The brief medication management appointment confronts clinicians with challenges in identifying and treating patients at risk for suicide. The appointment can be as short as a “5-minute med check,” especially in high-volume practices. In this setting, screening for suicide risk is often overlooked for a variety of reasons, including heavy patient loads.1
Psychiatrists prescribe only 23% of all psychotropic medications in the United States.2 General practitioners, obstetricians, gynecologists, and pediatricians write 59% of psychotropic prescriptions; other physicians and nonphysician providers prescribe 19%. Nonpsychiatric physicians prescribe psychotropic medications to treat psychological symptoms associated with medical illnesses as well as psychiatric conditions. When the focus is on medical issues, the psychotropic drugs may not be assessed regularly.
Psychoactive drugs as lethal means
The opportunity for drug overdose exists when clinicians prescribe large amounts of medication for at-risk patients who are seen briefly and infrequently.3 For example, daily 1000 mg of an anticonvulsant, 1200 mg of lithium, 40 mg of an antidepressant, 5 mg of an atypical antipsychotic, and 10 mg of a sleep medication are prescribed for a depressed bipolar patient. Thus, a 90-day prescription, provides the patient with 90,000 mg of an anticonvulsant, 108,000 mg of lithium, 3600 mg of an antidepressant, 450 mg of an atypical antipsychotic, and 900 mg of a sleep medication. A 30-day supply of these medications would be lethal if taken all at once. Nonadherence with the medication regimen can result in a lethal supply of prescribed drugs for the suicidal patient.4
Suicide attempts and completions with stockpiled, prescribed drugs are more likely to occur when visits are infrequent. Clinical continuity and vigilant monitoring break down. The therapeutic alliance can become attenuated or nonexistent. As a consequence, the high-risk suicidal patient may not contact the clinician for help when experiencing an acute crisis.
Screening for suicide risk
The Suicide Risk Screening Alert (Table 1) is derived from general evidence-based, commonly occurring, acute and chronic risk factors. The alert is not a comprehensive suicide risk assessment instrument. It has no psychometric properties. It is a clinical tool that assists the clinician in identifying evidence-based suicide risk factors quickly. Then if indicated, it assists in performing a comprehensive suicide risk assessment that systematically evaluates both risk and protective factors.3
Patients with complicated psychiatric conditions are routinely treated in split-treatment arrangements. Patients who have been recently discharged from psychiatric hospitals or from partial hospitalization programs remain at substantial suicide risk. Collaborative relationships can enhance identification and treatment of the suicidal patient. However, contact between the medication prescriber and therapist tends to be infrequent or nonexistent—insurance does not cover time spent in communicating about patients.
a clinical tool that assists clinicians in
identifying suicide risk factors
• Psychiatric diagnosis
• Suicidal ideation and plan
• Prior attempt(s) and deliberate self-harm
• Anxiety and depression
• Substance abuse
• Recent interpersonal loss
• Impulsivity and aggression
• Family history of suicide
• Recent discharge from a psychiatric hospital
• History of physical and sexual abuse
Table 2 lists intervention options available to the clinician treating the suicidal patient. The severity of the patient’s psychiatric condition and the clinician’s experience and training will determine the interventions. Consultation tends to be underused, often because consultations are not usually covered by insurance.
for patients at risk for suicide
• Conduct systematic suicide risk assessments
• Increase frequency and length of visits
• Review and adjust medications
• Refer patient to intensive outpatient psychotherapy program
• Refer patient to partial hospitalization program
• Maintain contact with therapist in split-treatment arrangements
• Obtain consultation; “never worry alone”
• Hospitalize patient
The distinction between acute and chronic high suicide risk informs clinical interventions. However, no bright line separates acute from chronic high suicide risk. The term “acute” describes the intensity (severity) and magnitude (duration) of the symptom. A high-risk factor is supported by an evidence-based association with suicide.5 Some patients remain at high risk for suicide for periods that can last for hours, days, weeks, or even a few months.5 Patients at chronic high risk for suicide can become acutely suicidal in response to specific psychosocial stressors or to idiopathic worsening of their disorders.
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