Psychiatry Clerkship - Suicide

Front 1

What % of pts see their PCP within a month of committing suicide?

Back 1

40%

Front 2

Male docs are _._x more likely to commit suicide then gen pop

Female docs are _-_ as likely

Back 2

Male docs are 1.5x more likely to commit suicide then gen pop

Female docs are 3-4x as likely

Front 3

% of med students with suicidal ideation each year

Back 3

~11%

Front 4

Minimum suicide assessment

Back 4

- Is the pt thinking about suicide?
- If so, is there a plan?
- If so, how far has the pt come to following through?
- Will the pt be safe if he leaves?

Front 5

Residents with a gun in their home are how much more likely to experience a suicide?

Back 5

5x more!

Front 6

What medical dz is intimately associated with depression?

Back 6

Heart disease

Front 7

one in ___ people have an episode of major depression.

One in ___ people with heart disease have an episode of major depression.

Back 7

one in SIX people have an episode of major depression.

One in TWO people with heart disease have an episode of major depression.

Front 8

______ out of ten pts with depressive illness will improve through txt with medicine and psychotherapy.

Back 8

EIGHT out of ten pts with depressive illness will improve through txt with medicine and psychotherapy.

Front 9

Most significant risk factor for suicide besides past attempt

Back 9

presence of a psychiatric disorder.

Front 10

Psych dx that carry the greatest risk of suicide

Back 10

Major depressive d/o
Cluster B personality d/o
Schizophrenic d/o
Substance use d/o

Front 11

As well as past suicide attempts, it is important to ask about _____ attempts.

Back 11

As well as past suicide attempts, it is important to ask about ABORTED attempts.

Putting a gun to one's head and not firing.

Not jumping, etc.

Front 12

Something to consider when rx antidepressants to suicidal pts

Back 12

Make sure meds are low lethality in overdose.

Front 13

T or F: benzos should be tapered off

Back 13

T

Front 14

Studies have shown major reductions in the risk of both suicide and suicide attempts with use of what drug?

Back 14

Long-term txt of bipolar d/o and MDD with lithium salts.


But has a toxicity in overdose!

Front 15

T or F: anti-convulsants for mania have been shown to decrease suicide attempts

Back 15

F. No evidence yet.

Front 16

What anti-psychotic medicine has been shown to decrease suicide risk?

Back 16

Clozapine (for schizophrenia and schizoaffective d/o)

Front 17

SE of clozapine?

Back 17

Agranulocytosis
Myositis

Front 18

Txt of choice in pts with catatonic sx?

What other types of pts can benefit from this txt?

Back 18

ECT. Regardless of dx!

Pts in whom medical tx is not appropriate (pregnancy, prior tx failure)

Front 19

Chronic suicidal ideation is best treated in what setting as long as what is present?

Back 19

Best treated on an outpatient basis, as long as both a supportive living situation and an ongoing doctor-patient relationship are available.

Front 20

Release from ED with f/u recommendations may be possible after a suicide attempt or in the presence of suicidal ideation/plan when:

Back 20

1. Suicidality is a reaction to precopitating events (eg, exam failure, relationship difficulties)

2. Plan/method and intent have low lethality

3. Patient has stable and supportive living situation

4. Patient is able to cooperate with recommendations for f/u, with treater contacted, if possible, if pt is currently in treatment.

Front 21

Three general steps to suicide assessment

Back 21

1. Elicitation of SI from pt (and corroborating sources if possible)

2. Data about known risk factors increasing SI: age, sex, EtOH, presence of psychosis

3. Clinical decision about the acute danger.

Front 22

Describe the "Behavioral Incident" validity technique.

What are some prototypes?

What is a caveat with this method?

Back 22

Instead of "Do you date often?" (patient is embarrased to say no), say "How many dates have you had in the past several years?"

Prototypes:
- What did you father say then?"
- Did you put the razor blade up to your wrist?
- When you say you "threw a fit," what exactly did you do?
- How many bottles of pills did you store up?
- Tell me what happened next

Caveat: this method is time-consuming

Front 23

Describe the "Gentle assumption" validity technique.

What are some prototypes?

What is a caveat with this method?

Back 23

Instead of:
"How many times do you masturabate?" ask
"How many times do you find yourself masturabating?"

Can add "...if at all" at end to soften

Prototypes:
- What other types of street drugs do you like to use?
- How many times a week do you and your wife argue?
- What other ways have you thought of killing yourself?

Caveat: these are leading questions!

Front 24

Describe the "Denial of the specific" validity technique.

What are some prototypes?

What is a caveat with this method?

Back 24

After a pt has denied "What other street drugs have you used?" then can often get answers using specific questions

Prototypes:
- Have you thought of hanging yourself?
- Have you thought of overdosing?
- Have you thought of shooting yourself?

Caveat: Need to pause between each question. Do not ask multiple questions at once.

Front 25

What are the four time-frames of the CASE approach?

Back 25

1. Presenting (first) events
2. Recent events (in last 8 weeks)
3. Past events
4. Immediate events and plans for the future.

Front 26

What is a good question to assess how a patient feels about the fact that the suicide attempt was not completed?

Back 26

"What are some of your thoughts about the fact that you are still alive now?"

Front 27

Three questions you might forget to ask about suicide assessment

Back 27

1. Were you drinking?
2. What do you think stopped you from taking more (pills)?
3. Not really? How about even vague thoughts?

Front 28

What is the basic general idea of the CASE method of assessing suicidal ideation?

Back 28

Asking pt to relate a "verbal videotape" of four different time frames.

Front 29

Basic method of step 2 of the CASE method: Exploration of recent suicidal events

Example questions

Back 29

After step one (the presenting event), the clinician uses a Gentle Assumption to reveal the next method of suicide, followed by a series of Behavioral Incidents

A Gentle Assumption is then used to reveal the third method, followed by a series of Behavioral Incidents,

If a Gentle Assumption is answered with a blanket denial, then the clinician should use a series of Denial of the Specific.

This is then followed by an exploration of combined recent suicidal ideation: "I was wondering, over the past 2 months, how much time have you been spending htinking about various ways of killing yourself, just so I have a clear idea of this?"

"Do you have a gun in your house?"
"Have you ever gotten the gun out with the intention of thinking about using it to kill yourself?"
"Have you ever loaded the gun?"
"Have you ever put the gun up to your body or head?"
"How long did you hold the gun there?"
"Did you take the safety off?"
"What stopped you from pulling the trigger?"

Front 30

Step 4 of the CASE method

Back 30

Exploration of Immediate Events: focusing on Now/Next

"Right now are you having any thoughts about wanting to kill yourself?"

"What would you do later tonight or tomorrow if you began to have suicidal thoughts again?"

Front 31

What is useful about a safety contract for suicide?

Back 31

It is a very sensitive assessment tool! You can assess the patient's level of commitment.

Provider can change mind based on hesitancy to contract, avoidance of eye contact, or other signs of deciet or ambivalence.

"It looks as though this contract is hard for you to agree on. What's going on in your mind?"