The Suicidal Patient
A Patient-Centered, Evidence-Based
Diagnostic and Treatment Process
A Presentation for SOMC Medical Education
Kendall L. Stewart, MD, MBA, DFAPA
November 20, 2009
1My
aim is to offer practical insights you can put to practical use in your professional life.
let me know whether I have succeeded on your evaluation form.
2Please
Why is this important?
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One percent of Americans will die
by suicide.
30,000 people take their own lives
each year in the US.
Suicide is the 8th leading cause of
death in this country.
Our suicide rate has averaged 12.5
per 100,000 for the past century.
Adolescent rates have tripled over
the past 40 years to 13.3 per
100,000 making suicide the 3rd
leading cause of death in this age
group.
8-10 people attempt suicide for
every one who completes it.
More than 12,000 children under 13
try to kill themselves each year.
If you pursue clinical practice, these
people will come to you for help and
your reactions will be second
guessed.
1Consulting
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After learning the material in this
presentation, you will be able to
answer the following questions?
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What are some of the demographic risk
factors for suicide?
What are the most common methods
for committing suicide?
What is the role of mental illness in
suicide?
What medical illnesses are associated
with increased risk?
What is the relationship between
suicide and heredity?
What about antidepressants and
suicide?
How can you assess for suicide risk?
There is no way to predict suicide with
certainty.
Involving a mental health professional
in the assessment process is the usual
way of sharing the professional
liability.1,2
does not entirely relieve the physician of the risk.
once consulted the judge when the local mental health clinic employee disagreed with my assessment
of a man I considered homicidal.
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What are some of the demographic
risk factors for suicide?
• Age
– Caucasians aged 75-84
suicide 2 times more than
those aged 15-24
– Rates in African
Americans highest in
males aged 25-34
• Race
– Whites complete suicide
2 times more often than
blacks or Hispanics
– American Indians and
Alaskan Natives suicide
1.7 times as often as
whites
1Don’t
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• Sex
– M:F ratio 3:1 to 4:1
– Women make up to 70%
of attempts
– Attempt : Success is
23:11,2
• Marital status
– Divorced or widowed >
single > married
– Among women, the more
children, the lower the
rate
fall into the trap of assuming that these patients are “not serious.”
saw a young woman who took an overdose of ASA to “numb myself up to jump in front of a car.”
What are the most common methods
for suicide?
• Men
1People
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fe
m
al
es
es
Bl
ac
k
fe
m
al
es
te
m
al
ac
k
Bl
on drugs may not realize or remember that they tried to kill themselves.
interviewed a woman who was blacked out when she shot herself with a handgun.
W
hi
al
es
m
te
Drug ingestion1,2
Firearms
Gasses or vapors
Hanging
W
hi
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20
18
16
14
12
10
8
6
4
2
0
so
ns
• Women
Suicide Deaths per
100,000
lp
er
Firearms
Hanging
Gasses or vapors
Drug ingestion
Al
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What is the role of mental illness in
suicide?
• 95% suffer from mental
illness at the time of
death
• Up to 70% are
depressed1,2
• Degree of hopelessness
is predictive
• The six months after
hospital discharge is a
high risk period
1Suicide
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• Major depression (15%)
• Bipolar disorder (1015%)
• Schizophrenia (10%)
• Alcohol dependence
(2%)
• Borderline personality
(4-9.5%)
• Antisocial personality
(5%)
is a selfish act; their pain blinds them to the impact this will have on others.
treated a man who refused to take antidepressants. I interviewed his wife and children afterwards.
What medical illnesses are associated
with increased risk?
• AIDS (Up to 36
times)
• GI cancers1,2
• Head injury
• Epilepsy (5 times)
• Temporal lobe
epilepsy (25 times)
• Peptic ulcer disease
• Spinal cord injury
1Your
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Multiple sclerosis
Porphyria
Delirium tremens
Cushing’s disease
Hemodialysis (5
times)
• Huntington’s chorea
• Klinefelter’s
syndrome
glib answers will diminish with age.
was consulted on a patient with inoperable cancer who wanted to spare his family.
What about suicide and heredity?
• Relationship is not entirely clear
• Incidence 4% in biologic relatives of adoptees who
suicide but only 1% in adoptive relatives and in
biologic relatives of non suicidal matched controls
• Monozygotic twins 6 times greater concordance for
suicide than in dizygotic twins
• Difference may represent heritability of mental
illness
• Suicidal persons may copy behavior of a loved one
• Personally knowing a suicide victim is a risk
factor1
1Remember
Stewart’s “Aircraft Carrier Landing Theory” of impulse control.
What about antidepressants and
suicide?
• About 50% of depressed persons feel
suicidal, so some persons on
antidepressants will suicide.
• Fluoxetine and other SSRIs do not
increase suicide but protect against it.1,2
• There are new warnings about using
these drugs in children and adolescents.
• Lithium is the most effective anti-suicide
drug.
• Lithium and the older antidepressants
are the most commonly used drugs in
fatal overdoses.
1A
patient threatened to sue me over fluoxetine (Prozac)
way you manage such things is different in a small town.
2The
What are some of the essential steps in
the evaluation of a suicidal patient?
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Answer the question, “Why now?”
Careful history
Mental Status Examination
Accurate diagnosis1
Evaluate social support
Develop a plan
Arrange for follow up
once evaluated a “suicidal” patient who was obsessed with suicide.
How do suicide risk factors rank?
1. Age (45 and older)
2. Alcohol dependence
3. Irritation, rage,
violence
4. Prior suicidal
behavior
5. Male
6. Unwilling to accept
help
7. Longer than usual
duration of depression
8. Prior inpatient
psychiatric treatment
9. Recent loss or
separation
10. Depression
11. Loss of physical
health
12. Unemployed or
retired
13. Single, widowed or
divorced
What acronym will help you assess
suicide risk?
Sad
Age
Depression
Previous attempts
Ethanol abuse
Rational thinking loss (psychosis)
Social supports lacking1,2
Organized plan
No spouse
Sickness
1The
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lack of social support can be startling.
once called the mother of a patient who said she had just be raped.
The Suicidal Patient
A Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process
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Introduce yourself using AIDET1.
Sit down.
Make me comfortable by asking some
routine demographic questions.
Ask me to list all of problems and
concerns.
Using my problem list as a guide, ask me
clarifying questions about my current
illness(es).
Ask me directly about suicide and
homicide.
Using evidence-based diagnostic criteria,
make accurate preliminary diagnoses.
Ask about my past psychiatric history.
Ask about my family and social histories.
Clarify my pertinent medical history.
Perform an appropriate mental status
examination.
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Review my laboratory data and other
available records.
Tell me what diagnoses you have
made.
Carefully assess my suicidal and
homicidal risk.
Outline your recommended treatment
plan while making sure that I
understand.
If you believe I am at risk, discuss my
options without threatening me.
Acknowledge that I am ultimately the
boss.
Explain the transient nature of most
suicidal and homicidal impulses.
Explain that you will make your best
recommendation, but that the
disposition of my case may be up to
the court.
Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment.
Explain what is going to happen next. Thank your patients for the opportunity to serve them.
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Where can you learn more?
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American Psychiatric Association, Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition, Text Revision, 2000
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical
Psychiatry, Third Edition, 20081
Flaherty, AH, and Rost, NS, The Massachusetts Handbook of
Neurology, April 20072
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry
Clerkship, Second Edition, March 2005
Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and
Review, Twelfth Edition, March 20093
Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the
Brain, January 2008
Median, John, Brain Rules: 12 Principles for Surviving and Thriving
at Home, Work and School, February 2008
Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous
Patients,” 2000
Where can you find evidence-based
information about mental disorders?1
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1Please
Explore the site maintained by the organization where evidence-based
medicine began at McMaster University,
http://hsl.mcmaster.ca/resources/ebpractice.htm.
Sign up for the Medscape Best Evidence Newsletters in the specialties
of your choice at http://www.medscape.com/psychiatry.
Subscribe to Evidence-Based Mental Health at http://ebmh.bmj.com/.
Search a database at the National Registry of Evidence-Based Programs
and Practices maintained by the Substance Abuse and Mental Health
Services Administration at http://ebmh.bmj.com/.
Explore a limited but useful database of mental health practices that have
been "blessed" as evidence-based by various academic, administrative and
advocacy groups collected by the Iowa Consortium for Mental Health at
http://www.medicine.uiowa.edu/ICMH/evidence/.
visit www.KendallLStewartMD.com to download related White Papers and presentations.
Are there other questions?
Jeffrey Hill, DO
OUCOM 1987
www.somc.org
Justin Greenlee, DO
OUCOM 2004
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