Suicide

1
Suicide

• As of 1 Feb 2014. Questions, unless otherwise
  indicated, are from the APA Practice Guideline on
  suicide or Kaplan Sadock 2007, unless
  otherwise noted.

2
DSM-5

• DSM-5 additions are NOT included since the 2014
  Board exams are to be based on DSM-IV-TR

3
Suicide rate

• Q. What is the rate of suicides in the US, the
  annual number per 100,000?

4
Suicide rate

• Ans. 12/100,000

5
Among Medical Specialties

• Q. Among medical specialties, which has the
  highest rate?

6
Among Medical Specialties

• Ans. Psychiatrists, followed by ophthalmologists
  and anesthesiologists. Women psychiatrists are
  especially vulnerable, about 4 times the national
  average.

7
Spinal Fluid

• Q. Spinal fluid findings of suicides?

8
Spinal fluid

• Ans. Reduced levels of serotonin and of 5-HIAA

9
Suicide assessment

• Q. What is the value of a suicide assessment? Do
  such assessments have a high predictive level?

10
Suicide assessment.

• Ans. Not a reliable predictor of suicide, but are
  of value as to what questions to ask, providing
  answers that assist the clinician in making the
  clinical assessment and judgment.
• Suicide Practice Guideline, AJP Supplement,
  November 2003

11
Protective as to suicide

• Q. The Practice Guideline on suicide list ten
  items that are relatively protective. List them.

12
Protective as to suicide - 1

• Ans. We all know exceptions, but the following
  tends to be statistically true.
• Children in the home
• Sense of responsibility to family
• Pregnant
• Religiosity
• Life satisfaction
• See next slide

13
Protective as to suicide - 2

• 6. Reality testing ability
• 7. Positive coping skills
• 8. Positive problem-solving skills
• 9. Positive social skills
• 10. Positive therapeutic relationship.
• Note that 1 and 3 are ripe for examiners
  questions. Two other factors not mentioned 1
  female 2 obesity seems protective.

14
Risk per disorder

• Q. While prior suicide attempt is riskier than
  any Disorder, which disorder has the highest rate
  of suicides?

15
Risk per disorder

• Ans. Eating Disorder has the highest rate, just
  ahead of MDD.

16
Low rate

• Q. All disorders have a higher rate than the
  general population -- except which Disorder?

17
Low risk

• Ans. Intellectual Disability pts have a lower
  rate than the general population.

18
Med that reduces suicides

• Q. Which med has the strongest evidence of
  reducing suicides?

19
Med that reduces suicides

• Ans. Li

20
Anticonvulsants

• Q. What about anticonvulsants that are regarded
  as mood stabilizers? Can they reduce suicide?

21
Anticonvulsants

• Ans. No evidence they decrease the risk of
  suicide. Even studies with a large N have not
  come close to equally the protective impact of
  Lithium.

22
FDA

• Q. Which, if any med, has FDA approval for
  reducing the risk of suicides?

23
FDA

• Ans. Clozapine when used with people who have
  schizophrenia is seen as protective against
  suicide.

24
ECT

• Q. ECT any help in reducing suicide?

25
ECT

• Ans. Practice guideline say yes, at least in the
  short term.

26
Psychosocial approaches

• Q. Do psychosocial approaches reduce risk of
  suicide?

27
Psychosocial approaches

• Ans. CBT and DBT both have studies suggesting
  they are effective.
• Probably no exam question will assume that
  psychosocial approaches are not helpful.

28
Documentation

• Q. Role of documentation?

29
Documentation

• Ans. While suicide risk is not predictable, any
  exam question will expect a thorough
  documentation of the risk partially for legal
  protection should the pt suicide. Restated, good
  documentation that you explored and weighed the
  risks reduces your legal risks.

30
Suicide contracts

• Q. Value of suicide contracts?

31
Suicide contracts

• Ans. Not recommended in ER, or when pt is
  agitated, psychotic, impulsive, or under the
  influence. Has no legal standing.

32
Communications with others

• Q. What to do if pt seems very suicidal and
  refuses to let you speak to his wife or anyone
  else?

33
Communications with others

• Ans. The psychiatrist is justified in
  attenuating confidentiality to the extent needed
  to address the safety of the pt.

34
Post-suicide communications

• Q. Your pt has suicided? What to tell his family?
  What not to tell?

35
Post-suicide communications

• Ans. In allaying grief and, if indicated, helping
  family members, you should avoid
• -- revealing confidential info
• -- avoid self-incriminating statements
• -- avoid self-exonerating statements