By:- firoz qureshi

Dept. psychiatric nursing

SUICIDE MANAGEMENT

MANAGEMENT OF SUICIDAL PATIENT

INTRODUCTION

Suicide is derived from Latin word for “self murder”. It ranges from thinking about suicide to acting it out. Suicidal ideation is more common than completed suicide. Most person who commit suicide have a psychiatric disorder at the time of death. Although most patients with suicidal ideation do not ultimately commit suicide, the extent of suicidal ideation must be determined, including the presence of a suicide plan and the patient’s means to commit suicide.

RISK FACTORS AND SYMPTOMS ASSOCIATED WITH COMPLETED SUICIDE

EPIDEMIOLOGIC FACTORS PSYCHIATRIC DISORDERS PAST HISTORY

Male, white, agegreater than 65 yearsWidowed or divorcedLiving alone, no children under the age of 18 in the householdPresence of stressful life eventsAccess to firearms

Major depressionSubstance abuseSchizophreniaPanic disorderBorderline personality disorderAdditionally in adolescents, impulsive, aggressive and antisocialbehavior, presence of family violence and disruption

History of previous suicide attemptFamily history of suicide attemptSymptoms associated with suicideHopelessnessAnhedoniaInsomniaSevere anxietyImpaired concentrationPsychomotor agitationPanic attacks

GENERAL SCREENING GUIDELINESDuring the initial evaluation of new patient, ask about

• h/o psychiatric disorder

• h/o suicidal ideation and attempts

• Alcohol abuse using CAGE questionnaire

• A brief MSE to be recorded

• Recent stressors and suicidal ideation

• Evaluation for affective or anxiety disorder

New and established patients with evidence of major depression, substance abuse, anxiety disorder or a recent stressor, ask about,

• Suicidal ideation and plans including the means

• Identify associated symptoms

• Review risk factors

• Interview family or significant others

• Synthesize and formulate a treatment plan

INTERVIEW GUIDELINES• Show willingness to talk and show interest

• Make an introductory statement followed by specific statement

• Ask about onset, duration and lethality and furtherance of plans

• Should be interviewed alone as long as their capability

• Get the consent of the patient for interviewing the family members

• Some questions to be asked are,

• Identifying associated symptoms like hopelessness that appears to be necessary for development of suicidal intent – by MSE and history

• Identify the risk factors associated with suicide

Extent of suicidal ideation Plans for furtherance and lethality

•When you begin to have the thoughts?•Event precipitating?•How often? Do you feel life isn’t worth?•What makes you feel better?•What makes you feel worse?•Any plan to end life?•How much control do you have?•What stops you from killing yourself?

Do you have any access?Have you imagined your funeral?Have you “practiced”?Have you changed your will or life insurance policy or given away your possessions?

ManagementThe key factor for treatment include the patient’s suicide plan, access to lethal means,

social support and judgment.-Hospitalization-patient express suicidal ideation

Patient has a plan patient do not have plan

Has access to lethal does not have access, has goodMeans, has poor social social support and goodSupport and poor judgmentJudgment and andCannot make a is able to make a contractContract for safety for safety

Hospitalize evaluate for psychiatric disorder or stressors

trust with antidepressants, refer for alcohol rehabilitation,and individual and/or family therapy

patient does not respond optimally

refer to psychiatric consultant

Admission is strictly voluntary but patient may also refuse treatment.

The grounds for involuntary commitments are,

1. Imminent danger to self or others and

2. An inability to care for one’s self.

Management in wards gives time to interview suitable informants and for psychotropic medications to be administered and for their beneficial effects or side effects to be closely monitored.

Psychotherapy – in various modalities. Individual, group, family or marital.

When patient hold a conversation and is able to describe his problem, feelings then supportive psychotherapy or brief problem – oriented psychotherapeutic approach are indicated.

Individual sessions of cognitive behavior therapy, interpersonal or dynamic psychotherapy would also be beneficial.

Suicide caution• Patient of immediate risk should be placed on ‘suicide caution’

Searching the belongings for dangerous objects

Ward environment- unnecessary tubes, wires or sharps etc

Shower units should be wall mounted

If forks or knives are used during meal, there should be accounted at the end

Windows should be protected with grills and ward doors lockable

Bed should be close to the nursing station

Observe for frequent interval and record

Attention to neurovegetative symptoms such as sleep and appetite disturbance

If lying motionless in the bed , do not assume sleeping

Subjective report of poor sleep should be checked with objective observation

Do not allow to leave the ward

Watch on appearance and affect

Spend time to describe difficulties of patient and listen in empathetic manner

MEDICATIONSAntidepressant

selective serotonin reuptake inhibitor – act more rapidly

tricyclic antidepressant should be avoided due to lethal potentials in overdose.

Safer agents,

Fluoxetine (Prozac) – 20 -40 mg/day

Sertraline (Zoloft) - 50-200mg/day

Paroxetine (Paxil) - 20-40mg/day

Fluvoxamine (luvox) -150 – 250mg/day

Venlafaxine (effexor) - 75-300mg/day

Nefazodone (serzone) -400-600mg/day

In anxiety and insomnia,

Lorazepam (ativan) - 0.5-4mg/day

Oxazepam (serax) - 15-45mg/day

Temazepam (restoril)- 15-20mg/day HS

Zolpidem (Ambien) 5-10mg HS

ECT is considered in patient who do not respond to medications

Discharge of the patient

OP appointment should be short to see the overdose of medication

i.e.. In 1 wk

Teach on the increase energy and drive as the depression lifts up

Prefer to live with family rather than to live alone

Any default to be brought to notice

Give telephone number to call in crisis and attend an earlier rescheduled OP appointment.

OUT PATIENT TREATMENT

Assess the level of impulse control, judgment and social support. frequently used technique is “NO HARM” contract.

Frequent follow up

Teach family member to remove all lethal means and system of monitoring

conclusion

Knowing of risk factors, assessment of severity of suicidiality should be closely observed and vigilance Is essential when the staffs are lowest.

Management requires multidisciplinary approach. Hospital staff should be acquaint with suicide prevention policies in their respective hospitals.

Policies should be revised and tested

New staffs should be trained

Management generally requires combined expertise of several members of the team.

despite the best measures, suicidal patient who are really vent on ending their lives will still succeed in doing so. Not withstanding, we should still preserve in our effort for in so doing, we might many save many from an untimely death.

Thank you