Suicide Assessment and Prevention _ ____________________________________________________________
Changes in behavior or speech can suggest that suicide is immi- nent; 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 [2]. WARNING SIGNS Most people who are suicidal exhibit warning signs, whether or not they are in an acute suicide crisis. These warning signs should be taken seriously and include observable signs of serious depression, such as unrelenting low mood, pessimism, hopelessness, desperation, anxiety, psychic pain, and inner tension; withdrawal from friends and/or social activities; sleep problems; and loss of interest in personal appearance, hobbies,
• I deation • S ubstance abuse • P urposelessness
• A nxiety • T rapped
• H opelessness • W ithdrawal • A nger • R ecklessness • M ood change
Intentional Self-Harm Intentional self-harm is behavior related to, but distinct from, suicide behavior and includes suicide attempts and nonsuicidal self-injurious behaviors, such as burning, cutting, and hair pull- ing, that does not have fatal intent [85]. Self-injurious behavior falls into three categories [85]: • Major self-injury: Infrequent, usually associated with psychosis or intoxication • Stereotypic self-injury: Repetitive and reflects a biologic drive of self-harm • Superficial-to-moderate self-injury: The most common form and is used by self-mutilators to relieve tension, release anger, regain self-control, escape from misery, or terminate a state of depersonalization Patients with a history of intentional and repetitive self-harm are likely to be highly impulsive with a diagnosis of borderline personality disorder, and distress over their inability to cur- tail the behavior may heighten suicide risk [85; 86; 87]. It is essential to recognize that previous nonlethal self-harm does not preclude the development of suicidal ideation or plans with serious intent and lethality [62]. It is important to assess the intent of self-harm behaviors during the risk assessment. Five days after the initial visit, in anticipation of follow-up later that day, the physician reviews Patient B’s laboratory results, all of which are normal. That afternoon, the patient is a “no-show,” and no further action is taken. Some time the following week, the office nurse asks her colleague about Patient B, stating “Something about her really bothered me.” She recommends that the physician call the patient to follow-up, which he does. The daughter answers with a mix of concern and relief. She states, “I’m really worried about my mother. She’s not making sense at times, seems really down, and says we’d all be better off if she just went to sleep and didn’t wake up…I didn’t mention it last week, but she and my dad are not doing well. He’s busy, on the road a lot, and I get the feeling she thinks he’s unfaithful to her.” At this juncture what do you do? • Ask the daughter to bring her mother to the office today, along with all supplements and herbal medicines she may have been taking.
work, and/or school [2; 13]. Other signs include: • Increased alcohol and/or other drug use
• Recent impulsiveness and taking unnecessary risks • Talk about suicide, death, and/or no reason to live • Making a plan (e.g., giving away prized possessions, sudden or impulsive purchase of a firearm, or obtain- ing other means of killing oneself, such as poisons or medications) • Unexpected rage, anger, or other drastic behavior change • Recent humiliation, failure, or severe loss (especially a relationship) • Unwillingness to “connect” with potential helpers. The following expressions of thoughts, feelings, or behaviors may also be warning signs of suicidal behavior [13]:
• Can’t stop the pain • Can’t think clearly • Can’t make decisions • Can’t see any way out • Can’t sleep, eat, or work
• Can’t get out of the depression • Can’t make the sadness go away • Can’t see the possibility of change • Can’t see themselves as worthwhile • Can’t get someone’s attention • Can’t seem to get control
A mnemonic device, IS PATH WARM, has been developed for use in identifying suicide risk [84]. 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 [84]:
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