4. Suicidal behavior

Question 1

The single strongest predictive factor of future suicidal behavior is what? (1)

Answer 1

previous suicidal behavior and attempts.

Question 2

Describe Progression of suicidal behavior

Answer 2

suicidal ideation (thought) → plan (consideration) → intent (action)

Question 3

True or False

Asking about suicide does not initiate suicidal thoughts or actions.

Answer 3

True

Question 4

What is the difference between:

• Suicidal ideation
• Plan
• Intent

Answer 4

• Suicidal ideation is the thought of ending one’s life by suicide.
• Plan is how the patient considers ending his or her life by suicide.
  
  • For example, hanging, jumping off a bridge, etc.
• Intent refers to how committed the patient is in acting on his or her suicidal thoughts and plans.
  
  • For example, the patient has had thoughts of committing suicide with a plan to hang himself or herself, but has little intent to act on these thoughts because he or she does not want to leave his or her loved ones behind.

Question 5

Name: The DDx for suicide ideation (11)

Answer 5

• Psychiatric disorder
  
  • Mood disorders: depression and bipolar
  • Psychotic disorders: schizophrenia (especially with delusions, paranoia, command hallucinations, loss of rational thinking, and disorganized behavior)
  • Substance use disorder: especially with substances that lead to more impulsivity (e.g., alcohol use disorder)
  • Personality disorders: borderline and antisocial show increased suicidal behaviors
  • Anxiety disorders (more common with panic disorder) especially in panic disorder
  • Delirium: altered level of consciousness, which can lead to increase in suicidal behavior
• Psychosocial stressors
  
  • Adverse childhood experience (trauma, emotional/physical/sexual abuse, etc.)
  • Change in marital status (divorced, widowed, break up, etc.)
  • Change in employment (unemployed, loss of skill set, laid off, etc.)
  • Lacking social support (single, no friends, no family, etc.)
• Other
  
  • Chronic medical conditions (cystic fibrosis, cancer, cirrhosis, etc.)

Question 6

Name ACUTE risk factors of suicide

Answer 6

Question 7

Name CHRONIC risk factors of suicide

Answer 7

Question 8

Decide HX of suicide (9)

Answer 8

• Asking about suicide will not initiate suicidal thoughts or actions.
• Screen for a psychiatric disorder (depression, anxiety, psychosis, substance abuse, PD)
• Screen for acute and chronic psychosocial stressors (i.e., loss of a family member, financial difficulties, etc.)
• Past suicide attempts and family history of suicide
• Screen for medical causes such as delirium
• Suicidal thoughts
  
  • Ask about frequency, intensity, and duration of thoughts
  • How does the patient control these thoughts?
• Suicidal plan
  
  • Has a plan been formulated? Has a time and date been set?
  • Does the patient have the means of following through on his or her plans? (i.e., patient has purchased a rope to hang himself or herself)
  • What preparations have been made?
• Suicidal intent
• How committed is the person to carrying out his plan?

Question 9

Describe General observations and physical exam: Suicide (6)

Answer 9

• Mental status examination: poor eye contact/psychomotor retardation, agitation (fidgeting, moving about, hand-wringing, nail biting, hair pulling, lip biting), dis- tress, restlessness/depressed mood/flat, restricted affect/suicidal or homicidal ide- ation, plan, and intent. In addition, look for signs of psychosis
• Examine vital signs
• Pupils, and skin for previous suicide attempts (e.g., cutting)
• Stigmata of drug and/or alcohol use
• Thyroid gland
• Weight loss

Question 10

Describe investigations: Suicide (14)

Answer 10

• Blood work =
  
  • CBC
  • electrolytes
  • BUN
  • creatinine
  • fasting blood glucose
  • liver profiles
  • thyroid profiles (TSH)
  • toxicology/drug screen (alcohol, cannabis, opioid, amphetamine/stimulant or cocaine withdrawal or intoxication)
• Urinalysis, urine drug screen
• Additional screening:
  
  • neurologic consultation
  • CXR
  • ECG
  • CT scan
  • EEG as indicated

Question 11

Describe Management of LOW suicidal risk (6)

Answer 11

• Reinforce importance of talking
• Going to ER when needed
• Calling crisis line
• Staying with a supportive person
• Availability and back up
• Instil hope!

Question 12

Describe Management of INTERMEDIATE suicidal risk (5)

Answer 12

• Low-risk interventions
• Increase frequency of contact
• Involve social supports/family
• Avoid alcohol or other triggers
• Consider voluntary hospitalization

Question 13

Describe the difference between Hospitalization/Certification/Observation (3)

Answer 13

• Hospitalization: urgent hospitalization should be considered if the patient is at imminent risk of self-harm.
• Certification: Mental Health Act Forms should be considered if the patient is not suitable as a voluntary patient (note: these differ between each province).
• Observation: frequent observation by nursing staff should be considered if the patient is at imminent risk of self-harm.

Question 14

When to access capacity of suicidal patients? (2)

Answer 14

• Assess patient’s capacity to make decisions for himself or herself if patient re- fuses treatment.
• If a patient wishes to leave hospital and is voluntary, you should assess the need to make that patient’s status involuntary under the provincial Mental Health Act.

Question 15

Describe tx: Suicidal behavior (2)

Answer 15

• Once safety has been addressed, treat the underlying disorders including general medical conditions (GMCs) or other psychiatric disorders with depression being the most common.
  
  • Biologic medications
    
    • Antidepressants
    • Antipsychotics (typical, atypical)
  • Psychological (requiring insight into disorders): psychotherapy, rehabilitation programs, and/or detoxification programs
  • Social: support group, community resources, family involvement
• Important: medications can only be for emergency purposes unless the patient provides informed consent. For example, you do not need consent to treat acute agitation. You do need consent from the patient to use medications to treat any underlying illness (i.e., depression, schizophrenia, etc.).

Question 16

Describe: Euthanasia (4)

Answer 16

• On 6 February 2015, the Supreme Court of Canada unanimously ruled in Carter v Canada (AG) that Canadian adults who are mentally competent and suffering intolerably and permanently have the right to a doctor’s help in dying. The court, however, suspended its ruling for 12 mo to give the government an opportunity to write legislation and draft new laws and policies around assisted dying (Carter v. Canada [At- torney General], 2015 SCC 5. http:// scc-csc.lexum.com/scc-csc/scc-csc/en/ item/14637/index.do)
• When faced with these issues, physicians should reassure the patients that they will not be abandoned and that continuous care will be provided indefinitely.
• Psychiatric referral should be considered in these types of cases as these patients are more likely to be de- pressed than having unbearable pain.
• A clear distinction must be made between terminating life-sustaining treatment(s), which is legal in Canada under special circumstances.