People often keep suicidal intentions to themselves. Clinical and personal risk factors play a role but are not the cause of suicidality. The approach to the suicidal patient lies in the narrative interview (“tell me how it got this far”). Concepts used to understand acute suicidality are psychological pain (“mental pain”) and suicidal mode (stress-induced state of emergency). The therapeutic procedure should be discussed with the patient. Individual warning signs and behavioral strategies for suicidal crises shall be developed and given to the patient in writing. The good doctor-patient relationship is the most effective prevention.
The big problem in clinical suicide prevention is that many suicidal people (men!) keep their suicidal intentions to themselves. After a suicide, it often becomes apparent that the person in question had seen a doctor in the days and weeks before, not infrequently even a few hours before the suicide, without the subject having come up. A Finnish study shows that at the last doctor’s appointment before suicide, the topic is raised in only 22% of cases [1]. In inpatient psychiatric treatment, it is not uncommon for patients to commit suicide even though they have signed a non-suicide contract [2].
Again and again, physicians express the wish for practically applicable risk scales. Unfortunately, this does not solve the problem. Risk scales can indicate a long-term increased risk, but hardly ever allow statements about the short-term risk – not least because suicidal patients often deny suicidal intentions even when questioned directly. The guidelines of the German Society for Suicide Prevention also state: “There is no such thing as absolutely safe suicide prevention, even under optimal caring and therapeutic-nursing conditions. Suicide prevention can only ever be an effort of all professionals involved in the patient’s care and relies on the patient ‘s cooperation” [3]. In general, if no relationship can be established with the patient in the examination (e.g., in the emergency department), one must assume an acute risk.
Risk factors
The most important risk factors indicating a long-term increased risk of suicide are psychiatric diagnoses, first and foremost that of depression, followed by addictive disorders and personality disorders, especially with anamnestic evidence of impulsivity and aggression. Personal factors such as experiences of loss (relationships, work), psychosocial problems (e.g. isolation) and somatic illnesses also play a role. By far the most important risk factor, however, is a prior suicide attempt. This increases the risk of suicide 60- to 100-fold in the long term, and increases with each subsequent suicide attempt [4]. Therefore, when taking the medical history – even outside of psychiatry – one should always ask about past mental crises and, if necessary, about past and current suicidal thoughts (just as it is part of a doctor’s routine to ask about operations and accidents that have been undergone). After all, about 5% percent of the population commit suicide attempts, although the number of those who have made suicide plans at least once in their lives is many times greater.
Talking about suicidality
For the therapeutic relationship with the suicidal patient, it is helpful to see suicide not as a symptom of a psychiatric disorder, but – quite simply – as an action. It is not depression but the person himself who commits suicide. In a survey of patients one year after the suicide attempt, as many as 10% said a prior visit to their doctor might have helped. Accordingly, many suicidal people do not feel “sick.” Actions have a history, even if it has not yet come to the point of suicide. The silver bullet for assessing suicide risk is the empathic narrative interview. The narrative in this context is defined as the story that the patient tells to an attentive listener to explain how the suicidal crisis occurred.
It has been our experience in our special consultation in Bern that patients after a suicide attempt are very well able to explain the personal logic of their suicidal crisis. It is important that the conversation begins with a narrative opening: “Please tell me the story behind this.” The patient thus becomes the expert of his or her story, in contrast to the usual doctor-patient interaction. The physician is in the position of the “not-knowing,” and the patient must educate him. On the other hand, the physician is the expert when it comes to the psychostatus and the indicated therapeutic measures.
Patients generally take between 20 and 30 minutes to tell their story, which means this level of access to the patient is also possible in the primary care physician’s office. Sometimes it may be necessary to follow up with open-ended questions, “Can you say something more about this?” It is also possible to fill in what is missing in a next consultation. Questions about psychopathology (e.g., depressive symptomatology) may follow only after the narrative interview, otherwise it is practically impossible to get away from the usual pattern of the doctor-patient relationship (the doctor asks the questions).
The common understanding acquired in this way creates a basis of trust in which patients can speak openly about their inner experience and with which an individual assessment of risk is possible. Only then is it possible to discuss the further procedure together with the patient.
Understanding suicidality
To understand the stories of suicidal patients, the following concepts of suicidality are helpful.
Psychological pain (“mental pain”): People who have attempted suicide report unbearable mental pain, e.g., due to an experience of loss or serious conflict with a loved one. Existential crises of this kind can completely unbalance a person’s self-esteem, even identity, creating a state of psychological pain. This in turn can be experienced as so threatening that
the urge to put an end to this state becomes overwhelming. Suicide thus appears as an escape or redemption from an unbearable and – apparently – hopeless acute inner state of emergency.
The suicidal mode: the concept of mode describes a psychophysical state in response to threatening situations (so-called fight-flight pattern). This pattern, characterized by acute stress symptoms, can be reactivated at any time by specific trigger events (on/off mechanism). The suicidal mode includes changes in cognition, emotion, body symptoms (autonomic nervous system), and behavior (suicide as a solution to a condition experienced as intolerable). Neurobiologically, the suicidal mode is a stress-induced change in neuronal activity similar to an acute traumatic state [5]. Due to the deactivation of certain parts of the prefrontal cortex, the problem-solving ability is massively limited, i.e. in the suicidal state of emergency we can no longer act in a considered manner, our usual strategies for coping with problems are no longer available. In suicidal mode, patients often experience dissociative states (the feeling of not being themselves, in a kind of trance state, or acting as if in “autopilot mode”). Analgesia is often also present (patients have no pain when they cut themselves) as well as an altered sense of time.
Therapeutic and preventive measures
The good doctor-patient relationship, based on a shared understanding of the suicidal crisis, is not only the most effective prevention, but also allows a much more reliable assessment of short-term suicide risk. In times of crisis, close appointments (even if they are only for a duration of 20-30 minutes), possibly telephone appointments or e-mails, can take on a vital function. Referral to a consultant psychiatrist or mental health service will often be necessary and should always be discussed with the patient. Inpatient treatment with FU (Fürsorgerischer Unterbringung) may be indicated, but would have to be explained to the patient in any case. Patients can also often be convinced that inpatient treatment with FU is necessary for their own safety. In doing so, the doctor is allowed to speak openly about his view: “I am convinced that there is a future after the crisis, and I see my job as making sure that you survive it.”
Suicidal impulses can be triggered again at any time, even acutely – the patient and therapist must be aware of this. It is therefore essential to formulate the individual warning signs and safety strategies together with the patient and to give them to the patient in writing [5,6]. In the case of repeated suicidality, fixed control appointments are helpful, even if they take place at long intervals (“keeping the connection to the patient”). It is still the case today that physicians, especially primary care physicians and psychiatrists, are a “safe place” (in the sense of John Bowlby, founder of attachment theory) for many people, especially, of course, if a therapeutic relationship has been established in the past. Knowing you have a trusted professional in your background can be a lifesaver.
Medication
Benzodiazepines are useful and allowed for acute suicidality. Antidepressants are indicated and necessary for depression with suicidality, usually SSRIs or tricyclics (dispensed in small packages because of toxicity), possibly combined with a benzodiazepine. Caveat: There may be an initial increase in suicide risk (especially increase in suicidal ideation), so frequent checks and appropriate information to the patient are critical in the first ten days. Combination with modern neuroleptics is possible.
Literature:
- Isometsä E, et al: The last appointment before suicide: Is suicide intent communicated? American Journal of Psychiatry 1995; 152: 919-922.
- Busch KA, et al: Clinical correlates of inpatient suicide. Journal of Clinical Psychiatry 2003; 64(1): 14-19.
- Working Group “Suicidality and Psychiatric Hospital” of the German Society for Suicide Prevention DGS. Suicide Prevention 2011; 38(4).
- Owens D, et al: Fatal and non-fatal repetition of self-harm Systematic review. The British Journal of Psychiatry 2002; 181(3): 193-199.
- Gysin-Maillart A, Michel K: Brief therapy after suicide attempt; ASSIP – Attempted Suicide Short Intervention Program – Therapy Manual. Verlag Hans Huber, Bern 2013.
- Gysin-Maillart A, et al: A Novel Brief Therapy for Patients Who Attempt Suicide: A 24-months follow-up randomized controlled study of the Attempted Suicide Brief Intervention Program (ASSIP). PLOS Medicine 2016; 13(3): e1001968.
InFo NEUROLOGY & PSYCHIATRY 2017; 15(2): 14-16.
