hello fellow medics,
I hope you are all well and working hard towards your exams.
In this blog I am going to talk about an area that causes students/doctors a tiny bit of anxiety: being faced with a suicidal patient.
Both in a clinical setting and in the OSCE, there are some important considerations to make a safe risk assessment of the situation, and hence manage your patient accordingly.
Lets get started…
A good history
When taking any history will allow you to naturally pick up on information that will help you to find out if this patient is at risk of causing harm to themselves. So practice those skills of: taking a thorough psychiatry history and communication skills.
Previous psychiatric history
A patient with a previous psychiatry history is more at risk, i.e. a long history of depression/anxiety, substance abuse, previous deliberate self harm or suicidal ideations. You want to also find out if they have been admitted into a mental health hospital (informally or formally). Finding out why they had the admission, the treatments and for how long, will give you an idea of how serious their mental health has been and can be- don’t underestimate the past.
Social situation
I have emphasised in previous blogs how important social history is for so many reasons. In this case, if you have a patient who has suicidal ideation, you want to ask about: who they live with (living alone being more worrying than living with friends and family), do they partake in illicit drugs/alcohol (with these two, the act of deliberate self harm is far more risky), do they have family (this will be protective, i.e. a husband or brothers or sisters. More on this below). Do they have a job? Do they have financial difficulties?
Previous DSH (deliberate self harm) /suicidal ideations
Ask if they have ever done any DSH, if so: what type of DSH and what were their intentions (ending life Vs Getting some release/feeling pain). If they have had any suicidal intent in the past, what did they do and what happened? Did someone find them? Did they tell someone/call 999.
Protective factors
These are factors that may protect someone from committing suicide that you want to find out about. You would like to know their family set up, do they have children, do they have a caring wife/husband. Are they religious? Some would say that if they have a faith, that this may be protective. Do they live with people who can keep them safe. There are many factors which will make you feel that the patient is safe, this may be a combination of many things you have picked up or just a gut feeling. This gut feeling has to be supported by a good consultation however.
Access to items
Patients who have suicidal intent with an overdose and also have access to medications (i.e. they take antidepressants and may be stock piling) Vs a patient who would think about shooting themselves, but have no access to a gun (although this is debatable as the act of ‘shooting’ is more violent and therefore more worrying). The point is: Do they have access to anything harmful? Again, it takes some digging and communication skills to 1) maintain trust with the patient 2) avoid alienating them 3) show compassion.
Intent
Asking a patient with suicidal thoughts the question “Are you planning on ending your life?” may sound ridiculous, but patients may wish they were not here, want to be dead BUT not actually have the intent. Both situations are worrying, but if they have NO intent to do it, it gives time to organise community mental health team rather than a ‘crisis’. This comes with practice and trust between you and your patient.
I hope you found the above useful and it has given you some notes to go by. It is an intense subject, but so common in real life and also tested in OSCEs. The key message: be kind, compassionate and have great communication skills. Listen to the patient and be a non judgemental empathetic doctor/medical student.
Best of luck with all your revision, i know it has been tough on all students and doctors throughout the World, don’t lose hope and keeping working towards the end goal.
L x