ASSESMENT AND MANAGEMENT OF SUICIDAL PATIENT.pptx

Suicide assesment

1. ASSESMENT AND MANAGEMENT OF SUICIDAL PATIENT DR. ARLINA NURUDDIN PAKAR PSIKIATRI HOSPITAL KAJANG

2. OVERVIEW Introduction Definition Why people commit suicide? Rationale for prevention Risk assessment Risk management

3. INTRODUCTION Suicide is complex and is influenced by innumerable underlying factors. Globally, suicide is believed to account for an average of 10-15 deaths for every 100 000 person each year (WHO 2002) Suicide rates have increased by 60 per cent in the past 45 years, with an estimated seven people attempting suicide daily. (Malaysian Psychiatric Association)

4. SUICIDE CASES IN 2008 Feb 18 : A cancer victim threatens to stab himself at the MCA Public Services and Complaints Department but department head Datuk Michael Chong and a security guard manage to coax the 64-year-old into surrendering his knife. Feb 19 : A woman, in her 20s, stabs herself in the abdomen several times in a toilet cubicle at a shopping complex in Bukit Bintang . Workers force open the door and she is sent to hospital. April 9 : A 24-year-old man leaps from a restaurant at Genting Highlands but is saved by the Genting Skyway safety net. He spends six hours on the ledge of the net before being helped down. July 14 : A woman leaps from the 12th floor of an apartment building in Kuala Lumpur but her fall is broken by a glass walkway. She suffers a broken hip and legs. Oct 7 : A 36-year-old businessman attempts suicide by drinking weedkiller after he allegedly strangled his ex-girlfriend who had told him she was engaged to another man. www.malaysianbar.org.my/news_features/police_consider_using_the _ law_on suicide.html

5. National Suicide Registry Malaysia 2008 ‐2009 Nationwide registration system in Ministry of Health hospitals 2008 2009 N 290 328 Rate (per 100,000) 1.05 1.18 Previous attempts 16.2% 15.5% Medical illness 19.3% 20.4% Mental illness 18% 22% Life events 34% 41.2%

6. Definition of Suicide In ICD‐10: Suicide is categorized in Chapter XX (External causes of Morbidity and Mortality X60‐X84); “Intentional Self‐harm” Description of death Cause of Death – classification of diseases; a medical opinion Manner of death – natural, accident, suicide, homicide, (NASH); pending investigation or undetermined

7. ICD-10 CHAPTER XX : EXTERNAL CAUSES X60‐X69 ISP by and exposure to …. X67 ISP by and exposure to other gases and vapours (e.g. carbon monoxide) X68 ISP by and exposure to pesticides X70 ISH by hanging, strangulation and suffocation X71 ISH by drowning and submersion X72 ‐74 ISH by handgun discharge/ rifle, shotgun & larger firearm / unspecified X75 ISH by explosive material X76 ISH by smoke, fire and flames X77 ISH by steam, hot vapors and hot objects X78 ISH by sharp object X79 ISH by blunt object X81 X 82 X 83 X 84 ISH by jumping or lying before moving object ISH by crashing of motor vehicle ISH by other specific means ISH by unspecified means

8. A Basic Model of Suicidal Behaviour Suicide vs. Non‐suicidal self‐injury A learned method of problem solving to escape or avoid intense negative emotions Not all people with suicidal behaviour are mentally ill;and not all mentally ill persons are suicidal Suicidal behaviour originates from - extreme emotional pain - tolerance for pain is exhausted - strategies appear to not be working

9. A MODEL OF SUICIDAL BEHAVIOUR JJ Mann. Toward a Clinical Model of Suicidal Behaviour in Psychiatric Patients. Am J Psychiatry.1999; 156(2):181-189 HOPELESSNESS PERCEPTION OF DEPRESSION SUICIDAL IDEATION SUICIDAL PLANNING IMPULSIVITY SUICIDAL ACT AGGRESSIVITY LOW SEROTONERGIC ACTIVITY SMOKING SUBSTANCE ABUSE HEAD INJURY DEPRESSION / PSYCHOSIS LIFE EVENTS OBJECTIVE STATE SUBJECTIVE STATE AND TRAITS

10. Neuroscience SEROTONIN THEORY Post‐mortem studies on the brains of suicide victims (e.g.Asberg, 1990). Measured: Post‐synaptic serotonin 5‐HT & metabolite 5‐HIAA Findings: Decreases in CSF serotonin is associated with suicide, homicide, and violent Role of pre‐frontal cortex Mann (1998) posits that ventral pre‐frontal cortex is centrally implicated in suicidal behaviors. Mann has further proposed a stress‐diathesis model for suicide

11. RATIONALE FOR PREVENTION

12. The Role of Medical Illness Medical illness is associated with increased risk of suicide. Mediating factors: - pain - loss of function - disfigurement - psychological distress 50‐75% had seen a physician in the 6 months before death Strong evidence of effectiveness for suicide prevention exists for: Training for medical practitioners to increase detection Restriction of methods e.g.pesticide availability Gatekeeper education

13. Literature indicates that a substantial fraction of in‐hospital suicides involve medical/surgical patients Profile: received a life‐threatening diagnosis and who appear particularly agitated, despondent, or withdrawn, patients who have severe, intractable pain Suicide in General Hospitals Bostwick JM, Rackley SJ. Completed suicide in medical/surgical patients: who is at risk? Current Psychiatry Rep 2007;9:242–246. [ PubMed : 17521522]

14. Suicide in General Hospitals Rare yet devastating suicides Different characteristics from suicides in psychiatric inpatients Emphasis – suicides are almost invariably impulsive : Motoric agitation Readily available lethal means Traditional risk factors are typically absent : past history of psychiatric illness, substance abuse, or suicidality current depressive episode and known suicidality Close surveillance of agitated patients, with interventions to calm them and secure their surroundings, will assure safety and save lives Bostwick JM, Rackley SJ. Completed suicide in medical/surgical patients: who is at risk? Current Psychiatry Rep 2007;9:242–246. [ PubMed : 17521522]

15. BARRIERS TO DETECTION AND PREVENTION OF SUICIDE Stigma and secrecy Failure to seek help Lack of suicide knowledge and awareness among health professionals Suicide is a rare event

16. STRATEGIES FOR SUICIDE PREVENTION

17. PRIMARY PREVENTION Breaking Bad News The manner will determine how soon afterwards and how successfully a person will grieve { Vandekieft , 2001} Training in communication skills and techniques to facilitate breaking bad news ‐ improve patient satisfaction and physician comfort Essential qualities: being truthful, sensitive, open and supportive {Reiget, 2001}

18. Limit Access

19. Increase awareness Improving coping & life skills Public education programs: - Info on suicide warning signs, how to get help, stress management - Need to be more focused: crisis & suicide prevention centres , school programs - Centres must have good relationship with various gatekeepers & professionals. - National level: launching of the National Suicide Prevention Strategic Action Plan in June 2012

20. SECONDARY PREVENTION Gatekeeper training Who is the gatekeeper? - healthcare, religious officers, police & fire fighters; custodial personnel Training includes: - Judgment and ethics when working with high risks individual - know how to handle the caretaker and organization - know the procedures in handling suicidal attempt victims - know your limitations

21. TERTIARY PREVENTION POST SUICIDE INTERVENTION Based on four principles: Support Counsel Learn Educate

22. Support and Counsel Direct services (such as support and counselling ) to the suicide bereaved Grief response focuses on: - emotions such as guilt and anger, - feelings of rejection, - a sense of stigmatization, - suicidal ideation, and - struggles to find an explanation

23. Learn Mortality review It should be conducted in non-judgmental and supportive manner Recommendations from such reviews should be taken into consideration for policy or service direction

24. Educate protocols in workplace to ensure appropriate multi‐level response to suicide deaths; Media interviews should use the event to focus on general issues and help both public and professionals understand rather than sensationalize

25. TERTIARY PREVENTION Community Coordination and Collaboration Befrienders Klinik Kesihatan Family doctor Friends Hospital School Counsellor Rape crisis centre Psychiatric Facility

26. RESPONSES THAT INDICATE SUICIDAL THOUGHTS AND A CRY FOR HELP Suicide prevention begins by recognizing the warning signs and taking them seriously “I wish I were dead” “ I just can’t take it anymore” “There is no way out”

27. RISK ASSESMENT & RISK MANAGEMENT

28. QUESTIONS TO ASSESS SUICIDE INTENT “ASKING ABOUT SUICIDE WILL NOT MAKE THEM SUICIDAL” I appreciate how difficult this problem must be for you at this time. Some of my patients with similar problems/symptoms have told me that they have thought about ending their life. I wonder if you have had similar thoughts? When did you have these thoughts? How often do you have these thoughts? Do you think that that your situation is hopeless? Do you have a plan to take your life? Have you had similar thoughts before? Have you ever attempted to harm yourself before? Questions to assess for suicidal plan Have you thought of harming yourself? What have you thought of doing? Have you come close to acting on this? Have you made any plan to carry this out? What has stopped you up until now? Suicide Risk Assessment Quick Reference-Suicide Risk Management Committee Hospital Selayang

29. RISK FACTORS FOR SUICIDE Patient demographics Past and current suicidality Psychiatric diagnosis and psychiatric symptoms Individual history:- medical family psychosocial neurobiology Personality strengths and weaknesses

30. SIGNS OF ACUTE SUICIDE RISK Talking about suicide or thoughts of suicide Seeking lethal means to kill oneself Purposeless – no reason for living Anxiety or agitation Insomnia Substance abuse Hopelessness Social withdrawal – from friends / family / society Anger – uncontrolled rage / seeking revenge / partner violence Recklessness – risky acts / unthinking Mood changes – often dramatic

31. OTHER RISK FACTORS Suicide Risk Assessment Quick Reference-Suicide Risk Management Committee Hospital Selayang

32. PROTECTIVE FACTORS Internal protective factors External protective factors Good coping and problem-solving skills Strong perceived social supports/ connection Ability to seek and access help Family cohesion Positive values and beliefs Peer group affiliation Spirituality Children or pets at home Capacity for reality testing Religious prohibition Reasonable frustration tolerance Sense of responsibility to family Hopefulness/ optimism Receiving mental health care Fear of suicide Positive therapeutic relationships Fear social disapproval

33. RISK LEVEL- LOW RISK PATIENTS

34. MODERATE RISK PATIENTS

35. HIGH RISK PATIENTS

36. SAD PERSONS SCALE 1 Factor Points Score S = Sex (male) 1 <2: discharge with outpatient psychiatric evaluation 3-6:hospitalization or at least very close follow-up ≥7: hospitalise A = Age (<19 or >45 years) 1 D = Depression 1 P = Previous suicide attempt 1 E = Ethanol abuse 1 R = Rational thinking loss 1 S = Social supports lacking 1 O = Organised plan 1 N = No spouse / significant other ( A = Availabilty of lethal means) 2 1 S = Sickness (chronic debilitating illness) 1 1. Patterson WM, Dohn HH, Bird J et al. Evaluation of Suicidal Patients : the SAD PERSONS scale. Psychosomatics. 1993;24(4): 343-345, 348-349. 2. Campbell WH. Revised ‘SAD PERSONS’ helps assess suicide risk. The Journal of Family Practice. 2004; 3(3). Pattterson WM,Dohn

37. INDICATION FOR PSYCHIATRY INPATIENT MANAGEMENT After a suicide attempt or aborted suicide attempt if: Patient is psychotic Attempt was violent, near-lethal, or premeditated Precautions were taken to avoid rescue or discovery Persistent plan and/or intent is present Distress is increased or patients regrets surviving Has limited family and/or social support Current impulsive behaviour , severe agitation, poor judgment , or refusal of help is evident. Change in mental status secondary to changes in medical condition B. Presence of suicidal ideation with: Specific plan with high lethality High suicidal intention Severe anxiety and agitation

38. BEFORE DISCHARGING Check that : i . Firearms and lethal medications have been secured or made inaccessible to patient. ii. A supportive person is available and instructed in follow up observation and communication regarding signs of escalating problems or acute risk. iii. A follow-up appointment with a psychiatrist and/or counselor scheduled. iv. Patient understands the conditions that warrant a return to the emergency department . v. Patient has the name and number of local agency that can be called in a crisis such as BEFRIENDERS.org 03-7956 8144/8145 or Talian An-Nur: 15999. Document: • Observations • Mental status • Level of risk • Rationale for all judgments and decisions to hospitalize or discharge • Interventions based on level of risk • Informed consent and patient’s compliance with recommended interventions • Attempts to contact significant others and current and past

39. FLOW CHART FOR SUICIDE RISK ASSESSMENT & TRIAGE Adapted from Suicide Risk: A Guide for ED Evaluation and Triage (available from the Suicide Prevention Resource Centre) and Guideline on Suicide Risk Management in Hospital Selayang

40. CASE SCENARIO 1 21 year old male, single, account student, lives with family in Sg . Long Admitted to medical for ingestion of Clorox after an argument with his girlfriend & broke up with her prior to the incident. First attempt, impulsive, told family after he ingested the Clorox. No history of DSH before, no history of psychiatric illness in the past. After the incident, regretted his actions. Remorseful. Mood was low but no more suicidal thoughts. Has good family support. What is his suicidal risk?

41. CASE SCENARIO 2 46 year old Chinese lady, widow, secretary, lives alone in Cheras . Brought in by neighbour ,unconscious after ingesting 70 tablets of tricyclic antidepressant. 4 attempts in the past, recent attempt 3 months ago –slashed her left wrist. On further questioning; Diagnosed with depression 2 years ago but not compliant to medication. Has on-going conflict with boyfriend re: marriage Estranged from her family In debt with loan shark Has friends but no one who can monitor her Planned attempt, suicidal intent, alone, disappointed that she was still alive

42. In the ward, Asking for early discharge Becomes agitated & tried to abscond when told that she still requires observation Still expresses suicidal thoughts such as - asking the doctor to kill her, - making statements such as “I don’t want my life” No family/friends can be reached Making poor decisions such as wanting to confront boyfriend at his workplace Made promises to come back within a few hours after she has spoken to her boyfriend Refuses for further treatment & has no insight. What is her suicide risk?

43. CASE SCENARIO 3 Mrs. F is a 23 year-old single waitress who has not been able to obtain steady work She has cut herself wrists with a kitchen knife after an argument with her boyfriend This is the 3 rd episodes of wrist cutting she has experienced in the last 3 months She also has cigarette burn marks on her upper arms She does not have any history of psychiatric disorder She occasionally drink to release her stress She complains about feeling sad but denies hopelessness She does not want to kill herself but does not know what to do WHAT IS HER SUICIDE RISK?

44. CASE SCENARIO 4 Mrs. PCL is a 64 y.o Chinese lady, married with 4 children Was diagnosed to have Ca uterus 4 years ago. Had undergone total hysterectomy ,pelvic radiation treatment and chemotherapy Unfortunately, she developed vaginal stenosis which caused her discomfort and pain. Her pain became worse 2 weeks prior to the admission. She kept on saying that she couldn’t take it anymore.

45. 1 week prior to contact, she informed her daughter the password for her account and said that if anything happened to her, they could withdraw her money. She was left alone at home everytime daughter went to work. Usually her daughter will come back during lunch hour. On the day admission, daughter found her lying on the floor in her room with a deep cut on her wrist and neck surrounded by a pool of blood and multiple sizes of knives on the floor. There was a suicide note saying, ‘I can’t take it anymore. The pain is so unbearable.’

46. In ward, -she was accompanied by her daughters -good family support -daughter planned to hire a maid to look after her -she was referred back to O&G for her vaginal stenosis - she felt regret with her suicide attempt and willing to accept treatment and help from the managing team. What is her suicide risk?

47. CASE SCENARIO 5 Mr. H is a 37 y.o male, who comes to your clinic, and says that he heard voices asks him to kill himself. He claims that the voices are voices from the sky- asking him to kill his wife and himself as ‘they are possessed by a devil’ He goes to your clinic to seek for help WHAT IS HIS SUICIDE RISK?

48. REFERENCES Suicide Risk Assessment Quick Reference-Suicide Risk Management Committee Hospital Selayang Stan Kutcher &Sonia Chehil ; Lundbeck Institute ;Suicide Risk Management –A Manual for Health Professionals

49. Thank You