Crisis Intervention: Triage to Prevent Suicide and Suicide Attempts

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Crisis Intervention Triage to Prevent Suicide
and Suicide Attempts
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Major risk factors

• Death of a loved one
• Chronic pain physical or psychiatric
• Social isolation
• Loneliness
• Substance abuse, especially alcohol
• Changes in social roles
• Intense humiliation / loss of face (more likely
  in Asian patients)

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Clues / Risk factors

• Changes in eating or sleeping habits
• Unexplained fatigue or apathy
• Trouble concentrating or being indecisive
• Crying for no apparent reason
• Inability to feel good about themselves or unable
  to express joy
• Behavior changes or are just "not themselves"

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More clues / risk factors

• Withdrawal from family, friends or social
  activities
• Talk about or seem preoccupied with death
• Give away prized possessions
• Take unnecessary risks
• Have had a recent loss or expect one
• Increase their use of alcohol, drugs or other
  medications

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More clues / risk factors

• Failure to take prescribed medicines or follow
  required diets
• Acquire a weapon
• Prolonged sad mood (more than just a few days)
• Impulsive nature
• Loss of interest in hobbies, work, etc.
• Loss of interest in personal appearance
• Male sex
• Older male sex, alcoholic, alone in life, no
  friends

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Somewhat lower risk factors

• Transient sad mood
• Female sex
• No substance abuse
• Family members and friends
• Reactive mood
• Can think of something that would help him/her
  feel better
• Roman Catholic

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Assessment

• ASK!
• You cannot prevent a suicide if you dont ask the
  patient
• You will not suggest suicide by asking the
  patient (a common myth)

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How to ask some suggestions

• Build rapport
• Let the patient tell his/her own story
• Can you tell me more about what has been
  happening to you?
• Give empathy and sympathy
• It sounds like life has really been difficult for
  you
• Im sorry things have not been going well. I
  hope I can help you

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How to ask more suggestions on what to say

• People often ashamed to tell what they have been
  thinking
• Create commonality
• Other people, like you, who have been having a
  really rough time, have told me that they feel
  life is no longer worth living
• Have you had such thoughts?
• Can you tell me more about those thoughts?

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How to ask more suggestions on what to say

• Have you had thoughts about ending your life?
• How long have you been feeling this way?
• If yes, consider asking the following
• Do you have a plan?
• How would you do it?
• Do you have the means to do it?
• Pills, gun
• Who would be upset if you died?

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How to ask more suggestions on what to say

• Have you ever made a suicide attempt in the past?
• Past history of suicide attempt is often thing of
  any true predictive value
• How many times have you attempted to end your
  life?
• When did you do this?
• How did you try to end your life?

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How to ask more suggestions on what to say

• How likely are you to do it (1 unlikely, 10
  highly likely)?
• Do you have any spiritual orientation?
• What do you feel about the meaning of your life?
• What could happen that would stop you from trying
  to end your life?
• What could happen to help you feel better?

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Further elements of a risk assessment

• Current suicidal thoughts, intent, and plan
• History of suicide attempts (eg. lethality of
  method, circumstances)
• Family history of suicide
• History of violence (eg. weapon use,
  circumstances)
• Intensity of current depressive symptoms
• Current treatment regimen and response
• Recent life stressors (eg, marital separation,
  job loss)
• Alcohol and drug use patterns

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Further elements of a risk assessment

• Psychotic symptoms
• Current living situation (eg, social supports,
  availability of weapon)
• Patients with altered perceptions of reality,
  such as those caused by intoxication or psychosis
• Obtain a complete history of alcohol and drug
  use.
• Note whether suicidal thoughts occur during
  intoxication or sobriety, or both.
• The presence of psychotic symptoms in a depressed
  patient with suicidal ideation is an ominous
  sign.

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Diagnostic / symptomatic categories for patients
at high risk

• Depression
• Alcoholism
• Chronic non-psychiatric medical illness
  (demoralization)
• Chronic psychiatric medical illness
• Mourning / grief
• Personality disorders with impulsiveness

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Diagnostic / symptomatic categories for patients
at high risk

• Three types of psychotic symptoms are
  particularly worrisome and could push a patient
  to commit suicide
• Auditory hallucinations commanding suicidal acts
• Thoughts of external control (feeling that an
  outside force controls one's actions)
• Religious preoccupation.
• Patients may not readily report these symptoms
  collateral interviews with family members can
  help confirm psychosis.

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Differential features

• Is the patient talking about being discouraged
  with life because of chronic illness?
• Is the patient talking about end of life issues?
• Is the patient talking about loss of meaning to
  life?
• Does the patient have a reactive mood?
• Is the patient attempting to upset someone with
  whom they are angry?
• Does the patient have true major depression?

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Sad Persons Scale

• S ex (male)
• A ge (elderly or adolescent)
• D epression
• P revious suicide attempts
• E thanol abuse
• R ational thinking loss (psychosis)
• S ocial supports lacking
• O rganized plan to commit suicide
• N o spouse (divorced gt widowed gt single)
• S ickness (physical illness)

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Differential features

• Has the patient lost the ability to control
  his/her life (physically or emotionally)
• Has the patient lost a sense of meaning to
  his/her life?

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Three Groups

• It is useful to categorize depressed patients who
  are potentially suicidal into three groups
• Patients with ideation, plan, and intent
• Patients with ideation and plan but without
  intent, and
• Patients with ideation but no plan or intent.

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Interventions / treatment issues

• With all patients, one should employ
• Empathy / sympathy
• I care. I would be upset if you ended your
  life
• Give 800 number
• National 1-800-273-TALK (8255)
• Local [phone]
• Arrange for frequent visits
• Arrange for people at patients living place to
  check the person more often

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Interventions / treatment issues

• Depressed patients with suicidal ideation, plan,
  and intent should be hospitalized, especially if
  they have current psychosocial stressors and
  access to lethal means.
• When a patient's life is in imminent danger, the
  caregiver may breach confidentiality and contact
  a family member.
• Depressed patients who refuse hospitalization may
  be involuntarily hospitalized

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Interventions / treatment issues

• Caregivers can contact their local crisis center,
  or emergency department for assistance in
  arranging such commitments.
• Depressed patients with suicidal ideation and a
  plan but without intent may be treated on an
  outpatient basis, especially when they have good
  social support and no access to lethal means.
• However, some of these patients need
  hospitalization, especially if their environment
  does not offer adequate safety measures, such as
  responsible supervision.
• Outpatient treatment may consist of
  antidepressant therapy (preferably with
  antidepressants that are safe in overdose),
  referral to a drug and alcohol treatment program,
  psychotherapy, or all of these.

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Interventions / treatment issues

• Depressed patients who express suicidal ideation
  but deny plan or intent should be evaluated
  carefully for psychosocial stressors.
• Caregivers should encourage the patient or family
  members to remove weapons and other potentially
  lethal means from the patient's environment.
• In general, patients in this category may be
  safely treated with antidepressant medication on
  an outpatient basis, but they should be seen by
  their physician often as long as suicidal
  thoughts persist.

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Interventions / treatment issues

• No suicide contract or handshake
• Although some caregivers use a written "no
  suicide" contract / no suicide handshake with
  patients
• This is never a substitute for a thorough risk
  assessment.
• Many patients who sign such a contract later
  commit suicide.
• Therefore, the use of these contracts / handshake
  may give caregivers a false sense of security and
  provides no protection from legal liability

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The case manager, therapist, peer or caregiver

• How would you feel if a patient of yours ended
  their life?
• Has it ever happened to you?
• What things would you do to help yourself?
• Seldom is the caregiver / therapist considered
  after a suicide