Discussion Upon review of Mrs. B.’s history, the admitting physician noted that three months earlier she indicated that her husband had been unfaithful. She tried to cope with this stressor on her own, and although she saw a counselor monthly, she intentionally kept that information from the counselor at her last visit two months prior. She had also cancelled her last two counseling sessions but did call a suicide hotline three weeks before her attempted suicide. The suicide hotline attempted to follow up and check in with her, but she was dismissive and ended up refusing to take their calls. In addition to her primary care physician, she saw her gynecologist four weeks before her suicide attempt. Her gynecologist did notice that she was not her usual self, but when she pressed the patient, Mrs. B. reported that her antidepressant dose was being adjusted by her therapist and so she would be fine in a few weeks. In conclusion, Mrs. B. had four interactions with healthcare professionals within a three-month period before her suicide attempt. Although two of those providers suspected something was off, they did not fully appreciate the gravity of the situation. Part of the challenge with caring for patients who are seeing multiple providers is that communication among providers Case study 2: Adolescent suicidal ideation Ella is a 16-year-old high school student. She requests to see a school therapist after a bad breakup with her boyfriend of three months. During her initial consultation with the school therapist, she reports that she has had suicidal ideation as well as intent and a plan. She reports that she has a plan to swallow a bottle of Tylenol to “make the pain go away.” When asked if she had access to Tylenol, she reports that she bought a bottle a few days ago and was just waiting to find the right time. The school counselor promptly contacts Ella’s parents who come in to meet with her. Ella’s mom reports that Ella tends to be dramatic and that she has made such threats after her previous three breakups; she suggests that all Ella needs to do is to stop being distracted by boys and focus on her future. At the counselor’s insistence, the mom promises to report the counselor’s findings to her pediatrician. The next week Ella is found dead by her best friend on her bathroom floor.
can be extremely challenging; providers often have to rely on patients for accurate communication of updates and pertinent findings. In retrospect, her son, who was aware that his mother had a history of a prior suicide attempt, was also aware that she had contacted the suicide hotline before her attempt, but he did not want to betray her confidence by reporting his suspicion to the public. Clearly, there is a need for continued education regarding mental illness and how it affects families. Patients with children who are old enough should be encouraged to share their diagnosis with families and encourage their families to use a support system as much as they feel comfortable. Lastly, the nurse at Mrs. B.’s primary care office, Joan, should have been more proactive and should have screened Mrs. B. for suicidal ideation and intent during her last visit given that she had some context and a better understanding of Mrs. B.’s history than did the physician who was filling in. She chose to defer to Dr. Cook’s authority and failed to act on her intuitive nursing judgment. She should have at least reported her suspicions to Dr. Duke when he returned from his vacation four days after her visit. Discussion Managing and treating suicidal ideation can be challenging, especially in children whose parents are dismissive of the warning signs in their children. The counselor in this case reacted appropriately by promptly reporting her findings and suspicions to Ella’s parents. However, Ella’s mom’s denial regarding the challenges her daughter faced was a particular hindrance in securing the right help for Ella. The counselor should have tried to contact Ella’s father and tried to convey her sense of urgency regarding the immediacy of Ella’s needs. This was especially important given that her mother was being so resistant to getting Ella the help she needed. In the aftermath of Ella’s death, her friends and classmates should receive counseling. Additionally, Ella’s parents should receive grief counseling to help them cope with the loss of their daughter. schizophrenia, and borderline personality disorder. Indeed, major depressive episodes, which are associated with either major depressive disorder or bipolar disorder, account for at least half of suicide deaths. Among patients with bipolar disorder, mixed-state episodes are most strongly associated with suicide attempts, with the associated risk increasing significantly as the time spent in the mixed-state depressive episodes extends (Perlis et al., 2016). Mixed-state bipolar disorders and psychotic episodes concurrent with underlying depression can significantly increase the risk of imminent suicidal acts and require special attention. The diagnoses thought to be most closely associated with increased risk for suicide are major depressive disorder, disruptive mood dysregulation disorder, bipolar disorder, substance use disorder, obsessive compulsive disorder, posttraumatic stress disorder, anorexia nervosa, schizophrenia, and borderline personality disorder. Finally, non-suicidal self- injury (NSSI) is a behavior that is linked to suicidal behavior, and there is currently growing support for a new diagnosis of non-suicidal self-injury disorder (Selby, Kranzler, Fehling & Panza, 2015). sadness that can last for a protracted amount of time ranging from weeks to months or even longer. The DSM-5 (2013) outlines the criteria for diagnosis that includes suicidal ideation. Five (or more) of the following symptoms must have been present during the same two-week period and
PSYCHIATRIC DIAGNOSES AND SUICIDE
Mental illness is a major factor in both understanding and predicting suicidal behavior; in fact, psychiatric illness is one of the most highly-correlated risk factors with suicidal behavior (Turecki, Brent, Gunnell, O’Conner, Oquendo, et al., 2019). The vast majority (90 to 95%) of individuals who die by suicide have some diagnosable disorder at the time of death (Choi, Lee, & Han, 2020), and it is likely that the fraction who did not were experiencing subclinical levels of psychopathology. Indeed, psychiatric diagnosis has been found to increase the odds of death by suicide 10.83-fold and increase the odds of a suicide attempt 3.56-fold, relative to those with no diagnostic history (Gili, Castellvi, Vives, de la Torre-Luque, Almenara, et al., 2019). In this section, references of mental illness or psychiatric diagnoses are specifically referring to diagnoses as outlined by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition ( DSM-5 ; APA, 2013). The risk of suicide may be influenced by different dimensions of psychopathology, such as mood variability and psychoticism, along a spectrum of affective and psychotic disorders (Ventriglio, 2016). Some psychiatric illnesses are more strongly associated with suicidal behaviors than others, especially major depressive disorder, bipolar disorders, posttraumatic stress disorder, Major depressive disorder Depression, known formally in th e DSM-5 as major depressive disorder, is a clear and consistent precursor to suicidal thoughts and behavior (Veisani et al., 2017). Depression is more than just being unhappy or sad, it is a disorder of intense and severe
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