March 13, 2003 Robbie N Drummond MD

Approach to Suicide Risk and Assessment in the ER Resident Presentation

March 13, 2003

Robbie N Drummond MD

OVERVIEW

• 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

• 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

• 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

• To be, or not to be: that is the question:Whether 'tis nobler in the mind to sufferThe 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 endThe heart-ache and the thousand natural shocksThat flesh is heir to, 'tis a consummationDevoutly 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 comeWhen we have shuffled off this mortal coil,Must give us pause: there's the respectThat makes calamity of so long life;.........

Suicide and Depression Emerg Med Cl may 2000 Harwitz

• “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

• “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.”

• “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”

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1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

East

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North

402

309304

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FMC PLC RGH

No. of ED Visit with Suicidal Primary Dx from Apr. 2002 to Jan. 2003

No. of ED Visits with Suicidal Dx by Month, by Site

34

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48

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4644

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23

51

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3134

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29 3430

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200204 200205 200206 200207 200208 200209 200210 200211 200212 200301 Average

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FMC PLC RGH

Contact with mental health and primary care providers before suicide Luoma Am J Psychiatry 2002

• 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

• 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

• 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

– 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

• in USA firearms account for nearly 60% of all suicides

• 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

• independently increases the risk of suicide for both genders and across all age groups even after correcting for confounding factors

• women: drugs medications, second; for men: hanging

Assessment and Treatment of Suicidal Patients Hirschfield NEJM 1997

• Up to one third of persons in the general population have suicidal ideation at some point in their lives

• 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

• forecasting the weather vs predicting astronomical events • predicting short term risk 24 -48 hours more reliable than longterm

• Approximately 25% of suicidal patients do not admit to being suicidal (Fawcett et al., 1990).

• one of eighteen attempts is completed

• 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

• 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

• 1) the disease is prevalent• 2) the disease may not be evident to the person who has it• 3) the disease is treatable• 4) early intervention is advantageous • 5) the screening test is reliable• 6) 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

• 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

• four two hour sessions to 33 health and voluntary workers using role-playing,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

• 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

• 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 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

• 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

• emotional, physical and sexual abuse, household substance abuse, mental illness, and incarceration, and parental domestic violence, separation, or divorce

• as number of adverse experiences increase the risk increses dramatically

• 67 % of suicide attempts are attributable to traumatic childhood experiences

5 Questions

• 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

• 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

• the risk factors for suicide are additive

nontraditional risk factors:

• drinking within three hours of the suicide attempt • changing residences within the past 12 months• existing medical conditions• impulsive behavior

• 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

• the difficulty with risk factor for suicides is that they lead to many false positive predictions

SAD PERSONS: a mnemonic for assessing suicide risk

• S Sex (male) • A Age (elderly or adolescent) • D Depression • P Previous suicide attempts • E Ethanol abuse • R Rational thinking loss (psychosis) • S Social supports lacking • O Organized plan to commit suicide • N No spouse (divorced > widowed > single) • S Sickness (physical illness) • Adapted from Patterson et al (12). • 0 -3 close follow up consider admit, 4 -5 consider admit, >5 admit

No Hope Scale

• N No framework for meaning• O Overt change in clinical condition• H Hostile interpersonal environment• O Out of hospital recently• P Predisposing personality factors• E Excuses for dying are present and strongly believed

• 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

The best predictor of completed suicide is a history of attempted suicide

• subsequent attempts greater lethality and intent

• careful inquiry about past suicide attempts essential part of tisk assessment

• two thirds of suicides occur with first attempt

• the greatest risk occurs within 3 months of the first attempt•

Suicide after Parasuicide Runeson BMJ 2002

• The risk of suicide is generally most prominent during the first months after psychiatric care

• 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

• the initial high risk declines each year

Suicide rate 22 years after parasuicide:cohort study Jenkins BMJ 2002

• 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

• traced record 22 years 63% of the original sample

• 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

• main protective factors accurate, early diagnosis and effective treatment of psychiatric disorders

• 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

• Axis 1, 2, and 3 predisposing factors Axis 4, and 5 potentiating

Risks depending on diagnosis:

• 60% have mood disorders• followed by schizophrenia, alcoholism, substance abuse and

personality disorder• most people with psychiatric disorder never attempt suicide

• 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

• 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• 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

• 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)

• Usually one uses either the Hamilton or Beck depression inventory or scale, since suicide outcomes correlate highly with depressive disorders

• five symptoms to make diagnosis in 2 week period

• S = sleep• I = interest• G = guilt• M = mood• E = energy• C = concentration• A = appetite• P = psychomotor retardation or agitation• S = suicidal ideation

• 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

• 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

• 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

• 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

• 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

• 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

• psychoanalyst says adamancy is main trait

Chronic suicidality among patients with borderline personality disorder Paris J Psychiatric Serv June 2002

• One in ten completes suicide

• not preventable usually does not occur in treatment

• chronic suicidality a way of communicating distress

• hospitalization unproven benefit possible negative effects

• fear of litigation not a reason to admit

• 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

• 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

• 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

• recent evidence many schizophrenics more likely to commit suicide in remission when they are apt to feel depressed and hopeless

• 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 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

• 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

• 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

• good evidence that unipolar and bipolar disorders in adolescents is essentially identical to that in adults

• efficacy of antidepressants in a teenage population

• adult doses of SSRI’s

• 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

• no clear criteria for hospitalizing and discharging a patient at moderate risk for suicide

• hospitalization for altered mental status,actively abused substances,recently attempted suicide, experience hopelessness or impulsivity, lack of parental supervision

Disease as Risk Factor

• 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

• depressive disorders respond quickly to ECT can take 4-6 weeks for response to meds

• other therapies conjoint cognitive psychotherapy, dialectical behavioral therapy or behaviour modification techniques

• TCA’s, MOAI’s, SSRI's inconsistent effect on suicide risk

• antipsychotics uncertain effect suicide risk (akithisia from older drugs haldol and fluphenazine may have contributed to some suicidal attempts)

• newer atypical antipsychotics (clozapine et al) lower rate of life threatening suicide attempts in schizophrenics

• 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

• 20 randomized trials in Cochrane data base that looked at effectiveness of treatment randomized controlled trails metaanalysis

• some benefit with low statistical power for

• 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

• 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....

•

• Patients with a plan, access to a lethal means, recent social 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

• 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

• within the time constraints of the busy ER can help to crystallize the physicians understanding of the patient’s mental state

• how the patient responds more critical than what the contract states

• therapeutically establishes alliances if presented in a caring and a careful way clear limits set accountability on patient’s part

• opportunity for patient to reflect immediate sense of relief by their being able to contract for safety in a limited time frame

• in patients who resist confrontation and clarification possible

• therapeutic for physician relieves anxiety

medicolegal issue:

• 1) patient often does not meet threshold legal criteria for competence\

• 2) no valuable consideration given• 3) no mutual obligation beyond NHC• 4) exculpatory clause for physician contravenes public policy

misuses

• 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.

• The Study:• Postcard questionnaire mailed to 514 psychiatrists in Minnesota

• 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.

The Suicide prevention contract clinical, legal and risk management issues Simon RI J Acad Psych Law Jan 2000

• 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

• 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

• Number one cause of malpractice suits against psychiatrists

• between 1996 and 2000 there were 242 closed legal actions against ED’s

• seven percent involved psychiatric problems (no breakdown)

• same time frame 221 closed legal actions for psychiatrists

• 19 percent represented patients who attempted or committed suicide

• represented 25 % of the costs for the psychiatrists

• of the cases involving suicide 25 % were lost either settled or at trial

• a physician can be defended if there is adequate assessment and documentation

• 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

• 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

• 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)

• occasionally , patients may not allow the clinician to contact their families. When someone’s life is in imminent danger, confidentiality may be breached.

Documentation

• if not documented not done

• because suicide risk and ideation complex needs more documentation

• no-harm contracts not a substitute

• well-documented suicide risk assessments provide a solid legal defense

• 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:

• 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

• Says we do a very good job at assessing these patients

• suicidal ideation is common suicide is relatively rare

• important to balance plans and ideation with withholding factors

• command voice in psychotic patients a high risk factor

• balance seriousness of medical risk against seriousness of intent

• important to get collateral information can break confidentiality ask permission first

• assess demographics carefully SADPERSONS e.g.

• borderline personality disorder 10% overall but odds of episode 54 very small. Most important factor: is there regular follow-up?

• 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

• 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

• 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

• 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

• was admitted to short term assessment unit at PLC

Poster Boy for Prozac

• 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

• form 1......direct admit to psychiatry....cancel acts II -V

The Rest Is Silence.......