Suicide
Epidemiology
Risk Factors
Epidemiologic factors
Past history
Clinical Features
Symptoms associated with suicide
Assessment
1 point 0 point
S ex M F
A ge 15-24/>65 others
D epression Y N
P revious attempts Y N
E xcess EtOH/drugs Y N
R ational thinking loss Y N
S uicide in family Y N
O rganised plan* Y N
N o support Y N
S ickness Y N
*C ontext (What were the circumstances of this attempt?/ What were you planning?)
L ethality (Did you think it will kill you?)
I ntent (What did you want to achieve?)
P reparations (Have you started preparations? Access to tools?)
0-4 = low risk
5-6 = moderate risk
7-10 = high risk
Management
Source
Toronto Notes 2012
- Attempted:completed = 20:1
- M:F = 3:1 for completed; 1:4 for attempts
Risk Factors
Epidemiologic factors
- Age: increases after age 14; second most common cause of death for ages 15-24; highest rates in persons >65 yrs
- Sex: male
- Race/ethnic background: white or native Canadians on reserve
- Marital status: widowed/divorced
- Living situation: alone; no children <18 yrs old in the household
- Other: stressful life events; access to firearms
- Mood disorders (15% lifetime risk in depression; higher in bipolar)
- Anxiety disorders (especially panic disorder)
- Schizophrenia (10-15% risk)
- Substance abuse (especially alcohol- 15% lifetime risk)
- Eating disorders (5% lifetime risk)
Past history
- Prior suicide attempt
- Family history of suicide attempt/completion
Clinical Features
Symptoms associated with suicide
- Hopelessness
- Anhedonia
- Insomnia
- Severe anxiety
- Impaired concentration
- Psychomotor agitation
- Panic attacks
Assessment
1 point 0 point
S ex M F
A ge 15-24/>65 others
D epression Y N
P revious attempts Y N
E xcess EtOH/drugs Y N
R ational thinking loss Y N
S uicide in family Y N
O rganised plan* Y N
N o support Y N
S ickness Y N
*C ontext (What were the circumstances of this attempt?/ What were you planning?)
L ethality (Did you think it will kill you?)
I ntent (What did you want to achieve?)
P reparations (Have you started preparations? Access to tools?)
0-4 = low risk
5-6 = moderate risk
7-10 = high risk
Management
- Depends on the level of risk identified
- Higher risk
- Patients with a plan, access to lethal means, recent social stressors, and symptoms suggestive of a psychiatric disorder should be hospitalized immediately
- Do not leave patient alone; remove potentially dangerous objects from room
- If patient refuses to be hospitalized, complete form for involuntary admission
- Lower risk
- Patients who are not actively suicidal, with no plan or access to lethal means
- Discuss protective factors and supports in their life, remind them of what they live for, promote survival skills that helped them through previous suicide attempts
- Make a safety plan - an agreement that they will not harm themselves, avoid alcohol, drugs, and situations that may trigger suicidal thoughts, follow-up with you at a designated time, and contact a health care worker, call a crisis line or go to an emergency department if they feel unsafe or if their suicidal feelings return or intensify
- Depression: hospitalize if severe or if psychotic features are present; otherwise outpatient treatment with good supports and SSRls/SNRls
- Alcohol-related: usually resolves with abstinence for a few days; if not, suspect depression
- Personality disorders: crisis intervention/ confrontation, may or may not hospitalize
- Schizophrenia/psychosis: hospitalization
- Parasuicide/self-mutilation: long-term psychotherapy with brief crisis intervention when necessary
- Proper documentation of the clinical encounter and rationale for management is essential
Source
Toronto Notes 2012