This morbid story is designed to help remember the essentials of a risk assessment for patient that has attempted to commit suicide.
Mr Suicide has come into the emergency department having taken an overdose. You are the doctor on call and have to decide how to manage his case. You must perform a risk assessment to see if he’s safe to go home.
Mr Jones is a 70 year old man who lives on his own in a small house on a hill.
Mr Jones has been planning his suicide for a long time. He’s just not felt like himself since his divorce, and was already depressed after the death of his first wife.
Mr Jones used to work at a chainsaw factory, because his dad killed himself with a chainsaw, and since then Mr Jones was determined to make chainsaws as safe as possible to stop this from happening.
Mr Jones’ job at the chainsaw factory ended when the factory was shut down for unsafe working conditions, as many of the employees, Mr Jones included, had contracted irreparable lung damage from the particulate matter in the air. To fill this void in his life he’s been drinking more, to the point where he admits to himself he’s probably dependent on alcohol. Being quite an impulsive person he had also spent a lot of his money on gambling.
Mr Jones’ plan for this evening was the same as the last two times he tried. He was going to drink a lot to make himself feel better, and then take a lot of paracetamol. Last time he tried, he didn’t take enough and he was angry that it didn’t work, so this time he’s been stockpiling them from the local chemist’s for months.
Mr Jones has never really been satisfied with his life, he has always felt like somewhat of a failure, and believes this is largely due to the impact his father had on him as a child. His father would hit him with a belt every time he was ‘bad’, but often randomly, so he didn’t really know how to behave to make his father happy.
As a result he’s always been very anxious around other people and very worried about doing the wrong thing. He was told that his father had a mental illness of some sort, and that’s why his behaviour was so strange, but it didn’t really ever get better, and he’s always thought that he might take his own life at some point.
Mr Jones took as many paracetamol as he could, but doesn’t remember exactly at what time, and then hid in his bathroom and locked the door so that he wouldn’t be found. He hadn’t written a note because he didn’t feel there was anyone to tell.
It was only by chance that a neighbour had popped round to ask him to keep an eye on their house while they went on holiday, and heard someone crying inside. They called the police and then an ambulance, and Mr Jones was brought in.
When you see him, he feels very upset that it didn’t work, and wants to be discharged so that he can go home and do it properly. He refuses any sort of help from the hospital or the mental health team and there is no next of kin that you can call. He claims there is ‘nothing he wants to stay alive for‘.
This is a ‘worst case’ scenario, designed to highlight the relevant risk factors that may help you decide the risk of a person with a suicide attempt. The following are the key points:
- Divorced, single, widower
- Hx of mental illness
- Access to lethal means
- FHx of suicide
- Chronic health issue
- Substance abuse
- Impulsive personality
- Loss of money
- FHx of mental illness
- Ongoing intent to take own life
- Didn’t want to be found
- Upset that attempt failed
- Intent to try again
- Refusal of help
- No support network
- No children
- No reason to stay alive
Table from bestpractice.bmj.com
Once you have assessed the major components of suicide:
- Suicidal ideation
- Intent and plan
- Access to lethal means
- History of attempts
You should do the following:
- Remove means for suicide (treat overdose/address wounds)
- Stabilise the patient medically
- Try and obtain a collateral history and locate next of kin
- High risk patients should be admitted for observation
- Those with chronic ideation but no prior attempts may be monitored on an outpatient basis
- The main factors are providing a support network
- Address any pre-existing mental issues
- substance abuse
- eating disorders
- Psychosocial and psychotherapeutic interventions may be warranted:
- Psychodynamic interpersonal therapy
and don’t forget those around the person! Suicide attempts hit families hard, and have huge consequences especially in children. Make sure they’re not neglected.
I hope that having this ‘disaster’ scenario in the back of your mind will help remind you the questions that you need to ask when assessing someone’s risk with regards to a suicide attempt.