Suicide and Homicide
Ian C. Dawe
SUICIDE
Individuals with suicidal thoughts, plans, or behaviors are some of the most common and challenging patients for clinicians and allied health staff in the psychiatric emergency room. With a base rate of approximately 10.5 per 100,000 in the U.S. population, suicide remains a rare and complex event (1). Suicidal ideation, however, is common in emergency settings, with an estimated annual incidence of 5.6% and estimated lifetime prevalence of 13.5% in the general population (2). Unfortunately, risk assessments have a low predictive value for completed suicide, and based on our current knowledge, suicide seems impossible to predict at the individual level.
This section of the chapter presents guidelines to assist the clinician in the emergency room (ED) to evaluate and manage patients who present with suicidal ideation or behavior.
Presenting Clinical Features
Patients may present to the ED reporting suicidal thoughts, with specific plans to die by suicide, or after having made an actual suicide attempt. The “chronically suicidal” individual presents a different series of challenges in both the assessment and management stages and will be dealt with separately toward the end of the section. The primary focus of this portion of the chapter is on the individual with acute suicidality.
The presence of a psychiatric disorder is strongly associated with suicidal behavior. Suicidal ideation or attempts can occur in patients with mood, psychotic, and personality disorders, as well as in those experiencing acute intoxication or withdrawal states. Comorbid diagnoses, especially those with alcohol or substance use or both, are essential to identify because the risk of suicide increases with the number of diagnoses present. Of course, the absence of a psychiatric disorder does not necessarily mean that the risk is low.
Commonly, individuals with suicidal ideation or intent will present to the hospital with strong feelings of hopelessness. Severely depressed patients often feel that their situations are not only intolerable but also unlikely to ever improve. A study by Beck et al. (3) prospectively followed 165 individuals hospitalized with suicidal ideation. Ten of the 11 patients who eventually suicided during the follow-up period had severe hopelessness as measured by standardized scales.
IMMEDIATE INTERVENTIONS FOR ACUTE PRESENTATIONS
The assessment of a suicidal individual begins at the triage desk. At this point, the focus is on identifying individuals at the highest risk so that immediate action may be taken to ensure the patient’s safety. These initial interventions may include the use of one-to-one constant observation by clinical staff and security officers, evaluation in a secure, locked area so as to guard against elopement, and the administration of medications or physical restraints or both as clinically indicated.
Although an ED physician may need to initially manage the medical complications of an actual attempt (overdoses, lacerations, wounds, etc.), qualified mental health personnel should begin their assessment in a concurrent fashion with medical staff. This will ensure that the client’s urgent mental health needs are assessed and met in as rapid a fashion as possible.
EVALUATION
In the absence of an empirically validated and reliable suicide assessment instrument, a skilled clinical interview remains the essential tool by which to estimate a patient’s risk. During the evaluation, the clinician must obtain information about the patient’s psychiatric history and his or her current mental state. This information should be obtained through both the use of direct questioning and observation, as well as through whatever collateral sources are available.
After addressing the patient’s immediate safety, the goal of the evaluation is to identify the specific risk factors that influence the possibility for suicide, especially those that could be modified with acute interventions. A further goal of the evaluation is the determination of the most appropriate setting for treatment, be it inpatient, outpatient, or some form of short-term crisis hospitalization. Finally, the information obtained in the evaluation will allow a psychiatrist to develop an appropriate differential diagnosis with which to guide future treatment. Table 15.1 presents the important domains of a suicide risk assessment (4).
TABLE 15.1 Characteristics Evaluated in the Psychiatric Assessment of Patients with Suicidal Behavior | |||||||||||
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Tanney (5) asserts that there is an important and compelling relationship between suicidal acts and mental disorder. Mood disorders, substance abuse or dependence, acute anxiety, and schizophrenia remain the most important axis I diagnoses that influence suicide risk. Cluster B diagnoses, especially borderline personality disorder, are clearly associated with suicidal acts.
A history of suicide attempts, including deliberate self-harm (DSH) behavior, is one of the strongest risk factors for future suicide. A follow-up mortality study in the United Kingdom of more than 11,000 patients who presented with DSH between 1978 and 1997 found that 300 had died by suicide or probable suicide by the time the follow-up period ended in 2000. Thus, for those who present with suicidal behaviors, the authors calculated a suicide risk of 0.7% in the first year following presentation, a rate 66 times the annual risk in the general population (6).
Access to lethal methods increases suicide risk. In the United States, firearms are the most common method for suicide (7,8). Readily accessible lethal means may substantially increase the lethality of impulsive behaviors, and clinicians are well advised to investigate such access during periods of suicidal crises. This may include such things as stockpiles of over-the-counter and prescription medications, firearms, knives, and other weapons, as well as alcohol and other illicit drugs, which may themselves be used as a means to end one’s life.
Investigating a past history of psychiatric treatment, including recent hospitalizations, is an important part of the evaluation of an individual’s risk. Many studies have shown an increased risk of suicide following changes in both the intensity and the location of treatment. A substantial increase in rates of suicide after hospital discharge has been observed in individuals with major depressive disorder, bipolar disorder, schizophrenia, and borderline personality disorder. Although the rates generally decline with time, they may remain high for as long as a year following discharge (9).
The clinician must also quantify the current and historical use of alcohol and drugs in patients presenting with suicidal thoughts or behaviors. It is often necessary to observe an intoxicated patient in a safe setting until the intoxication resolves and a thorough suicide assessment can be completed. Although active intoxication may not prevent the initial assessment from taking place, the intoxicated suicidal client must be reassessed when sober to fully evaluate the person’s risk.
DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS
Suicidal ideation and attempts can occur in many different psychiatric disorders, but are not specific to any. They can occur in patients with affective, psychotic, and personality disorders, and in acute intoxication or withdrawal states. The focus of this portion of the evaluation is to categorize an individual’s level of risk.
A high-risk individual would be a person who:
Has made a nearly lethal or serious suicide attempt
Has persistent suicidal ideation along with a significant intent to die and has taken planning steps toward an attempt
Is psychotic and experiencing command hallucinations
Was recently discharged from a psychiatric inpatient unit
Has had a recent onset of severe psychiatric symptoms, especially depression and hopelessness for the future
Is intoxicated
Has a history of previous suicide attempts or deliberate self-harm behavior
In general, the higher the number of risk factors a person has, the higher that individual’s risk would be.
Individuals at moderate risk might include those individuals who have suicidal ideation along with some intent to die, but who have not
initiated any planning for an attempt, have few other current risk factors, and are currently in ongoing psychiatric treatment.
initiated any planning for an attempt, have few other current risk factors, and are currently in ongoing psychiatric treatment.
A lower risk category would include those individuals who have some mild or passive suicidal ideation, but who have no plan or intent to die, have no history of suicide attempts, and have a strong and accessible support system around them in the community.
MANAGEMENT
Having spent time evaluating a suicidal person’s acuity of risk, the clinician can then attempt to determine the appropriate setting for further treatment. The American Psychiatric Association’s 2003 “Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors” reviewed the various factors involved in this decision (4). A summary appears in Table 15.2.
TABLE 15.2 Guidelines for Selecting a Treatment Setting for Patients at Risk for Suicide or Suicidal Behaviosr | ||
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