James talks to Dr Joanne Ferguson about a basic approach to a suicidal patient.
Summary Writer: Lucinda Burke
Editor: James Edwards
Interviewee: Joanne Ferguson
Joanne Ferguson is a Clinical Associate Lecturer, Psychiatry and Addictions, Croydon Community Health Centre, Concord Clinical School. Staff Specialist Psychiatrist, Drug Health Services, Rozelle and Concord Hospitals.
With Dr Joanne Ferguson, Staff Specialist Psychiatry and Addiction Medicine, Royal Prince Alfred Hospital, New South Wales, Australia
Talking about suicide is regarded as one of the most stressful conversations that staff can have with patients. Patients who have expressed suicidality or thoughts of self-harm to staff are often quite ambivalent and express fear and a sense of powerlessness about these thoughts, however, they are often open to discussion. As a junior doctor, you shouldn’t be afraid to talk with patients about this.
You are asked to review a patient on the ward who has told nursing staff he is having suicidal thoughts.
ISSUE | HIGH RISK | MEDIUM RISK | LOW RISK |
‘At risk’ mental status
– Depressed – Psychotic – Hopelessness, despair – Guilt, shame, anger, agitation – impulsivity |
E.g. Severe depression
Command hallucinations or delusions about dying Preoccupied with hopelessness, despair, feelings of worthlessness Severe anger, hostility |
E.g. Moderate depression
Some sadness Some symptoms of psychosis Some feelings of hopelessness Moderate anger, hostility |
E.g. Nil or mild depression, sadness
No psychotic symptoms Feels hopeful about the future None/mild anger, hostility |
Suicide attempt or suicidal thoughts
– Intentionality – Lethality – Access to means – Previous suicide attempts |
E.g. Continual/specific thoughts
Evidence of clear intention An attempt with high lethality (ever) |
E.g. Frequent thoughts
Multiple attempts of low lethality Repeated threats |
E.g. Nil or vague thoughts
No recent attempt or 1 attempt of low lethality and low intentionality |
Substance disorder
– Current misuse of alcohol and other drugs |
Current substance intoxication, abuse or dependence | Risk of substance intoxication, abuse or dependence | Nil or infrequent use of substances |
Corroborative History
– Family, carers – Medical records – Other service providers/sources |
E.g. Unable to access information, unable to verify information, or there is a conflicting account of events to that those of the person at risk | E.g. Access to some information
Some doubts to plausibility of person’s account of events |
E.g. Able to access information / verify information and account of events of person at risk (logic, plausibility) |
Strengths and Supports (coping and connectedness)
– Expressed communication – Availability of supports – Willingness/capacity of support persons – Safety of person and others |
E.g. Patient is refusing help
Lack of supportive relationships/hostile relationships Not available or unwilling/unable to help |
E.g. Patient is ambivalent
Moderate connectedness, few relationships Available but unwilling/unable to help consistently |
E.g. Patient is accepting help
Therapeutic alliance forming Highly connected/good relationships and supports Willing and able to help consistently |
Reflective practice
– Level and quality of engagement – Changeability of risk level – Assessment confidence in risk level |
Low assessment confidence or high changeability or no rapport, poor engagement | High assessment confidence/low changeability
Good rapport, engagement |
|
No (foreseeable) risk: Following comprehensive suicide risk assessment, there is no evidence of current risk to the person. No thoughts of suicide or history of attempts, has a good social support network |
(Suicide Risk Assessment and Management Protocols Community Mental Health Service NSW Department of Health, September 2004)
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