Suicidal Behaviorand DepressionSummerschool 2014Jeroen Terpstra, MD PhDPsychiatristHead of the 24h/Acute Psychiatry, Flevoland

Disclosure conflicts of interest

(potential) conflicts of interest See below 

Relevant relations with commercial entities Company names

• Grands and/or sponsorships• Fees or other (financial)

compensation• Shareholder• Other relationships, being …

 

• none• Janssen-Cilag, Pfizer 

• Haerst BV i.o.• none

Theoretic background

Multi-disciplinairy Guideline: Diagnosis and Treatment of Suicidal Behaviour (2012)

Epidemiology• About 1500 suicides per year• About 15.000 attempts per year as recorded at

various caregivers (GP/ER/MH/EPS/IC)• Rise since 2007• Clear relation with economy (Shu-Sen Chang

(University of Hong Kong) en colleagues in BMJ (2013;347:f5239))

• 70% of people with suicidal behaviour have no previous history of mental care

View on Suicidal Behaviour• The term ‘suicidal behaviour’ points to the

entire constellation of thoughts, preparatory-acts and attempts that signify a certain intention to kill oneself

• Besides an intention to die, there almost always is an intention to live

• Important: suicides are not predictable! Only the risk can be assessed with reasonable predictability!

The “stress, vulnerability and entrapment” model

Common Principles• Basic skills:

– recognising suicidal behaviour;– assessment of the suicidal state;– assessment of the complex variety of

factors that, in the individual patient, have led to the suicidal behaviour;

– assessment of the extent to which the patient may be able to be considered to oversee and to appreciate his/her interests.

Common Principles (cont.)• Structural-diagnosis:

– a description of the current suicidal state;– a description of the relevant stress- and

vulnerability-factors;– hypotheses about the aetiology (raison

d’être) and pathogenesis (how it came to be) of the suicidal behaviour;

– a description of the degree of mental competence.

Common Principles (cont.)• Make contact!

– empathic, non judgemental• Involve those around the patient!

– weigh the balance between privacy en safety

• Safety and continuity of care!

Diagnostics• Dare to ask• Dare to ask further• CASE-approach (Chronological Assessment of

Suicide Events: Shea, 1998): – first ask about actual thoughts and events– then ask about recent history (4-8 weeks)– then ask about the broader history and previous

episodes– finally ask about the patients view of the future,

which plans, and what should change to regain perspective/hope.

Treatment• Admission (Closed): in case of

psychosis/delirium• Admission (Open): in case of other Axis I and II,

when ambulant care is impossible (e.g. no social support)– recovery own (partial) responsibility/autonomy– NB: admission does not, in the absolute

sense, prevent suicide!• Ambulant: whenever possible (social support,

cooperation, etc)

Treatment (cont.)• treat the underlying psychiatric disorder (when

present)• restore perspective/hope• restore contact• restore role

Case 1• 23 year old female, well known by mental

health caregivers from when she was 16. Many suicide attempts with medication. Also automutilation. Many diagnoses: PTSS, Dysthymia, Borderline.

• Calls the ER dat she took 4 boxes of PCM and a half a bottle of vodka

Case 1 (cont.)• Admitted to the ER, lavaged and admitted to

the internal medicine ward for observation• Next day the Internist asks for a psychiatric

evaluation

Case 2• 52 year old male, no previous psychiatric

history• Recently lost his job, in dept. At the point of

losing his house. His wife wants a divorce.• Has started drinking, heavily• Comes to the GP with sleeping-problems

Case 2 (cont.)• After deliberate assessment of the suicidal

state, he admits have ideations. He even has made some preparations (rope and hook for in the barn). Goodbye letter has already been finished.

• GP refers to EPS