|
| A) | They are expected manifestations of uncomplicated grief. | ||
| B) | They indicate a potential imminent suicide crisis requiring prompt assessment. | ||
| C) | They suggest chronic suicide risk but no immediate danger. | ||
| D) | They are protective behaviors demonstrating acceptance of the loss. |
While risk factors for suicide represent broader, durable, and ongoing factors, a suicide crisis is a time-limited event that signals an immediate danger of suicide. A suicide crisis can be triggered by a particularly distressing event, such as loss of a loved one or career failure, and involve an intense emotional state in addition to depression, such as desperation (anguish plus urgent need for relief), rage, psychic pain or inner tension, anxiety, guilt, hopelessness, or acute sense of abandonment. Changes in behavior or speech can suggest that suicide is imminent; speech may be indirect, with statements such as, "My family would be better off without me." Persons contemplating suicide may also talk as if they are saying goodbye or going away, exhibit actions ranging from buying a gun to suddenly putting one's affairs in order, or deterioration in social or occupational functioning, increasing use of alcohol, other self-destructive behavior, loss of control, or rage explosions [1].
| A) | Increased appetite | ||
| B) | Social withdrawal | ||
| C) | Improved concentration | ||
| D) | Greater occupational engagement |
A mnemonic device IS PATH WARM has been developed for use in identifying suicide risk [3,4]. This mnemonic device was derived from the consensus of internationally renowned clinical researchers held under the auspices of the American Association of Suicidology. It consists of the following [3,4]:
Ideation
Substance abuse
Purposelessness
Anxiety
Trapped
Hopelessness
Withdrawal
Anger
Recklessness
Mood change
| A) | Screen universally beginning at 8 years of age. | ||
| B) | Screen only adolescents who have a diagnosed depressive disorder. | ||
| C) | Screen all patients 12 years of age and older and screen patients 8 to 11 years of age when clinically indicated. | ||
| D) | Use depression screening alone because it identifies nearly all pediatric patients at risk for suicide. |
The American Academy of Pediatrics (AAP) recommends universal screening for suicide risk throughout adolescence (12 years of age and older) and clinically indicated screening for children 8 to 11 years of age [12]. Screening should be performed in a developmentally and medically appropriate manner. The AAP notes that screening for depression is not the same as screening for suicide risk and that screening for depression alone misses 36% of patients at-risk for dying by suicide [12]. Screening children younger than 8 years of age is not recommended, but warning signs or parental reports of self-harm or suicidal behaviors should be assessed further; these may include [12]:
Talking about wanting to die or wanting to kill oneself
Grabbing their throat in a "choking" motion, or placing their hand in the shape of a gun pointed toward their head
Acting with impulsive aggression
Giving away their treasured toys or possessions
| A) | "You are not thinking about suicide, are you?" | ||
| B) | "Why would you want to hurt yourself?" | ||
| C) | "You look very upset. Tell me more about what is happening." | ||
| D) | "Please answer yes or no: Do you intend to die?" |
Healthcare providers may encounter a patient they suspect is suicidal. This suspicion may be prompted by the presence of one or more of the risk factors for suicide described previously, patient history, a statement expressed by the patient, or by their intuition. This scenario may present a dilemma of how to proceed. Although some healthcare professionals are uncomfortable with suicidal patients, it is essential not to ignore or deny the suspicion of suicide risk. The first and most immediate step is to allocate adequate time to the patient, even though many others may be scheduled. Showing a willingness to help begins the process of establishing a positive rapport with the patient. Closed-ended and direct questions at the beginning of the interview are not very helpful; instead, use open-ended questions such as, "You look very upset; tell me more about it." Listening with empathy is in itself a major step in reducing the level of suicidal despair and overall distress [7,8]. It is helpful to lead into the topic gradually with a sequence of useful questions, such as [7,8]:
Do you feel unhappy and helpless?
Do you feel desperate?
Do you feel unable to face each day?
Do you feel life is a burden?
Do you feel life is not worth living?
Have you had thoughts of ending your own life?
| A) | The patient has nonspecific thoughts without a plan or intent. | ||
| B) | The patient has developed a specific plan, intends to act, and has access to lethal means. | ||
| C) | The patient is willing to discuss reasons for living. | ||
| D) | The patient identifies several supportive family members. |
After the patient confirms an initial suspicion of suicidal ideation, the next step is to assess the frequency and severity of the ideation and the possibility of suicide. It is important to ask the patient about whether a method has been developed and planned, the accessibility to the means to attempt suicide, and the magnitude of lethal intent in a manner that is not demanding or coercive, but is asked in a warm and caring way that demonstrates empathy with the patient. Such general questions might include [7,8]:
Have you made any plans for ending your life?
How are you planning to do it?
Do you have in your possession [pills/guns/other means]?
Have you considered when to do it?
In general, the more an individual has thought about suicide, made specific plans, and intends to act on those plans, the greater the suicide risk. Thus, as part of the assessment of suicide risk it is essential to inquire specifically about the patient's suicidal thoughts, plans, behaviors, and intent. Such questions may often flow naturally from discussion of the patient's current situation, but in other cases they should be explicitly asked [14].
| A) | Discharge the patient after obtaining a verbal commitment to seek help. | ||
| B) | Delay all intervention until the patient independently returns when sober. | ||
| C) | Maintain the patient in an urgent care setting and repeat the assessment after the patient is sober. | ||
| D) | Accept the initial assessment as definitive because intoxication does not affect suicide-risk evaluation. |
All patients at acute risk for suicide who are under the influence (intoxicated by drugs or alcohol) should be evaluated in an urgent care setting and be kept under observation until they are sober. If the patient is intoxicated when the initial assessment is completed, it should be repeated after he or she is sober [15].
| A) | Provide routine follow-up at the next scheduled visit. | ||
| B) | Give the patient educational materials and recommend independent counseling. | ||
| C) | Maintain direct observation, limit access to lethal means, and arrange immediate transfer with an escort for emergency evaluation and hospitalization. | ||
| D) | Refer the patient for outpatient evaluation within several weeks. |
DETERMINE LEVEL OF RISK FOR SUICIDE AND APPROPRIATE ACTION
| Risk of Suicide Attempt | Indicators of Suicide Risk | Contributing Factorsa | Initial Action Based on Level of Risk | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| High acute risk |
|
|
| ||||||||||
| Intermediate acute risk |
| Existence of warning signs or risk factorsb and limited protective factors |
| ||||||||||
| Low acute risk |
| Existence of protective factors and limited risk factors |
| ||||||||||
| |||||||||||||
| A) | Dialectical behavior therapy addresses life-threatening behaviors before therapy-interfering or quality-of-life behaviors. | ||
| B) | Psychotherapy should be avoided in patients with suicidal thoughts because discussing suicide increases risk. | ||
| C) | Cognitive-behavioral approaches focus exclusively on medication adherence. | ||
| D) | Relapse prevention is inappropriate until all suicidal thoughts have permanently resolved. |
In addition to pharmacotherapy, various psychotherapy approaches have been shown to decrease suicide risk in patients at low or intermediate risk for suicide [26]. Post-admission cognitive therapy is a cognitive-behavioral therapy approach designed to help patients who have suicide-related thoughts and/or behaviors. It consists of three phases of therapy for outpatients or inpatients [26]:
The patient is asked to tell a story associated with her or his most recent episode of suicidal thoughts, behavior, or both.
The patient is assisted with modifying underdeveloped or overdeveloped skills that are most closely associated with the risk of triggering a suicidal crisis.
The patient is guided through a relapse-prevention task.
Another cognitive-behavioral approach is cognitive-behavioral psychotherapy for suicide prevention, which involves "acute and continuation phases, each lasting about 12 sessions, and includes a chain analysis of the suicidal event, safety plan development, skill building, psychoeducation, family intervention, and relapse prevention" [27].
Dialectical behavior therapy was originally designed to address the self-harm impulses of patients with borderline personality disorder, but it has good evidence for use in most suicidal individuals. Dialectical behavioral therapy is an adaptation of cognitive-behavioral therapy and is based on the theoretical principle that maladaptive behaviors, including self-injury, are attempts to manage intense overwhelming affect of biosocial origin. It consists of the two key elements of a behavioral, problem-solving approach blended with acceptance-based strategies and an emphasis on dialectical processes. Dialectical behavioral therapy emphasizes balancing behavioral change, problem-solving, and emotional regulation with validation, mindfulness, and acceptance of patients. Therapeutic targets are ranked in hierarchical order, with life-threatening behaviors addressed first, followed by therapy-interfering behaviors, and then behaviors that interfere with quality of life.
| A) | Give the patient a list of providers and end the existing clinical relationship. | ||
| B) | Explain the reason for the referral, help arrange the appointment, and maintain follow-up with the patient. | ||
| C) | Avoid discussing the referral so the patient does not become anxious about stigma. | ||
| D) | Transfer all responsibility to the mental health professional immediately. |
Depending on the level of suicide risk, referral to a mental health professional (e.g., psychologist, counselor, therapist), psychiatrist, or hospitalization may be warranted. Long-term treatment and follow-up will be required for many patients, and appropriate referral to outpatient facilities is often necessary. If the person is currently in therapy, the therapist should be called and involved in the management decision. If the patient does not have a therapeutic relationship with a mental health professional, referral to one should be made. Suicidal patients should be referred to a psychiatrist when any of the following are present: psychiatric illness; previous suicide attempt; family history of suicide, alcoholism, and/or psychiatric disorder; physical illness; or absence of social support [7,8]. After deciding to refer a patient to a mental health professional, the clinician should explain to the patient the reason for the referral and help alleviate patient anxiety over stigma and psychotropic medications. It is also important to help the patient understand that pharmacologic and psychological therapies are both effective and to emphasize to the patient that referral does not mean "abandonment." The referring clinician should also arrange an appointment with the mental health professional, allocate time for the patient following the initial appointment with the therapist or psychiatrist, and ensure the ongoing relationship with the patient [7,8].
| A) | Ask the patient to sign a general promise not to engage in self-harm. | ||
| B) | Develop a written plan collaboratively that identifies warning signs, coping strategies, supportive contacts, professional resources, and methods for reducing access to lethal means. | ||
| C) | Use the same standardized plan for every patient to ensure consistency. | ||
| D) | Keep the plan exclusively in the medical record so it remains confidential. |
Safety planning is a provider-patient collaborative process—not a "no harm" contract. The safety planning process results in a written plan that assists the patient with restricting access to means for completing suicide, problem-solving and coping strategies, enhancing social supports and identifying a network of emergency contacts including family members and friends, and ways to enhance motivation. These plans are tailored to the patient by assisting with identifying his or her specific warning signs and past effective coping strategies [15].
The safety plan should include the following elements, as appropriate:
Early identification of warning signs or stressors
Enhancing coping strategies (e.g., to distract and support)
Utilizing social support contacts (discuss with whom to share the plan)
Contact information about access to professional help
Minimizing access to lethal means (e.g., weapons and ammunition or large quantities of medication)