Suicide: Three Cases and a reference point

This month I am planning a series on suicide.  Suicide remains an enigmatic problem for doctors, medicine and society.  For a long time I have been fascinated by the philosophy around suicide and the psychology that drives an individual to take their own life.  So I thought I would open a forum to discuss it all – the big-picture philosophical stuff, down to the pragmatic decision-making we employ when we see patients at risk.

Albert Camus famously wrote this as the opening paragraph to his essay:

There is but one truly serious philosophical problem and that is suicide. Judging whether life is or is not worth living amounts to answering the fundamental question of philosophy. All the rest – whether or not the world has three dimensions, whether the mind has nine or twelve categories – comes afterwards. These are games.
The Myth of Sisyphus – Albert Camus.

OK, enough of the philosophy.  Down to reality – making a decision about and with the patient in front of you.

There are a number of “suicide risk assessment tools” out there – but they all suffer the same problems.  At best they are generic reminders of the sort of history and environmental factors that we should consider when making the call to admit or refer.  My guess – we will never have a solid, evidence-based tool which can reliably predict risk in suicide – the presentation is just too broad and heterogeneous, intensely individual in its nature and often comes down to a “gut call” – which is why it is so scary.  Sure there are a few deal-breakers on history etc – but usually it comes down to your perception of risk based on the information you can dig up and your rapport with the patient.

Rob Orman (ER Cast) did a great podcast on Risk Assessment a while back which included the TRAPPED SILO SAFE mnemonic to help in your history and mental-state exam. If you haven’t heard it then check it out ASAP.

There has never been a validated risk assessment tool for suicide.  Predicting suicide is tough.  This is serious badness we are trying to prevent.  Unlike most bad diseases – we have no solid decision aides, no safety net and little in the way of efficacious interventions to offer in the short-term.

In order to get you thinking about suicide I wanted to present a few case scenarios – have a read through them and imagine you are in your ED, practice or clinic.  Think about your risk assessment, how you feel about admission, or what you might say to the Psych team when you discuss the disposition.  Then let me know – which patient are you most concerned about?  What is your plan for each?  What do you think you might be able to achieve in each case?

Kurt is a 38 y.o. man who has a background of chronic paranoid schizophrenia since age 18. He is managed by the community mental health team with fortnightly depots, is unemployed and lives with his parents.  He did attempt suicide (overdose of benzos) about a year after his initial psychotic episode.

Kurt is brought in by his father after he has become agitated at home and threatened his mother.  He has the delusional belief that she is inserting commands into his brain urging him to harm himself .  On questioning there are persistent voices that he identifies as his mother’s telling him to hang himself and degrading him.

He has been relatively stable recently, had his normal medications.  You note from the chart though – this is his 3rd presentation in a week to ED requesting “PRN” sedation to cope with his symptoms.

On specific questioning – he has resorted to alcohol to get some sleep in the past few days.  He has had 4 beers prior to arrival this evening. Denies any gunja or other drugs.  His father is concerned: he usually can talk him down when he is ‘on edge’, but tonight he seems ‘unreachable.'

Janice is well known to the ED. She has a long history of self-harm presentations. Mainly ‘cutting’ and overdoses of paracetamol, alcohol and her antidepressants.  Janice has been diagnosed with BPD, PTSD, anxiety and depression.  She is now 43, living intermittently between her mother’s and recurrent boyfriend’s homes.  Currently taking a large dose of venlafaxine-XR 300 mg.

Janice presents stating she is suicidal, she lost her meds 3 days ago and has been going “nutso” ever since.  Not sleeping or eating.  She has taken a razor blade to the bathroom twice in the last 24 hours – but not “gone through with it.”.  Her boyfriend got “sick of her shit” after this so she left there, her mother berated her when she went “home” to “get some room”.  They argued until she slapped her mother and then promptly departed – so she is essentially homeless.  Now she is in your ED.

The consultation is not going well, Janice is sobbing heavily and accusing you of “not caring” before you get past ‘Hello’.  After 20 minutes you have a detailed history of her recent relationship dilemmas.  BUt you feel she doesn’t want to discuss anything to do with admission and you don’t really trust her assurances of safety.

Sylvia is a 67 yo. woman whom you have never met before. She has presented with a referral letter from her GP. She has a history of Crohn’s disease which has been complicated by numerous laparotomies and bowel resection / division of adhesions. She suffers with chronic abdominal pain, malnutrition, nausea and struggles to keep a BMI over 18.  The letter states she has had more pain recently and the GP would like a surgeon to consider investigating her for recurrent obstruction.

As you are dutifully pulling all the data together for the Surg referral the phone rings… it is the GP.  He apologizes – sorry, new information to hand.  Sylvia’s husband has just been in to see the GP – he thinks she is planning to kill herself.  She has been systematically stockpiling her usual opiates, has made a new will and been writing ‘worrying things’ on her Facebook wall.  Hmmm.  What to do?

Now those are the 3 cases for discussion.  Just to throw a spanner in the works and keep you thinking  – I will describe one more patient.  This patient is our reference point for risk.  He serves as the benchmark for “risk of badness” in a much more familiar and well established area of risk – ACS.  Think about the potential 30-day mortality of all these cases, then how you decide what you will do to make it better.
Mr Clog is a 56 yo. man with ‘diet-controlled’ type2 DM, he is obese, still smokes and has stage 1 hypertensive renal impairment. He has presented with a 3 hour history of dull, central chest pain which came on during a particularly exciting game of rugby (on the TV).  He waited until the final whistle before presenting!  He has had no previous coronary events to date.  His initial ECG is clean and a high-sensitive Troponin is negative at 3 hours.  He is not suicidal – although Australia did narrowly go down to the All Blacks [again].  He is getting admitted for a second troponin – and given it is late, probably won’t be discharged until morning .
OK, a lot of data, a lot of risk and potential for disaster.  Definitely no correct answers this month!  Have a think, let me know – who gets a bed?  What therapy might help each of the patients?  What do you ask or want to know about each of them in order to make your call?
Hope to do some discussion with the FOAMed guys on this soon.
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