The waxing and waning nature of suicidality is one of the difficult challenges in the care of the suicidal patient and often requires that suicide assessments be repeated over time (Table 2). Al- though a full suicide assessment is not required at each encounter with the patient, the psychi- atrist should use reasonable judgment in determining the extent of the repeat assessment needed to estimate the patient’s current suicide risk. In inpatient settings, repeat suicide assess- ments should occur at critical stages of treatment (e.g., with a change in level of privilege, abrupt change in mental state, and before discharge). When a reassessment is done, the psychi- atrist often finds that a patient who initially reported suicidal ideation with lethal intent no longer reports suicidal ideation at a subsequent visit. As stated earlier, it is not possible to pre- dict which individuals with recent suicidal ideation will experience it again nor which patients will deny suicidal ideation even when it is present. Nonetheless, if a patient is assessed as being at high risk for suicide, a plan to address this risk must be implemented and documented. This plan may include changes in the setting of care or level of observation, changes in medication therapy or psychotherapy, or both kinds of changes.
Patients with a recent onset of severe suicidal ideation should be treated with particular caution. For those experiencing suicidal ideation in the context of an underlying depressive disorder, it can
be useful to monitor other depressive symptoms. The psychiatrist also needs to be mindful of other symptoms that may be associated with increased suicide risk, such as hopelessness, anxiety, insom- nia, or command hallucinations. Behaviors that may be associated with an acute increase in risk include giving away possessions, readying legal or financial affairs (e.g., finalizing a will, assigning a power of attorney), or communicating suicidal intentions or “goodbye” messages.
Patients who are responding to ongoing treatment or who are in remission with continua- tion or maintenance treatment should be assessed for suicide risk when there is evidence of an abrupt clinical change, a relapse or recurrence, or some major adverse life event. In this context, the new emergence of suicidality should be responded to by an alteration of the treatment plan. The nature of this alteration depends on the clinical situation and can include a change in treat- ment setting or level of observation, increased visits, a change of medication or psychothera- peutic approach, inclusion of a significant other person, and consultation. With changes in clinical status or as new information becomes available, the psychiatrist must also be prepared to reevaluate the patient’s psychiatric diagnosis and also evaluate the nature and strength of the therapeutic alliance.
1. Patients in a suicidal crisis
There will be times when a patient in ongoing treatment is in an acute suicidal crisis and the psychiatrist has to respond immediately. There may be communications directly from the pa- tient, the family, or significant others, including employers or co-workers. In urgent situations, it may be necessary to have telephone calls traced or involve the police. The challenge for the psychiatrist is not only to evaluate the extent of the emergency but also to assess the content of the communication and its source. To better assess the situation, it is critical to speak with the patient directly, if at all possible. In addition, the psychiatrist should remain mindful of issues relating to confidentiality and breach confidentiality only to the extent needed to address the patient’s safety (see also Section V.C, “Communication With Significant Others”).
Under some circumstances, the psychiatrist may need to refer a suicidal patient to an emergency department for evaluation or hospitalization. When doing so, it is important for the psychiatrist to communicate with the psychiatric evaluator in the emergency department. Although such communication may not always be possible because of the exigencies of the emergency situation, such contact does provide hospital personnel with the context for the emergency. Particularly when a patient is brought to the hospital by police, it is not unusual for the patient to minimize the symptoms and reasons for the referral after arriving in the emergency setting. Adequate information about the reasons for the emergency department referral and about the patient’s previous and recent history can be crucial in helping the emergency department evaluator determine a safe and appropriate setting for treatment. When hospitalization is recommended by the referring psychiatrist, the reasons for that rec- ommendation should similarly be communicated to the emergency department evaluator who will be making the final determination about the need for hospital admission.
2. Patients with chronic suicidality
For some individuals, self-injurious behaviors and/or suicidality are chronic and repetitive, re- sulting in frequent contacts with the health care system for assessment of suicide potential. It is important to recognize that self-injurious behaviors may or may not be associated with sui- cidal intent (518). Although self-injurious behaviors are sometimes characterized as “gestures” aimed at achieving secondary gains (e.g., receiving attention, avoiding responsibility through hospitalization), patients’ motivations for such behaviors are quite different. For example, with- out having any desire for death, individuals may intentionally injure themselves to express an- ger, relieve anxiety or tension, generate a feeling of “normality or self-control,” terminate a state of depersonalization, or distract or punish themselves (519, 520). Conceptualizing such behav-
iors as “gestures” is also problematic because suicide attempts may be downplayed when asso- ciated with minimal self-harm. Self-destructive acting out can also result in accidentally lethal self-destructive behaviors even in the absence of suicidal intent. Furthermore, a past or current history of nonlethal self-injurious behaviors does not preclude development of suicidal ideas, plans, or attempts with serious intent and lethality (521). In fact, among suicide attempters with suicidal intent, those who also had histories of self-injurious behaviors without suicidal intent were more likely to underestimate the objective lethality of their attempt and to have symptoms associated with greater suicide risk (251). Thus, in assessing chronic self-injurious behaviors, it is important to determine whether suicidal intent is present with self-injury and, if so, to what extent and with what frequency. In addition, an absence of suicidal intent or a minimal degree of self-injury should not lead the psychiatrist to overlook other evidence of in- creased suicide risk.
For patients who are prone to chronic self-injurious behavior, each act needs to be assessed in the context of the current situation; there is not a single response to self-injurious behaviors that can be recommended. For example, there are times when outpatient management is most appropriate; under other circumstances, hospitalization may be indicated. In general, for such individuals, hospitalization should be used for short-term stabilization, since prolonged hospi- tal stays may potentiate dependency, regression, and acting-out behaviors. When chronic self- injurious behaviors are present, behavioral techniques such as dialectical behavior therapy can be helpful (522, 523). In addition, at times when care of the patient is being transitioned to another clinician, the risk of suicidal behaviors may increase.
Diagnostically, severe personality disorders, particularly borderline (521) and antisocial per- sonality disorders, predominate among patients who exhibit chronic self-injurious behaviors without associated suicidal intent. Such individuals may also have higher rates of comorbid panic disorder and posttraumatic stress disorder (524). Patients with schizoaffective disorder, bipolar disorder, and schizophrenia may also be represented, but more often such patients have ongoing thoughts of suicide or repeated suicide attempts in the presence of suicidal intent. There is evi- dence that the presence of comorbid personality disorders or substance use disorders not only increases suicide risk in these individuals but also decreases treatment response. For example, pa- tients with a combination of affective disorder and personality disorder are prone to frequent sui- cidal crises, difficulties with mood instability and impulse control, and problems with treatment adherence. Consequently, for patients whose nonadherence contributes to a chronic risk for sui- cide, psychiatrists should be familiar with statutes on involuntary outpatient treatment, if it is applicable in their jurisdiction (525).
When treating chronically suicidal individuals, it is important for the psychiatrist to moni- tor his or her own feelings, including countertransference reactions. Careful attention to the treatment relationship and the psychosocial context of the patient is also critical. Consistency and limit-setting are often needed, but the latter needs to be established on the basis of clinical judgment and should not be framed in punitive terms. Helping patients develop skills for cop- ing with self-injurious impulses is often a valuable part of treatment.
In outlining a detailed treatment plan, it is helpful to incorporate input from the patient and significant others, when clinically appropriate. During periods of crisis, disagreements may oc- cur about the need for hospitalization. In some circumstances, the psychiatrist may view hospi- talization as essential, whereas the patient or family members may not. Alternatively, the patient, family members, or other involved persons may demand hospitalization when outpatient man- agement may seem more appropriate. When such disagreements occur, power struggles are best avoided. Instead, gaining a deeper understanding of the conflicting viewpoints will often lead to a successful resolution. In addition, educational efforts with the patient and others should dis- cuss the fact that risk in chronically suicidal individuals will be increased on an ongoing basis. Thus, the risk of suicide outside of the hospital must be balanced against the potentially detri- mental effects of hospitalization (see Section III.C, “Determine a Treatment Setting”).
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I. MONITOR PSYCHIATRIC STATUS AND RESPONSE TO TREATMENT
In addition to reassessing the patient’s safety and degree of suicidality, it is equally important for the psychiatrist to monitor the patient’s psychiatric status and response to treatment. This is particularly the case during the early phases of treatment, since some medications, particu- larly antidepressants, may take several weeks to reach therapeutic benefit. Also, with the excep- tion of suicides in persons with alcoholism, suicides tend to occur early in the course of most psychiatric disorders, when individuals are least likely to have insight into having an illness and are least likely to adhere to treatment. Moreover, clinical observations suggest that there may be an early increase in suicide risk as depressive symptoms begin to lift but before they are fully resolved. Thus, ongoing monitoring of the patient’s clinical condition is needed to determine the patient’s symptoms and response to treatment (e.g., determining the optimal dose of a drug and evaluating its efficacy). Often the course of treatment is uneven, with periodic setbacks, for example, at times of stress. Such setbacks do not necessarily indicate that the treatment is inef- fective. Nonetheless, ultimate improvement should be a reasonably expected outcome. Fur- thermore, as treatment progresses, different features and symptoms of the patient’s illness may emerge or subside. Significant changes in a patient’s psychiatric status or the emergence of new symptoms may indicate a need for a diagnostic reevaluation, a change in treatment plan, or both. Such modifications may include a change in treatment setting, medication, or frequency of visits; involvement of significant others; referral for additional treatments (e.g., dialectical behavior therapy, ECT) that are targeted at specific symptoms or syndromes; and consultation.