Transcript Approach to Suicide Risk and Assessment in the ER Resident

Approach to Suicide Risk and Assessment in the ER
Resident Presentation
March 13, 2003
Robbie N Drummond MD
OVERVIEW
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Statistics for our Region
Some basic epidemiology
Causes of Suicide
Risk Factors
Psychiatric Illness and Suicide
The No Harm Contract and Medico-legal Aspects of Suicide
A summary of my discussion with Dr. Phil Stokes
Case 1
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39 year old accountant presents with 3 suicide attempts in one day
sat for 3 hours in car with hose from exhaust when it did not work cut
wrist and sat in hot tub then drank approx 100 cc’s methyl chloride
paint thinner
former alcoholic quit x 2 years
physical abuse in childhood
recently fired from job due to embezzlement of funds
wife left him suddenly for Ontario with 2 children
when she called said he was safe despite having just attempted suicide
friend found him
evidence of depressed affect on exam
– foot note CO carboxyhemoglobin stayed high despite high fiO2
Case 2
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21 year old Scandinavian youth
aristocratic background presents with agitation
says he is not sleeping at nights up pacing on the roof of his building
cannot concentrate on his studies recently quit college
feelings of guilt and that he is being punished
feeling very down socially isolating himself from his family
recent stressors sudden death of his father
not drinking
has hallucinations his dead father telling him to kill his uncle who has
recently remarried to his mother
Suicide Note
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To be, or not to be: that is the question:
Whether 'tis nobler in the mind to suffer
The slings and arrows of outrageous fortune,
Or to take arms against a sea of troubles,
And by opposing end them? To die: to sleep;
No more; and by a sleep to say we end
The heart-ache and the thousand natural shocks
That flesh is heir to, 'tis a consummation
Devoutly to be wish'd. To die, to sleep;
To sleep: perchance to dream: ay, there's the rub;
For in that sleep of death what dreams may come
When we have shuffled off this mortal coil,
Must give us pause: there's the respect
That makes calamity of so long life;.........
Suicide and Depression Emerg Med Cl may 2000
Harwitz
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“Just as a consultation request for a patient with complaints of chest
pain is more efficient when accompanied by a concise history, list of
medications current vital signs, electrocardiogram, blood chemistry and
response to initial management such is the case in referral of a suicidal
patient”
Richard Bukata Emergency Medicine Abstracts 2002
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“The implication of routine consultation in the setting of suicide
attempts is either that others are perceived to know more about
assessing suicidality than we are or that we want someone to agree
with us who has some psychiatric credentials of some sort. The bottom
line is we the initially treating physicians are ultimately left with the
disposition decision.”
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“A person who is determined to kill himself or herself will probably
prevail despite the best efforts of family members and health care
professionals, However the overwhelming majority of people who
decide to kill themselves at one time will feel very different after
improvement in their depression or after receiving help with other
problems”
No. of ED Visit with Suicidal Primary Dx from Apr. 2002 to Jan. 2003
450
400
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350
402
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300
Visits
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East
304
West
North
309
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150
100
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1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
50
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FMC
PLC
RGH
No. of ED Visits with Suicidal Dx by Month, by Site
FMC
PLC
RGH
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51
48
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Visits
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30
23
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37
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200204
200205
200206
200207
200208
200209
Month
200210
200211
200212
200301
Average
Contact with mental health and primary care providers
before suicide
Luoma Am J Psychiatry 2002
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review of 40 studies
3/4 suicide victims contact with primary care providers within year of
suicide
45% within one month
1/3 with mental health within one year, 1/5 one month
especially older patients not so much young men
future research re mechanisms of action in contacts
Suicide Maris The Lancet 2002
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1999 deaths by suicide made up 1.2 % of all deaths in the USA
fell steadily from 1990 to 1999 (14% REDUCTION IN RATE Over that
time suicide had dropped from the eighth to the eleventh leading cause
of death
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30000 deaths per year in USA
18.7 per 100.000 men, 4.4 per 100,000 women
<1 per 100000 in Syria >40 per 100000 in USSR
whites >2x African Americans
third leading cause of death in persons 15 to 34
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A Current perspective of Suicide and Attempted Suicide Mann Ann Int Med 2002
Identification of Suicide Risk Factors Using
Epidemiologic Studies Moscicki 1997 psy Cl North America
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in USA firearms account for nearly 60% of all suicides
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10 studies show that a whether handgun or rifle in the house even if
unloaded increases the risk of suicide in adults and youths strongest
proximal risk factor
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independently increases the risk of suicide for both genders and across
all age groups even after correcting for confounding factors
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women: drugs medications, second; for men: hanging
Assessment and Treatment of Suicidal Patients
Hirschfield NEJM 1997
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Up to one third of persons in the general population have suicidal
ideation at some point in their lives
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Physicians are sometimes reluctant to ask patients about suicide
fearing that the question may lead to suicidal thinking and precipitate
suicidal acts. There is no evidence to support this concern
Most patients are ambivalent and relieved to talk
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forecasting the weather vs predicting astronomical events
predicting short term risk 24 -48 hours more reliable than longterm
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Approximately 25% of suicidal patients do not admit to being suicidal
(Fawcett et al., 1990).
one of eighteen attempts is completed
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suicidal ideation: thoughts of ending one’s life
passive: absence of plan “I wish I were dead”
active: presence of plan “I’ve saved my medicines.....
Suicidal gesture: no realistic expectation of death
suicidal attempt: clear expectation of death
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National Comorbidity Survey
suicide ideation to suicide plan were 34%
plan to attempt were 72%
transition directly from ideation to an unplanned attempt was 26%
90% of unplanned and 60% of planned first attempts happened within
one year of suicide ideation
Criteria for Screening Diseases WHO
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the disease is prevalent
the disease may not be evident to the person who has it
the disease is treatable
early intervention is advantageous
the screening test is reliable
the cost and burden of screening is moderate
An educational intervention for front-line health professionals in the
assessment and management of suicidal patients (the STORM project
Applebee Psychological Medicine 2000
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previous study Morriss et al suicide risk assessment and management
skills do not change without training
training delivered to 167 health professionals primary care accident and
emergency departments
47% of all available staff two training sessions in 6 month period
non mental health professionals improved significantly in assessment,
clinical management and problem-solving
with marked improvement in confidence
satisfaction with training was high
Teaching Front line health and voluntary workers to assess and manage
suicidal patients Morriss et al J of Affective Disorders 1999
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four two hour sessions to 33 health and voluntary workers using roleplaying,interview skill training and video feedback
overall risk assessment and management skills retained for at least 1
month confidence improved
training too brief to produce improvements in general interview skills
may require up to 6 months to attain
Gotland Study
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education of general practitioners in the recognition and treatment of
depression in 1983 was associated with increased antidepressant
prescriptions and a decrease in the annual suicide rate from 20 to 7 per
100,000. The high level of medical contact before suicide means that
effective preventive treatment is possible
The Neurobiology of Suicide Risk,Mann J Cl Psych 1999
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genetic modulation of serotonergic activity
aggression and impulsivity changes found in substance abuse and
depression
18 studies look a 5 hydroxyindoleactic acid 5HIAA in CSF
low levels in suicide attempters
the more lethal the attempt the lower the level of 5 HIAA
gene for tryptophan hydroxylase is affected
altered serotonin function lack of serotonin transporter binding in nerve
terminal
changes in prolactin responses to serotonin responsivity
increased serotonin receptors on platelets
PET scanner shows significant reduction of resting glucose metabolism
in prefrontal cortex of murderers and skewed serotonin circuitry in
suicidal patients
suicidal patients have higher serum cortisol levels
Genetics of Suicide in Depression
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Roy et al J clin Psych 1999
11% of completed suicides had another first degree relative who had
committed suicide (Hemmingway family grandfather, father, son,
granddaughter)
significantly more in a patient that had made a violent attempt
genetic transmission of psychiatric disease
twin and adoption studies high concordance for suicide rates
of 35 twins for whom 1 twin had committed suicide 10 of the 26 living
monozygotic twin had attempted compared to 0 of the dizygotic twins
significantly more of adopted children of biological parents who
committed suicide themselves committed suicide Copenhagen study
genetic susceptibility to suicide only likely to manifest in times of
severe stress or when ill with major psychiatric illness
heritable trait analogous to other disorders e.g. bipolar
Childhood Abuse, Household Dysfunction and the Risk of
Attempted Suicide Throughout the Life Span Dube et al JAMA 2001
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well designed study: 9367 women, 7970 men
retrospective cohort study of 17,337 adults HMO members
survey of childhood abuse household dysfunction and suicide attempts
lifetime prevalence of 1 suicide attempt: 3.8%
adverse childhood experiences increased the risk 2 -5 fold
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emotional, physical and sexual abuse, household substance abuse,
mental illness, and incarceration, and parental domestic violence,
separation, or divorce
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as number of adverse experiences increase the risk increses
dramatically
67 % of suicide attempts are attributable to traumatic childhood
experiences
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5 Questions
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do you ever get so depressed that you think life is not worth living?
do you think of hurting yourself or taking your own life?
do you have a plan?
do you have the means to follow through with the plan?
have you ever attempted suicide?
Demographic Risk Factors
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gender women three times as likely to attempt men four times as likely
to die
race whites and native Americans
age 60 years and older
leading cause of death in 10 to 49 years old in our region
lack of social support unmarried divorced or widowed
financial difficulties unemployment
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the risk factors for suicide are additive
nontraditional risk factors:
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drinking within three hours of the suicide attempt
changing residences within the past 12 months
existing medical conditions
impulsive behavior
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50% of people who died by suicide in Chicago had no close friends the
presence of of a therapist, spouse, or other person (only one other
person) is crucial
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the difficulty with risk factor for suicides is that they lead to many false
positive predictions
SAD PERSONS: a mnemonic for assessing suicide
risk
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Sex (male)
Age (elderly or adolescent)
Depression
Previous suicide attempts
Ethanol abuse
Rational thinking loss (psychosis)
Social supports lacking
Organized plan to commit suicide
No spouse (divorced > widowed > single)
Sickness (physical illness)
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0 -3 close follow up consider admit, 4 -5 consider admit, >5 admit
Adapted from Patterson et al (12).
No Hope Scale
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only three scales have predictive validate Beck’s hopelessness scale,
Linehan’s reasons for living and Cull and Gill’s suicide probability scale
no one psychological test is highly predictive of suicidal acts
Risk factors fall into 2 categories predisposing factors and potentiating
factors
the combination of psychiatric disorder and a stressor
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No framework for meaning
Overt change in clinical condition
Hostile interpersonal environment
Out of hospital recently
Predisposing personality factors
Excuses for dying are present and strongly believed
The best predictor of completed suicide is a
history of attempted suicide
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subsequent attempts greater lethality and intent
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careful inquiry about past suicide attempts essential part of tisk
assessment
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two thirds of suicides occur with first attempt
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the greatest risk occurs within 3 months of the first attempt
Suicide after Parasuicide
Runeson BMJ 2002
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The risk of suicide is generally most prominent during the first months
after psychiatric care
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The risk of repetition and consequently of suicide is believed to be
highest during the first one or two years after an episode of
parasuicide
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the initial high risk declines each year
Suicide rate 22 years after parasuicide:cohort
study Jenkins BMJ 2002
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The rate of suicide for people who have had an episode of parasuicide
is 100 times higher in the year following the episode than that of the
general population
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traced record 22 years 63% of the original sample
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the risk of suicide for people with a history of parasuicide persists over
many years 4.3 per 1000 per year > 3 x normal rate
More than 90% of suicide victims have a diagnosable
psychiatric illness
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main protective factors accurate, early diagnosis and effective
treatment of psychiatric disorders
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important to be aware of Axis formulation
Axis 1 major psychiatric disorder including substance abuse
Axis 2 personality disorder including impulsivity and aggressivity
Axis 3 major contributing physical illness esp in elderly
Axis 4 recent major stressors
Axis 5 highest level of functioning which would include withholding
factors
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Axis 1, 2, and 3 predisposing factors Axis 4, and 5 potentiating
Risks depending on diagnosis:
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60% have mood disorders
followed by schizophrenia, alcoholism, substance abuse and personality
disorder
most people with psychiatric disorder never attempt suicide
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lifetime risk:
Bipolar 20%
alcoholism 18%
major depression 15%
schizophrenia 10%
borderline and antisocial personality disorder 5-10%
Depression Screening as an Intervention Against Suicide
Jacobs J clin Psychiatry 1999
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prevalence of current major depression has been estimated 4.9%
lifetime prevalence is 17.1%
less than 40 % of lifetime depression are diagnosed
less than 20% current depression were in treatment
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national depression screening day 30 sites malls libraries corporations army
bases hospitals started Quincy Mass
October during Mental Illness Awareness Week
Zung Self Rated Depression Scale
400,000 screened followed by one on one interview and referral
20% found to have severe depression 1444 hospitalized
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only 15% of a sample of individuals who killed themselves had received
antidepressant medication in New York 84% of a sample of people who
committed suicide had not taken any antidepressant or neuroleptics
Maris the Lancet 2002
SIG ME CAPS (prescribe me caps)
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Usually one uses either the Hamilton or Beck depression inventory or
scale, since suicide outcomes correlate highly with depressive disorders
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five symptoms to make diagnosis in 2 week period
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S = sleep
I = interest
G = guilt
M = mood
E = energy
C = concentration
A = appetite
P = psychomotor retardation or agitation
S = suicidal ideation
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hard to find conclusive evidence of the syllogism that clinical
depression is the leading cause of suicidal behaviour, that depression is
highly treatable and adequate treatment should reduce suicide risk
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however statistics in USA show decline likely due to increased
awareness and use of newer antidepressants
Suicidality and Substance Abuse in Affective
Disorders Goldberg J CLin Psych 2001
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5- 10 fold increase
more medically dangerous attempts
abuse higher in bipolar than any other Axis 1 diagnosis
alcohol worsens the course of all affective illnesses
56 % male bipolar suicide are alcoholic
impulse control disorders 40% alcohol dependence
likely higher levels of aggression
greater levels of panic disorder, phobic disorders and GAD
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serotonin dysfunction implicated:
impulsivity, aggression, alcohol dependence, suicide and affective
disorders
up to 50% of all people who commit suicide are intoxicated at the
time of death 18% of alcoholics will die by suicide
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increases brain serotonin at first depletes later
reduces impulse control
adolescent suicide victims with alcohol abuse more vulnerable to
interpersonal losses and psychosocial stressors
social isolation and alcohol abuse linked to suicide middle-aged men
SSRI’s diminish alcohol symptoms as well as depressive features in
depressed alcoholics with suicidality
specific psychotherapies cognitive behavioral therapies, dialectical
behavioral therapy effective in borderline personality, alcoholism,
depression
Intoxicated or psychotic patients unknown to clinician who say they are
suicidal should be transported securely to the nearest crisis center.
These patients can be dangerous and impulsive.
Personality Traits
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more subjective depression and hopelessness
greater lifetime aggressively and impulsivity
patients with a history of violence greater lifetime risk of self harm
personality based suicide results from feelings of anger aggression or
vengeance
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psychoanalyst says adamancy is main trait
Chronic suicidality among patients with
borderline personality disorder Paris J Psychiatric Serv
June 2002
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One in ten completes suicide
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not preventable usually does not occur in treatment
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chronic suicidality a way of communicating distress
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hospitalization unproven benefit possible negative effects
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fear of litigation not a reason to admit
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suicide risk not a contraindication for OPD treatment
Characteristics of suicide attempts of patients with major
depressive episode and borderline personality disorder a
comparative study. Soloff PH Am J Psych Apr 2000
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Co morbidity of borderline personality disorder with major depressive
episode increases risk
Hopelessness, impulsive aggression increase risk in both patients with
borderline personality disorder and in patients with major depressive
disorder
“The same combination of biologic and psychodynamic factors that can
render these persons unpleasant to treat are also those that place
them at risk for repeated and possibly fatal injury to themselves. ED
staff should be equipped to tolerate and manage such behaviour until
the patient is medically stable and appropriate follow-up consultation
with psychiatry is arranged”
Advanced Techniques of Interviewing, Craig
1996 Suicidality in Psychotic Patients
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small but significant number of people who attempt suicide are actively
psychotic
any evidence of psychosis warrants a thorough evaluation of lethality
three particular areas command hallucinations, feelings of alien control,
and hyper religiosity
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recent evidence many schizophrenics more likely to commit suicide in
remission when they are apt to feel depressed and hopeless
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demographic factors are relevant
recent losses and poor support systems
alcohol drugs or any physiologic insult to the CNS
interview corroborative informants
Suicide in Teenagers
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Zametkin JAMA 2001
rate of suicide among adolescents has significantly increased in past 30
years
– less likely less than twelve
– however 170 children aged 10 or younger commit suicide each year
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same risk factors in addition male greater than 16, living alone, history
of physical or sexual abuse,substance abuse
high percentage of suicidal ideation 27% in teenaged population
Less specific Alarming Factors
recent dramatic personality change
psychosocial stressor (trouble with family or friends or a disciplinary
crisis)
writing thinking or talking about death
altered mental status (agitation hearing voices, delusions, violence,
intoxication
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No proof yet that gay and lesbian youth higher proportion of suicide
deaths (higher rates of substance abuse and mental disorder)
adolescents are generally not compliant with psychiatric treatment
two studies up to 50% removed from therapy for not attending
suicide attempters ended therapy earlier than nonsuicidal children
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good evidence that unipolar and bipolar disorders in adolescents is
essentially identical to that in adults
efficacy of antidepressants in a teenage population
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adult doses of SSRI’s
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suicide risk is highest at the beginning of a depressive episodes
suicide awareness programs in schools have not been effective either in
reducing suicidal behaviour or in increasing help seeking behaviour
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no clear criteria for hospitalizing and discharging a patient at moderate
risk for suicide
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hospitalization for altered mental status,actively abused
substances,recently attempted suicide, experience hopelessness or
impulsivity, lack of parental supervision
Disease as Risk Factor
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increased suicide risk with immobility , disfigurement, or severe pain
evidence of hopelessness or helplessness
hostile interpersonal environment may increase risk
strong framework of meaning decreases risk
sudden change in clinical condition either positive or negative may
indicate an increased risk
cigarette smoking
Barraclough: HIV, Huntington’s malignant neoplasms, MS, PUD, renal
disease (esp dialysis patients) spinal cord injuries and SLE all
associated with psychiatric illness
Pharmacological Interventions in Suicide
Prevention Tondo et al. J clin Psych 2001
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depressive disorders respond quickly to ECT can take 4-6 weeks for
response to meds
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other therapies conjoint cognitive psychotherapy, dialectical behavioral
therapy or behaviour modification techniques
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TCA’s, MOAI’s, SSRI's inconsistent effect on suicide risk
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antipsychotics uncertain effect suicide risk (akithisia from older drugs
haldol and fluphenazine may have contributed to some suicidal
attempts)
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newer atypical antipsychotics (clozapine et al) lower rate of life
threatening suicide attempts in schizophrenics
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Lithium has been shown to consistently reduce risk of suicide in pts
with bipolar disorder
prophylactic unrelated to mood stabilizing effect
may be beneficial in unipolar depression as well
discontinuation of lithium maintenance sharp increase in suicide risk
carbamazepine less effective than lithium in preventing suicide
benzodiazepines may modify the risk of suicide by reducing anxiety
anxiety and insomnia associated with completed suicide these
symptoms should be treated quickly
Deliberate self harm: systematic review of efficacy of psychosocial
and pharmacological treatments in preventing repetition
Hawton et al BMJ 98
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20 randomized trials in Cochrane data base that looked at effectiveness
of treatment randomized controlled trails metaanalysis
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some benefit with low statistical power for
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1) problem solving therapy
2) provision of emergency contact card
3) intensive aftercare, plus outreach
4) antidepressant treatment compared with placebo
5) significantly reduced rates for multiple repeaters for depot
flupentixol
Assessment of Suicide Risk 24 Hours After Psychiatric
Hospital Admission Russ et al Psychiatric Services 1999
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some evidence that acute hospitalization is not effective in reducing
risk
small sample size
of 69 patients 30 44% were found to be completely free of suicidal
ideation 24 hours after admission
pts who recently made an attempt less likely to have ideation 24 hours
later
did not suggest changes
wondered about refinement of tools to identify patients who might
benefit from rapid assessment and referral to treatment in community
No evidenced based data that psychiatric hospitalization prevents
immediate or eventual suicide
in one study parasuicidal adult patients randomized to home or hospital
no significant difference was found in outcome as measured by
subsequent suicide or general functioning
In the Final Analysis....
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stressors and evidence of a psychiatric disorder should be
hospitalized.
The No Harm Contract in the Emergency Assessment of
Suicidal Risk Stanford et al J clin Psych 94
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no studies that meet criteria for scientific research design
review of use since 1973
Suicidal patient is asked to agree not to harm or kill herself or himself
for a particular period of time
the patient may 1) agree with this proposal verbally or by signing
written statement, 2) suggest modifications, 3) refuse compliance, or
4) choose not to answer
1979 1980’s Goulding characterized NHC’s as a high priority tool
by the 1980’s firmly established in the literature minimal empiric base
Diagnostic and Therapeutic Uses
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within the time constraints of the busy ER can help to crystallize the
physicians understanding of the patient’s mental state
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how the patient responds more critical than what the contract states
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therapeutically establishes alliances if presented in a caring and a
careful way clear limits set accountability on patient’s part
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opportunity for patient to reflect immediate sense of relief by their
being able to contract for safety in a limited time frame
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in patients who resist confrontation and clarification possible
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therapeutic for physician relieves anxiety
medicolegal issue:
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patient often does not meet threshold legal criteria for competence\
no valuable consideration given
no mutual obligation beyond NHC
exculpatory clause for physician contravenes public policy
misuses
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inappropriate disposition
replace complete evaluation
replace comprehensive treatment planning
attempt to prevent malpractice suit
inappropriately reassure patient and staff
when a NHC is used documentation should show thorough diagnostic
assessment thorough risk factor analysis and risk benefit analysis of
hospitalization along with measure of patient’s competency
used in context of of structured suicidal risk evaluation
Use of No-Suicide Contracts by Psychiatrists in
Minnesota. Kroll, J Am J Psychiatry 2000.
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The Study:
Postcard questionnaire mailed to 514 psychiatrists in Minnesota
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There was a 52% response rate.
57% of the psychiatrists used no-suicide contracts: 62% verbal only,
38% written
77% of psychiatrists had used contracts b/c they thought it was
helpful; 23% used them, but thought they were not helpful.
41% of the psychiatrists had patients who had committed suicide/
made a serious suicide attempt after making the contract.
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The Suicide prevention contract clinical, legal and risk
management issues Simon RI J Acad Psych Law Jan 2000
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The suicide prevention contract is not a legal document that will
exculpate the clinician from malpractice liability if the patient commits
suicide. The contract against self-harm is only as good as the
underlying soundness of the therapeutic alliance. The risks and benefits
of suicide prevention must be clearly understood
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Suicide prevention contracts are clinical contracts. They have no legal
force (Simon, 1999). There are no studies that demonstrate suicide
prevention contracts are effective in reducing suicide.
Reliance on a suicide prevention contract may falsely reassure the
clinician and lower vigilance, possibly increasing the risk of suicide
CMPA
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Number one cause of malpractice suits against psychiatrists
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between 1996 and 2000 there were 242 closed legal actions against
ED’s
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seven percent involved psychiatric problems (no breakdown)
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same time frame 221 closed legal actions for psychiatrists
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19 percent represented patients who attempted or committed suicide
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represented 25 % of the costs for the psychiatrists
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of the cases involving suicide 25 % were lost either settled or at trial
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a physician can be defended if there is adequate assessment and
documentation
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the medico legal risk involves either a failure to recognize risk or
failure to supervise and protect the patients
Suicide and Litigation:Lessons Learned in Risk
Management Simon, Psych Times Sept 2002
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Suicides account for the largest number of malpractice suits filed against
psychiatrists, as well as the highest percentage of settlements and verdicts paid
by malpractice carriers
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No standard of care exists for the prediction of suicide. A standard of care does
exist requiring psychiatrists to adequately assess suicide risk when it is clinically
indicated
The assessment of suicide risk is an informed clinical judgment call, not a
prediction. A risk of suicide, rather than a suicide itself, is foreseeable
Foreseeability is not the same as predictability, for which no professional
standards exist.
In the case of a lawsuit, the chart will be examined to determine whether the
physician recognized the risk factors and considered the benefits of exerting
greater control over the patient (e.g. Hospitalization, calling the family)
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occasionally , patients may not allow the clinician to contact their families. When
someone’s life is in imminent danger, confidentiality may be breached.
Documentation
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if not documented not done
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because suicide risk and ideation complex needs more documentation
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no-harm contracts not a substitute
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well-documented suicide risk assessments provide a solid legal defense
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A review of records in psychiatric malpractice cases often reveals the
following: Patient denies SI/HI, CFS (no suicidal ideation or homicidal
ideation, contracts for safety) or, at most, "Patient denies suicidal
ideation, intent or plan
Need:
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1) description of suicide ideation and lethality,
2) risk factors
3) past medical and psychiatric history (meds)
4) basic formulation of psychiatric illness,
5) history of substance abuse,
6) family history
7) previous attempts,
8) access to lethal means,
9) social support structures
10) clear delineation of therapeutic interventions put in place
Discussion with Dr Phil Stokes head of
Ambulatory Psychiatry at PLC
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Says we do a very good job at assessing these patients
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suicidal ideation is common suicide is relatively rare
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important to balance plans and ideation with withholding factors
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command voice in psychotic patients a high risk factor
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balance seriousness of medical risk against seriousness of intent
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important to get collateral information can break confidentiality ask
permission first
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assess demographics carefully SADPERSONS e.g.
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borderline personality disorder 10% overall but odds of episode 54 very
small. Most important factor: is there regular follow-up?
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ED assessment should take 15 minutes need to assess basic risk
factors get basic history clarify diagnosis. Full mental status (especially
if referral probable) will likely be duplicated
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form 1 should almost always be assessed by psychiatrist unless signed
when patient was severely intoxicated and the next day is sober
judgement called for
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missed suicide is the most likely cause for lawsuit for psychiatrist not
true for primary care physicians.Psychiatrists are the suicide experts
and their expertise exposes them to liability
Case 1
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White male
history of alcoholism (not drunk at time)
history of childhood abuse
possible symptoms of major affective disorder
no previous attempt
serious attempt with attempt to deceive
major psychosocial stressors loss of job, marital separation
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was admitted to short term assessment unit at PLC
Poster Boy for Prozac
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Risk factors: male, in adolescent period, white, decreased social
withholding factors,
clear signs that he is suffering from major affective disorder
depression
suicidal ideation even intent
recent major stressors has dropped out of school murder of his father
no evidence of substance abuse
most concerning command hallucinations suggest possible psychotic
features
call the crisis team
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form 1......direct admit to psychiatry....cancel acts II -V
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The Rest Is Silence.......