para>FDA posted black box warning for antidepressant use in the pediatric population after increased suicidality was noted. If risk of untreated depression is sufficient to warrant treatment with antidepressants, children must be monitored closely for suicidality.
First Line
ECGs before prescribing or continuing antidepressants or antipsychotics to look for QT prolongation
ISSUES FOR REFERRAL
Consider a psychiatric consult. All decisions regarding treatment must be carefully documented and communicated to all involved health care providers.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- Inpatient hospitalization, if patient is suicidal with a plan to act or is otherwise at high risk; if immediate risk for self-harm, may be hospitalized involuntarily
- Immediately after a suicide attempt, treat the medical problems resulting from the self-harm before attempting to initiate psychiatric care.
- Order lab work (e.g., solvent screen, blood and urine toxicology screen, aspirin and acetaminophen levels). Patients may not disclose ingestions if they wish to succeed in their attempt or if they are undergoing mental status changes.
- Risk for self-harm continues even in hospital setting. Immediate search for and remove potentially dangerous objects, one-to-one constant observation, medication. Mechanical restraints only if necessary for patient safety
- The period after transfer from involuntary to voluntary hospitalization is also a time of high risk.
Discharge Criteria
- No longer considered a danger to self/others
- Clinicians should be aware that a patient may claim that he or she is no longer suicidal in order to facilitate discharge " and complete the act. Look for clinical and behavioral signs that the patient truly is no longer in despair and is hopeful, such as improved appetite, sleep, engagement with staff, and group therapy. Clinicians should check with family and ancillary staff because patients may share more information with them than with doctors.
- Provide information about 24/7 resources.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
- Increase monitoring at the beginning of treatment, when changing medications, and on discharge.
- Educate family members and other close contacts/confidants to the warning signs of suicidality. For adults: despair/hopelessness, isolation, discussing suicide, stating that the world would be a "better place " without them, losses in areas key to the patient 's self-worth. For youths: may exhibit the same signs and symptoms, but one should be aware of these additional risks: history of abuse (e.g., sexual, physical), bullying in person or via electronic media (e.g., text messages or social Web sites), family stress, changes in eating and sleeping patterns, suicidality of friends, and giving away treasured items
- Make sure that the patient is willing to accept the type of follow-up offered. Do not assume that just setting it up is sufficient protection.
- Curtail access to firearms.
- Limiting the number of pills may be appropriate for an impulsive patient. However, clinicians may believe that by simply limiting the number of pills they prescribe, they are preventing further suicide attempts, an example of "magical thinking. " Clinicians who find themselves thinking this way can take it as a warning sign that their patients may actually be at increased risk of suicide.
PATIENT EDUCATION
Patients who feel they are in danger of hurting themselves should consider one or several of these options:
- Call 911.
- Go directly to an emergency room.
- If already in counseling, contact that therapist immediately.
- Call the National Suicide Prevention Hotline at (800) 273-TALK (8255).
- Servicemen and servicewomen and their families can call (800) 796-9699; if there is no immediate answer, call (800) 273-TALK (8255); text 838255.
PROGNOSIS
The key to a favorable course and prognosis is early recognition of risk factors, early diagnosis and treatment of a psychiatric disorder, and appropriate intervention and follow-up.
COMPLICATIONS
- According to the American Association of Suicidality (AAS), the grief process for significant others of suicide victims can be lifelong and can be expressed in emotions ranging from anger to despair. Survivors often attempt to shoulder the burden on their own because of the added guilt and shame of the nature of the attempted death or death.
- The AAS recommends the following:
- Counseling: could include short-term behavioral therapy as well as psychotherapy; some therapy should focus on the survivors ' relationships to their current and future significant others. Survivors often seek out life partners as "replacements " for those they lost " could interfere with mourning (6).
- Sympathetic listening by friends
- Support during holidays
- More self-help strategies: www.survivorsofsuicide.com
REFERENCES
11 Jollant F, Bellivier F, Leboyer M, et al. Impaired decision making in suicide attempters. Am J Psychiatry. 2005;162(2):304 " 310.22 Brown GK, Ten Have T, Henriques GR, et al. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA. 2005;294(5):563 " 570.33 Ghahramanlou-Holloway M, Neely L, Tucker J. A cognitive behavioral strategy for preventing suicide. Current Psychiatry. 2014;13(8):19 " 28.44 Maltsberger JT, Buie DH. Countertransference hate in the treatment of suicidal patients. Arch Gen Psychiatry. 1974;30(5):625 " 633.55 Cipriani A, Pretty H, Hawton K, et al. Lithium in the prevention of suicidal behavior and all-cause mortality in patients with mood disorders: a systematic review of randomized trials. Am J Psychiatry. 2005;162(10):1805 " 1819.66 Massicotte WJ. Faculty, Canadian Institute of Psychoanalysis; Chair, National Scientific Program Committee. Correspondence, April 24, 2009.
ADDITIONAL READING
- Bryan CJ, Jennings KW, Jobes DA, et al. Understanding and preventing military suicide. Arch Suicide Res. 2012;16(2):95 " 110.
- O 'Connor E, Gaynes BN, Burda BU, et al. Screening for and treatment of suicide risk relevant to primary care: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2013;158(10):741 " 754.
CODES
ICD10
- R45.851 Suicidal ideations
- T14.91 Suicide attempt
- Z91.5 Personal history of self-harm
ICD9
- V62.84 Suicidal ideation
- 300.9 Unspecified nonpsychotic mental disorder
SNOMED
- 44301001 Suicide (disorder)
- 82313006 suicide attempt (event)
- 267073005 Suicidal (finding)
- 6471006 Suicidal thoughts (finding)
- 225444004 At risk for suicide
CLINICAL PEARLS
- Key preventative measure is to listen to a patient and take steps to keep him or her safe. This could include immediate hospitalization. Questions to explore include, "Are you thinking of killing yourself?, " "Who do you have to live for?, " and "What should change so that you could live with your suffering? "
- Clozapine, lithium, and cognitive-behavioral therapy are associated with a reduction in the risk of suicide.
- Family members and contacts of people who have attempted or committed suicide suffer from reactions ranging from rage to despair. Their grief is often longer lasting and less well-treated because of the shame and guilt associated with the act. Encourage them to discuss this and consider counseling.
- Resources for clinicians: www.suicidology.com; www.suicideassessment.com