Assessment and Treatment of Suicidal Thoughts

Suicidal Thoughts: Don't Deal with Them on Your Own

The assessment of people with suicidal thoughts is far from an exact science.

• If a person is evaluated by the primary health-care professional, he or she may be instructed to go immediately to the emergency department for further evaluation.
• If evaluated in the emergency department, the emergency doctor may enlist the help of a psychiatrist for more expert diagnosis and treatment.

The assessment, whether in the medical office or emergency department, includes the following parts.

Medical interview: A person who is having thoughts of suicide is interviewed extensively by medical professionals. Questions will look for warning signs that a suicide attempt is imminent, such as the following:

• Have you swallowed any medications or drugs?
• What plan do you have for ending your life?
• What circumstances in your life brought you to the point of suicide?
• Have you ever attempted suicide in the past?
• What is your family history of emotional problems or suicide, if any?
• Have you used alcohol or drugs?
• Have you recently experienced any emotional loss (such as the death of a loved one or a divorce)?
• Do you have any medical illnesses or a history of surgery?
• Are you currently taking any herbal, over-the-counter, or prescribed medications?

Mental status: A crucial part of history is the mental status examination.

• This is a formalized series of questions and commands designed to point toward any psychiatric or neurologic problems, such as depression or schizophrenia.
• The questions may seem insultingly easy, but they are designed to highlight disordered thinking and disorientation that could signal mental illness.

Physical examination: The medical professional performs a head-to-toe physical examination to look for a medical problem, particularly one that could contribute to the person having suicidal thoughts.

• The person's strength, sensation, coordination, reflexes, and ability to walk and balance are checked.
• Depending on the person's age and health status, this may take anywhere from a few minutes to over 20 minutes.
• Any abnormalities may require further evaluation because certain disease states and certain medications can actually cause depression and lead to suicidal thoughts.

Lab tests: The decision to order lab tests are based on the findings of the interview and physical examination.

• No lab test is available for depression, and no lab test is available to tell if someone is serious about committing suicide.
• Any suggestion of medical illness, drug or alcohol intoxication or overdose, or poisoning usually mandates lab tests.
• Blood and/or urine may be checked for drug and alcohol levels.

In some cases, x-ray films, CT scans, or ECGs may be ordered.

For the otherwise healthy person with no signs of depression, a psychiatric disorder, or drug or alcohol abuse, fleeting thoughts about death are usually harmless. However, any current desires to die make home care completely inappropriate.

If anyone, including the suicidal person, has concerns that the person might be depressed or have other difficulties, then home care is not appropriate.

A concerned friend, partner, or other loved one should inquire directly about thoughts of suicide.

• Contrary to conventional wisdom, asking about suicidal thoughts or plans does not put the idea in the person's head.
• If you are concerned that someone may be depressed or suicidal, then ask in a direct and caring manner.
• You might simply say, "You seem down to me, and I'm concerned. Is everything all right? Do you have any fear of being alone? Are you experiencing thoughts about death or suicide?"

The treatment for suicidal thoughts might range from gentle reassurance to hospital admission.

• In some cases, the person is sent home with instructions to return if the thoughts become persistent, symptoms of depression become evident, or the person otherwise has difficulty coping with their feelings or with situations in a healthy manner.
• In this case, follow-up with a mental-health professional is usually arranged within 48 hours.
• A medication may be started right away in an attempt to relieve the symptoms of the sufferer of suicidal thoughts. They may include:
• An antianxiety medication, like
  • buspirone (Buspar),
  • clonazepam (Klonopin), or
  • lorazepam (Ativan),
• an antidepressant, like
  • fluoxetine (Prozac),
  • sertraline (Zoloft),
  • citalopram (Celexa), or
  • venlafaxine (Effexor),
• or a medication to address anger or mental agitation, like
  • risperidone (Risperdal) or
  • aripiprazole (Abilify).
• If the person's suicidal thoughts or other tendencies are believed to be of a dangerous nature, follow-up is likely to be immediate with admission to the hospital.

If someone is admitted to the hospital because of suicidal thoughts, he or she undergoes extensive evaluation by a psychiatrist and is often started on medication and scheduled for follow-up counseling with a therapist.

From the doctor's perspective, suicidal thoughts are always to be taken seriously and evaluated thoroughly. Predicting suicide is difficult.

• People who actually commit suicide are usually terribly depressed.
• They often have alcohol or drug abuse problems.
• Many are diagnosed with schizophrenia - a serious mental illness.
• Many commit suicide in response to difficulties in their lives.
• By the same token, most depressed people, people with drug or alcohol problems, and those with schizophrenia never attempt suicide.

People who actually attempt suicide need close psychiatric follow-up and counseling.

• This may seem obvious, but many suicidal people do not get good follow-up treatment and often end up thinking of suicide (or even attempting it) again.
• Follow-up usually consists of counseling and medication for depression.
• Family therapy for teens with suicidal thoughts may be particularly helpful.

Keeping follow-up appointments in the case of suicidal thoughts is so important that the referring health-care provider will likely contact the consultant before discharging the person from the office or the emergency department.