Develop a Suicide Protocol
It is important for a health care clinic to develop its own suicide protocol, taking into account the organization's workflow and resources. Each individual clinic should determine:
- A clear process for risk assessment
- When to involve the on-call mental health clinician
- When and how to use local or national hotlines
- When to use on-site security, if available
- When and how to access 911, and what to with the patient while waiting
A recommended resource for establishing a clinic-based protocol to assess and minimize suicide risk is Bonner L, et al., Suicide Risk Response: Enhancing Patient Safety Through Development of Effective Institutional Policies. Advances in Patient Safety: From Research to Implementation. Vol 3, February 2005.
More About Risk Factors for Suicide
Literature suggests that a history of self-harm attempts, in combination with a history of well-developed suicide plans, place the patient at a greater eventual risk of completing a suicide attempt (Bostwick, 2000).
In a national clinical survey, suicides were found to be most frequent in the first two weeks following hospital discharge. The highest suicide completion rate occurred on the first day post-discharge. Additional suicide risk factors included patients being less likely to continue community care, more likely to have missed the last follow-up appointment, and more often out of contact with services at the time of suicide (Meehan, 2006).
The clinician should consider previous history of suicide attempts; chemical dependency; personality disorder and/or physical illness; family history of suicide; single status; recent loss by death, divorce or separation; insomnia; panic attacks and/or severe psychic anxiety; diminished concentration; anhedonia; hopelessness post-traumatic stress disorder (PTSD); or suicidal ideation (Claassen, 2007). Circumstances such as clear past examples of a sense of competence to execute an attempt, a sense of courage to make the attempt, behaviors that ensure the availability of means and opportunity to complete, concrete preparations to enact the suicide plan, and a current episode of severe depression combine to pose a greater danger of eventual completed suicide.
Patients with comorbid major depressive episode and PTSD are more likely to have attempted suicide. Women with both disorders were more likely than men with both disorders to attempt suicide (Oquendo, 2003).
In addition to the risk factors listed above, the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study found that previous suicide attempters had more concurrent general medical and psychiatric comorbidities, an earlier age of onset of the first depressive episode, as well as more depressive episodes. The study found no racial or ethnic distinctions between previous attempters and non-attempters, when controlled for age, gender and severity of depressive symptoms (Claassen, 2007).
More About Interventions to Prevent Suicide
In the Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) study, suicidal ideation rates declined in patients who receive care based on treatment guidelines and who used a care manager (Bruce, 2004).
In the Improving Mood Providing Access to Collaborative Treatment (IMPACT) Study, 1,801 primary care patients were randomly assigned to collaborative care or usual care. Intervention subjects had less suicidal ideation at 6 and 12 months, and there were no completed suicides for either group in 18 months (Unützer, 2006).
Another study found suicide attempt incidences highest in patients who received medication from psychiatry (1,124 per 100,000 patients) versus from primary care (301 per 100,000 patients) (Simon, 2007).
Involve Mental Health Specialists
Involve same-day mental-health for any of these situations:
- Suicidal thoughts and/or plans that make the clinician uncertain of the patient's safety
- Assaultive or homicidal thoughts and/or plans that make the clinician uncertain about the safety of the patient or others
- Recent loss of touch with reality (psychosis)
- Inability to care for self/family
Involvement could include:
- Appointment with psychiatrist and/or psychotherapist
- Phone consultation with psychiatrist and/or psychotherapist
- Referral to the emergency department
(Dieserud, 2001; Whooley, 2000)