Clinical Notes : Mental Health

163. Suicide Risk Management

 

Definition​

Suicide risk management refers to the identification, assessment, and treatment of a person exhibiting suicidal behaviour. Suicidal behaviour includes death by suicide, suicide attempt, suicide plan, and suicidal ideation.

 

There are 5 key components to suicide:

  • ideation

  • intent

  • plan

  • access to lethal means

  • history of past suicide attempts

Epidemiology​ 

Suicide is

  • the fourth leading cause of death and the sixth leading cause of ill health and disability worldwide, making suicide a significant public health concern.

  • usually more common among males than females, but the opposite may be true for suicidal thoughts.

  • the most common cause of death in correctional settings

In developed countries, the suicide rate is high for people in midlife and in older people, whereas in developing countries it is highest in people <30 years of age, therefore, while suicide is a global concern, it must be understood within the local or regional contex.

 

Etiology​

The 2 most prevalent mental disorders associated with suicide are major depressive disorder and substance abuse.

 
 

Medical illness and increased risk of suicide are thought to be associated in part through the presence of a concurrent mental illness.

 

Other factors associated with increased risk of suicide are :

Social disadvantage

non-intact family of origin

parental psychopathology

history of childhood physical or sexual abuse

sexual orientation

unemployment

Assessment

Suicide risk assessment has 4 steps: 

  1. Assessment of the 5 components of suicide: ideation, intent, plan, access to lethal means, and history of past suicide attempts

  2. Evaluation of suicide risk factors

  3. Evaluation of current experience (what's going on?)

  4. Identification of targets for intervention.

When initiating the suicide assessment, the following SHOULD be done:

  • Establish rapport

  • Use a calm, patient, non-judgemental, and empathic approach

  • Begin with supportive statements and open-ended inquiries

  • Start with general and then move towards more specific questions in a sensitive and non-judgemental way that creates an opportunity for dialogue; do ask specific questions about self-harm, suicidal thoughts, plans, attitudes towards suicide, history of suicidal behaviour, thoughts of death, and feelings of hopelessness.

 

The following SHOULD NOT be done:

  • Allow your personal feelings and reactions to influence assessment and treatment

  • Rush the patient or ask leading questions

  • Interrogate the patient or force the patient to defend his or her actions

  • Minimise the patient's distress

  • Undermine the seriousness of the suicidal thought or action.

 

Acquiring collateral information:

  • A patient may not explicitly admit to suicidal thoughts, behaviours, or history (passive suicidality).

    • Family, friends, health professionals, teachers, co-workers, or others may also provide valuable information to support the assessment.

  • If no informants are able to provide collateral information and the patient does not directly answer questions, clinical judgement based on apparent risks, possible warning signs for hidden suicidal ideation, intent or plan (e.g., presence of psychosis, despondence, anger, agitation; inability to develop rapport, make eye contact, answer direct questions about suicide), and subjective impressions may need to be called upon.

    • Furthermore, the clinician may need to review hospital or clinic records for evidence of past self-harm behaviours, and pay close attention during the physical examination for signs of suspicious injuries

The Tool for Assessment of Suicide Risk (TASR) can be used by the assessing clinician in the clinical setting to determine the probability of imminent suicide risk.

 

It has no numeric scoring system or cut-off score that predicts suicide, but helps to ensure that the most important issues pertaining to suicide risk are considered, allowing the best-informed decision as to how to proceed to be made.

Also provides a good record of details of suicide assessment and can be appended to patient's chart/record in any setting.

 
 

Management for suicide risk in OOH

Considered at significant risk :

  • refer to local hospital A+E or directly to local psychiatric 24/7 service where available :

    • local psychiatric 24/7 services usually do not accept referrals if intoxicated individuals, and require initial referral to hospital A+E for drying out 

Considered safe to discharge home with responsible support :

  • provide both patient and carer with contact cards carrying the name and phone number of a crisis worker that they can call should the situation worsen

  • lethal means such as guns should be removed from the home

  • ensure follow-up counselling

    • either via direct referral

    • or via family

  • ensure carer understands and accepts actions required from them in case of deterioration and considered at significant risk and refusing referral

Considered at significant risk and refusing referral :

  • consider Involuntary Admission Procedure

  • consider calling Garda to apprehend and detain for own safety

    • re-evaluate later in Garda station for voluntary vs involuntary admission

Carefully document all aspects of encounter.

 

Helplines

Suicide Helpline 

Pieta House

24-hour on 1800 247 247.

Or, alternatively, text HELP to 51444 (standard message rates apply)

 

Suicide Helpline

Samaritans.org 

(24-hour freephone helpline) on 116 123

text: 087 260 9090 (standard rates apply)

Depression helpline

Aware.ie 

1890 303 302 (seven days a week, from 10am to 10pm)

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Mental Health Commission

Mental Health Act, 2001 and Regulations

Access

Mental Health Commission

Your Rights : Guide to the Mental Health Act, 2013

Access

 

Assessment of suicide risk in people with depression. A clinical Guide

Centre for Suicide Reasearch, University of Oxford

Access

NICE Guideline NG105

Preventing suicide in community and custodial settings

Sept 2018

Access

Preventing suicide: Guidance for emergency departments

New Zealand Ministry of Health

April 2016

Access

Large M, Smith G, Sharma S, et al.

Systematic review and meta-analysis of the clinical factors associated with the suicide of psychiatric in-patients.

Acta Psychiatr Scand. 2011 Jul;124(1):18-29.

Access

Chan MK, Bhatti H, Meader N, et al.

Predicting suicide following self-harm: systematic review of risk factors and risk scales.

Br J Psychiatry. 2016 Oct;209(4):277-83.

Access

Saving Lives and reducing Harmful Outcomes : Care Sysytems for Self-Harm and Suicidal Behaviour

National Guidelines for the Assessment and Management of Patients Presenting to Irish Emergency Departments following self-harm. HSE

March 2012

Access

There should be a single point of contact for ED staff to access MH services for patients and the referral procedure should be a simple one. Services should be available in the ED that span the entire age range and are provided irrespective of the catchment area /address of the patient.

 

Adults:

Liaison Psychiatry: During agreed hours for adults, this should be the Liaison Psychiatry team based on-site as there is consensus in Ireland and elsewhere that mental health service delivery to acute/emergency medical patients is best provided by a specialist ‘Liaison’ mental health team based on-site.

Out-of-hours in all 24/7 EDs, there should be mental health staff available on-site, supported by a Consultant on-call.

 

Children & Adolescents:

Timely access to MH services must be available at all times for children and adolescents attending the ED in crisis.

All major EDs should have defined access to assessment by Child and Adolescent Mental Health services (CAMHS) via a simple referral procedure. Ideally this should be a dedicated Liaison CAMHS supported by the on-call CAMHS.

This service should be accessible 24/7 via a single point of contact.

In any event, the MH service responsible for assessment of 16 and 17 year-olds in the ED should be explicit.

In addition to this it is essential that there should be access to child protection services including out of hours and weekends.

Stay Alive app

Suicide prevention resource.

Can be used by individual having thoughts of suicide, or by other individual concerned about someone else who may be considering suicide.

Includes an interactive Wellness Plan, customisable reasons for living, and a LifeBox for photos and memories storage.

UK based, but local support and emergency contact details may be added.

OOHCPD.com
 

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