The Suicidal PatientThe Suicidal PatientA Patient-Centered, Evidence-Based A Patient-Centered, Evidence-Based Diagnostic and Treatment Process Diagnostic and Treatment Process

A Presentation for SOMC Medical EducationA Presentation for SOMC Medical Education

Kendall L. Stewart, MD, MBA, DFAPAKendall L. Stewart, MD, MBA, DFAPANovember 20, 2009November 20, 2009

1My aim is to offer practical insights you can put to practical use in your professional life.2Please let me know whether I have succeeded on your evaluation form.

Why is this important?

• One percent of Americans will die by suicide.

• 30,000 people take their own lives each year in the US.

• Suicide is the 8th leading cause of death in this country.

• Our suicide rate has averaged 12.5 per 100,000 for the past century.

• Adolescent rates have tripled over the past 40 years to 13.3 per 100,000 making suicide the 3rd leading cause of death in this age group.

• 8-10 people attempt suicide for every one who completes it.

• More than 12,000 children under 13 try to kill themselves each year.

• If you pursue clinical practice, these people will come to you for help and your reactions will be second guessed.

• After learning the material in this presentation, you will be able to answer the following questions?

– What are some of the demographic risk factors for suicide?

– What are the most common methods for committing suicide?

– What is the role of mental illness in suicide?

– What medical illnesses are associated with increased risk?

– What is the relationship between suicide and heredity?

– What about antidepressants and suicide?

– How can you assess for suicide risk?

• There is no way to predict suicide with certainty.

• Involving a mental health professional in the assessment process is the usual way of sharing the professional liability.1,2

1Consulting does not entirely relieve the physician of the risk.2I once consulted the judge when the local mental health clinic employee disagreed with my assessmentof a man I considered homicidal.

What are some of the demographic risk factors for suicide?• Age

– Caucasians aged 75-84 suicide 2 times more than those aged 15-24

– Rates in African Americans highest in males aged 25-34

• Race– Whites complete

suicide 2 times more often than blacks or Hispanics

– American Indians and Alaskan Natives suicide 1.7 times as often as whites

• Sex– M:F ratio 3:1 to 4:1– Women make up to

70% of attempts– Attempt : Success is

23:11,2

• Marital status– Divorced or widowed

> single > married– Among women, the

more children, the lower the rate

1Don’t fall into the trap of assuming that these patients are “not serious.”2I saw a young woman who took an overdose of ASA to “numb myself up to jump in front of a car.”

What are the most common methods for suicide?

• Men– Firearms– Hanging– Gasses or vapors– Drug ingestion

• Women– Drug ingestion1,2

– Firearms– Gasses or vapors– Hanging

Suicide Deaths per 100,000

02468

101214161820

All p

erso

ns

Whi

te m

ales

Blac

k males

Whi

te fe

males

Blac

k fe

males

1People on drugs may not realize or remember that they tried to kill themselves.2I interviewed a woman who was blacked out when she shot herself with a handgun.

What is the role of mental illness in suicide?

• 95% suffer from mental illness at the time of death

• Up to 70% are depressed1,2

• Degree of hopelessness is predictive

• The six months after hospital discharge is a high risk period

• Major depression (15%)

• Bipolar disorder (10-15%)

• Schizophrenia (10%)• Alcohol dependence

(2%)• Borderline

personality (4-9.5%)• Antisocial

personality (5%)

1Suicide is a selfish act; their pain blinds them to the impact this will have on others.2I treated a man who refused to take antidepressants. I interviewed his wife and children afterwards.

What medical illnesses are associated with increased risk?

• AIDS (Up to 36 times)

• GI cancers1,2

• Head injury• Epilepsy (5 times)• Temporal lobe

epilepsy (25 times)• Peptic ulcer

disease• Spinal cord injury

• Multiple sclerosis• Porphyria• Delirium tremens• Cushing’s disease• Hemodialysis (5

times)• Huntington’s

chorea• Klinefelter’s

syndrome1Your glib answers will diminish with age.2I was consulted on a patient with inoperable cancer who wanted to spare his family.

What about suicide and heredity?

• Relationship is not entirely clear• Incidence 4% in biologic relatives of

adoptees who suicide but only 1% in adoptive relatives and in biologic relatives of non suicidal matched controls

• Monozygotic twins 6 times greater concordance for suicide than in dizygotic twins

• Difference may represent heritability of mental illness

• Suicidal persons may copy behavior of a loved one

• Personally knowing a suicide victim is a risk factor1

1Remember Stewart’s “Aircraft Carrier Landing Theory” of impulse control.

What about antidepressants and suicide?

• About 50% of depressed persons feel suicidal, so some persons on antidepressants will suicide.

• Fluoxetine and other SSRIs do not increase suicide but protect against it.1,2

• There are new warnings about using these drugs in children and adolescents.

• Lithium is the most effective anti-suicide drug.

• Lithium and the older antidepressants are the most commonly used drugs in fatal overdoses.

1A patient threatened to sue me over fluoxetine (Prozac)2The way you manage such things is different in a small town.

What are some of the essential steps in the evaluation of a suicidal patient?

• Answer the question, “Why now?”

• Careful history• Mental Status Examination• Accurate diagnosis1

• Evaluate social support• Develop a plan• Arrange for follow up

1I once evaluated a “suicidal” patient who was obsessed with suicide.

How do suicide risk factors rank?

1. Age (45 and older)2. Alcohol

dependence3. Irritation, rage,

violence4. Prior suicidal

behavior5. Male 6. Unwilling to accept

help7. Longer than usual

duration of depression

8. Prior inpatient psychiatric treatment

9. Recent loss or separation

10. Depression11. Loss of physical

health12. Unemployed or

retired13. Single, widowed

or divorced

What acronym will help you assess suicide risk?

SadAgeDepressionPrevious attemptsEthanol abuseRational thinking loss (psychosis)Social supports lacking1,2

Organized planNo spouseSickness

1The lack of social support can be startling.2I once called the mother of a patient who said she had just be raped.

The Suicidal PatientA Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process

• Introduce yourself using AIDET1.• Sit down.• Make me comfortable by asking some

routine demographic questions.• Ask me to list all of problems and

concerns.• Using my problem list as a guide, ask

me clarifying questions about my current illness(es).

• Ask me directly about suicide and homicide.

• Using evidence-based diagnostic criteria, make accurate preliminary diagnoses.

• Ask about my past psychiatric history.

• Ask about my family and social histories.

• Clarify my pertinent medical history.• Perform an appropriate mental

status examination.

• Review my laboratory data and other available records.

• Tell me what diagnoses you have made.

• Carefully assess my suicidal and homicidal risk.

• Outline your recommended treatment plan while making sure that I understand.

• If you believe I am at risk, discuss my options without threatening me.

• Acknowledge that I am ultimately the boss.

• Explain the transient nature of most suicidal and homicidal impulses.

• Explain that you will make your best recommendation, but that the disposition of my case may be up to the court.

1Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment. Explain what is going to happen next. Thank your patients for the opportunity to serve them.

Where can you learn more?

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000

• Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 20081

• Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 20072

• Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005

• Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 20093

• Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007

• Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January 2008

• Median, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008

• Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000

Where can you find evidence-based information about mental disorders?1

• Explore the site maintained by the organization where evidence-based medicine began at McMaster University, http://hsl.mcmaster.ca/resources/ebpractice.htm.

• Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice at http://www.medscape.com/psychiatry.

• Subscribe to Evidence-Based Mental Health at http://ebmh.bmj.com/.

• Search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration at http://ebmh.bmj.com/.

• Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health at http://www.medicine.uiowa.edu/ICMH/evidence/.

1Please visit www.KendallLStewartMD.com to download related White Papers and presentations.

SafetySafety QualityQuality ServiceService RelationshipsRelationships Performance Performance

Are there other questions?

www.somc.orgwww.somc.org

Jeffrey Hill, DOJeffrey Hill, DOOUCOM 1987OUCOM 1987

Justin Greenlee, DOJustin Greenlee, DOOUCOM 2004OUCOM 2004