_______________________________________________________________________ Depression and Suicide
Suicide Warning Signs: Indications for Urgent/Immediate Action Suicide warning signs are recent, unusual changes in the patient, often an acute response to precipitants, and proximally associated with imminent suicide risk. Intent may be signaled through emotions, thoughts, or behaviors. Danger is elevated with previous suicide attempts, family history of suicide, or possession of a lethal method. Presence of any of the following warning signs requires immediate attention, mental health evaluation, and possibly hospitalization to ensure patient safety, stability, and security: • Suicide communication—threatening to harm or kill self • Preparations for suicide • Seeking access, or recent use, of lethal means Other warning signs may further elevate acute suicide risk include [366; 368]: • Verbalizations: Hopelessness (feeling of defeat, that nothing can improve their situation), purposelessness (sense of purpose or reason to live is absent), feeling trapped (no way out, no escape possible), or guilt/ shame (overwhelming self-blame, remorse, self-hatred) • Behaviors: Anger, rage, revenge-seeking, reckless/impul- sively risky behavior, marked mood changes, anhedonia, withdrawal from family, friends, society • Inability to sleep • Command hallucinations Acute Suicidality Risk Level and Intervention After a patient’s suicide risk level has been assessed and assigned, based on clinical judgment, the level of intervention may be selected ( Table 8 ). The Cognitive State The cognitive/affective state of suicidal patients is typified by ambivalence, impulsivity, and rigidity. The desire to die and live alternates; clinicians may explore ambivalence to reinforce reasons for living. The transient nature of impulse permits
Thinking and cognition are often clouded, and intention- ally or not, many patients with increased suicide risk give inaccurate, incomplete, and unreliable histories. Patients can misunderstand their symptoms, condition, and risk and usually cannot predict their impulses and behaviors [493; 494]. Clini- cians often believe suicidal patients view them as allies, but they are more likely seen as adversaries with conflicting goals: preserving versus ending life. This is a fundamental change in the patient-provider relationship after a patient decides to attempt suicide [494]. As such, alternative lines of evidence may be necessary to confirm suspicions of suicide risk, including obtaining objec- tive evidence and collateral information/permissions [493; 494]. Patients who attempt suicide may communicate intent to relatives before clinicians [494]. Among inpatients who die by suicide, 78% denied suicidal ideation in their last commu- nication with staff, 60% told their spouse, and 50% told other relatives; however, only 18% told their physician [459]. Other providers, relatives, and close others can be vital information sources to help ascertain acute suicide risk level and are often more reliable than severely suicidal patients. Assessing Suicidality As discussed, many areas of patient information emphasized by standard practice guidelines as crucial for patient risk assess- ment have been found to lack risk prediction value. Instead, clinicians should focus on critical factors related to suicide risk, identified by studies of callers to suicide prevention hotlines, including [493; 495]: • Suicidal desire: Suicidal ideation, psychologic pain, hopelessness, helplessness, perceived burden to others, feeling trapped, feeling intolerably alone • Suicidal capability: History of suicide attempts, expo- sure to someone else’s death by suicide, available means of killing self/others, current intoxication, substance abuse, acute symptoms of mental illness, extreme agita- tion/rage • Suicidal intent: Attempt in progress, plan to kill self/ others, preparatory behaviors, expressed intent to die
ACUTE SUICIDE RISK LEVEL AND INTERVENTION
Risk Level
Contributing Factors
Suicidality Level
Possible Interventions
High
Acute, severe psychiatric illness or symptoms Acute precipitating event
Lethal attempt Ideation, strong intent to act/plan
Continuous observation; limit access to lethal means; immediate transfer to emergency department for hospitalization Prompt referral to mental health clinician Limit access to lethal means Outpatient referral Give emergency/crisis numbers
Cannot control impulses Rehearses/prepares suicide Ideation No intent to act Impulse control intact Ideation No plan, intent, behavior
Moderate
Multiple warning signs or risk factors
Low
Risk factors modifiable Protective factors strong
Source: [364; 366; 368]
Table 8
211
EliteLearning.com/Psychology
Powered by FlippingBook