UBC Objectives: Mental Health, Priority Topic: Crisis, Priority Topic: Depression, & Priority Topic: Suicide

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Recognize, and appropriately respond to, the need for urgent and emergent intervention
• Assess a patient’s suicide risk, homicide risk and judgment
  

Crisis

Key Feature 2: Identify your patient’s personal resources for support (ex: family, friends) as part of your management of patients facing crisis.
Skill: Patient Centered, Clinical Reasoning
Phase: History, Treatment

Key Feature 3: Offer appropriate community resources (ex: counselor) as part of your ongoing management of patients with a crisis.
Skill: Patient Centered, Professionalism
Phase: Treatment

Key Feature 4: Assess suicidality in patients facing crisis.
Skill: Clinical Reasoning
​Phase: Hypothesis generation, Diagnosis

Key Feature 8: Negotiate a follow-up plan with patients facing crisis.
Skill: Clinical Reasoning, Communication
Phase: Treatment, Follow-up

Depression

Key Feature 1a: In a patient with a diagnosis of depression: Assess the patient for the risk of suicide.
Skill: Clinical Reasoning, Selectivity
Phase: History

Key Feature 1b: Decide on appropriate management (i.e., hospitalisation or close follow-up, which will depend, for example, on severity of symptoms, psychotic features, and suicide risk). 
Skill: Clinical Reasoning, Selectivity
Phase: Treatment

Suicide

Key Feature 1: In any patient with mental illness (i.e., not only in depressed patients), actively inquire about suicidal ideation (ex: ideas, thoughts, a specific plan).
Skill: Clinical Reasoning
Phase: History

Key Feature 2: Given a suicidal patient, assess the degree of risk (ex: thoughts, specific plans, access to means) in order to determine an appropriate intervention and follow-up plan (ex: immediate hospitalization, including involuntary admission; outpatient follow-up; referral for counselling).
Skill: Clinical Reasoning, Selectivity
Phase: Diagnosis, Treatment

Key Feature 3: Manage low-risk patients as outpatients, but provide specific instructions for follow-up if suicidal ideation progresses/worsens (ex: return to the emergency department [ED], call a crisis hotline, re-book an appointment).
Skill: Clinical Reasoning
Phase: Treatment, Follow-up

A 19 year old female presented to clinic for a yearly refill of her antidepressant. When I asked her what she takes it for, she said it was for depression and anxiety. She didn't elaborate. I probed further by  asking how her mood has been lately. She said it had been worsening over the past month or so but again was brief in her answer. By around this point I started to clue in to the fact that not only were her answers minimally detailed, she was also slow to speak them (psychomotor retardation). I asked her if she was having thoughts about self-harming or suicide. She responded to say she was having suicidal thoughts. She denied any homicidal ideation. I asked her if she had thought of a plan for committing suicide, and without time to think she answered very matter-of-factly, "Yeah I think about hanging myself. When I was younger I used to think I'd want to drown, but now I think hanging makes the most sense." I asked if she's been thinking about going through with it, and she said, "There are all these deaths that seem to be happening around me, even like celebrities and whatnot, and I think to myself how those people have the courage to do what I haven't been able to. But then I think to myself how that's just a temporary solution to a bigger problem sort of thing." I didn't quite understand what she meant by her last sentence, but I was a little relieved to hear she had a protective thought. Just how at risk was this patient of completing suicide?

In patients who endorse having suicidal thoughts, it's important to clarify 

1. Onset and frequency
2. Active vs passive (thinking about taking an action to commit suicide vs wishing death would happen to them such as wanting to die in an accidental car crash)
3. Organized plan +/- final arrangements (ex: suicide note) and whether they have the means (ex: have rope at home)
4. Intent: "Do you want to end your life?"
5. Past attempts (how, what happened) or practiced attempts
6. Provocative factors
   1. Predisposing factors
      1. Abuse (physical, sexual, verbal, emotional, financial)
      2. Neurological concerns (head trauma, dementia, stroke)
      3. Developmental issues
      4. Legal concerns
   2. Precipitating factors (ex: substance use, relationship distress)
7. Protective factors (coping mechanisms, supports)
8. Ambivalence: "I wonder if there is a part of you that wants to live, given that you came here for help?"

SADPERSONS mnemonic for risk-stratifying patients with suicidal ideation (1 pt for each if present)

1. Sex = male
2. Age < 19 or > 45
3. Depression 
4. Previous attempt or FHx
5. EtOH/substance use
6. Rational thinking loss (poor insight, impaired judgment)
7. Social supports lacking
8. Organized plan
9. No spouse
10. Sickness

• 0-4 = low risk
• 5-6 = medium risk
• 7-10 = high risk

​
According to the SADPERSONS suicidal ideation risk stratification mnemonic, this patient was low risk. Note that depression gives one point on the SADPERSONS scale, which is something important to note as it raises the point that suicidal ideation is not a phenomenon that is unique to patients with depression. According to the UpToDate article, "Suicidal ideation and behaviour in adults," "The psychiatric disorders most commonly associated with suicide include depression, bipolar disorder, alcoholism or other substance abuse, schizophrenia, personality disorders, anxiety disorders including panic disorder, posttraumatic stress disorders, and delirium." This article also notes, "Anxiety disorders more than double the risk of suicide attempts (odds ratio 2.2), and a combination of depression and anxiety greatly increases the risk (odds ratio 17). Symptoms of psychosis (delusions, command auditory hallucinations, paranoia) may increase the risk regardless of the specific diagnosis."

Once you've got a patient in front of you who endorses suicidal ideation, what are your next steps? My approach to a patient that is risk-stratified for suicidal ideation (SI) as either low, medium, or high risk is as follows:

1. Low risk: Develop safety plan patient agrees to that includes:
   1. Setting up a follow-up appointment, preferably within 1 wk or so, ideally with the same primary care provider and a professional counselor
   2. Avoiding triggers including substances
   3. Not harming themselves, and to contact health care worker (or present to Emergency Department) or call crisis line if feelings return or intensify
2. Medium risk: My decision to admit to hospital +/- Form 1 in a medium risk patient depends on:
   1. The degree of social supports present
   2. Whether there is a loss of rational thinking (psychosis)
   3. Whether the patient is likely to encounter any acute SI precipitants (ex: substance use)
3. High risk = Hospitalization +/- Form 1

The 19 year old patient in the office agreed to follow-up in clinic in one week, agreed to avoiding triggers (aka precipitants) for her SI, and agreed to present to the ED or call a suicide crisis line before taking any action if she was having thoughts about completing suicide.

The Canadian Association for Suicide Prevention website has a list of local crisis centres organized by province on their home page. I provide both the CSAP website address and the province-wide crisis line (1-800-SUICIDE) to patients at risk of SI.