Suicide

As of 1 Feb 2014. Questions, unless otherwise indicated, are from the APA Practice Guideline on suicide or Kaplan & Sadock [2007, unless otherwise noted.

DSM-5

DSM-5 additions are NOT included since the 2014 Board exams are to be based on DSM-IV-TR

Suicide rate

Q. What is the rate of suicides in the US, the annual number per 100,000?

Suicide rate

Ans. 12/100,000

Among Medical Specialties

Q. Among medical specialties, which has the highest rate?

Among Medical Specialties

Ans. Psychiatrists, followed by ophthalmologists and anesthesiologists. Women psychiatrists are especially vulnerable, about 4 times the national average.

Spinal Fluid

Q. Spinal fluid findings of suicides?

Spinal fluid

Ans. Reduced levels of serotonin and of 5-HIAA

Suicide assessment

Q. What is the value of a suicide assessment? Do such assessment’s have a high predictive level?

Suicide assessment.

Ans. Not a reliable predictor of suicide, but are of value as to what questions to ask, providing answers that assist the clinician in making the clinical assessment and judgment.

Suicide Practice Guideline, AJP Supplement, November 2003

Protective as to suicide

Q. The Practice Guideline on suicide list ten items that are relatively protective. List them.

Protective as to suicide - 1

Ans. [We all know exceptions, but the following tends to be statistically true.]

1. Children in the home2. Sense of responsibility to family3. Pregnant4. Religiosity5. Life satisfaction6. See next slide

Protective as to suicide - 2

6. Reality testing ability

7. Positive coping skills

8. Positive problem-solving skills

9. Positive social skills

10. Positive therapeutic relationship.

[Note that #1 and #3 are ripe for examiner’s questions.] Two other factors not mentioned: 1] female; 2] obesity seems protective.

Risk per disorder

Q. While “prior suicide attempt” is riskier than any Disorder, which disorder has the highest rate of suicides?

Risk per disorder

Ans. Eating Disorder has the highest rate, just ahead of MDD.

Low rate

Q. All disorders have a higher rate than the general population -- except which Disorder?

Low risk

Ans. Intellectual Disability pts have a lower rate than the general population.

Med that reduces suicides

Q. Which med has the strongest evidence of reducing suicides?

Med that reduces suicides

Ans. Li

Anticonvulsants

Q. What about anticonvulsants that are regarded as mood stabilizers? Can they reduce suicide?

Anticonvulsants

Ans. No evidence they decrease the risk of suicide. Even studies with a large N have not come close to equally the protective impact of Lithium.

FDA

Q. Which, if any med, has FDA approval for reducing the risk of suicides?

FDA

Ans. Clozapine when used with people who have schizophrenia is seen as protective against suicide.

ECT

Q. ECT any help in reducing suicide?

ECT

Ans. Practice guideline say yes, “at least in the short term.”

Psychosocial approaches

Q. Do psychosocial approaches reduce risk of suicide?

Psychosocial approaches

Ans. CBT and DBT both have studies suggesting they are effective.

[Probably no exam question will assume that psychosocial approaches are not helpful.]

Documentation

Q. Role of documentation?

Documentation

Ans. While suicide risk is not predictable, any exam question will expect a thorough documentation of the risk – partially for legal protection should the pt suicide. Restated, good documentation that you explored and weighed the risks reduces your legal risks.

Suicide contracts

Q. Value of suicide contracts?

Suicide contracts

Ans. Not recommended in ER, or when pt is agitated, psychotic, impulsive, or under the influence. Has no legal standing.

Communications with others

Q. What to do if pt seems very suicidal and refuses to let you speak to his wife or anyone else?

Communications with others

Ans. “The psychiatrist is justified in attenuating confidentiality to the extent needed to address the safety of the pt.”

Post-suicide communications

Q. Your pt has suicided? What to tell his family? What not to tell?

Post-suicide communications

Ans. In allaying grief and, if indicated, helping family members, you should avoid:

-- revealing confidential info

-- avoid self-incriminating statements

-- avoid self-exonerating statements