Suicide assessment and management self-test: How do you score?

As explained in the first part of this article in the October 2014 issue of Current Psychiatry, assess­ing and managing suicide risk are complex, difficult tasks without clear-cut, easy solutions. The case-based, mul­tiple-choice self-test, with accompanying commentary, pre­sented here is designed to enhance one’s ability to provide care for patients at risk for suicide. Part 2 of this article poses the remaining 7 of 15 questions, which are based on clinical experience and the referenced work of others.

Question 9
Mr. N, age 62, will be discharged from the psychiatric unit tomor­row. He was admitted after an overdose suicide attempt. Mr. N was depressed after the loss of his business and was “treating” his depres­sion and anxiety with alcohol. He is successfully withdrawn from alcohol and responds to medication and supportive psychotherapy. During a family meeting with staff, Mr. N’s wife states that he keeps a gun by his bedside. Mr. N has improved and is eager to go home.

Before discharging Mr. N, the psychiatrist or staff should:
a) instruct Mr. N to remove the gun from his bedside
b) instruct his wife to remove the gun from the home
c) instruct the wife to look for >1 gun
d) instruct the wife, before Mr. N’s discharge, to call the staff once guns and
ammunition are safely removed according to the pre-arranged safety plan
e) instruct the wife to lock up the gun in a place that is not known to the patient

The best response option is D
Guns in the home are associated with a sig­nificant increase in suicide. All patients at risk for suicide must be asked if guns are available at home or easily accessible else­where, or if they intend to purchase a gun. Gun safety management requires a collabor­ative team approach including the clinician, patient, and person designated responsible for removing guns from the home.¹ The responsible person should be required to call the clinician to confirm that the guns have been removed and secured according to the plan. The principles of gun safety manage­ment apply to outpatients, inpatients, and emergency patients, although implementa­tion varies according to the clinical setting.

Asking the patient to remove guns from the home is too risky. Guns must be safely secured before the patient is discharged. Asking a spouse, other family member, or partner is necessary. The person asked must be willing to remove guns and ammunition according to a pre-arranged plan requiring a callback upon completion. A callback is essential because a family member in denial may do nothing to remove the guns or lock or “hide” them in the home where they will be found by a determined suicidal patient. Guns may be available outside the home, such as in the car, at the work place, or for purchase.

The essence of gun safety management is verification. Trust but verify or, better yet, verify, then trust.

Question 10
A recently admitted 56-year-old inpatient was discovered wrapping a towel around her neck. She denied suicidal intent; however, the treat­ment team viewed the incident as a suicide rehearsal. She was placed on one-to-one close observation.

Inpatient suicides frequently occur:
a) shortly after admission
b) during staff shift changes
c) at meal times
d) shortly after discharge
e) all of the above

The best response option is E
Inpatient suicides also occur at increased frequency when psychiatric residents fin­ish their rotations and in understaffed psychiatric units.² Undue delay in the evaluation of a newly admitted acute, high-risk patient might allow the patient to commit suicide.

Most patient suicides occur shortly after hospital discharge (a few hours, days, or weeks later). Appleby et al³ found that the highest number of suicides occurred during the first week after discharge. Meehan et al⁴ found that suicide occurred most frequently during the first 2 weeks post-discharge; the highest number of suicides occurred on the first day after discharge.

Question 11
Ms. G, a 43-year-old, single woman in acute sui­cide crisis, is admitted to the psychiatric unit of a general hospital. She is diagnosed with bipolar I disorder, most recent episode depressed, and borderline personality disorder. She has had multiple psychiatric hospitalizations, all pre­cipitated by a suicide crisis. The average length of stay on the psychiatric unit is 6.3 days. After 7 days of intensive treatment, Ms. G is stabilized and suicide risk is reduced. The treatment team prepares for her discharge.

Ms. G’s suicide risk at discharge is most likely at:
a) indeterminate risk
b) low risk
c) moderate risk
d) chronic high risk
e) acute high risk