Manage​

The focus of suicide risk management

All people who are suicidal are ambivalent, wanting to die and wanting to live. Keep in mind that suicidality is a fluid state and can change dramatically in the space of a few hours.

Suicide management should:

• optimize the safety of the person
• communicate concern, caring and support
• intervene wherever possible to decrease risk and increase reasons for living
• provide immediate symptomatic relief for insomnia, agitation, anxiety
• treat identified psychiatric disorders (see Table 13.2 for management of suicidality issues for specific psychiatric diagnoses)
• offer hope of a positive treatment outcome

Personal safety for primary care providers is equally important. If a suicidal patient is threatening in any way, remove yourself and others from the situation and call 911.

Table 13.2: Management of suicidality issues for specific diagnoses

Psychiatric disagnosis	Implications for management
Major depressive disorder	Antidepressants can increase suicidality (uncommon); occurs early, may be higher in adolescents. Follow up weekly for first four weeks; biweekly for next four weeks.
Schizophrenia	Clozapine is indicated in patients at high risk for suicidal behaviour.
Bipolar disorder	Lithium may be the drug of choice in patients at high risk for suicidal behaviour.
Substance abuse disorder	Assess over early weeks of abstinence / decreased intake for sustained depression.
Borderline personality disorder	Dialectical behavioural therapy and other psychotherapies can reduce the risk of suicidal behaviour.

The patient with a suicide plan and high intent

If your patient has a plan and tells you that he or she has a strong intent to follow through, or if the plan is highly lethal (e.g., firearm), further questioning is probably not warranted. This patient should be transferred immediately to the nearest emergency room.

The patient with low intent but serious risk factors

If your patient denies a plan or has low intent to follow through in the short term, but has one or more serious risk factors, request an urgent psychiatric consultation (within 24 to 48 hours). Also, follow these steps:

• Wherever possible (with the patient's agreement) get corroborative history from family, friends or co-workers to confirm your assessment of risk.
• Remove lethal weapons and medications from the home. Have a responsible family member or friend call you to report that this has been done. If you have reason to doubt that the weapons or medications have been removed, involve the police.
• Ensure that the patient and family know how to reach you if suicidal thoughts worsen.
• Provide symptomatic relief (e.g., small quantities of benzodiazepine for agitation or insomnia, but a high enough dose to be effective).
• See the patient the next day to reassess, and then frequently (as dictated by level of suicidal intent) until psychiatric consultation takes place.

The patient with suicidal thoughts but no plan

Patients who have suicidal thoughts but no plan and no serious risk factors (e.g., previous attempt) can often be managed in the primary care setting.

• Talk to a family member, friend or co-worker of the patient to confirm your impressions and get additional history.
• Remove any lethal weapons or dangerous amounts of medication from the home. Have a responsible family member or friend call you to report that this has been done. If you have reason to doubt that the weapons or medications have been removed, check with another family member, or involve the police if firearms are involved.
• Ensure that the patient and family know how to reach you if suicidal thoughts worsen.
• If your patient lives alone, try to find a family member or friend who will stay with the person until treatment begins to have an effect.
• Provide symptomatic relief (e.g., small quantities of benzodiazepine for agitation or insomnia, but a high enough dose for it to be effective).
• Start treatment for depression. Whenever possible opt for an SSRI over more lethal drugs such as tricyclic medications or MAOIs. Educate your patient about depression and communicate hope and reassurance about a positive outcome.
• Encourage the patient to reduce or eliminate alcohol use.
• Address relationship issues and other stressors. Refer the patient for counselling if you do not provide counselling yourself.
• See the patient at least weekly for the first month to monitor:
  • suicidality
  • treatment compliance
  • side-effects of medication
  • response to treatment