The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 10: Psychiatric ProblemsTable 10-20: Risk Factors and Considerations in the Evaluation of Suicide Risk• Significant suicidal ideation*26 picas• Specific intent or plan*; available means• Hopelessness*• Previous suicide attempts*• Depressed mood, mood disorders*• Family history of suicide or mood disorders*• Schizophrenia, psychosis (not necessarily command hallucinations)*• Organic mental syndromes*• Intoxication with alcohol*, other substances• Recent major loss, particularly through suicide• Preoccupation with death• Fantasies of reunion through death• Homicidal rage• Caucasian race**These factors have been documented as risk factors for suicide.XSource: Kobayashi J. Psychiatric Issues. In Anderson JR, ed. Guide to Clinical Care of Women with HIV. Rockville, Maryland: U.S.Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, 2001, p.308.It is important to ask specific and direct questions such as the following:• How are you feeling today?• Has it ever become so (painful, frustrating, difficult, frightening) that you havethought about giving up? About ending your life? Would you ever considerdoing so? Under what circumstances have you considered this?• Do you currently have any thoughts or plans to hurt yourself? 66When a patient admits to suicidal ideation, inquire about whether he or she has thought abouta specific plan to carry it out. Ask about the consequences of doing so, to the patient and thosein the patient’s life. Assess whether there is an intent to die, even if the methodology seems notvery lethal to the provider, for example, the patient says he or she will take 20 pills which maynot be biologically lethal, but psychologically is intended to end life.Providers are often reluctant to ask about suicidal ideation. Asking does not engender suchideas in people who do not have those thoughts to begin with. When a provider asks aboutsuicidal ideation, it acknowledges the amount of pain and suffering the patient has endured,and often feels supportive and caring to the patient. It is also important to understand that theidea of suicide may provide to some a sense of ultimate control when it appears that control overthe mind, body, or environment is slipping away. It would be unusual for anyone who experiencesthe shock of a new diagnosis of HIV, cancer or loss of function to not consider how muchlife is worth living and under what circumstances. Simply being able to verbalize the feeling ofhaving ultimate control, and deciding if that is even a possibility, may help patients feel understoodand more in control of their lives. Suicidal ideation may also be a sign of undiagnoseddepression, undertreated pain, or other co-morbid conditions.U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 231