Makindo Medical Notes

In hospital all overdose patients get or should get a psychiatric evaluation. In General practice, depressed patients are commonly found and the doctor should have a good idea who is at risk of self-harm. Some common features help identify individuals at greater risk. Check your local policy but anyone with a suicide attempt should have a psychiatric evaluation before discharge. Patients may even try to self-discharge. Get help from psychiatry and take senior advice.

Initial Assessment of Suicide Risk

Assessing the risk of suicide is a critical component of patient care, especially in individuals presenting with depression, severe anxiety, or other mental health issues. Key steps include:

• Direct Inquiry: Ask about suicidal thoughts, plans, and intentions directly but sensitively. Example: "Have you had thoughts about harming yourself?"
• Assess for Plans and Means: If the patient acknowledges suicidal thoughts, ask about specific plans (e.g., "Do you have a plan for how you would do this?") and access to means (e.g., weapons, medications).
• Evaluate the Severity of the Risk:
  • Presence of a specific plan
  • Access to lethal means
  • Previous suicide attempts or self-harm history
  • Psychiatric conditions (e.g., depression, psychosis, substance abuse)
  • Lack of social support
• Those who are committed to ending their lives will often tell no one and conceal it from their family and healthcare staff

Suicide Risk and Mental health

Risk Factors for Suicide

• History of previous suicide attempts
• Mental health conditions (e.g., major depressive disorder, schizophrenia, borderline personality disorder)
• Substance use disorders (alcohol or drug abuse)
• Chronic medical conditions (e.g., chronic pain)
• Recent significant life events (e.g., job loss, bereavement, relationship breakdown)
• Family history of suicide
• Social isolation or lack of support

Immediate Management of Suicide Risk

• Low Risk (No Active Suicidal Ideation):
  • Monitor the patient closely with regular follow-up appointments.
  • Provide emotional support and refer for psychological counseling (e.g., cognitive-behavioral therapy).
  • Consider starting or adjusting medications (e.g., antidepressants, antipsychotics) if indicated.
• Moderate Risk (Suicidal Thoughts, No Immediate Plan):
  • Increase frequency of follow-up visits or arrange daily check-ins by phone or in person.
  • Develop a safety plan with the patient, including identifying personal coping strategies and emergency contact numbers.
  • Involve family or close friends for additional support, with the patient's consent.
  • Consider referral to a mental health specialist or crisis intervention team.
• High Risk (Active Suicidal Ideation, Specific Plan, or Access to Means):
  • Immediate referral to emergency psychiatric services or hospitalization, especially if the patient is acutely unsafe.
  • Remove or restrict access to lethal means (e.g., firearms, medications) in the patient’s environment.
  • Involve family or friends to ensure constant supervision until professional help is obtained.
  • Provide emergency treatment for any co-occurring psychiatric conditions (e.g., severe depression, psychosis).

4. Long-Term Management and Follow-Up

• Psychological Therapy: Refer the patient for evidence-based therapies such as cognitive-behavioral therapy (CBT) or dialectical behavior therapy (DBT) for individuals with chronic suicidal ideation or underlying conditions like borderline personality disorder.
• Medication Management: Antidepressants (e.g., SSRIs), mood stabilizers, or antipsychotics may be prescribed based on the underlying diagnosis.
• Social Support: Encourage the patient to engage with support systems, including family, friends, and community groups.
• Regular Follow-Up: Schedule consistent follow-up appointments to monitor the patient’s mental health, assess treatment effectiveness, and re-evaluate suicide risk.
• Safety Plan Review: Continually review and update the safety plan during follow-up visits, adjusting it based on the patient’s progress and circumstances.

Self-harm is a prevalent issue with various underlying causes. It significantly heightens the risk of suicide, though most individuals who engage in self-harm do not ultimately take their own lives. Effective management involves a comprehensive assessment of suicide risk, considering factors such as known risk factors, the level of suicidal intent, the presence of mental disorders, substance use, and the availability of social support. Management strategies should be tailored to each individual and always include crisis planning.

Referral and Specialist Involvement

• Refer to a psychiatrist for comprehensive mental health evaluation and ongoing care if high-risk or complex psychiatric conditions are identified.
• Involve crisis intervention teams or community mental health services if immediate intervention is needed but hospitalization is not required.
• Consider inpatient psychiatric admission if the patient remains at high risk for suicide despite outpatient interventions.

Documentation

Ensure thorough documentation of the suicide risk assessment, clinical reasoning, safety plan, and management decisions. Include details of all discussions with the patient and their family or caregivers.