twrama 1990_final oc.. - AMA WA

COVER STORY
Compassion is key
26 MEDICUS October
By Dr Alexandra Welborn - Psychiatrist, Royal Perth Hospital
Member, Mental Health Advisory Council of the Mental Health Commission
daily request of our Consultation Liaison Psychiatry
A team at Royal Perth Hospital: “kindly assess this person
who has attempted suicide by jumping…overdose…stabbing…
cutting…burning…gassing…car crash…shooting…hanging”.
Suicide is one of the constant sorrows of psychiatry, and its
spectre is ever present in the minds and hearts of the clinicians
working with troubled patients. Kindness is essential in the
approach to patients who have harmed themselves. I have
been asked to provide a clinical perspective on suicide for the
readers of Medicus.
Karl Menninger was an American psychiatrist who
built his practice and a substantial legacy on the tenets of
humanity, kindness and compassion for his patients. He
sought understanding of the adverse early life experiences
that contributed to patients’ difficulties. Menninger made
the brilliant observation that suicidal patients may have three
interlinking motivations. There is clearly the desire to die,
but also present is the desire to be killed and the desire to kill
(Menninger, 1938).
Menninger’s beguilingly simple message provides a searing
insight into the violence that is necessarily present in an
attempt to end a life. Menninger’s understanding provides
insight into both murder/suicides and patients who attempt
suicide by enticing another to kill them, as is seen with those
who set out to behave in such a way to be killed by police.
Assessments for risk of suicide must therefore also include
the assessment of the risk of homicide, and the risk of being a
victim of homicide or accidental death.
There are historical risk factors for completed suicide.
Any previous suicide attempt is the single strongest risk
factor for death by suicide (Hawton, 2005). A person who
has made a previous attempt will then always carry this
increased historical risk. Perhaps more useful are possible
precipitants for suicide impacting on a person in the hours and
minutes before their suicidal act. These include intoxication,
interpersonal conflict, acute loss, shame and acute loss of selfesteem.
Young people might be goaded to suicide by others
on Facebook, Twitter and Tumblr. Precipitants are always
intensely personal to the individual.
Talking about suicide is sometimes difficult for nonpsychiatric
colleagues, who may be concerned that bringing
up the subject increases risk in suggestible patients. There is
no evidence that speaking of suicide with patients increases
their risk of acting.
I tend to start with a question about thoughts – “Have you
been troubled by suicidal thoughts?” This then progresses
to exploring the presence of specific plans involving
methods. This may require an interview technique called
‘normalisation’, which implies that all people may have these
thoughts from time to time. Closely observe the patient’s
affective response when asking about methods. “Have you
stockpiled tablets, bought a hose, strung up a rope, gone up
to a height?” The final set of questions in the ‘thoughts, plans
and intent’ pyramid is intent. If the person has plans try to get
a sense of how likely they are to act on them, and when.
Be alert for the possibility of evasiveness in a patient’s
response as it may indicate that you cannot access that person’s
intent. Racing thoughts indicate internal agitation. Crying and
tearfulness can indicate high levels of distress. Psychosis must
be excluded, and if present, is particularly concerning.
What can we do? The most restrictive intervention for a
patient who is assessed to be a risk of suicide is referral under
the Mental Health Act to become an involuntary patient
allowing secure care in a locked setting. Within the locked
wards and on general wards the patient can also be managed
with a 1:1 special. Medications have a place to assist with
symptomatic relief based on diagnostic understanding.
Known specific increased risk periods for suicide include
transitional times such as the two weeks on release from a
psychiatric hospitalisation, the two weeks on reception into
prison whether remanded or sentenced and the two weeks on
release from prison. Transition to care in the community requires
high levels of interagency communication, and aspirations
of seamlessness of care. Other times of risk in close-knit
communities such as schools and prisons occur after a completed
suicide in one of the members, and this is known as contagion.
Prevention of access to lethal methods such as guns and cars
is specifically important to consider in young people, as their
impulsivity is greater for biological reasons. Another important
point to note with young people is that if their friends express
suicidal thoughts and ask for confidentiality, then the message
that a responsible adult be told is critical (Brent, 2011).
We cannot predict who will die by their own hand. We can,
though, conduct a careful assessment, guided by experience,
to inform a management plan. Establish a therapeutic alliance.
Try to understand the person. Any management plan attempts
to prevent in the short term, in the medium term and in the
long term the death of the person, by suicide. However, it is not
always possible to prevent suicide. Colleagues whose patients
have died require extra compassion. To finish with the words
of Menninger, “Hope is a necessity for a normal life and the
major weapon against the suicide impulse.” ■
References:
Menninger, K., & Menninger, K. A. (1938). Man against himself.
New York: Harcourt, Brace and Company.
Hawton, K. (2005). Prevention and treatment of suicidal
behaviour. New York: Oxford University Press.
Brent, D. A., Poling, K. D., & Goldstein, T. R. (2011). Treating
depressed and suicidal adolescents: A clinician’s guide. New York:
Guilford Press.