PART 3 / CH 19

Suicide

Roy Perlis

A. Risk assessment

· take a detailed history

· gather information from collateral sources (family, e.g.)

Key elements of suicide evaluation

in	look for
HPI	precipitants degree, persistence of SI details of plan (means, chance of rescue)
ROS	comorbid psychiatric illness, substance abuse
Psych	lethality of past attempts
FH	psychiatric illness, suicides
SH	extent of supports (lives alone? connections?)
MSE	delirium or intoxication; restlessness/akathisia; mood/anxiety; psychosis; impulsivity; poor judgement

B. Psychiatric illness is the major risk factor for suicide

C. Risk factors in selected populations

1. Major depression (short term risks)

· Severe anhedonia

· Panic attacks/ psychic anxiety

· Global insomnia

· Impaired concentration

· Alcohol abuse

2. Alcohol abuse

· Loss of relationship within 6 weeks

· Other concurrent drug use

· Late in disease course

D. Interventions should be carefully documented

Discharge checklist

1. Access to means of suicide removed

2. Precipitants addressed

3. Underlying psychiatric illness treated,

including substance abuse

4. Increased outpatient supports (ie, not alone)

5. Close follow-up arranged

6. Decision-making and safety documented

· There is no evidence that “contracts for safety” are effective in reducing suicide attempts!

source: Fawcett J, Clark DC, Scheftner WA (1991) Psychiatr Med 9: 299-311.