Suicide Clinical Presentation

A host of thoughts and behaviors are associated with self-destructive acts. Although many assume that people who talk about suicide do not follow through with it, the opposite is true. Those who threaten suicide actually do kill themselves. Suicidal ideation is highly correlated with suicidal behaviors. Furthermore, in addition to thinking and talking about suicide, the patient is actually planning it. The potential for a self-destructive act definitely increases.

Numerous activities are associated with committing suicide, including the following:

• Making a will
• Getting the house and affairs together
• Unexpectedly visiting friends and family members
• Purchasing a gun, hose, or rope
• Writing a suicide note
• Visiting a primary care physician: A significant number of people see their primary care physician within 3 weeks before they commit suicide. They come for a variety of medical problems. Rarely will they state they are contemplating suicide; yet, they do visit their doctors. Therefore, the practitioner must pay attention to the entire person—the physician must look for other things in the patient's life in addition to the chief complaint.

Individuals who are suicidal have a number of characteristics, including the following:

• A preoccupation with death
• A sense of isolation and withdrawal
• Few friends or family
• An emotional distance from others
• Distraction and lack of humor: They often seem to be "in their own world" and lack a sense of humor (anhedonia).
• Focus on the past: They dwell in past losses and defeats and anticipate no future. They voice the notion that others and the world would be better off without them.
• Haunted and dominated by hopelessness and helplessness: They are without hope and therefore cannot foresee things ever improving. This is a terrible feeling. They also view themselves as helpless in 2 ways: (1) They cannot help themselves, and all their efforts to liberate themselves from the sea of depression in which they are drowning are to no avail; and (2) No one else can help them.

The mental status review is designed to focus on evaluating an individual's suicide potential.

Appearance

In addition to the dress and hygiene notes in people who are depressed (eg, disheveled, unkempt and unclean clothing), the following should be noted. First, look for physical evidence of suicidal behavior. This includes wrist lacerations and neck rope burns. Be aware that more than one sign can indicate suicidal behavior. For example, a woman was brought to the emergency department because she had cut her left wrist. A careful physical examination also revealed 5 vertical lacerations on her abdomen.

Affect

Depression and anxiety are commonly seen in people who are suicidal. One specific emotion of concern is the patient exhibiting a flat affect when describing his or her thoughts and plans of suicide and self-destructive behavior.

Thoughts

Three types of thought changes represented areas for major focus and concern. The first are command hallucinations telling the patient to kill himself. These are usually auditory in nature and often take the form of the deity's voice (eg, "I hear God commanding me to kill myself, because I am bad."). The second type is delusions. These include, "The world and my family would be better off with me dead" or "If I take my life, I will be reunited in heaven with my mother." Finally, the third involves the obsession of a patient wanting to take his or her own life. Some patients focus their lives on their suicide.

Suicide and homicide

Inquiring into suicidal potential is an absolute requirement. The more specific the ideas and plans of suicide, the greater the possibility of suicide. Those with plans to purchase a gun exhibit a clear danger.

In addition to suicide inquiry, the clinician must ask about homicidal potential. Aggression turned inward is suicide; aggression turned outward is homicide. Homicide needs to be inquired about for the following reasons. First, it is part of a complete mental status examination. Second, there is linkage between the homicide and suicide. For example, in adolescents, 2 of the 4 leading causes of violent death are homicide and suicide.^[60] Third, although infrequent, homicide/murder and suicide are a reality.^[61]

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Judgment, insight, and intellect

An assessment of the person's judgment is important. Suicide is a permanent solution to a temporary problem. How a person has handled stress and will handle it in the future is a major concern. Keep in mind: The less the judgment, the greater the potential.

How does the individual see suicide? The person who sees the overdose as a cry for help has better insight than the person who awakes from an overdose and says, "I wish I were dead."

The key idea with intellect assessment is whether the person understands the sequences of the behavior. For example, did the person know that walking into traffic would be dangerous?

Orientation and memory

The focus of this part of the mental status is to determine if the person is delirious or has dementia. In either case, the patient in his disorientation and loss of recollection can do many self-destructive behaviors.

A clear and complete evaluation and clinical interview provide the information upon which to base the intervention. Although risk factors offer major indications of the suicide danger, nothing can substitute for a focused patient inquiry. However, although all the answers a patient gives may be inclusive, a therapist often develops a visceral sense that his or her patient is actually going to commit suicide. The clinician's reaction counts and should be considered in the intervention.

Determine whether the person has any thoughts of hurting him or herself. Suicidal ideation is highly linked to completed suicide. Some inexperienced clinicians have difficulty asking this question. They fear the inquiry may be too intrusive or that they may provide the person with an idea of suicide. In reality, patients appreciate the question as evidence of the clinician's concern. A positive response requires further inquiry.

If suicidal ideation is present, the next question must be about any plans for suicidal acts. The general formula is that more specific plans indicate greater danger. Vague threats, such as suicide occurring sometime in the future, are reason for concern. However, responses indicating that the person has purchased a gun, has ammunition, has made out a will, and plans to use the gun are more dangerous. The plan demands further questions. If the person envisions a gun-related death, determine whether he or she has the weapon or access to it.

Determine what the patient believes his or her suicide would achieve. This suggests how seriously the person has been considering suicide and the reason for death. For example, some believe that their suicide would provide a way that family or friends would realize their emotional distress. Others see their death as relief from their own psychic pain. Still others believe that their death would provide a heavenly reunion with a departed loved one. In any scenario, the clinician has another gauge of the seriousness of the planning.

Any question of suicide also must be coupled with an inquiry into the person's potential for homicide. Suicide is often thought to represent aggression turned inward, whereas homicide represents aggression turned outward. Because suicide constitutes an aggressive act, the question regarding homicidal tendencies must be asked.

Collateral questions should be asked based on the reviewed risk factors. These questions deal with any family members or friends who have killed themselves and include questions about symptoms of depression, psychosis, delirium and dementia, losses (especially recent ones), and substance abuse.

The following is a list of 12 things that should alert a clinician to a real suicide potential:

• Patients with definite plans to kill themselves: People who think or talk about suicide are at risk. However, a patient who has a plan (eg, to get a gun and buy bullets) has made a clear statement regarding risk of suicide.
• Patients who have pursued a systematic pattern of behavior in which they engage in activities that indicate they are leaving life: This includes saying goodbye to friends, making a will, writing a suicide note, and developing a funeral plan.
• Patients with a strong family history of suicide: Family history of suicide is especially indicative of suicide risk if the patient is approaching the anniversary of such a death or the age at which the relative committed suicide.
• The presence of a gun, especially a handgun
• Being under the influence of alcohol or other mind-altering drugs: Drug abuse is especially significant if the drugs are depressants.
• If the patient encounters a severe, immediate, unexpected loss (eg, when a person is fired suddenly or left by a spouse)
• If the patient is isolated and alone
• If the person has a depression of any type: The twin aspects of depression—hopelessness and helplessness—take a significant toll. The person sees no hope or any possibility of hope. The person views the world as black and anticipates no end to the blackness. Furthermore, the patient's self-perception is that he or she is beyond help; nothing has helped and nothing will help. This type of depression can occur in the context of medical or mental disorders. Persons with progressive, fatal, painful illnesses, such as chronic obstructive pulmonary disease (COPD) or cancer, are at high risk for suicide. Persons with mental disorders, such as schizophrenia, perceive the reality of their disease and the losses it has brought. In the midst of an anxiety disorder or Alzheimer disease, the person feels despair and depression.
• If the patient experiences command hallucination: A command hallucination ordering suicide can be a powerful message of action leading to death.
• Discharge from psychiatric hospitals: Patients are at suicide risk upon discharge from psychiatric hospitals, which is a very difficult time of transition and stress. The structure, support, and safety of the institution are no longer available to the patient. The patient feels apprehension and is confronted with the reality of change. This all translates into fright and vulnerability.
• Anxiety: Anxiety in all of its forms causes the risk for suicide. The constant sense of dread and tension proves unbearable for some.
• Clinician's feelings: As mentioned earlier, regardless of what the patient says or does, if the clinician has a feeling that patient is going to commit suicide—consider it a sixth sense or great clinical intuition—the clinician's feelings matter. They are part of clinical judgment and are an important part of the suicide assessment and intervention.

Other sources of information

Utilize all the information available. In addition to the material obtained through the clinical interview, information from other sources includes family interviews or interviews with friends or coworkers. First responders or other medical personnel may also have key information.

A suicide note may have been written.

A number of written and online tests will indicate both the presence of a significant depression and significant thoughts and plans of self-destruction. These include the following self-administered tests: Beck Depression Inventory, Hamilton Depression Rating Scale, the HANDS (Harvard Department of Psychiatry/National Depression Screening Day Scale) Depression Screening Questionnaire,^[62] and the Minnesota Multiphasic Personality Inventory (MMPI).

Using the Collaborative Longitudinal Study of Personality Disorders (CLPS), Yen et al found that the predictive power of the self-harm subscale of the Schedule for Nonadaptive and Adaptive Personality (SNAP) may be a helpful screening tool for risk of suicide attempts in nonpsychotic psychiatric patients.^[63]

Ballard et al conducted a study to determine how children react to suicide screening in an ED. The results suggest that pediatric patients supported suicide screening in the ED after being asked numerous suicide-related questions. Further studies are needed to evaluate the impact of such screening on referral practices and to link screening efforts with interventions.^[64]