Chapter 229. The Suicidal Patient

1. What terms and concepts are required for understanding suicidality?

2. What are chronic or predisposing risk factors for suicide?

3. What are acute or potentiating risk factors for suicide?

4. What are protective risk factors for suicide?

5. How does the hospitalist determine in the patient is at baseline risk for suicide or elevated risk?

6. How does the hospitalist device a plan of care for the suicidal patient?

Suicidality (defined as one's attraction to suicide) is very common in patients with severe psychiatric disorders even though completed suicide (killing oneself) is relatively rare. The risk of suicidality is never zero. Even patients hospitalized for medical or surgical reasons, many of whom also have severe psychiatric disorders, experience suicidality but since the focus of their care is medical or surgical rather than psychiatric, their suicidality often goes unnoticed, unevaluated and untreated. Given, then, the hospitalist's high likelihood of treating patients experiencing suicidality, all hospitalists require the knowledge and skills necessary to assess and manage patients with varying levels of suicidality. Accordingly, a working knowledge of, and fluency with, terminology surrounding suicidality is required. Assessment (including screening) involves exploring the patient's overall risk profile, including chronic/predisposing factors, the acute/potentiating factors, and protective factors. Subsequently, the hospitalist must determine whether the patient's overall suicidel risk is at or above baseline. Finally, the hospitalist must devise appropriate management to address the patient's suicide risk.

A hospitalist is most likely to address suicidality with patients in three distinct situations:

1. Patients who may not overtly express suicidality but are at increased risk for suicide and should be assessed

2. Patients who express suicidality while hospitalized

3. Patients admitted after a suicide attempt

Patients who are admitted after suicide attempts are the most conspicuous examples of suicidality and because of this receive the most attention in our literature. However, hospitalists will see many more patients silently at risk for suicide than those who are admitted for overt suicide attempts. Many hospitalists do not detect the underlying increased risk for suicide and therefore do not inquire further. This chapter addresses the practical knowledge and skills required to assess suicidality in any hospitalized patient. This information can be applied in most commonly found situations where suicidality is suspected. The hospitalist can be a first line of defense against suicide by accurately assessing and treating the hospitalized patients who are at increased risk for suicide.

The terminology used to describe thoughts and actions related to self-harm is often confusing for health care professionals. The following construct (Figure 229-1) frames the essential vocabulary and concepts, defines key terms, and describes an easily accessible construct for suicidality.

The Spectrum of Suicidality

The terms suicide, completed suicide, or “successful” suicide all refer to the actual act of killing oneself. A suicide attempt is ...