1. Louis A. Cancellaro, PhD, M.D. Professor Emeritus Interim Chair Department of Psychiatry and Behavioral Sciences Quillen College of Medicine East Tennessee State University SUICIDE

2. General Information Suicide is the 11 th leading cause of death in the US 5th cause of death in children and teenagers ages 5-14 years 3 rd cause of death in teenagers 15-24 years Highest Risk Group: Elderly white males

3. General Information Lowest Risk Group: Black females Rate is higher in men than women Suicides to completion 4:1 in the elderly ratio compared to 8:1-25:1 attempts in the general population 90% of suicides have a substance abuse or mental disorder

4. General Information Women 2-3 times more likely to attempt suicide Men are more likely to die from suicide 4:1 ratio 60% overall use firearms with 75% used by older adults 90% male caregivers of chronically ill female partners involved in homicide-suicide dyad

5. General Information 50-70% have seen a physician within a month prior to death; 20% within 24 hours 40% of suicides occur within 1 month of discharge from hospital 65 to 87% have been diagnosed as having a depressive disorder 1 in 6 leave a note

6. General Information Those who have attempted suicide, have in the next 12 months a risk 100 times greater than the general population Physician suicides are estimated at 400 per year Medical student suicides more common in second and 4 th year of medical school; particularly in months of January and February

7. DSM – IV Diagnosis Encountered Mood Disorders – Depression – Bipolar Alcohol and substances related disorders Schizophrenia & other Psychotic Disorders Delirium, Dementia, Amnestic and other Cognitive Disorders

8. DSM – IV Diagnoses Encountered Anxiety Disorders – Panic States Personality Disorders Disorders of CNS -Epilepsy-Huntington’s and CVA’s Mental Disorder due to a medical illness -Pain-disfigurement limited function and fear of dependency Other Conditions that may be a focus of clinical attention - Relationship Problems

9. The Clinician must: Evaluate for potential lethality - Extent and seriousness of thoughts - Risk factors that can be modified Intervene to prevent lethality – Physical protection – Disease specific interventions

10. Assessment of Suicidal Risk Lethality of attempt Imminence of rescue Past suicidal attempts Family history of suicide Depression Panic attacks/severe psychic anxiety Expressed thoughts of suicide

11. Assessment of Suicidal Risk Chronic, painful illness Sudden life changes Divorced males Older or widowed males Alcoholism Psychosis

12. Protective Factors Religious prohibitions or spiritual beliefs Positive relationships Sense of family responsibilities Social support Resilience during past personal crisis

13. Consider these questions in your assessment What were the patient’s intentions when the attempt was made? – Was the act planned or carried out on impulse? – Were precautions taken against being found? – Did the patient seek help? – Was the method chosen dangerous or was it just believed to be so? – Was there a final act like writing a note? – Is the patient glad to be alive?

14. Consider these questions in your assessment Did the patient think he/she would be rescued? Is the precipitating crisis resolved? Is there a psychiatric disorder? What are the current problems? – Loneliness or health Is there a covert wish on the part of the family to see the patient dead? What are the patient’s resources?

15. Be Attentive When you think the patient is wasting your “valuable” time by taking it from patients whom you believe are “really sick” and require your attention. When you assume an unsuccessful suicidal attempt is not serious and can easily be ignored. When you communicate disbelief of the patient’s intention to self destruct.

16. Consider These Questions Have you felt so sad or depressed that life is not worth living? Have you thought of harming yourself or taking your life? Do you have a plan or a way to kill yourself? Do you have the means to carry out this plan?

17. Consider These Questions Did you choose a location? Did you rehearse this plan? Have you attempted suicide in the past? What prevented you from killing yourself?

18. Management Guidelines Place the patient under constant surveillance when the slightest possibility exists that the patient will leave before your evaluation is complete. Inform the patient that despite their feelings of helplessness you will try to understand and assist. Enlist the support of family and/or friends. Explore possible precipitating events by probing the patient’s present feelings and thoughts.

19. Treatment Patients in imminent danger should be admitted to inpatient unit. If they refuse, the physician is responsible for involuntary procedures. Reduce immediate risk by administering anxiolytic drug to reduce anxiety/tension/ agitation.

20. Treatment If psychotic, use a neuroleptic. Admission does not guarantee safety. ECT useful for acute agitated psychosis associated with a major affective disorder.

21. Legal Ramifications Basis for malpractice claims can be attributed to either dereliction of duty or negligence. Concept of duty relates to the prevailing standard of care in the community and to the contractual relationship that exists between the physician and patient.

22. Legal Ramifications Negligence generally implies a failure to diagnose, inadequate or inappropriate treatment, or abandonment of patient. Be aware of errors of omission as in failure to supervise patient or errors of co-mission, i.e. RX for large quantity of drugs.

23. Summary Risk Evaluation – Lethality of attempt – Factors of importance: Major depression Alcoholism Substance abuse Social support Serious medical co-morbidities

24. Summary Contract – May not be reliable: a concrete plan is essential. Be conservative; if in doubt clear up the doubt Clarify the treatment plan Communicate to other care givers Be cognicent of medical-legal risk Utilize family members and friends

25. Summary Document, Document, Document – Document a clear rational approach in the record, as well as reasons why alternative courses, if any, were not chosen.

26. Selected References Busch, K. A., Fawcett J., Jacobs D. G. Clinical Corelates of Inpatient Suicides Journal of Clinical Psychiatry, 2003; 64 (1) 14-19 Jacobs, D.G., Brewer, M.L. Klein-Benheim, M. Suicide Assessment: An overview and recommended protocol's. In Jacobs D.G. Editor, Harvard Medical School Guide to Assessment and Intervention, 1999: 3-39 Jossey-Bass Publisher