Instructions: Spend 5-10 minutes reviewing the case below and considering the question and disscusion that follows. While working an evening shift in the Emergency Department, your next patient, Cindy, presents with a chief complaint of “Headache”. While reviewing the chart, you noticed that during the suicide screening done at triage, the patient answered “Yes” to the question, “Over the past two weeks have you had thoughts of killing yourself?” Upon review of Cindy’s records, you note that she has had a dozen visits for non-specific complaints like “weakness”, “back pain”, and “headache.” Entering Cindy’s room, you notice that she maintains little eye contact. Case Study 3
1. What are some elements of Cindy’s case that would increase your concern about her? Consider ways you might approach her to adequately evaluate her risk for suicide.
Discussion: After evaluating her headache complaint, you ask “What did you mean when you stated you had thoughts of killing yourself?” You sit down, giving her your full attention. Although initially reluctant to explain, your empathetic yet persistent tone reassures her that assistance is available. She shares that she is severely depressed and has planned in the past to hang herself because she cannot bear the pain any longer. You persuade her that speaking with a mental health professional will help her start healing, and contact the psychiatrist on duty to perform a suicide assessment.
In recognizing the risk to all age groups, it is imperative that healthcare workers accurately assess for suicidal ideation. To do this, healthcare workers must: • Identify individual risk factors. • Use appropriate screening and/or assessment tools to determine suicide risk. • Identify levels of risk. Healthcare workers must be aware of risk factors that make a person vulnerable to suicidal ideation (SI). Suicidal thoughts and behaviors are linked to many different circumstances, including illness and life stressors—notably periods of crises, such as illness, chronic pain, financial stress (particularly sudden financial stress or loss, compared to chronic poverty), and relationship breakups. 15,19 According to the WHO, the strongest predictor of suicide is one or more previous attempts. 7 Suicide and mental disorders, such as depressive disorders and substance use disorders, have been well-established as linked to death by suicide, particularly in high-income countries. Alcohol consumption is a significant risk factor associated with suicide and has been identified as the fifth-
leading worldwide risk for disability-adjusted life year (DALY), a time-based measure that combines years of life lost due to premature mortality and disability. It remains the leading risk factor for suicide among individuals between the ages of 14 and 49 years. 15 Often, patients who have attempted suicide are discharged with no community support or appropriate follow-up, making them vulnerable to reattempting suicide. In low-resource settings, geographic inaccessibility to healthcare facilities and the absence of trained professionals have been identified as potential obstacles. 15 Evidence-Based Practice A history of a previous suicide attempt places an individual at high risk for suicide and is the strongest predictor of suicide. A study examining medical records from 1987 to 2007 identified 1490 individuals with a first suicide attempt reaching medical attention. More than 59% died immediately from the first suicide attempt, and amongst those who survived, 85% killed themselves within one year. 2
Classifying risks There are various ways of classifying specific levels of risk. Zero Suicide identifies three levels of risk within the two categories of acute and chronic: low, intermediate, and high. The following algorithm to help clinicians identify and understand levels of risk based on acute or chronic SI (Table 7). 49 Appropriate actions for different levels of risk Zero Suicide offers the following guidelines for specific actions according to their respective levels of risk (See Table 8 on the next page). 49 PLEASE COMPLETE CASE STUDY 4 ON THE NEXT PAGE.
Table 7. Levels of suicide risk
Acute
Chronic
High risk: Patients have suicidal ideation with the intent to die by suicide. They are unable to maintain safety without external support. Intermediate risk: Patients have suicidal ideation, but no intent based on identified reasons for living (ie children) and ability to follow a safety plan and maintain safety. Preparatory behaviors are likely absent. Low risk: Patients are identified to be at low risk if they have suicidal ideation, but do not currently have a plan for suicide or suicidal behaviors. Another feature is collective high confidence (from patient, care provider, family member) in the ability of the patient to maintain safety independently.
High risk: Patients with chronic suicidal ideation and an increase or change in baseline mood, behavior or talk about suicide/dying.
Intermediate risk: Patients with chronic suicidal ideation but have protective factors, coping skills, reasons for living and psychosocial stability suggesting the ability to endure future crisis without resorting to suicide. Low risk: Patients with chronic suicidal ideation but have abundant strengths and resources. The following is generally NOT present: history of self-directed violence; chronic SI; highly impulsive; risky behaviors; marginal psychosocial functioning.
Note. Adapted from Zero Suicide. (2019). Therapeutic risk management – Risk stratification table. 49 https://zerosuicide.edc.org/sites/default/files/Risk%20Stratification%20 Table%20MCHGM.pdf
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