Introduction

  • 5000 deaths/year in the UK
  • Increasing in young males
  • In men <35, suicide is the greatest cause of death
  • At all ages, men are at greater risk than women
    • In those >35, they are likely to have seen their GP within the last month
    • Those <35 are not
  • Methods
    • Men more likely to use violent methods (shooting, hanging)
    • Women more likely to take prescribed/OTC drug overdoses
  • Causes
    • About 90% of suicide patients are mentally ill
    • Most common illnesses are depression, bipolar disorder, and substance abuse

In one study in the USA, 10% of adolescents had seriously contemplated suicide within the last 12 months and 6% had a suicide attempt or episode of self harm. In Australia a similar study shows self harm in 4% of adolescents in the preceding 12 months.

Suicidal ideation is almost always associated with a mental health disorder, which is most commonly depression.

Suicide should be distinguished from non-suicidal self-injurious (NSSI) behaviour
  • Suicidal behaviour involves in part some wish to end one’s life
  • NSSI involves an intent to harm without an attempt to end life

Self Harm – NSSI

  • Increasing in the last few decades
  • 300 to 400 per 100 000
  • In women – most common cause of acute admission
    • Peak age – 15-24
    • In the UK, women of south Asian origin 2.5x risk than general population
  • In men – second most common cause
    • Peak age – 25-34
  • Roughly equal rates in men and women (women used to be higher)
  • Causes – Bipolar, depression, eating disorders, personality disorders
  • Repetition
    • 15% of cases will have further self harm episodes in the next year
    • Most of these occur soon after the initial incident
    • Suicide after self harm – there is a 1% suicide rate in the next year in those who have committed self harm. This rises to 3% in 5 years and 7% in 10 years. Those who commit suicide tend to be: Older, Male, Have a mental illness, Have poor physical health

Assessing Suicide Risk

Assessing suicide is an important part of any psychiatric exam.
Talking about suicide DOES NOT increase the risk of a suicidal attempt or self harm.
This is even true when a patient is ‘in crisis’ (i.e. just after a suicide attempt). In fact, often the reverse is true, and the individual may feel relief at being able to talk about these issues.
  • Some debate exists of whether or not you can truly estimate the suicide risk

Risk factors for suicide

Important factors highlighted

  • Demographics
    • Male
    • Older adolescent age
    • Non-heterosexual orientation
  • Clinical
    • Dx of psychiatric disorder
    • Recent discharge from psychiatric institution
    • Previous suicide attempt
    • FHx of suicide
    • PMHx of sexual abuse
    • Childhood trauma
    • Insomnia
    • Poor physical health
    • Low self-esteem
    • Poor treatment compliance
  • Family and environment
    • Life stress – especially unemployment, legal issues or school issues
    • Lack of social support
    • Exposure to other with suicidal behaviour
      • Recent friend or relative with suicide attempt / suicide
    • Split family (e.g. divorce)
    • Parental mental illness
  • Mental State
    • Suicidal thoughts,  especially is specific acts planned
    • Homicidal ideation
    • Drug and alcohol use
    • Impulsivity

Suicide risk assessment should be perform both in the acute crisis setting (i.e. after an attempt of self harm or suicide) and routinely as part of a mental health history. Particularly useful in mental health history taking in adolescents is the HEADSS assessment tool:

H – Home and environment

  • What is home life like?
  • Who do they live with?
  • Do they feel safe?
  • Is there someone they can talk to?

E – Education

  • How is school?
  • Are they enjoying it?
  • What are their future education and career plans?

A – Activities

  • What do they get up to in their spare time?
  • Are their friends from school of from elsewhere?
  • DO they have a lot of friends?
  • Do they feel they can talk openly with their friends?
  • DO they spend much time with family?

D – Drugs and alcohol

  • Do you drink?
  • Do you take any drugs?
  • How often? How much?
  • How do you pay for them?
  • How does it make you feel?
  • Are you aware of the risks?

S – Sexuality

  • Relationship history
  • Sexual orientation
  • Current relationship difficulties
  • Cervical screening
  • STI screening

S – Suicide and depression (as above)

Assessing a patient in crisis

Talk to the patient – but remember they may still be drowsy after any drugs they have taken (both in the suicide attempt, and afterward at hospital)

Collateral history

History from friend or relative if present:

  • Look for evidence of continued suicide intention
  • Is the patient happy to still be alive?
  •  If they took an overdose, What did they take?
  • Did they think this would be enough to die?
  • What did they take it with? (e.g. water, alcohol)
  • Did they want to be found?
  • Who found them? Was this person expected home? In the house? Did they phone them?
  • Did they leave a note?
  • Have they been planning it?
  • E.g. giving away possessions
  • Stocking up on pills over several weeks/days/months

Management

  • If the patient tries to leave before the assessment is complete…you may need to detain them – if you believe they pose a risk to their own (or anybody else’s) safety
  • Some patients may be fine to go home (usually with care of a relative…e.g. a girl who takes 10 paracetomol in front of her girlfriend after a row. She says she has no intention to kill herself, and seems upset by the incident.)
  • When discharging it is VITAL that you inform community care representatives..e.g. the GP, community mental health team. You should phone as well as sending a letter. Usually, there is a follow-up clinic appointment made as well.
  • Don’t prescribe any potentially lethal drugs for the patient to take home with them!
  • You may need to get a psychiatrist to advise you in other cases/cases where patients may need detaining…e.g. an old man who has been stockpiling paracetomol for a long time. He lives alone, and took an overdose whilst in his shed. He was discovered by chance by a neighbour. He had left a note, and had been giving away his belongings.
Pathos score – mainly used in adolescents (age 13-18) who present with an overdose. It is used to asses
  • P – Problems – have you had problems for more than 1 month?
  • A – Alone – were you alone at the time?
  • T – Time – have you planned it for more than 3 hours?
  • Ho – Hopeless – are you feeling hopeless about the future
  • S – Sad – were you feeling sad for most of the time before the overdose?
Each ‘Yes’ answer is an indicator of greater risk of future harm, and intent.

References

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