Chapter 2: Suicide Risk Assessment and Management

 Suicide outnumbers homicide and the number of suicides is more than twice
death related to HIV/AIDS complications
 Factors influencing suicide
 Life event: marital isolation, parental loss through death before age 11, and
a childhood history of physical and sexual abuse
 Hopelessness: a key variable linking depression to suicidal behavior and a
predictor of completed suicide
 Low self-esteem
 Comorbid conditions: alcohol abuse, substance abuse, cluster B personality
disorders
 Four types of ER presentation related to suicide
 Patients who report suicidal ideation
 Patients who just survived a suicide attempt
 Patients presenting with other, usually somatic complaints but in whom
suicidal thoughts are discovered during a comprehensive evaluation
 Patients who deny suicidal ideation but whose behavior (or family’s report)
suggests suicidal potential or risk
 Foreseeing suicide is difficult: the presence of a suicide note or a specific plan
has not been associated with the seriousness of the current suicide attempt or
the severity of future attempts
 Table 2-1 factors associated with an increased risk of suicide
 History of suicide attempts or threats  strongest single predictor
 Psychiatric disorders
 Psychiatric illness a strong predictor
 >90% suicide attempters and >95% suicide completers have a mental
disorder
 Severity of psychiatric illness associated with suicide risk
 Most commonly associated psychiatric illnesses: depression, bipolar,
alcoholism, SUD, schizophrenia, PD, anxiety disorders, delirium
 Comorbid anxiety disorder doubles the risk of suicide attempts 
Anxiety disorder being an immediate risk factor potentially modifiable
 Depressive disorders: first 3 months after MDE onset & first 5 years
after MDD onset  the highest risk periods for attempted suicide
 Hopeless and impulsivity
 Adverse childhood experiences
 Family history and genetics: having a first-degree relative who committed
suicide increases the risk 6-fold
  Gender: Females attempt 3X more and males die by suicide 4X more (USA)
 Marital: (suicide risk in descending order) those never married > widowed,
separated or divorced > married without children > married with children
 Unemployed and unskilled
 Physical illness: chronic pain, recent surgery, chronic or terminal disease
 History of violence
 Antidepressant use
 Miscellaneous
 access to weapons
 patients living alone or having recently lost a loved one or experienced
a failed relationship within 1 year
 Anniversary of a significant relationship loss
 Social factors as risk factors: intimate-partner problems, a crisis in the
preceding 2 weeks, physical health problems, professional problems,
financial problems
 Protecting factors for suicide
 Family cohesiveness
 Parenthood
 Pregnancy
 Religious affiliation
 Social support
 A tetrad of warning signs
 The wish to die (to end suffering or facilitate a reunion with lost loved
ones)
 The wish to kill (to cause the destruction of others and the patient himself)
 The wish to be killed (a form of reaction formation, ie I don’t hate you; you
hate me)
 The wish to be rescued (a sign of ambivalence; a desire to prove they are
loved and desired)
 Other behavior that is concerning
 Talking of: wanting to die, feeling hopeless, feeling trapped, in unbearable
pain, being a burden, revenge
 Looking for a way to kill oneself
 Increasing alcohol or substance use
 Displaying extreme mood swing
 Acting anxious or agitated
 Suicide Assessment (Table 2-3)
 A thorough psychiatric evaluation
  Psychiatric s/s
 Past suicidal behavior
 Past treatment and treatment relationship
 Familial history of suicide, mental illness, and dysfunction
 Psychosocial situation and the nature of crisis
 Patient’s psychological strengths and vulnerabilities
 Inquiry into suicidal thoughts, plans and behaviors
 Elicit presence or absence of suicidal ideation and plan
 Assess the degree of suicidality (intent and lethality)
 Establish a diagnosis
 Estimate the suicide risk, develop a treatment plan and determine the
appropriate setting
 Provide education
 Monitor the patient’s psychiatric status and response to treatment
 Reassess safety and suicide risk
 Ensure adequate documentation and risk management
 Management
 Primary prevention
 Psychoeducation and training of health care workers
 Diagnosing and treating people with mental disorders
 Addressing SUD
 Reducing access to means of suicide
 Treatment intervention
 Risk reduction through hospitalization
 Imminent suicide risk: intent and means, severity of mental
illness, the presence of psychosis or hopelessness, a lack of
personal resources and older age among men
 Suicidal behavior is on impulse  support for psychiatric holds
 Hospitalization enables observation and thus enables accurate
diagnosis and would help design a more definitive treatment plan
 Voluntary admission should be sought first
 Close monitoring without hospitalization
 Not suitable for those too psychotic, lacking a support structure,
already showing self-injurious or dangerous behavior
 If the patient is to be discharged home, all lethal means should
be removed or secured (e.g., firearms, medications…)
 Involve friends, family, OPD doctors, therapists
 Patient’s reluctance of clinical contact  cause for concern and
 highlight for safety  necessitates hospitalization
 Agreement to contract for safety means little but unwillingness to
contract for safety indicates unsafety in an OPD setting and may
necessitate hospitalization
 Considerations in the management of suicidal patients
 Post-suicidal patients should be seen as very high risk
 Initiate or continue involuntary psychiatric hold
 Initiate or continue 1:1 supervision, even when family
members are present
 Never leave the patient alone
 Maintain visual monitoring at all times (even when going to
the bathroom)
 Remove objects that are dangerous
 Sharp objects: forks, knives or chopsticks. Cut and prepare
the food by the staff if needed
 Long and flexible objects: loose sleeves, telephone cords,
shoelaces…
 Obtain collateral information
 Transfer the patient to the ward on the ground floor if possible
 Provide close follow-up
 Initiate pharmacotherapy if indicated
 Educate the lag between medication initiation and relief of
symptoms, risk of abrupt discontinuation, possible adverse
effects and what to do if there is any
 Secondary prevention
 Identify high-risk patients
 Close follow-up and ongoing prevention of suicide
 Develop a suicide prevention action plan
 Develop a list of reasons why the life is worth living
 Develop in advance, with help from others, and update as
needed
 Be proactive in taking care of oneself and looking after one’s
physical health
 Exercise regularly, maintain a balanced diet, regular sleep-
wake cycle, and avoid mind-altering substances
 Seek help immediately if abusing any substances
 Develop a mental fitness plan
 Meditation, compassion training, self-hypnosis, and
 progressive relaxation
 Beware of triggers and recognize one’s warning signs that signal a
potential suicidal crisis
 Personal situations, thoughts, images, thinking styles, mood
and behavior
 Know one’s limits
 Do not wait until limits are reach to take appropriate action
 Before reaching “point of no return,” walk away from
stressful situations
 Know when to ask for help
 Know when is best to be alone and when to be with others
 Protect oneself
 Make the environment safe and harm-proof: no guns, no
knives, no lethal weapons
 Only keep the medications needed and don’t store them
 Develop a personal list of coping strategies and design a way to
employ them without needing to contact others
 The list is a predetermined set of activities that help take
one’s mind off the problems and prevent suicidal ideation
from escalating
 Activities can be physical or mental: a walk, painting,
drawing, yoga, writing, meditation, music, hypnosis…
 Don’t wait until the limits are reach to implement the coping
skills
 Develop a contact list of reliable external resources
 If the personal support team are not available or helpful,
consider going to ER or local clinics
 Develop a list of available mental health professionals
 Use the resources wisely
 Let the helping resources know what is needed for them to
help
 Share with your support team members:
 Your contact numbers
 A list of warning signs to help them determine if you
are in need
 Your safety plan
 Safety plan should adapt, change and grow
 Review and modify when needed (e.g., changing to a new
 environment…)
 Provision of contact information
 Psychoeducation
 Responsible media reporting
 Chapter 11: Seclusion and Restraint in Emergency Settings
 Terms
 Physical restraints: procedures or devices that are employed to limit a
person’s mobility
 Restraints: consist of trained people taking patients to the floor and
holding them until they are calm
 Therapeutic holds: restraints in the case of children
 Seclusions: temporary, involuntary confinement of a patient in a room or
area from which the person is physically prevented from leaving
 Chemical restraint: an out-of-favor term that has historically referred to the
administration of a medication that is used to control behavior or freedom
of movement but that is not a part of a patient’s daily medication regimen
 Indications
 Seclusion or restraint is to be used only in an emergency situation to
ensure a patient’s physical safety and after less restrictive interventions
have been determined to be ineffective to protect the patient or others
from harm
 Seclusion and restraint are prohibited to be used as a means of coercion,
punishment, discipline, convenience or retaliation by staff
 Seclusion and restraint may be used to prevent serious disruption of the
treatment milieu or damage to property
 Table 11-1
 Patient assessment
 Identifying causes of violence (including differential diagnosis), history of
violent behavior, early warning signs and triggers, relevant trauma history,
pre-existing medical conditions that place individuals at risk of injury of
death
 Choosing seclusion or medical restraint
 Empathy is useful and important
 Figure 11-1 algorithm
 Contraindications to Seclusion and Restraint
 APA: use of seclusion and restraint is relatively contraindicated in patients
with unstable medical conditions, those with delirium or dementia, and
those who are overtly suicidal
 AACAP: use of restraints in children having been sexually abused should be
avoided
 Prone restrain should be avoided in patients with increased abdominal
girth
 Observation
 A staff member should be designated to observe the restrained patient
continually for any sign of physical distress
 Never disregard a patient’s statement that he cannot breathe or explain
away as manipulation
 For the 1st hour the patient should be monitored vis-a-vis and may be
monitored using video and audio equipment
 TJC: patients should be monitored every 15 minutes for vitals, ROM, proper
body alignment, circulation and need for toileting and hydration, and
psychological comfort
 1-hour rule: within 1 hour of the application of a restraint or a patient’s
placement in seclusion, a staff member must conduct a vis-à-vis evaluation
of the patient
 Release from Restraint and Debriefing
 The rationale for the restraint and the criteria for release should be
informed to the patients, and should be re-iterated once the patient
becomes less agitated
 Before release, the patient should be oriented to the environment and
should have ceased verbally threatening the staff
 CMS: the facility is required to conduct an incident debriefing with staff and
patient within 24 hours of the release  to determine how to avoid a
similar event
 Death and Other Adverse Effects
 Common causes of death during restraint: asphyxia (most common),
aspiration, blunt trauma to the chest, malignant cardiac rhythm
disturbances secondary to massive catecholamine rush, thrombosis,
rhabdomyolysis, excited delirium with overwhelming metabolic acidosis,
and pulmonary embolism
 Documentation
 Include: nature of the emergency or the reason that restraint was
considered necessary, the measures enacted to de-escalate the patient to
prevent the need for restraint, antecedents to the violent behavior, the
type of restraint employed, the staff members who were involved, the
length of time of the restraint and the patient’s condition both during and
after the restraint
 Legal Considerations