Suicide Assessment Psychiatry evaluation or suicide assessment is performed by the psychiatrist or trained medical personnel under the direct supervision of a licensed psychiatrist. During the evaluation, the healthcare personnel obtain information vital to the patient's psychiatric well-being. Through direct questioning, observation, and third-party inquiries, information gathered may focus primarily on collateral history, observations about suicide behavior, identification of possible triggers and risk factors, medical history documenting any underlying conditions serving as a trigger or risk factor, evaluation of protective factors, and documentation of environmental/social triggers of SIB. Age-, sex- and occupation-specific information related to SIB may also be documented. From the therapy perspective, this information enables the psychiatrist to: ● Identify a specific factor or a combination of factors that may directly or indirectly affect the suicidality score, and the risk of suicide or serve as modifiable targets for therapy ● Consider the specific factors identified and address the patient’s safety immediately, especially in emergency settings; personnel are also expected to leverage the information presented for the design and execution of an appropriate therapeutic setting ● Develop a conclusive differential diagnosis based on medical history or underlying medical conditions and plan a patient- oriented therapy regimen. While assessing a patient’s risk of suicide risk, the psychiatrist is cautioned against simply asking direct questions about suicidal ideation or death. Depending on the patient’s personal, cultural, and religious beliefs, a direct question about suicide or death may not elicit an accurate or truthful response, as many patients assessed in psychiatric settings often fail to understand the need for a thorough evaluation. The psychiatrist needs to focus on essential information that will reveal the frequency, nature, depth, timing, and persistence of suicidal ideation and behavior. If suicidal ideation is present, more information about the presence of a specific plan for a suicide attempt should be obtained. Plans and preparations already made concerning suicidal ideation should also be discussed. In many cases, patients directly deny suicidal ideation, even in the presence of clinical signs indicating the progression of a suicide course. If the denial of suicide appears to be inconsistent with other clinical information provided, the psychiatrist is advised to probe further and proceed accordingly. In the case of a positive history of suicide attempts, information about the timing, consequences, method, and means of suicide should be obtained. This information allows the psychiatrist to further understand whether suicide behavior is triggered by different life contexts in the patient's social or environmental settings such as intoxication, loss of a loved one, substance abuse, or employment termination. Information about the specific method of attempted suicide is considered to be vital to the assessment process. If a patient is too unstable to give this information, third-party inquiries should be leveraged. By leveraging information about a specific method of suicide, the psychiatrist can further ascertain the patient’s expectations about the method’s lethality. If the actual lethality exceeds what is expected, the patient’s risk for accidental suicide may be high, even if the clinical presentation suggests a lower risk of suicidal ideation. Patients with higher degrees of suicidal intent and a specific method should generally be assigned a prominent level of risk. Also, lethality should be considered alongside the availability of means. If a patient has unrestricted access to a firearm, the psychiatrist is advised to discuss different recommendations aimed at restricting access or securing or removing the means. Third-party help and discussion with a patient’s spouse or other relative may be important in this regard.
The suicide assessment process should end with proper documentation of all information gathered. This is important for tracking behavior changes as the patient undergoes therapy. It is also helpful for tracking and identifying new suicidal ideation and behavior that emerge during therapy. Proper documentation also reflects the efficacy of therapy (or the lack thereof). The APA guidelines on suicide also summarize specific characteristics to be addressed in the psychiatric evaluation of a patient with SIB. These include the following. The Current Presentation of Suicidality ● Suicidal or self-harming thoughts, plans, behaviors, and intent. ● Specific methods considered for suicide, including their lethality and the patient’s expectation about lethality, as well as whether firearms are accessible. ● Evidence of hopelessness, impulsiveness, anhedonia, panic attacks, or anxiety. ● Reasons for living and plans for the future. ● Alcohol or other substance use associated with the current presentation. ● Thoughts, plans, or intentions of violence toward others. Psychiatric Illnesses ● Current signs and symptoms of psychiatric disorders, paying particular attention to mood disorders (primarily major depressive disorder or mixed episodes), schizophrenia, substance use disorders, anxiety disorders, and personality disorders (primarily borderline and antisocial personality disorders). ● Previous psychiatric diagnoses and treatments, including illness onset and course, along with psychiatric hospitalizations and treatment for substance use disorders. History ● Previous suicide attempts, aborted suicide attempts, or other self-harming behaviors. ● Previous or current medical diagnoses and treatments, including surgeries or hospitalizations. ● Family history of suicide or suicide attempts, or family history of mental illness, including substance abuse. Psychosocial Factors ● Acute psychosocial crises and chronic psychosocial stressors, which may include actual or perceived interpersonal losses, financial difficulties or changes in socioeconomic status, family discord, domestic violence, and past or current sexual or physical abuse or neglect. ● Employment status, living situation (including whether there are infants or children in the home), and presence or absence of external supports. ● Family constellation and quality of family relationships. ● Cultural or religious beliefs about death or suicide. Individual Strengths and Vulnerabilities ● Coping skills ● Personality traits Another important aspect of suicide assessment as specified by the APA guidelines is specific inquiries about suicidal thoughts, plans, and behavior (Harmer et al., 2022). The APA has drafted a series of questions to ask during a patient suicide assessment as follows: 1. Begin with questions that address the patient’s feelings about living. • Have you ever felt that life was not worth living? • Did you ever wish you could go to sleep and just not wake up? ● Past responses to stress ● Capacity for reality testing ● Ability to tolerate psychological pain and satisfy psychological needs
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Book Code: PYMA2024
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