Evaluating and managing suicidal outpatients has long made clinicians fearful. Now, as managed and capitated care continues limiting hospitalizations and outpatient treatments, clinicians have become even more anxious about treating patients who are suicidal. Fortunately, a few basic principals of patient management greatly facilitate treating self-destructive outpatients and preventing their suicides.
It is not always possible to prevent suicide, but in most instances the impulse can be significantly reduced when clinicians, patients and patients' families understand the factors that impact suicide risk. Hopelessness, more than depression, predicts suicide. Patients who suicide do not want to die; they simply want to end their pain. When they can see another way to end the pain, they use it. People kill themselves when they feel there is no alternate way to ameliorate their anguish. Many of these deaths could be avoided if these individuals had received aggressive treatment, psychopharmacological therapy, and had their social supports rallied to assist them.
The majority of suicides had psychiatric diagnoses that, if identified and treated, would have diminished the risk of suicide. When initially seen, all patients should be asked if they have ever considered suicide, if they are currently suicidal, and if they have ever made an attempt. Developing a plan for managing suicidal impulses begins with the therapist's first encounter with patient, or arises during the course of treatment when patients fail to respond to diagnostic-specific treatments.
Risk Assessment
Approximately 60 percent of all suicides suffer major depression, and 15 percent of the patients with major depression die by suicide. Twenty percent of the people who suicide suffer disorders with a strong affective component, such as dysthymic disorder, post traumatic stress disorder, or schizoaffective disorder. Of the remaining 20 percent who die, a few are so-called "rational" suicides. It is notable that over 10 percent of those stating they want to suicide because they have an incurable illness do not have the illness; instead they have a monosymptomatic delusional disorder with the false belief that they have a fatal illness.
Study after study confirms that most individuals who commit suicide suffer from depression. Such affectively ill patients, as a group, are especially creative as artists, politicians, and entrepreneurs; their loss to suicide represents not only a loss of life but society's disproportional loss of their talents. Individuals who are gay especially adolescents or have anxiety disorders or learning disorders are at increased risk. An unrecognized learning disorder such as attention deficit hyperactivity disorder (ADHD) can lead to poor school performance despite superior intelligence. A child whose best efforts fail first becomes demoralized, and then falls hopeless as teachers and family fail to recognize the disorder. Some young people self-medicate ADHD or depression with recreational stimulants (e.g. speed or cocaine) or alcohol, further enhancing their impulsivity and risk.
Hospitalization
Most individuals with suicidal thoughts do not require hospitalization; only when their desire to die or impulsivity is great is this necessary. Their suicide risk is greatest shortly after a recent suicide attempt, especially if they have a plan to try again if no relief is forthcoming. Hopelessness, psychosis, absence of social supports, substance abuse, and impulsivity all indicate an increased need for observation and sometimes restraint in a protected environment. Extremely suicidal patients, even in a hospital, may require "arms length" observation to prevent self-harm.
Psychopharmacotherapy
In most instances, appropriate psychopharmacotherapy remarkably reduces suicide risk. If the immediate risk of impulsive suicide is exceptionally great, or if symptoms fail to respond to medication, electroshock therapy may be needed.
Most suicides result from fundamental changes in neurotransmitters in the brain that impair perception and affect, resulting in a sense of hopelessness and impulsivity leading to attempts that end in death. The neurochemical defect appears in most cases to be a deficiency of serotonin reflected in a decrease in its principle metabolite, 5-hydroxyindole acetic acid, in the cerebrospinal fluid. This decrease is associated not only with suicide but also homicide. Regardless of their diagnosis, individuals with decreased brain serotonin are also at risk for homicide and for severe and impulsive suicide attempts.
A new generation of antidepressants, the selective serotonin reuptake inhibitors (SSRI's) specifically remedy serotonin deficiency, improving impulsivity, depression, eating disorders and obsessive compulsive disorders, and reducing symptoms of other disorders which increase suicide risk. The wide safety margin of these SSRI's reduces the hazards of overdose seen with older antidepressant drugs.
Social Support
People at greatest risk for suicide are the most socially isolated: particularly divorced, single, or separated men in late life. As adolescents, gay youth do not have support for their gender identity, resulting in their over-representation among adolescent suicides. Support groups for HIV positive patients, gay youths, and single parents reduce some stress by reducing isolation and allowing sharing of coping skills.
Psychoeducation
Patients, families, clergy, care givers, and others should be taught to recognize individuals at risk, and they should be educated to the role of medication, therapy and social support in reducing suicide risk. Weight loss, social isolation, sleep disturbances, impulsivity, decreasing work and school performance and agitation indicate worsening depression. Lack of plans for the future and giving away of prized possessions suggest an evolving plan to die.
Access to Help
All patients at risk should be provided with the therapists' phone numbers, their backups, and places to call if neither respond in a timely manner. Lack of access to help at a time of despair may result in panic, anger and impulsive acts.
Realistic Goals
The anxiety of caregivers and family members is reduced by mutual understanding of the limits to what is possible. Most depressions respond to antidepressants many with the first drug chosen but side effects can limit choice and dosage. The suicide risk may increase in therapy when patients' energy returns before their feelings of hopelessness, helplessness and worthlessness abate. Schizophrenia, on the other hand, has the same lifetime risk of suicide as major depression, but a somewhat worse prognosis. What works at one point in the course of treatment may not be effective at another point, and management of the illness needs to be altered as circumstances dictate. In some instances, a long time is required for diminution of the desire to die. Even more time may be required to restore or acquire a lust for life that, in itself, would counter a desire to die.
Surviving Suicide
Loss of a loved one to suicide is perhaps the most painful of human experiences. The pain of the loss of someone to suicide is never totally ameliorated. It is always there, and the survivor's eye is quick to find it. It only becomes tolerable as the thread of loss is woven into the fabric of the survivor's life with threads of more happy moments. Few understand that the death is seldom self-determined, but rather driven by a distortion of perception by a biochemical defect.
Surviving is wrought by confused feelings. Guilt, grief, anger, and despair increase survivors' own risk of self-inflicted death. Each day they may play the game of if's: "What if I said or did that?" "What if I didn't?" Survivor groups help those left behind to learn what feelings to expect, and to learn the course of grief.
Summary
Most suicides are preventable if the psychiatric disorders responsible for clinical symptoms and impulsivity are identified early and treated aggressively, and psychosocial stress factors are reduced through therapy. However, a clinician is not omnipotent. Profoundly despairing people can lie about plans and hoard medicine even if prescribed cautiously. The best care for potentially suicidal patients is initial and recurrent assessment of risk, timely intervention, and the provision of support to those especially at risk, regardless of the presence of symptoms.
Dr. Slaby is Clinical Professor of Psychiatry at New York University and New York Medical College.
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