvement of family
• Short-term:
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Transfer to psychiatric ward
Treat psychiatric disorder
Manage social stress
Psychological treatments
Management of suicide
• Long-term:
• Maintenance of treatment
• OPD follow-up
• Social support
• Samaritans (easy contact to service)
• Watch of relapse
Myth vs. Fact about suicide
Myth: People who talk about suicide don’t die by suicide.
Fact: Many people who die by suicide have given definite
warnings to family and friends of their intentions. Always take
any comment about suicide seriously.
Myth: Suicide happens without warning.
Fact: Most suicidal people give many clues and warning signs
regarding their suicidal intention.
Clayton, J. Suicide Prevention: Saving Lives One Community at a Time. American Foundation for Suicide
Prevention. http://www.afsp.org/files/Misc_//standardizedpresentation.ppt
Myth vs. Fact about suicide
Myth: People who are suicidal are fully intent on dying.
Fact: Most suicidal people are undecided about living or dying
– which is called suicidal ambivalence. A part of them wants to
live; however, death seems like the only way out of their pain
and suffering. They may allow themselves to “gamble with
death,” leaving it up to other to save them.
Myth: Males are more likely to be suicidal.
Fact: Men die by suicide more often than women. However,
women attempt suicide three times more often than men.
Clayton, J. Suicide Prevention: Saving Lives One Community at a Time. American Foundation for Suicide
Prevention. http://www.afsp.org/files/Misc_//standardizedpresentation.ppt
Myth vs. Fact about suicide
Myth: Asking a depressed person about suicide will push
him/her to kill themselves..
Fact: Studies have shown that patients with depression have
these ideas and talking about them does not increase the risk
of them taking their own life.
Myth: Improvement following a suicide attempt or crisis means
that the risk is over.
Fact: Most suicides occur within days or weeks of
“improvement” when the individual has the energy and
motivation to actually follow through with his/her suicidal
thoughts.
Clayton, J. Suicide Prevention: Saving Lives One Community at a Time. American Foundation for Suicide
Prevention. http://www.afsp.org/files/Misc_//standardizedpresentation.ppt
Recommendations to Saudi health care policy to
deal with suicide
• 15% of healthcare budget should go to psychosocial
services. ( currently, ? Less than 1%)
• Force medical insurance companies to cover
psychiatric treatment in the insurance pill ( currently,
the insurance does not cover plastic, dental and
psychiatric services?!!, despite 25-33% of population
will have psychiatric disorder anytime in their live).
• Integrate psychiatric services as part of general
medical hospitals ( currently, we have only isolated
neglected stigmatized mental hospitals).
Recommendations to media
• Reports should be factual, concise, non-repetitive
• Reports should avoid oversimplified explanations of
cause
• Detailed descriptions of method should not be
provided
• Reports should not glorify victim or imply that
suicide was effective in helping the person to attain
some goal
• Reports should provide information on how to get
help
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Aggression assessment and
management
• Patient was brought to ER in a state of severe
verbal and physical aggression.
• Moreover, His father reported he was destructive to
properties at home.
• How to assess Aggressive Patient?
• How to manage Aggressive Patient?
Assessment of Agitated and Aggressive Patients
• What is agitation:
• Tension state in which anxiety is manifested in
psychomotor area with hyperactivity. Seen in
depression, schizophrenia & mania.
• What is aggression:
• Hostile or angry feelings, thoughts or actions directed
towards an object or person. Seen in impulsive
disorders, impulse control disorders & mania.
Epidemiology
• Patients with mental disorders do not commit most violent
crimes
• The probability of violent behavior among patients with mental
disorders is greater than that for the general population
especially in low-crime countries.
• A Sweden study (1)from found that patients with severe mental
illness commit 1 in 20 violent crimes).
• Young, male, Substance abuser esp. Alcohol has the highest
relative risk for violence.
• Using case registries in Australia (N = 4156), the odds ratio for
violent offenses was 2.4 for male individuals with schizophrenia
with no substance abuse problems and 18.8 for schizophrenia
complicated by substance abuse(1).
•
( 1) Fazel S, Grann M. 2006 (2)Wallace C,1993
Risk factors of aggression among mentaly ill
patients
A) Male
B) young
C) previous aggression
D) Dx :
1) schizophrenia
2) Major depression
3) Bipolar disorder
4) substance abuse
5) antisocial or borderline personality
6) Dementia
7) delirium
8) traumatic brain injury
9) Epilepsy
Risk factors of aggression among mentaly ill
patients
E) Symptoms of :
confusion
intoxication
akathesia
fearfulness
agitation
paranoid delusion
command hallucination
****** specific IN-PATIENT medical setting :
 Post-operative delirium
Pain
First 48 hours ( withdrawal state)
Risk factors of aggression in Emergency
setting
Patients factors
• intoxication
• Psychiatric
disorders including
personality
• Involuntary
• negative
perception of
hospital staffs
• possession of
weapon at
presentation
staff factors
Environmental
factors
System factors
• Impoliteness
• high noise level
• pts volume
• insensitivity
• overcrowding
• Increase waiting
time
• inadequate training
• uncomfortable
waiting rooms
• decrease staff
• decreased training
in management of
aggressive patients
Mechanism of aggression
impulsive
Relatively
unplanned
Decrease CSF
5HIAA
premeditated
Deliberate
Predatory
Pathological
Increase DA,NE
Evaluation of aggression
 History :
setting-sequences-outcome
 MSE:
repeated assessment of dangerousness, suicide
& insight.
• P/E :
V/S, exclude injury
Clinical progression of aggression in general hospital
Evaluation of aggression
• Investigations:
blood tests (anemia ,infection, electrolytes,
biochemistry)
Toxicology
EEG
CT scan or MRI
• FORMULATION
General Strategy in Evaluating the Patient
I. Self-protection
• Know as much as possible about the patients before meeting them.
• Leave physical restraint procedures to those who are trained.
• Be alert to risks of impending violence.
• Attend to the safety of the physical surroundings (e.g., door access,
room objects).
• Have others present during the assessment if needed.
• Have others in the vicinity.
• Attend to developing an alliance with the patient (e.g., do not confront
or threaten patients with paranoid psychoses).
II. Prevent harm Prevent self-injury and suicide. Use whatever
methods are necessary to prevent patients from hurting themselves
during the evaluation.
General Strategy in Evaluating the Patient
 Prevent violence toward others. During the evaluation,
briefly assess the patient for the risk of violence. If the
risk is deemed significant, consider the following options:
1)
2)
3)
4)
5)
Inform the patient that violence is not acceptable.
Approach the patient in a nonthreatening manner.
Reassure, calm, or assist the patient's reality testing.
Offer medication.
Inform the patient that restraint or seclusion will be used if
necessary.
6) Have teams ready to restrain the patient.
7) When patients are restrained, always closely observe them,
and frequently check their vital signs. Isolate restrained
patients from surrounding agitating stimuli. Immediately plan a
further approach e.g. medication, reassurance, medical
evaluation.
III. Rule out secondary psychiatric disorders.
IV. Rule out impending psychosis.
Assessing and Predicting Violent Behavior
• Assess the risk of violence
1) Consider violent ideation, wish, intention, plan,
availability of means, implementation of plan, wish for
help.
2) Consider demographics e.g.sex (male), age (15 to 24),
socioeconomic status (low), social supports (few).
3) Consider past history: violence, nonviolent antisocial
acts, impulse dyscontrol (e.g., gambling, substance
abuse, suicide or self-injury, psychosis).
4) Consider overt stressors (e.g., marital conflict, real or
symbolic loss).
Differential
diagnoses of
violent behavior
Nonpharmacological management of aggressive
behavior
 Assess the environment for potential dangers (e.g.,
objects that can be thrown or used as a weapon).
 Assess the physical demeanor of the patient (e.g., many
patients make a fist before punching or kicking).
 Know where the patient is at all times (e.g., do not turn
your back to the patient; do not leave the patient alone
and therefore unobserved).
 Take verbal threats seriously.
 Remain several feet away to avoid crowding the
patient.
Nonpharmacological management of aggressive
behavior
 Clear the area of other patients.
 Call for additional help (a "show of force" or a "show of
concern"); this is not a time for heroics.
 Remain calm, maintain a confident and competent
demeanor, and attempt to deescalate by engaging the
patient in conversation.
 Avoid arguments between staff members in front of the
patient.
 If restraints are necessary, have at least 4 people available.
Non pharmacological Tx of chronic aggression
• Multimodal ( behavioral, psycho educational &
family)
 Behavioral :

token economy

aggression replacement strategies

Decelarative techniques
psycho educational :
Pts & family must learn to identify warning behaviors
e.g. cursing, threatening and then apply alternative
pleasurable behaviors
Family : increase coping & ability to manage
aggressive behaviors
Tx of acute agitated behavior
BDZ
• Lorazepam
• P.O 0.5-2 mg
every 1-6
hours
• IM or I.V
• If I.V route
push slowly
< 2mg/ min
Antipsychotics
• Haloperidol
• 1-5 mg
• Give 1-5 mg
each 30 min
until
aggression is
controlled
• P.O ,IM or I.V
others
• seclusion
• restraint
Tx of chronic aggression
Tx of chronic aggression