La tensión en el oyente

Suicidality – Suicidality is a topic relevant to all health care providers. It is highly prevalent, representing one of the leading causes of mortality in the United States. It is the leading cause of violent death in this country. Up to one-third of people in the general population report having had suicidal ideation during some point in their life. As many as two-thirds of patients who commit suicide visited their physician within one month of their death.

Evaluation of the Potentially Suicidal Patient consists of three main parts: a. Eliciting suicidal ideation, intent, and/or planning

b. Gathering data on risk as well as protective factors for suicide c. Weighing items one and two to make clinical decisions about safety.

A. Eliciting Suicidal Ideation, Intent, and/or Planning

Ideally, eliciting suicidal ideation, intent, and/or planning involves a free and honest exchange of information between the patient and clinician. Unfortunately, this is not always so. Familiarity with the existing epidemiological and demographic data concerning suicide (see below) is useful in generating an index of suspicion. From there, direct questioning regarding suicidal ideation/intent/planning may be initiated. There are no data demonstrating an increased rate of suicide attempts or deaths following questioning about suicide. Avoid rushing this part of the history or putting it off.

Despite the lack of reliable measures of suicide risk among individuals, a basic assessment should: 1. Determine presence/absence of depression, delirium, and/or psychosis

2. Elicit patient’s statements about his/her suicidality

3. Elicit patient’s own ideas concerning what would help attenuate or eliminate suicidal ideation/intent/planning

4. Attempt to gather collateral data from a third party in order to confirm the patient’s story 5. A suggested sequence of suicide questions to ask is:

o Are you discouraged about your medical condition (or social situation, etc.)? o Are there times when you think about your situation and feel like crying? o During those times, what sorts of thoughts go through your head?

o Have you ever felt that if the situation did not change, it would not be worth living? o Have you reached a point that you’ve devised a specific plan to end your life? o Do you have the necessary items for completion of that plan readily available? 6. Formulate an acute and chronic management plan. Encourage active patient participation

in negotiating a plan for follow-up:

o What epidemiological risk factors are present (may have to inquire about each one individually)?

o What other psychiatric conditions are present (besides the ones mentioned above)? o What is the level of psychological defense functioning?

o Has there been a will made recently? o Is there talk of plans for the future?

o What is the makeup and condition of the patient’s social support system? How can the patient be contacted?

o Is there active suicidal ideation? “How strong is (your) intent to do this?” o “Can you resist the impulse to do this?” “Do you tend to be impulsive?” o “Have you ever rehearsed how you would kill yourself?”

o “Have any family members or people close to you ever killed themselves?”

B. Gathering Data on Risk as Well as Protective Factors for Suicide

The causes of suicide are multifactorial. The risk for suicide increases with the accumulation of riskfactors in an individual. Clinician should be alert for suicide risk in patients with a sad or depressed mood, suicidal ideation and one or more risk factors.

There is no accepted standard screening instrument for suicidal risk. Recent publications including the VA Education Module, "Prevention of Suicide: Everyone’s Concern”, and the article by Hirschfeld and Russell provide examples of brief, thorough screening tools (Hirschfeld & Russell, 1997).

Patients with evidence of intent for suicide should be offered mental health counseling and possibly hospitalization (U.S. PSTF, 1996).

Patients with definite intent (suicidal/homicidal ideation, intent, and/or plan) to harm self or others require voluntary or involuntary emergency psychiatric treatment (APA, 1993; DHHS pub. no. 95- 3061, 1995).

The endorsement of suicidal ideation or intent represent obvious risk factors for suicide completion, especially if intent exists with an active plan for carrying it out. Other identified risk factors are listed below:

o Presence of psychiatric illness – Greater than 90 percent of adults who successfully complete suicide have some form of psychiatric illness. A symptom triad of mood symptoms, aggressiveness and impulsivity has been described as representing a major contribution to risk of suicide completion. The presence of hopelessness has been similarly classified.

o Serious medical illness – This is especially true of disorders marked by a debilitating course. Even so, suicide in this particular population rarely occurs in the absence of a psychiatric condition.

o Means for suicide completion readily available – Refers to immediate accessibility of firearms or other highly lethal modality. The presence of firearms in the home is believed to greatly increase the danger if other risk factors are present. Males in general tend to choose highly lethal means, such as firearms, which greatly increases the risk of death. o Psychosocial disruption – Includes recent separation, divorce, loss of job, retirement,

bereavement, or other perceived negative life event (including living alone).

o History of previous suicide attempts – One percent of suicide attempters will go on to completion each year, and 10 to 20 percent will eventually succeed at some point.

o Active substance abuse and/or dependence - is a contributing factor in approximately half of suicide completions, although the involvement of intoxication as a risk factor decreases in the elderly.

o Impulsivity or history of poor adaptation to life stress. o Family history of completed suicide or suicide behavior.

o Male sex - though females attempt suicide three times as frequently as males, 75 percent of completed suicides are by males.

o Advanced age – Higher rates of suicide completed and suicide attempts are reported in patients greater than age 60. Age generally becomes a risk factor beginning at age 45. This is a gross generalization of a complex body of data.

o Caucasian race – Risk is highest for Caucasians.

C. Evaluating the Available Data to Make Clinical Decisions About Safety:

If suicide risk is present, a stratification system is useful in terms of formulating a strategy for intervention. One such system includes the following divisions: (1) imminent (suicide may be attempted within the next two days); (2) short-term (days to weeks); and (3) long term.

1) Imminent Risk – Suspect if patient endorses suicidal intent, an organized plan is presented, lethal means are available, signs of psychosis (especially command hallucinations) are present, extreme pessimism is expressed (despair, hopelessness, etc.), or several additional risk factors for suicide are present.

Management suggestions:

a. Immediate action is required. Hospitalize or commit. DO NOT leave the patient alone.

2) Short-Term Risk – Suspect if several risk factors for suicide are present, but no suicidal behaviors are present.

Management suggestions:

a. With patient’s permission, involve family member or other person close to patient and advise them of the situation.

b. If potentially lethal means of suicide completion are available, initiate steps to make these items inaccessible.

c. Collaboratively generate a safety plan with the patient and/or family member (after obtaining patient consent). The plan should include emergency contact numbers for the national suicide hotline (1-800-SUICIDE) as well as information for local hospital(s) or emergency center(s).

d. Stay in contact with the patient (telephone calls, more frequent office visits, etc.). Frequently re-evaluate risk. Document all contact and explain decision-making process for management.

e. Treat psychiatric conditions as appropriate, including substance abuse/dependence (may require consultation from mental health

professional). Close follow-up will help to improve compliance and continue risk assessment.

f. Consider hospitalization as appropriate.

3) Long-Term Risk – The therapeutic goal is to eliminate or improve modifiable suicide risk factors. This may involve treatment of psychiatric illness (through biological means or through psychotherapy), treatment of substance abuse, etc. Frequent reassessment is still a useful guideline, and acute situations mandating psychiatric referral or hospitalization may arise. Thus, all of the aforementioned management suggestions should be considered even here.

The clinician should be reminded that the assessment of suicidal potential is far from exact, and that the above text serves only as one of many suggested approaches. In any case, the provider should adopt a systematic approach, such as the one offered above, in order to more comfortably assess and manage the potentially suicidal patient.

The clinician is also encouraged to document all aspects of the case in a thorough manner. Clinical notes should clearly indicate patient’s current level of suicide ideation, intent, and/or planning and subsequent risk (none, mild, moderate, or severe). Specific risk and protective factors should be outlined. The clinician should provide a brief outline of the assessment strategies utilized (e.g., screening instrument, clinical interview, consultation with colleague, conversation with spouse) and comment on the results of the assessment. A succinct explanation should be provided to outline the sequence of decision making steps to arrive at the decision to hospitalize or not to hospitalize.

Finally, the clinician is urged to seek consultation when necessary. Research has demonstrated that a team approach to risk management is protective of both the patient and the provider.

REFERENCES

Hirschfeld RM, Russell JM. Assessment and treatment of suicidal patients. N Engl J Med 1997 Sep 25;337(13):910-5.

U.S. Preventive Services Task Force. Screening for Suicide Risk. Guide to Clinical Preventive Services. (2nd ed) 1996. Baltimore, Maryland. 541-546, 699-710, 861-862.

Appendix D: Pharmacotherapy