Makindo Medical Notes

🧠 Introduction

• Suicidal thoughts (suicidal ideation) refer to thinking about, planning, or desiring one’s own death.
• They are a symptom, not a diagnosis, often linked to underlying psychiatric, social, or medical conditions.
• Early recognition is critical: suicidal ideation is one of the strongest predictors of suicide attempts.

🔬 Pathophysiology & Risk Factors

• Neurobiology: Linked to dysregulation of serotonin and dopamine pathways, HPA axis dysfunction, and altered prefrontal cortex activity.
• Mental Health: Depression, bipolar disorder, schizophrenia, borderline personality disorder, PTSD.
• Substance misuse: Alcohol and drugs increase impulsivity and reduce inhibition.
• Medical illness: Chronic pain, terminal illness, neurological disease (e.g., MS, epilepsy).
• Social: Isolation, unemployment, financial stress, history of abuse or trauma.
• Previous attempts: The single most important predictor of future suicide.

📋 History Taking

• Directly ask: “Have you had thoughts of harming yourself?” – evidence shows asking does not increase risk.
• Frequency & intensity: Are thoughts fleeting or persistent?
• Planning: Is there a plan, method, or access to means (e.g., tablets, weapons)?
• Intent: Does the patient want to die, or are thoughts more about escape/relief?
• Protective factors: Family, children, faith, future goals.

🩺 Examination

• Mental State Examination (MSE): Mood, affect, thought content, insight, judgement.
• Physical exam: Look for self-harm injuries, intoxication, or underlying medical causes (e.g., delirium).
• Risk stratification: Assess dynamic risks (acute stressors) and static risks (past attempts, psychiatric history).

🔎 Investigations

• Blood tests: FBC, U&E, LFTs, toxicology screen if overdose suspected.
• Drug/alcohol screen: To assess contribution of substances.
• Psychometric tools: PHQ-9 (depression), GAD-7 (anxiety), Columbia Suicide Severity Rating Scale (C-SSRS).

⚡ Immediate Management

• Ensure safety: Remove access to means (medications, ligatures, weapons).
• Do not leave alone: Supervision until safe management plan in place.
• Treat acute medical issues: Overdose, self-harm injuries, intoxication.
• Crisis services: Involve psychiatric liaison, crisis team, safeguarding if at risk.

💊 Longer-Term Management

• Psychological therapies: CBT, DBT, problem-solving therapy.
• Pharmacological: Antidepressants (SSRIs), mood stabilisers, antipsychotics as indicated – caution with toxicity in overdose (e.g., TCAs).
• Social interventions: Address housing, finances, employment, family support.
• Follow-up: Regular review by GP/mental health team; safety plan in place.

🚨 Red Flags (High Risk)

• Clear suicidal plan with access to means.
• Hopelessness, worthlessness, or nihilistic delusions.
• Previous serious suicide attempts.
• Recent major loss or stressor (e.g., bereavement, relationship breakdown).
• Lack of protective factors.

💡 Clinical Pearls

• Always assess for capacity – those lacking capacity may need Mental Health Act admission for safety.
• Suicidal thoughts ≠ intent – clarify whether the patient has a plan, intent, or just passive thoughts.
• Engage with compassion – building trust often reduces acute suicidal ideation.
• Involve family/support network (with consent) for safety planning.

🌟 Takeaway: Suicidal thoughts are a medical and psychiatric emergency. Early recognition, empathetic communication, and rapid access to mental health services save lives.

🧠 Case 1 — Young Adult with Depression

• Scenario: 22-year-old student with low mood, anhedonia, poor appetite, and social isolation. Reports suicidal thoughts but no active plan.
• Context: Triggered by academic failure and loneliness.
• Teaching Point: 💡 Suicidal ideation in young adults often reflects underlying depression and psychosocial stressors. Risk assessment should explore intent, plans, and protective factors. Early mental health support is key to preventing escalation.

🧠 Case 2 — Older Adult with Chronic Illness

• Scenario: 68-year-old man with chronic pain and disability after stroke. Feels like a burden, with recurrent suicidal thoughts.
• Context: Has access to medications at home, no immediate plan stated.
• Teaching Point: 💡 In older adults, suicide risk is closely linked to chronic illness, pain, and isolation. Clinicians should assess intent and access to means, while reviewing medications and engaging family. Rapid specialist referral is crucial.

🧠 Case 3 — Adolescent with Self-Harm

• Scenario: 15-year-old girl attends A&E after cutting her arms. Reports persistent suicidal ideation and bullying at school.
• Context: Parents unaware of the extent of her distress.
• Teaching Point: 💡 In adolescents, self-harm may be both a coping mechanism and a cry for help. Safeguarding is essential, with early CAMHS involvement, school support, and family engagement to reduce risk of repetition.