Introduction
Clinicians should clearly instruct medical support staff about how to manage emergencies involving patients with suicidal or violent behavior, such as contacting emergency services or isolating the patient from other patients.
Clinicians should obtain an emergency evaluation if they determine that a patient is at imminent risk of harm to self or others. Patients who are not at immediate risk should be referred to outpatient mental health services when the mental health treatment by the primary care clinician is unsuccessful.
Clinicians should assess HIV-infected patients for depression to ensure early detection and treatment of patients who may be at increased risk of suicide due to depressive symptoms.
Key Point:
A significant percentage of patients who commit suicide will have seen their primary care clinician in the month before their suicide. This underscores the importance of routine mental health screening in the primary care setting, which can help identify patients who are at risk for suicide and enable them to receive treatment for the underlying cause of their suicidal behavior.
Prevalence and Risk of Suicide and Violence
Key Point:
The combination of mental health and substance use disorders places people at the greatest risk for violence
Assessment of Suicidal and Violent Behavior
Detection of Suicidal and Violent Behavior
Clinicians should assess for suicidal and violent behavior at baseline and at least annually as part of the mental health assessment. (See Figure 1 in the original guideline document for the algorithm: "Assessing and Managing Suicidal or Violent Patients.")
Estimation of Risk for Suicide or Violence
Clinicians should assess patients who have expressed thoughts of suicide or violence for specific risk factors that indicate suicidal or violent intent and for impaired impulse control (see Tables 1 and 2 below).
| Table 1. Risk Factors for Suicide and Violence |
| Category |
Risk Factors |
| Suicide |
Violence |
| Demographic |
- White
- Male (males more often complete; females more often attempt*)
- Older age (>45 years)
- Divorced, never married, or widowed
- Unemployed
|
- Young
- Male
- Limited education
- Unemployed
|
| Historical |
- Previous suicide attempts, especially with serious intent, lethal means, or disappointment about survival
- Family history of suicide
- Victim of physical or sexual abuse
|
- Previous history of violence to self or others, especially with high degree of lethality
- History of animal torture
- Past antisocial or criminal behavior
- Violence within family of origin
- Victim of physical or sexual abuse
|
| Psychiatric |
- Diagnosis: Affective disorder, alcoholism, panic disorder, psychotic disorders, severe personality disorder (especially antisocial and borderline)
- Symptoms: Suicidal or homicidal ideation; depression, especially with hopelessness, helplessness, anhedonia, delusions, agitation; mixed mania and depression; psychotic symptoms, including command hallucinations and persecutory delusions
- Current use of alcohol or other drugs
- Recent hospitalization for mental health disorder
|
- Diagnosis: Substance-related disorders, especially alcoholism; antisocial personality disorder, conduct disorder; intermittent explosive disorder, pathological alcohol intoxication, psychoses (e.g., paranoid)
- Symptoms: Physical agitation; intent to kill or take revenge; identification of specific victim(s); psychotic symptoms, especially persecutory delusions and command hallucinations to commit violence
- Current use of alcohol or other drugs
|
| Environmental |
- Recent loss such as that of a spouse or job
- Access to guns or other lethal weapons
- Social acceptance of suicide
- Patient's perception of a lack of social support,** or actual lack of social support
|
- Access to guns or other lethal weapons
- Living under circumstances of violence
- Membership in violent group
- Patient's perception of a lack of social support,** or actual lack of social support
|
| Medical |
- Severe medical illness: Presence of HIV-related physical symptoms; poor adjustment to HIV disease; failed medical treatment or first hospitalization for medical illness; loss of function or intractable or chronic pain from medical illness
- Delirium or confusion caused by central nervous system dysfunction
|
- Severe medical illness: Presence of HIV-related physical symptoms; poor adjustment to HIV disease; failed medical treatment or first hospitalization for medical illness; loss of function or intractable or chronic pain from medical illness
- Delirium or confusion caused by central nervous system dysfunction
- Disinhibition caused by traumatic brain injuries and other central nervous system dysfunctions
- Toxic states related to metabolic disorders, such as hyperthyroidism
|
| Behavioral |
- Antisocial acts
- Poor impulse control, risk taking, and aggressiveness
- Preparing for death (e.g., making a will, giving away possessions, stockpiling lethal medication)
- Well-developed, detailed suicide plan
- Statements of intent to inflict harm on self or others
|
- Antisocial acts
- Agitation, anger
- Poor impulse control; risk-taking or reckless behavior
- Statements of intent to inflict harm
|
Adapted, with permission, from Cournos F, Cabaniss D. Clinical evaluation and treatment planning: A Multimodal Approach. In: Psychiatry, Second Edition. (Tasman A, Kay J, Lieberman J, eds). Chichester, England: John Wiley and Sons Ltd.; 2003.
* This distinction between male and female suicidal behavior may not apply to gay and lesbian youth, who may be at increased risk for suicide attempts associated with experience of harassment, homophobia, gender nonconformity, and disclosure of sexual identity.
** In some cases, patients who are depressed may have family or friends who are supportive, but the patients do not perceive them as being supportive.
Key Point:
People who lack adequate impulse control may represent a serious risk despite stated wishes not to harm themselves or others.
| Table 2. Factors That May Increase Impulsivity |
- Patients do not feel able to control their feelings, impulses, behaviors
- Patients are currently using or withdrawing from alcohol or ther substances
- Patients are acutely psychotic and experiencing command auditory hallucinations and persecutory delusions
- Patients have had a decline in cognitive function (gradual or accelerated)
- Patients are agitated or manic
|
Management and Referral of Suicidal and Violent Patients
Clinicians should maintain an up-to-date list of easily accessible mental health referral resources for patients who require either immediate mental health assessment or for whom assessment is less urgent.
Clinicians should attempt to involve people whom the patient perceives as supportive, such as friends and family, in treatment planning and management.
Key Point:
Social support is fundamental to effective management of suicidal and potentially violent patients and can enable patients to accept help. Sources of support may include involvement of family, friends, or community-based services and the clinician's interest in understanding reasons for patients' wishes to harm themselves or others.
Imminent Suicidal or Violent Potential
The clinician, or a member of the health care team, should escort a patient to the emergency department or call 911 when the patient expresses suicidal or violent thoughts accompanied by risk factors that indicate imminent danger. (See Figure 1 in the original guideline document for the algorithm: "Assessing and Managing Suicidal or Violent Patients.")
Non-imminent Suicidal or Violent Potential with Accompanying Risk Factors
Clinicians should refer patients who express suicidal or violent thoughts, but who are not at imminent risk, for a complete mental health evaluation when the mental health treatment by the primary care clinician is unsuccessful. (See Figure 1 in the original guideline document for the algorithm: "Assessing and Managing Suicidal or Violent Patients.")
Clinicians should discuss with patients the reasons why they think about suicide or violence and should develop a plan to modify risk factors.
Key Point:
Patients with chronic suicidal and/or violent ideation often require long-term psychiatric treatment.
Chronic Suicidal or Violent Ideation
Clinicians should refer patients who express chronic wishes to harm self or others for a comprehensive outpatient mental health evaluation and then maintain ongoing communication with the mental health provider(s) involved in the patients' mental health care.
| Table 3. Management Strategies for Chronic Suicidal and/or Violent Ideation |
| Type of Chronic Ideation |
Description |
Management Strategy |
| Chronic suicidal and/or violent ideation resulting from mental health disorders |
May be a feature of personality disorders, such as borderline or antisocial personality disorder, or a feature of chronic mental health disorder, such as schizophrenia. |
These patients usually require close coordination of treatment and communication between the primary care clinician and the mental health provider. Inpatient psychiatric hospitalization may be necessary during periods of acute crises. |
| Chronic suicidal ideation as a coping strategy |
May be a coping strategy for patients with chronic medical illness. For these patients, thinking about suicide may be an unconscious attempt to regain a sense of control over their lives. Patients may say or think, Well, if things get too overwhelming, I can always kill myself. Such thoughts may lend some sense of control to patients by providing a future option that never has to be acted on. When no other risk factors are present, most patients who express this type of suicidal thinking do not act on it. |
During acute crises or when other risk factors are present, these patients may be at more significant risk for suicide and require mental health assessment or inpatient hospitalization. |
| Chronic suicidal ideation among patients with desire for hastened death |
Some patients, usually those with more advanced disease, may request that their clinicians assist them in either suicide or hastened death. Additionally, some patients may wish to hasten their own deaths by refusing treatment. These patients may be suffering from a reversible mental health disorder, most notably depression, which could contribute to their wish to die. |
A mental health assessment should be performed to address any correctable problems, such as depression and poorly controlled anxiety, pain, or delirium. |
| Chronic suicidal ideation among self-injurious patients |
Patients may also present with chronic and repetitive self-injurious behaviors, such as cutting, that may or may not be associated with suicidal intent. These behaviors are more likely to occur in patients with borderline and antisocial personality disorders. In these patients, self-inflicted injury may be an expression of anger or frustration and serves to relieve internal tension. They may feel better after injuring themselves. |
These patients may benefit from ongoing specialized outpatient mental health treatment. They may also require brief mental health inpatient hospitalizations during crisis periods, when suicidal potential is heightened. See the National Guideline Clearinghouse (NGC) summary of the New York State Department of Health guideline Personality Disorders in Patients With HIV/AIDS. |
