A patient at risk of suicide

  • Risk of suicide in adolescence 1

Evidence Summaries

Essentials

  • Suicide is often an ending to a long process and the consequence of a lifelong accumulation of risk factors, an absence of protecting factors and, finally, the presence of precipitating factors.
  • In most cases of suicide (over 90%) the person has a previous history of mental health problems, usually mood disorders or substance abuse.
  • Suicides can be prevented by the assessment of both short-term and long-term suicide risk in those belonging to the risk groups.
  • The possibility of suicidal ideation and behaviour must always be explored in a depressed patient.
  • If the patient harbours suicidal thoughts, establish the degree of suicidal intent (plans, timing).
  • Ensure that the treatment of a suicidal patient is sufficiently protective and do not prescribe large amounts of medicines at any one time.

Prevalence

  • Transient suicidal ideation is fairly common (in about 10% of the general population).
  • Self-harm (self-inflicted cuts) and other behaviours suggestive of suicidal intentions are fairly common among adolescents in western countries (5–9%). If this is accompanied with a strong wish to die the person’s suicide risk is increased.
  • About 1–5% of the population has attempted suicide. Attempts are more common among young adults than in older individuals, and more than half of the attempts occur while intoxicated.
  • The suicide rates among adolescents in relation to all suicides have been on the increase in the 2000’s.

Risk factors

Factors which increase long-term suicide risk

  • Social risk factors (male gender, living alone, unemployed)
  • Suicide of a close relative or friend (a risk factor particularly among the young)
  • Previous self-destructive behaviour, suicide ideation
  • Mental health problems (mood disorders, substance dependence, unstable and antisocial personality disorder, psychoses)
  • Serious physical disease, pain
  • Genetic or familial predisposition
  • Tendency to impulsive-aggressive behaviour
  • In men severe mental symptoms in childhood (anxiety, behavioural symptoms)
Immediate or short-term suicide risk

  • Suicide attempt during the past 12 months
  • Negative life events: especially divorce/separation, experiences of loss and events leading to strong feelings of shame or guilt; especially in adolescents arguments and disappointments as triggering factors behind self-destructive behaviour 2
  • Psychological risk factors: hopelessness, negative life expectations, general dissatisfaction with life, impulsivity
  • Severely symptomatic psychiatric disorder
    • The risk of suicide is very high around a hospital admission for psychiatric treatment, at the start of the treatment and during the first month after discharge.
    • Depression
      • Psychotic depression, feelings of guilt, nihilistic and somatic delusions
      • Agitation, anxiety, panic attacks
    • Schizophrenia
      • Early years of the illness
      • Frequent hospitalisations, severe form of disease
    • Uncontrolled substance abuse (young individuals in particular)

Diagnostic assessment

  • Suicidality is not a disease, but a mode of behaviour. The best understanding can be achieved through viewing the patient’s overall psychosocial situation, for example by establishing how the patient experiences life in relation to his/her physical diseases and symptoms.
  • Questions relating to possible suicidality and the patient’s wish to die will often flow naturally
    • after the patient’s overall situation has been discussed; a patient with pain could be asked how he/she experiences the pain, for instance;
    • if the patient expresses negative feelings and experiences relating to, for instance, his/her physical disease.
  • How to ask questions?
    • How are you coping with your physical problems? Are you able to carry on? If indicated, you can proceed question by question: Have you ever thought that your life is not worth living? Would you like to die? Have you ever had suicidal thoughts? Have you contemplated suicide? In what way? What has stopped you from committing suicide? etc.
    • To elicit more information about self-destructive behaviour, ask specific questions about the content of any suicidal thoughts, the possible existence of a plan, timetable etc.
    • Questionnaires used to evaluate suicidal ideation and intent:
      • BDI (Beck Depression Inventory): depressive symptoms, contains a part dealing with the wish to die
      • SSI (Scale for Suicide Ideation): suicidal thoughts
      • SIS (Suicide Intent Scales): the seriousness of a suicide attempt
      • HS (Hopelessness Scales): hopelessness
  • However, the patient may deny any suicidal ideation if he/she has already made a firm decision about the matter.
    • Of the people who commit suicide, 40–60% have sought medical help during the last month of their life, 18% actually during the last day of their life due to problems associated with their general health, but only very few had communicated any suicidal ideation.

Management in immediate suicide risk

  • Consult psychiatric specialist services and, based on the consultation, proceed with a referral if
    • the patient exhibits suicidal behaviour (ideation, attempts) associated with a psychiatric disorder
    • a suicidal patient (ideation, attempts) has no social network to offer support.
  • Psychiatric hospitalisation is indicated when a suicidal patient
    • cannot control his/her self-destructive impulses and shows
      • psychotic thoughts
      • impulsive behaviour
      • intermittent uncontrolled substance abuse
      • strong self-destructive inclination.
    • is openly psychotic
    • is very distressed or agitated or shows severe hopelessness
    • is covering up or denying the suicide intent (e.g. after a planned suicide attempt).
  • The patient can be referred to a hospital for observation, with the view of possibly subsequently committing him/her to involuntary psychiatric treatment, if there is suspicion of a mental illness and risk of suicide; for a young person a suspicion of a severe mental disorder is sufficient for a referral.
  • Family members should be informed of the hospital admission unless explicitly forbidden by the patient.
Psychological management

  • Explore the reasons behind the patient’s wish to die (emotional distress, problems with life?).
  • It is important to relieve the feelings of hopelessness. Emphasise the irreversibility of death and that it is not a solution to problems or feelings of distress.
  • Relate the suicide ideation with the emotional distress: depression is often accompanied by a feeling of hopelessness and a wish to die, and these will improve as the depressive symptoms are relieved.
  • Explain how and in what timescale medication, and other treatment modalities, can ease the patient’s distress.
  • Explore factors in the patient’s life that can act as protective factors against suicide: including close family members and the effect of the possible suicide on their lives.

Points to consider during treatment

  • The full therapeutic benefit of antipsychotics and antidepressants is not reached until about a week after the treatment is started. Benzodiazepines relieve anxiety quickly.
  • Prescribe only small amounts of medicines at any one time.
  • Tell the patient how to get in touch and obtain crisis assistance 24 hours a day.
  • Attempt to find out whether the patient has specific equipment at home necessary for committing suicide (other medication, a weapon etc.)
  • Identify the patient’s social network (a support person) and aim at creating a safety net within health care, as well as an action plan for emergency situations.
  • Support the patient’s abstinence from substances of abuse, since these predispose to self-destructive behaviour.

Evidence Summaries

Treatment intervention for a person who attempted suicide

  • Guidelines for the treatment of a self-destructive patient have been crafted for example in the United States and the UK. In Finland the national suicide prevention project recommended that each patient that has attempted suicide should undergo a psychiatric or psychosocial evaluation and afterward this he/she should have the possibility to have at least one appointment of acute nature to address the crisis.
  • An active therapeutic approach that reaches for the patient is needed to make the patient who attempted suicide to commit to treatment. It is important to be in contact with the patient and to allow him/her to take contact even after the active treatment has ended. An agreement can be made with the patient that allows him/her to contact the treating unit without new referral for a period of e.g. 3 months, should his/her condition worsen again.

Suicide prevention (long-term suicide risk)

  • The most important aspect of prevention is the appropriate treatment of an underlying psychiatric disorder. In as many as 80% of completed suicides, the treatment of the psychiatric disorder has been insufficient.
    • In follow-up studies lithium used for bipolar disorder and clozapine used for schizophrenia seem to have a decreasing effect on self-destructiveness.
  • Scientific evidence exists on education programmes: depression recognition and appropriate treatment by general practitioners reduced local suicide rates during the follow-up period.
  • Various therapies and interventions have been developed for the treatment of a patient who is self-destructive or has attempted suicide; relevant research has been published particularly in journals oriented toward dialectic and cognitive methods.

Evidence Summaries

References

1. Henriksson MM, Aro HM, Marttunen MJ, Heikkinen ME, Isometsä ET, Kuoppasalmi KI, Lönnqvist JK. Mental disorders and comorbidity in suicide. Am J Psychiatry 1993 Jun;150(6):935-40.  [PMID:8494072]

2. Kessler RC, Borges G, Walters EE. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry 1999 Jul;56(7):617-26.  [PMID:10401507]

3. Suokas JT, Suominen K, Heilä H, Ostamo A, Aalto-Setälä T, Perälä J, Saarni S, Lönnqvist J, Suvisaari JM. Attempted suicide in mental disorders in young adulthood. Soc Psychiatry Psychiatr Epidemiol 2010 Jul 24;(): [Epub ahead of print].  [PMID:20658122]

4. Qin P, Nordentoft M. Suicide risk in relation to psychiatric hospitalization: evidence based on longitudinal registers. Arch Gen Psychiatry 2005 Apr;62(4):427-32.  [PMID:15809410]

5. Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D, Haas A, Hegerl U, Lonnqvist J, Malone K, Marusic A, Mehlum L, Patton G, Phillips M, Rutz W, Rihmer Z, Schmidtke A, Shaffer D, Silverman M, Takahashi Y, Varnik A, Wasserman D, Yip P, Hendin H. Suicide prevention strategies: a systematic review. JAMA 2005 Oct 26;294(16):2064-74.  [PMID:16249421]

6. Beck AT, Kovacs M, Weissman A. Assessment of suicidal intention: the Scale for Suicide Ideation. J Consult Clin Psychol 1979 Apr;47(2):343-52.  [PMID:469082]

7. Hawton K, van Heeringen K. Suicide. Lancet 2009;373(9672):1372-81.  [PMID:19376453]

8. Self-harm: longer-term management. NICE guidelines (CG133), November 2011 http://www.nice.org.uk/guidance/cg133/resources/guidance-selfharm-longerte...

9. Gysin-Maillart A, Schwab S, Soravia L et al. A Novel Brief Therapy for Patients Who Attempt Suicide: A 24-months Follow-Up Randomized Controlled Study of the Attempted Suicide Short Intervention Program (ASSIP). PLoS Med 2016;13(3):e1001968.  [PMID:26930055]

10. Linehan MM, Comtois KA, Murray AM et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry 2006;63(7):757-66.  [PMID:16818865]

11. Sourander A, Klomek AB, Niemelä S et al. Childhood predictors of completed and severe suicide attempts: findings from the Finnish 1981 Birth Cohort Study. Arch Gen Psychiatry 2009;66(4):398-406.  [PMID:19349309]

12. Cipriani A, Hawton K, Stockton S et al. Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis. BMJ 2013;346():f3646.  [PMID:23814104]


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TY - ELEC T1 - A patient at risk of suicide ID - 455068 BT - Evidence-Based Medicine Guidelines UR - https://evidence.unboundmedicine.com/evidence/view/EBMG/455068/all/A_patient_at_risk_of_suicide PB - Duodecim Medical Publications Limited DB - Evidence Central DP - Unbound Medicine ER -