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. This concept is important because clinicians can be lulled into false senses of security when the risk may seem to be low; consequently, clinicians may not fully assess a patient’s risk for suicide. Even when patients with severe psychiatric disorders are hospitalized for medical or surgical reasons, their suicidality often goes unnoticed, unevaluated and untreated, because the focus of their care is medical or surgical rather than psychiatric. Given the hospitalist’s high likelihood of treating patients experiencing suicidality, all hospitalists require knowledge and skills necessary to assess and manage patients with varying levels of suicidality. Assessment (including screening) explores the patient’s overall risk profile: chronic/predisposing factors, acute/potentiating factors, and protective factors. Clinicians must determine whether the patient’s overall suicidal risk is at or above that individual’s baseline. Finally, the hospitalist must incorporate this information and devise appropriate management to address the patient’s suicide risk.
There is a wide range of experience on suicide and suicide rates around the world depending upon cultural views. For example, Japan has many similarities to the United States but very different suicide rates, related demographics and phenomiology. This chapter will draw demographic and phenomonolgic information from data and experience within the United States. However, the broader concepts on screening and assessment for suicidality should translate to other cultures.
ASSESSMENT OF SUICIDALITY
A hospitalist is most likely to address suicidality with patients in three distinct situations:
Patients who may not overtly express suicidality but are recognized at increased risk.
Patients who express suicidality while hospitalized.
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 coverage in the literature. However, hospitalists will see many more patients silently at risk for suicide than those admitted for overt suicide attempts. This chapter will address the practical knowledge and skills required to assess suicidality and to formulate a cogent treatment plan for hospitalized patients.
The terms, suicide, completed suicide, or “successful” suicide all refer to the actual act of killing oneself. A suicide attempt is an act of deliberate self-harm with the intent to kill oneself. However, the act may not seem deliberate (eg, taking too many pain medications) so the degree of intent (ie, the wish to die) may be difficult to ascertain from the patient. The degree of lethality (ie, the likelihood of completion) is typically not difficult to ...