Approach to a suicidal patient

Approach to a suicidal patient

Feb 29, 2016 0
onthepods,psychiatry

James talks to Dr Joanne Ferguson about a basic approach to a suicidal patient.

Summary Writer:  Lucinda Burke

Editor:  James Edwards

Interviewee: Joanne Ferguson

About Dr 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.

A basic approach to a suicidal patient

With Dr Joanne Ferguson, Staff Specialist Psychiatry and Addiction Medicine, Royal Prince Alfred Hospital, New South Wales, Australia

Introduction

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.

Case

You are asked to review a patient on the ward who has told nursing staff he is having suicidal thoughts.

  • Assessing risk of suicide
    • The general consensus within the field is that there is no reliable way to predict suicide, nor does an assessment provide an accurate reflection on a patients risk for any prolonged period of time, and thus suicidality needs to be constantly reassessed.
    • There are some warning signs and risk factors to help estimate risk
      • Lower risk – e.g. occasional fleeting thoughts that life is too hard and they would be better off dead versus a patient who feels life is definitely not worth living and they would much rather be dead with plans of how to end their life.
      • Warning signs: things that may be predictive of suicide in the near future.
        • Planning to die, writing a note, selling business, sorting out finances.
      • Risk factors are associated with increased risk of suicide over the longer term.
        • Previously attempted suicide, social isolation, abused or neglected in childhood.
        • At risk mental status: depression, hopelessness, despair, agitation, shame, guilt, anger, psychosis including hallucinations and delusions.
        • Alcohol or drug intoxication or withdrawal.
        • Financial/legal difficulties including significant social losses.
  • Need to assess details, lethality and any preparations of planning -as any degree of planning would require a much more acute response.
    • Protective factors help balance the risk of suicide but do not mitigate –it has to be the patient’s identified protective factors, not ones we think, and should include:
    • Family support, love for family and children, ability to problem solve, coping strategies, cultural, social, spiritual and religious connections.
      • Often people will be reassured when you talk with them about their resilience and strengths.
    • The assessment of suicide risk is based on identifying warning signs, risk and protective factors.
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)

  • One of the challenges is there are no tests that can determine risk, thus the assessment is largely based on the history and is an estimate.
    • One thing that does help the assessment is transference that is a constellation of information that comes across from the patient to the medical practitioner, “gut feelings” and associated mood feelings. These are often subtle signs, often ignored, however, the skills can be developed and are widely useful.
  • Certain underlying disorders that are associated with suicidal thoughts or ideation need to be considered.
    • Up to 90% of people who die by suicide suffer from a diagnosable mental disorder usually depression/acute stress reaction (Conwell et al.).
      • Psychosis
      • Schizophrenia: 15% will suicide, about half of people with schizophrenia have attempted suicide.
      • Bipolar: 5-10% suicide
      • Serious substance disorder: 10% suicide
      • Severe personality disorder of the borderline type have significant ongoing suicidal ideation and many have made attempts on their life.
      • Any combination of the above will increase the risk.
  • Not a persistent feeling or thought.
  • Gather information:
    • Nursing staff: on how things are, if there is a change in behaviour or mood.
    • Organise a private/quiet place to see the patient.
      • You shouldn’t be afraid of approaching someone unless the patient is hiding a weapon or there is some concern they are feeling hostile or frightened – in that situation you approach the patient with other staff members and avoid private areas.
  • History:
    • A good opening question: have there ever been times when life is just too hard, when the suffering they have been experiencing is just too much to go on with?
    • Need to know how risky the patient is right now.
      • Something to ask staff over the phone before coming to see the patient:
        • The background of the patient.
        • Have they ever attempted suicide before?
        • Are they threatening to do anything immediately?
        • Is this something I need to come up for immediately?
        • Are they currently safe?
      • Determine risk factors, warning signs and protective factors.
      • Any current history of mental health conditions.
  • Examination:
    • General physical examination looking for signs of injury or self-harm
    • Examine surroundings for potential harm risks/dangerous objects
  • Assessing the level of intervention required depends on many factors.
    • Severity of illness
    • Degree of impulsivity
    • Degree of insight
    • Safety in current setting
    • Supports available
    • Ability and willingness of patient to engage
  • How quickly you escalate the management response depends on your assessment of how immediate the risk is.
    • High risk: ensure safe and secure environment, re-assess within hours, ensure plans are in place in case the situation escalates, including one to one nursing or transfer to a secure unit like Mental Health.
    • Medium risk: needs monitoring and re-assessment within 24-48 hours, however, you should also have plans in place in case of escalation.
    • Low risk: review as determined by acuity and services. Provided with information on 24-hour access to suitable care.
  • Escalating to a senior colleague or Mental health service.
    • Give a good history to your colleague.
    • Indicate: this a significant current risk.
    • Need to work out how to make the patient safe.
      • Special, private room, psych admission.
    • Always have a low threshold for escalating and asking for help.
    • Resources for junior doctors when facing such a patient:
      • Your best resources are colleagues.
      • Asking senior colleagues over the phone.
      • Speak with nursing staff.
      • Formal risk assessment: Forms available (Psychiatric Registrars can direct you to these).
      • Online resources and education.
        • SANE Australia
  • It can be a challenging area.
  • A difficult area to talk about with people.
  • Completed suicide of a patient is one of the most difficult things doctors have to face.
  • Talk to colleagues and friends, speak to Employee Assistance Program or supports.
  • When asked to assess someone, this is not something to be afraid of but something to take seriously, ask for help and have a low threshold for escalating and referring to a Psychiatric Registrar.

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Tags: #anger,#depression,#guilt,#mental disorders,#mental health,#patient care,#patient safety,#psychiatry,#self-harm,#shame,#suicidal patient,#suicidality,#suicide prevention

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