Dr Daniel Gileppa (MBBS, FRANZCP)
As medical practitioners, we are accustomed to a certain process when seeing patients. They come to us with signs and symptoms, we elucidate the history, perform a focused examination, and order investigations, and at the end of it we formulate a list of probability-based differential diagnoses. We communicate this to the patient and prescribe an appropriate treatment. The patient desires a life free of their ailment, with both doctor and patient in alliance against the identified disease process. This process is sometimes referred to as the “Medical Model”, and for all the criticism, we still follow it because we know it works. The suicidal person often turns this whole paradigm on its head. This type of patient does not want to live (or is at least ambivalent about living), and there is often not a disease per se, with the majority of cases of suicidal ideation arising from social factors such as relationship breakdown, lack of meaningful activities, financial pressure, accommodation instability, and social isolation. Individuals with a sense of purpose who are socially and financially stable are rarely suicidal. In addition to social stressors, there are often underlying patterns of unhelpful thinking and counterproductive behaviour, though these do not generally respond to pharmacological measures or coercive practices. Of course, there may be an underlying mental illness, and pharmacotherapy for these individuals may be appropriate, but we are then left with the dilemma of providing a potential means of suicide to a person with an established history of suicidal thinking. Further complicating matters is the potential for some psychotropic medication (particularly antidepressants) to increase suicide risk, and we do not yet have any reliable way to predict the patients in whom this adverse effect will occur.
The paradox in all of this is that we, as medical practitioners, are expected to be experts in assessing and managing what is essentially a sociocultural problem, when we are predominately experts in treating medical problems. So, what can we do?
My general approach:
Here is my general approach to the suicidal patient. There are countless online resources that outline how to undertake suicide risk assessment and management, many of which are several pages long, filled with charts and jargon – overwhelming for the novice and unwieldy to take into an interview. I’ve found the most helpful tools to be a piece of paper with a list of known risk factors for suicide, a safety plan template, and a positive attitude.
The first step is one that I don’t see in many assessment guides. One should take several deep breaths and do one’s best to extinguish prejudices and negative feelings about the patient. Kindness and empathy are your friends. There is nothing to be gained from taking an interrogative or accusatory stance. The patient is not behaving in this way to annoy you or to make your life hard. They are not doing it to draw attention, expect perhaps to draw attention to their last-ditch call for support before taking the final step to end their life. If you are unable to take an empathic, non-judgemental approach, then there is a real risk of doing more harm than good.
Talk to the patient as though they are a person. Run through their day. Elucidate the sequence of events that culminated in their presentation to hospital. What are the stressors? What has helped in the past? What do they think might help in the future? Who are the supportive people in their life? What gives their life meaning?
Next, ask questions that will help you to identify the patient’s risk factors for suicide. Try to determine which of these things could change, and who could help to make these changes happen. Some factors (such as cultural background and past history of suicide attempts) cannot be changed, and these factors help to determine the patient’s “baseline” suicide risk. Knowing this information will help you to make an informed risk statement, where you can comment on the patient’s current risk in relation to their baseline risk, as well as any efforts that could be made to mitigate the risk. This kind of qualitative statement is much more useful than the traditional quantitative (high/medium/low) approach to risk assessment.
Finally, if safe to do so, formulate a safety plan, preferably in collaboration with a family member or close friend. When in doubt, ask for the support of the mental health team.
Nobody wants to be a “difficult patient” or a “frequent flyer”. Learn how to centre yourself, how to calm yourself, how to not take things personally, and how to reframe difficult situations in a positive way. If you, as a (hopefully) functional and resourceful individual, are not able to do these things during a standard day, then how can you expect a patient to do them on what could well be the worst day of their life?
BE KIND – even when the patient is belittling and rejecting you. Especially when the patient is belittling and rejecting you. You’re dealing with a wounded animal – the onus is on you to prove that you mean no harm. Show them that the human race isn’t quite as terrible as they might imagine, and perhaps they won’t be so hasty to leave us behind.