Suicide Risk Evaluation

Case Presentation and Clinical Discussion

Dr. Muneeb Shahid,
Registrar Emergency Department
South Tipperary Hospital, Clonmel
 What We Will Know
Clinical Case
Section 12 of Child Protection Act
Basic Description and Etiology
Diagnostic Signs and Symptoms
Essential Workup
Diagnostics
Differentials
Treatment
Disposition
Pearls and Pitfalls
 The Casebook
A 16 year Old girl, who wanted to be addressed
as a boy; brought in by the Gardai, under section
12 of the Child Protection Act.
On inquiring the patient, she reported to have
not had any issues at all and that she was forced
to stay here when nothing was wrong.
The Garda Officer who brought her along
reported her to have had a quarrel with her
mother, where the patient had hit her mother.
Later that evening, the patient had threatened to
kill her mother and her 09 year old brother in a
text message to one of her friends; and commit
suicide.
 The patient didnt want to indulge in any talk
about the event earlier that evening initially;
she was ok to talk about everything else that
was brought up in our conversation.
The patients mother called the Gardai and
requested them to take the girl away as she
doesnt want any more problems from her.
 Examination
Vitals Stable
CNS No Gross Neurological Deficit.
CVS/Chest Clear. NAD
Abdomen Clear. NAD
Local Self inflicted abrasions over left
forearm.
 Past History
Total Hip Replacements x 2, SUFE
Previous Attempts at suicide
Medication
None
Allergies
NKDA
Smoking/Alcohol
Denied
 Differentials
Behavioral Problems
Gender Dysphoria/Gender Identity Disorder
Suicide Ideation
Risk to Family/People around
 Investigations
IV Access
Blood Work up FBC, FBP, Coags.
Toxicology Screen
ECG
CXR
 Intervention/Treatment
Abrasions Cleaned and Dressing done.
 Patient Disposition
Patient was referred to Psychiatry Team for
suicide risk evaluation and later to medical
team for admission under child protection act,
under section 12.
 Section 12 of the Child Protection Act

Suicide Risk Evaluation

 Section 12 of Child Protection Act
(1) Where a member of the Garda Sochna has
reasonable grounds for believing that
(a) there is an immediate and serious risk to the health or
welfare of a child.
(b) it would not be sufficient for the protection of the
child from such immediate and serious risk to await the
making of an application for an emergency care order
by a health board under section 13.
The member, accompanied by such other persons as
may be necessary, may without warrant, enter any
house or other place and remove the child to safety.
(2) The provisions of subsection (1) are without
prejudice to any other powers exercisable by a
member of the Garda Sochna.
 (3) Where a child is removed by a member of the
Garda Sochna in accordance with subsection (1), the
child shall as soon as possible be delivered up to the
custody of the health board for the area in which the
child is for the time being.
(4) Where a child is delivered up to the custody of a
health board in accordance with subsection (3), the
health board shall, unless it returns the child to the
parent having custody of him or a person acting in loco
parentis, make application for an emergency care order
at the next sitting of the District Court held in the same
district court district or, in the event that the next such
sitting is not due to be held within three days of the
date on which the child is delivered up to the custody
of the health board, at a sitting of the District Court,
which has been specially arranged under section 13(4),
held within the said three days, and it shall be lawful
for the health board to retain custody of the child
pending the hearing of that application.
Suicide Risk Evaluation
 Basic Description and Etiology
Then intentional taking of ones own life
Suicidal Ideation:
Passive: A conscious desire not to live
Active: Intention to die with or without a plan
Parasuicidal Behaviour: Self injury not
intended to cause death (e.g., Superficial
cutting, cigarette burns, head banging)
Reckless Behavior: Not taking prescribed
medications, taking too much or running into
traffic.
 Risk to Recue Ratio Lethality of plan
compared with likelihood of rescue:
High risk to rescue ratio indicates increased
severity of attempt.
Occult Presentation:
Many individuals at risk for suicidal behavior seek
care in the ED for non behavioral complaints
 Etiology
36,891 suicides in the US (CDC 2009)
12 -25 attempts per every completed suicide
25.4 per 100,000 males
7.4 per 100,000 females
11.1 per 100,000 general population
2 peak age groups
15-24 years (3rd leading cause for mortality)
>60 years (incidence increasing with age)
 Risk Factors for Suicide Behavior
Depression
Alcohol or drug abuse
History of physical or sexual abuse
Unemployment
Incarceration
History of Head injury or neurologic disorder
Firearms in the home
Cigarette Smoking
Positive Family Hx
Psychiatric or medical Comorbidities
 Gender
Women 3 x more likely to attempt suicide
Men 3 x more likely to complete suicide
Psychological
Impulsivity/Aggression
Depression/Anxiety/Hopelessness
Self Consciousness/social disengagement
Poor problem- solving abilities
Lack of social supports
Widowed/Divorced/Separated/Recent loss of
relationship/Anniversary of loss
 Environmental
Rural Areas:
Access to firearms
Poverty
Unemployment
Risk Factors for Completed Suicide
Male
Age >60 years
White Race
Living Alone
Unemployment/poverty
Past suicide attempt
 Methods Used
Firearms
Overdose
Hanging
Suffocation
 Populations at Highest Risk for
Completing Suicide
>90% of patients who commit suicide have a
psychiatric diagnosis
Depression
Anxiety and panic disorder
Alcohol or drug intoxication
Schizophrenia
Adolescents
 Others at Risk for Completing Suicide
Recent discharge from psychiatric facility
History of suicidal ideation or attempt
Serious physical illness present in up to 70% of
all attempts.
History of incarceration
Physicians
Victims of violence/abuse
 Interventions that Lower Risk
Patients with mood disorders (major
depression and bipolar disorder treated with
lithium)
Patient with major depression treated with
ECT
Patients with schizophrenia treated with
clozapine
 Protective Factors
Strong social supports
Family cohesion
Peer group affiliation
Good coping and problem solving skills
Positive values and beliefs
Ability to seek and access help
Diagnosis
 Signs and Symptoms
Depressed mood
Verbalization of suicidal ideation with or
without plan
Hopelessness/Helplessness
Anger/Aggression
Impulsivity
Psychotic Symptoms (i.e paranoia, command
auditory hallucinations)
 History
Obtain for risk assessment:
Asking about suicide does not increase risk for
attempt
Degree of suicidal ideation
Plan immediate risk of self injury?
Means available to complete plan
Activity towards initiating plan
Patients expectations of lethality of plan
Intent: Reasons, goal
Risk to rescue ratio
Plan or intent to harm others
 Presence of acute precipitants
Recent losses/Loss of social supports
Risk factors
History of past suicide attempts
Psychiatric Review of Symptoms: Depression,
psychosis, panic/anxiety
Chronic Medical illness
Alcohol/Drug abuse
Serial assessment of mental status, consistency of
responses
Factors preventing suicide
 Physical Exam
As needed to address acute medical issues
Look for evidence of injuries and signs of self
neglect
 Scoring Systems
Modified SAD PERSONS Score
Sex: Male 1 point
Age <19 or >45 years 1 point
Depression or hopelessness 2 points
Previous attempts or psychiatric care 1 point
Excessive Alcohol or drug use 1 point
Rational thinking loss 2 points
Separated/Divorced/Widowed 1 point
Organized or serious attempt 2 points
No social supports 1 point
Stated future intent 2 points
Data suggests that patints with a score of < 5 can
safely be managed as an outpatient
 Essential Workup
Collateral information from outpatient care
givers, family, friends
Safety plan
Would the patient immediately seek help if suicidal
ideation recurred?
Elimination of means of suicide
Access to other means of suicide
Support and Supervision in the outpatient setting
Prompt outpatiendt follow up with psychiatric therapy
Patient investment in not attempting suicide
Identifying reasons for living
Safety contracts are no guarantee that individuals will
not attempt suicide
Diagnostic Tests and Interpretation
Lab
Blood alcohol level
Serum toxicology screen
Urine Drug screen
Carbon monoxide
Imaging
Not routinely indicated
 Differential Diagnosis
Normal despondency
Bereavement
Adjustment disorder with depressed mood
Major depressive disorder
Bipolar disorder
Organic mental disorder
Schizophrenia
Panic and anxiety disorders
Alcohol and drug abuse
Borderline personality disorder
Antisocial personality disorder
Accidental death
Attempted Homicide
 Paediatric Considerations
A leading cause among young people
More than 4,000 adolescents commit suicide
every year in US
Less evidence available to link suicide in youth to
overt psychiatric illness
Early Warning Signs
Progressive declining schoolwork
Multiple physical complaints
Substance abuse
Disrupted family relations
Social withdrawal
Anhedonia
 Stresses
Prior attempts
Family disruption
History fo psychiatric disorder
Depression
Disciplinary crisis
Broken Romance
School difficulties
Bereavement
Rejection
History of physical or sexual abuse
 Geriatric Considerations
Suicide rates highest in >65 years
Completed suicide: 83% men
Risk factors: Divorced, widowed, male, social
isolation
Tend to use more lethal methods
Lower ratio of attempts to completion
 Treatment
Pre Hospital
For potentially dangerous patient who refuses
transport to treatment facility; involve police and
impose restraint.
Risk to medics on the scene in case of firearms or
other weapons.
Know state and local laws, availability of mobile crisis
units and when to involve the police
Initial Stabilization/Therapy
Prevent ability to elope
Ensure patient safety
Provide safe environment
Appropriate supervision
 ED Treatment/Procedures
Confer with patients outpatient therapist or
physician if possible
Voluntary admission to psychiatric facility
Involuntary admission if patient refuses voluntary
For involuntary psychiatric admission, patient
must have psychiatric disorder and 1 of the
following
Risk for danger to self
Risk for danger to others
Inability to care for self
 Medication
Treat the underlying psychiatric disorder.
 Disposition
Admission Criteria
If patient endorses suicidal ideation with plan and
intent, admission may be needed for safety.
If impulsivity, anger or aggression, hinder abilityto
control behavior
Discharge criteria
Patient has no suicidal ideation.
Patient agrees to return to ED immediately or seek
psychiatric help if suicidal ideation recurs.
Patient has passive suicidal ideation without planor
intent
Patient has good support network or placement in
appropriate crisis housing
 Appropriate Outpatient psychiatric follow up is
ensured
In some cases, patients who express suicidal
ideation while intoxicated may be discharged if no
longer suicidal once they are sober
Some patients with borderline personality
disorder and chronic suicidal ideation are
discharged after careful psychiatric evaluation in
consultation with long term outpatient caregivers.
 Pearls and Pitfalls
A careful history will identify risk factors for
suicide.
Access collateral sources of information about
patients recent thoughts and behavior
Maintain patient safety during evaluation
Hospital admission may be required if patient
endorses suicidal ideation and plan.