Psychiatry: Of Suicidality

While the previous OSCE exam had focused on suicidality risk assessment, it is good if we could refresh and revise a bit for those who had been through the posting, and some pointers for those who are soon to be in this posting. Let's have a simulated scenario here:

A 40-year old female is brought to the hospital in an attempt to slit her wrist. She has been stabilized for the past hour. You are a medical officer of the Psychiatry unit. Assess the level of suicide risk.

Note: It is essential to be sensitive and empathic, but there's no need to be in tears with the patient. Try to find out what has happened, evaluate the risk of ongoing suicidal ideation and possibility of future acts.

Checklist:

1. Antecedents of suicidal act
   
   • What leads to the act? ( Psychosocial stressors, etc)
   • Planning of the suicide attempt: Any final act, such as suicidal note or will?
   • Was the act impulsive or planned?
2. Circumstances of the suicidal act
   
   • What did the act consist of? For example, in an overdose, what was taken? Or where did the patient plan to hurt on his/her body part? Was the patient under the act of alcohol or illicit substances?
   • Where and where did it take place? Was the act performed in isolation? Were any precautions taken to prevent being found?
3. Consequences of the suicidal act
   
   • How did the patient came to medical attention? Did he/she called someone before committing the act? (Parasuicidality)
   • What was the true intention of the act? To really die or "cry for help"? (Again, parasuicidality)
   • Did the patient believe at the time that the act would be lethal? (Some patients might think that a pencil is merely enough to kill them, while some parasuicidal patients might think that organophosphate pesticide is harmless)
   • How does the patient feel about the act now? ( Is there any sense of guilt, sadness, affect blunting or even might be too happy to tell about it)
4. Current risk
   
   • How does the patient feel about the future?
   • Current mood?
   • Any further plans to harm self? What is stopping them from carrying out those acts?
5. Past psychiatric/medical history
   
   • Previous attempts of self-harm or suicide
   • Current or past psychiatric diagnosis, including treatment
   • Concurrent medical conditions which may be debilitating and had been a cause for such an act.
6. Extra questions
   
   • Mental state examination to assess presence of delusional beliefs and psychotic symptoms
   • Family history of psychiatric illnesses and suicide
   • Social circumstances, such as support network and accommodation issues
   • Use of Alcohol and illicit substances

While it does looked lengthy, the highlighted important features are:

• previous history of suicide attempt
• risk factors for suicidality
• severity of suicidal ideas
  
  • intention (not by mistake)
  • suicidal plans (not of impulsivity)
    
  • lethality of methods
  • suicidal notes
  • alone ( precautions of being found out)
    

Now that we've discussed on history taking of assessment of suicidality, here are the other aspects we'll need to address briefly. It's good to read up on these:

1. Definition of deliberate self-harm and suicide.
2. Difference between suicide and parasuicide
3. Difference between active and passive suicidal ideation, as well as suicidal intent.
4. Risk factors for suicidality
5. Causes of suicide ( Social and medical causes) - Oxford Core Text of Psychiatry
6. Differentials of a patient with suicide attempts (inclusive of personality disorders)
   
7. Principles of management of patient with risk of suicide
8. What is suicidal caution and how is it being practiced in the ward.