Suicide Assessment and Prevention _ ____________________________________________________________
All patients at acute risk for suicide who are under the influ- ence (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 [79]. Lethal Means All persons at risk for suicide should be assessed for avail- ability or intent to acquire lethal means, including firearms and ammunition, drugs, poisons, and other means in the patient’s home [79]. Clinicians should always inquire about access to firearms and ammunition and how they are stored. For military members and veterans, this includes assessing privately owned firearms. In addition, medication reconciliation should be performed for all patients. For any current and/or proposed medications, consider the risk/benefit of any medications that could be used as a lethal agent to facilitate suicide. Consider prescrib- ing limited supplies for those at elevated risk for suicide or with histories of overdose or the availability of a caregiver to oversee the administration of the medications. In addition to medications, the availability of chemical poisons, especially agricultural and household chemicals, should be assessed, as many of these are highly toxic [79].
• Has your view of things changed, or is anything differ- ent for you since the attempt? • Are there other times in the past when you’ve tried to harm (or kill) yourself? Repeated Suicidal Thoughts or Attempts • About how often have you tried to harm (or kill) your- self? • When was the most recent time? • Can you describe your thoughts at the time that you were thinking most seriously about suicide? • When was your most serious attempt at harming or killing yourself? • What led up to it, and what happened afterward? Persons with Psychosis, Hallucinations, and Delusions • Can you describe the voices (e.g., single versus multiple, male versus female, internal versus external, recogniz- able versus unrecognizable)? • What do the voices say (e.g., positive remarks, negative remarks, threats)? If the remarks are commands, deter- mine if they are for harmless versus harmful acts; ask for examples. • How do you cope with (or respond to) the voices? • Have you ever done what the voices ask you to do? What led you to obey the voices? If you tried to resist them, what made it difficult? • Have there been times when the voices told you to hurt or kill yourself? How often? What happened? • Are you worried about having a serious illness or that your body is rotting? • Are you concerned about your financial situation even when others tell you there is nothing to worry about? • Are there things that you have been feeling guilty about or blaming yourself for? Potential to Harm Others • Are there others who you think may be responsible for what you are experiencing (e.g., persecutory ideas, passivity experiences)? Are you having any thoughts of harming them? • Are there other people you would want to die with you? • Are there others who you think would be unable to go on without you? When assessing for suicide, it is important to be cautious of misleading information or false improvement [59; 60]. When an agitated patient suddenly appears calm, he or she may have made the decision to attempt suicide and feels calm after mak- ing the decision. Denial is another important consideration. Patients may deny harboring very serious intentions of killing themselves.
DETERMINING LEVEL OF RISK AND APPROPRIATE ACTIONS
The formulation of the level of risk for suicide guides the most appropriate care environment in which to address the risk and provide safety and care needs. The first priority is safety. Patients assessed as having a clear intention of taking their lives will require higher levels of safety protection than those with less inclination toward dying. Patients who are at high risk for suicide may require inpatient care to provide for increased level of supervision and higher intensity of care. Those at intermediate and low acute risk may be referred to an outpatient care setting and, with appropriate supports and safety plans, may be able to be followed-up in the community ( Table 2 ) [79]. Risk Assessment Tools Rating scales can be helpful in the assessment process. How- ever, a clinical assessment by a trained professional is required to assess suicide risk. This professional should have the skills to engage patients in crisis and to elicit candid disclosures of suicide risk in a non-threatening environment. The assess- ment should comprise a physical and psychiatric examination, including a comprehensive history (with information from patient, parents, and significant others whenever possible) to obtain information about acute psychosocial stressors, psychiat- ric diagnoses, current mental status, and circumstances of prior suicide attempts. Assessment tools may be used to evaluate risk factors, in addition to the clinical interview, although there is insufficient evidence to recommend one tool over another.
64
EliteLearning.com/Psychology
Powered by FlippingBook