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