The Suicidal Patient: First Line Assessment and Treatment
Rebecca Hopkinson, MD
PAL Consultant
Caring for a suicidal patient in the primary care setting can be stressful at best. A thirty-minute Well Visit can easily become an hour or more. The stakes are high, and physicians may leave the office worrying about the outcome. While it is not possible to predict with certainty if a patient will end their life, we can assess risk of harm, and take reasonable steps to minimize risk.
The initial task when a patient discloses suicidal ideation is to assess, ultimately for the purpose of triage and treatment. The assessment includes asking about risk factors, both chronic and acute. Chronic risk factors include such things as a family history of completed suicide, history of child abuse, parental mental health problems, adoption, LGBTQ identity, or a prior suicide attempt. While females are more likely to attempt suicide, males are more likely to use lethal means and thus die from the attempt. Factors such as substance use, mood disorders, anxiety disorders, disruptive behavior disorders, and psychosis also increase risk. Other risk factors include social isolation, bullying, not attending school, school difficulties, >5 hours per day of internet/game use, and non-suicidal self-injury. Suicide risk also increases after stressful life events such as a suicide within the peer group, a rupture in the parent-child relationship, or bullying. [1]
As a primary care provider, the status of many of these risk factors may already be known. Asking more about the suicidal thoughts is necessary. Are they morbid thoughts about death or dying, or is the patient fantasizing about their funeral and who would show up? Or are the thoughts about killing themselves? Have they thought about a plan? What is it? Have they taken any other steps? It is particularly concerning when a kid spends a lot of time researching effective ways to die, practicing, (for example, tying a scarf around their neck and untying it, walking to a bridge to look over it), or taking steps towards a concrete plan (gathering pills or implements such as knives, ropes, firearms). If they have had prior attempts, frequency and severity are important to know, as well as how they ended. For example, did they stop themselves or did someone else stop them? Did they tell someone? Have they recently engaged in non-suicidal self-injury? What are factors in their lives that are creating the hopelessness, and are they solvable? What are the factors or connections that make life worth living and keep them from acting on suicidal urges?
A measure that can help to guide a decision about the level of care required is the Child and Adolescent Service Intensity Instrument (CASII).[2] This measure has a dimension specific to risk of harm, and can provide a suggestion for the appropriate level of care. The descriptions of risk level can also help to direct questions.
While no one can predict with certainty when an adolescent will act on suicidal urges, the majority of suicide attempts are impulsive in nature. If a teen does not have access to means to die at the time they are having suicidal thoughts, those thoughts may pass once they are out of the acute crisis situation.
Thus parents can do a lot to minimize risk. If the adolescent is going home but is still considered high risk, parents should engage in “safety planning,” going room by room through their home and locking up or getting rid of any means that the teen could use to harm themselves. If a specific plan exists, the parents should remove the risk whenever possible. This can mean supervising the teen 24 hours a day, 7 days a week. Many parents in these situations choose to sleep in the same room with the patient to ensure that they are not alone at a vulnerable time of day.
While caring for suicidal patients can be frightening at times, there is so much that can be done to save the lives of these teens. Primary care doctors are at the front lines; by providing appropriate care at the right time, lives can be saved and kids and teens can pass through the negative times and have a chance to make their lives worth living.
References:
1. Shain, B. (2016). Suicide and suicide attempts in adolescents. Pediatrics, 138(1).
2. Fallon, T., Pumariega, A., Sowers, W., Klaehn, R., Huffine, C., Vaughan, T., ... & Grimes, K. (2006). A level of care instrument for children's systems of care: Construction, reliability and validity. Journal of Child and Family Studies, 15(2), 140-152.
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News & Notes
Register now for our May Webinar Conference!
Saturday, May 22nd
8:00 AM - 12:30 PM AKST
Topics and Speakers:
- "Depression" - Robert Hilt, MD, FAAP
- "Early Childhood Mental Health" - Douglas Russell, MD
- "Anxiety" - Erin Dillon-Naftolin, MD
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PAL Spotlight
 Dr. Erin Dillon-Naftolin joined the PAL team in September 2015. Born and raised in the Seattle area, she attended medical school at the University of Washington School of Medicine and completed her General Adult Psychiatry training there as well. She completed her fellowship at University of Washington/Seattle Children’s Hospital in 2014 and joined the faculty upon graduation. In addition to working for PAL, she does consultation in integrated care at the Roosevelt clinic and she is an attending psychiatrist in the outpatient psychiatric clinic at Odessa Brown and at Sound Community Mental Health Center. Her primary clinical interests are anxiety disorders, telemedicine, community mental health and consultation to primary care. Dr. Dillon-Naftolin lives in Seattle with her husband, daughters and labradoodle. Like a true northwestern native, she enjoys running, hiking, snowshoeing and camping, rain or shine.
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Upcoming CME Conferences
Webinars:
Information regarding upcoming webinars will be released soon.
Conferences:
May 22, 2021
This conference has been moved to an online webinar format.
Previously scheduled for Fairbanks, AK
Conferences run 8:00 AM - 12:30 PM AKST and are FREE to attend.
CME credits are available.
Visit our website for the most updated information on upcoming conferences and to view slides from our previous conferences.
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