Suicide

Suicide is the intentional act of causing one's own death. It has a major impact on supporting family and friends. In Canada the rate of suicide is approximately 11.1/100, 000 people. The highest demographic are males over the age of 65. In North America males are 3-4x more likely to die by means of suicide than females, however, females attempt suicide 4x more than males. In any patient with mental illness it is important to actively inquire about suicidal ideation including; ideas, thoughts, intent, and specific plans.

History

 * Assessment of suicidal ideation:
 * onset, frequency, content, change, duration, intensity
 * passive versus active
 * control, stopping these thoughts strategies
 * provoking factors
 * protective factors: support
 * Assessment of plan:
 * access to means
 * lethality (is the plan likely to end their life)
 * specific plan (time, place, rehearsed, isolated)
 * access to weapons
 * likelihood of completion
 * final arrangement planning (note, will, given away your belongings, etc)
 * Assessment of intent/behaviour
 * practice or aborted prior attempts: setting (?isolated), planned/impulsive, triggers/stresors at the time, substance use, medical attention needed (who brought patient in), time between suicide attempt and presentation to ER, expectation of dying, reaction to survival
 * Explore ambivalence: reason to live/die
 * PMHx, Past psych history, Medications, Family history (suicide, mental health d/o, substance use)
 * SHX: substance use, trouble with the law, gambling, support system, ocupation
 * Review of symptoms: hopelessness, insomnia, amotivational, anhedonia, panic attacks, concentration impaired, psychomotor changes, personality changes, mal-adaptive coping strategies, functional decline

Mental Status Examination
ABC STAMPLICKER
 * Appearance, Behaviour, Cooperation, Speech, Thought process/content, Affect, Mood, Psychomotor activity, Insight, cognition, knowledge, endings (suicidal, homicidal), reliability

Risk factors
SAD PERSONS Scoring Guide (not sensitive or specific) ** Highest predictive value of suicide is prior history of attempted suicide**
 * S- sex (male:1, female:0)
 * A- age (1+ 25-44, +65)
 * D - Depression
 * Previous attempt
 * ETOH use
 * Rational thinking loss
 * Social support lacking
 * Organized plan
 * No spouse (1+ divorced, widowed, separated)
 * Sickness
 * 0-2: consider home with family
 * 3-4: close f/u
 * 5-6: consider hospitalization
 * >7: hospitalize

Prevention

 * Safety contracts --> NO EVIDENCE
 * Canadian Task force:
 * Poor evidence to include suicide screen in the periodic health examination
 * Remain alert in high risk patients and consider screening: psychiatric d/o, substance abuse, prior attempts, family member completed suicide
 * Special attention to young, male, Native Americans
 * There is no effective screen available to actively predict those that will complete suicide.
 * Helpful adjuncts:
 * Columbia Suicide Severity Screening Tool - See google drive.
 * CAMS suicide status form - see google drive
 * Hope Kit: container that holds items that act as reminders of why you live. Can include: photos, letters, souveniers, song lyrics, safety plan, crisis line numbers, coping cards, a list of reasons to live

Trauma Patients

 * ALWAYS consider attempted suicide as the precipitating cause

Overdose Patients

 * See poisoning section for full details
 * ALWAYS screen for acetaminophen and ASA co-ingestions as they are common, dangerous and frequently overlooked

Management

 * Ensure proper documentation
 * Low risk: close follow-up, referral for counselling, referral for community supports, CBT
 * Provide specific instructions for follow-up if suicidal ideation progresses/worsens (e.g. return to Emergency department, call crisis line, f/u GP, f/u crisis worker)
 * Aggressively treat co-morbid conditions
 * High risk: immediate hospitalization including involuntary admission if required
 * Close f/u after discharge as at increased risk
 * Ensure you remove dangerous objects from room an do not leave patient alone
 * Ways to reduce immediate risk: involve a close family member or friend if allowed, remove access to lethal meals, manage underlying psychiatric disorder or substance use

Resources
Columbia Suicide Severity Screening Tool - See google drive

Ted talks Mark Henick

Tool Kit for Survivors of Suicide Loss

Crisis Line - Ottawa WITHIN OTTAWA 613.722.6914