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Suicide Evaluation in Medical Patients: A Pilot Study

Douglas Berger, M.D.

General Hospital Psychiatry, 15:2, 75-81; 1993.

Department of Psychiatry Einstein College of Medicine, Bronx New York U.S.A.

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ABSTRACT: Psychiatrists in a general hospital setting were given a questionnaire aimed at characterizing patients' suicidality. Patients evaluated for suicidality were studied for demographic, medical, psychiatric, and suicidal variables. Comparison with medical patients who had attempted/completed suicide in prior studies and recommendations to reduce suicidal impulses and improve the database were discussed.

Key Words: suicide, evaluation, medical illness/patient

INTRODUCTION

Suicidal patients are among the most challenging patients to confront a psychiatrist in the general medical setting. Chronic medical illness and pain have been found to be risk factors for suicide [1-4]. Psychiatrists working in general medical hospitals often get called to evaluate patients for suicidality. Approximately 9% of all psychiatric consultations at our institution are to evaluate suicidality. Because these high-risk patients have not been well studied, we felt that characterizing this group would give an empirical foundation for evaluation and treatment recommendations.

This was a pilot study aimed at studying the potential usefulness of a database that attempted to characterize any patient referred for suicide evaluation. Our study did not limit itself to a retrospective analysis of actual attempts or completed suicides as in previous studies.

Prior studies attempted to identify characteristics of medical patients who had attempted or completed suicide while hospitalized. One study found all attempts to be impulsive, associated with anger, and precipitated by loss of emotional support (5). These attempts were largely by patients with personality disorder and psychosis. Another study (6) characterized patients as having impaired relationships, excess emotional stress over their illness, a low pain tolerance, and a need to control the treatment. A general lack of emotional support as well as prior suicide threats were also present. Impaired alertness or disorientation was not correlated. Dialysis (7) and malignancies (8) have also been associated with suicidal behavior.

The purpose of comparing our group of patients with suicidal ideation to attempters or completers of suicide in the medical setting is to study the variables that these groups have in common and those that differ. This may allow clinicians to identify high-risk factors for suicide in patients who are consulted on for suicidal ideation. We also looked at those vaiables that were associated with greater suicidal impulses in our study in order to further deliniate potential high-risk patients.

METHODS

Subjects

Data were collected from the pool of psychiatric consult requests at Montefiore Medical Center, a 700-bed general hospital located in the Bronx, New York City. The study was conducted over a 4-month period, from February to June 1991. Databases were kept in the locked files of the researchers to protect patient anonymity. All patients were included for whom an initial consultation request was made to evaluate suicidality. These were patients who verbalized suicidal ideas to the treating clinicians, nursing staff, or family, who then relayed this information to staff. Because of this study's focus on suicidality in the hospital, consults to evaluate patients admitted for medical consequences of suicide attempts were excluded.

Procedure

Psychiatric consultants completed the Suicidal Ideation Assessment Form (SIAF) (see Appendix), a consultant-rated questionnaire, during the course of a consultation for suicide evaluation. The SIAF took approximately 5 minutes to complete for each patient. Initial orientation to the SIAF and ongoing review with the consultants by the researcher provided rating instruction.

Details of the variables studied in the database are included in the Results section. Degree of suicidal intent was rated by the two suicide subscales (ratings of current suicidal thoughts and recent suicidal behaviors) of the Bronx Municipal Hospital Center Psychiatric Emergency Room Violence and Suicide Assessment Form (9). This scale consists of a degree of impulsivity rating, as described under Results. Additional patient information was obtained from the Patient Consultation Record (PCR) described elsewhere [10]. The PCR consists of demographic data, Axis 1-4 diagnoses, and other consultation related information.

Statistical comparisons used two-tailed t-tests, Chi-square tests, or data were presented as percentages of the whole as described under Results.

RESULTS

Demographic Data

Twenty-seven completed SIAF questionnaires were included in this study, or about 9% of the total psychiatric consultation requests during this 4-month period. Incomplete data on some items is reflected in the total number reported for that item. PCR data were located on only 20 questionnaires because either the patient's name or chart number was not recorded on the SIAF. Subject data not compared with the whole was due to that variable being included in the SIAF though not in the PCR.

Subjects included 13 (65%) men and 7 (35%) women, with a mean age of 55 years. There was an almost even distribution of patients representing all age groups from 25 to over 75 years old. Racial groups included 9 (45%) Caucasians, 4 (20%) blacks, 6 (30%) Hispanics, and 1 (5%) Asian. Three (15%) were currently married and 16 (80%) were either single, separated, divorced, or widowed. Eight (40%) patients were Catholic, 6 (30%) were Jewish, 5 (25%) were Protestant, and 1(5%) came under the category Other. Nine (33.3%) patients lived alone, 15 (55.6%) lived with family, and 1(3.7%) lived in a nursing home. Five (18.5%) were working, 5 (18.5%) were disabled, 10 (37%) were retired, and 7 (25.9%) were unemployed (82.4% of patients were not in the active work force). Social supports were rated (in the clinicians' estimates) as poor in 5 (18.5%), fair in 9 (33.3%), good in 10 (37%), and excellent in 2 (7.7%).

Axis 4 stress level was rated from 1 (no stress) to 6 (catastrophic): 15 (75%) were rated as 5 or 6 level of stress. On Axis 5 global assessment of functioning (GAF), 17 (85%) were functioning above the 70 level in the past year and 8 (40%) remained above this level at the time of consultation.

Demographic data were compared with the PCR data for all consultation requests during the same 4month period (N = 277). There were no differences on age, race, marital status, religion, residence status, or global assessment of functioning.

There was a trend toward more male patients in the group consulted for suicidality (44% male in the group as a whole vs 65% suicidal, X2 = 2.87, df = 1, p = 0.09), as well as higher axis 4 stress levels in the suicidal group (54% axis 5 or 6 in the group as a whole vs 75% suicidal, X2 = 2.87, df = 1, y = 0.09). Neither social supports nor occupational status were recorded on the PCR data and could not be compared.

Medical Situation Data

Twelve (60%) of the suicide evaluations were on the medical service, 4 (20%) were on surgery, and 2 (10%) were on neurology/neurosurgery. This was similar in distribution to the consultations as a whole (all consultation requests for any reason). Though both the primary reason for hospitalizatioll as well as medical diagnosis spanned a gamut of conditions, it was notable that only one patient (3.7%) had a diagnosis of neoplasm compared with 56 (19%) of the whole. None of the subjects were on dialysis. Eight (40%) of the suicidal consults were diagnosed with delirium or dementia, whereas 165 (59%) were for the whole; this difference did not reach statistical significance.

Medical condition was rated as acute in 15 (55.6%) and chronic in 7 (25.9%). Five (18.5%) were rated terminal, and none with imminent death. Approximately half of the subjects were rated as either in physical pain or physical distress. Mean values for all sucidal subjects on a 0-10 visual analog scale were 3.5 for physical pain and 4.0 for physical distress, respectively.

Suicidal Characteristics

Eighteen (79%) of the subjects were consulted on within the first week after admission for assessment of suicidality. Breakdown of current suicidal thoughts (highest during current hospitalization), rated from 1 (no suicidal ideas) to 5 (intense wish for suicide) was 8 (29.6%) rated 1,11 (40.7%) rated 2, 5 (18.5%) rated 3, and 3 (11.1%) rated 5. Mean value was 2.3 (SD 1.3). Recent suicidal behaviors (during the past several weeks) were rated from 1 (no plans or attempts) to 6 (made a serious attempt). Results were 13 (48.1%) rated 1, 8 (29.6%) rated 2,1 (3.7%) rated 3, 2 (7.4%) rated 4, and 3 (11.1%) rated 6. Mean value was 2.1 (SD 1.6).

Suicidal ideas were rated chronic in only 6 (22.2%) cases and acute in 20 (74.1%). Five (18.5%) had made prior attempts, 2 of which were considered as having a serious prior attempt.

At the time of evaluation, clinicians rated subjects' affect as depressed/sad/despair in 17 (63%), angry/frustrated in 3 (11%), anxious in 1 (3.7%), intoxicated in 1(3.7%), and left this section unrated or not known in 5 (18.5%). Though given the opportunity to do so on the PCR, clinicians did not make a personality disorder diagnosis on these subjects, and no retrospective personality analysis was done.

Constant observation was ordered in 6 (30%) subjects with a mean duration of 2 days. There were no actual suicide attempts during this study period. Subjects were seen on an average of 5.3 follow-up visits by the psychiatrist. No significant data were found for room type or time of day that suicidal ideation was verbalized.

Precipitant of Suicidality Data

There was no limit to the number of precipitants that could be recorded for any subject. In decreasing frequency, the number of subjects rated with the following precipitants were as follows: 15 (55.6%) acute change in medical condition (new onset of symptoms or patient was informed of or perceived a change in diagnosis/prognosis (DX/PX) for the worse); 12 (44.4%) loss of physical function; 11 (40.4%) loss of role function; 9 (33.3%) maladaptive reaction to illness; 9 (33.3%) major depression; 6 (22.2%) reaction to pain; 6 (22.2%) interpersonal conflict; 5 (18%) conflict with staff; 4 (14.8%) family conflict; 4 (14.8%) bereavement; 3 (11.1%) organic disorder (delirium/dementia); 3 (11.1%) reaction to acute loss of emotional support; 3 (11.1%) related to loss of face (real or perceived); 2 (7.4%) related to drug or alcohol (intoxication or withdrawal); 2 (7.4%) attempt to manipulate patient's social situation; none rated as due to conflict with other patients or due to psychosis.

Comparison of High and Low Suicidal Impulses

Comparisons of both current suicidal thoughts and recent suicidal behaviors for those patients who had none or only mild suicidal impulses to those who had more serious impulses were made for each item on the SIAF. For recent suicidal behaviors, subjects rated 1 or 2 were considered less serious (N = 21, mean 1.4, SD 0.5), and those rated 3 or more were more serious (N = 6, mean 4.8, SD 1.3).

Only social supports differed significantly between less serious and more serious groups on recent suicidal behavior. Social supports were rated from 1 (none) to 5 (excellent). The less serious recent suicidal behavior group's social supports (mean 3.5, SD 0.8) differed significantly from the more serious (mean 2.6, SD 0.9) (t = 2.2 df = 25, p = 0.03); the more serious suicidal group was associated with poorer social supports. There was also a trend for prior attempts (rated as 1 Iyes] and 2 [no]) to differ between these groupsNIIle less serious recent suicidal behavior group (mean 1.9, SD 0.3) tended not to have prior attempts compared with the more serious group (mean 1.4, SD 0.5) (x = 2.8, df = 1, p = 0.09). The less and more serious groups on recent suicidal behavior maintained these differences when compared for current suicidal thoughts (rated similarly). The less serious group (mean 1.8, SD 0.7) differed significantly from the more serious group (mean 3.7, SD 2.0) (t = 3.6 df = 25, p = 0.001).

Current suicidal thoughts were also broken down into less serious (rated 1 or 2, N = 19, mean 1.6, SD 0.5) and more serious (rated 3 or more, N = 8, mean 3.9, SD 1.2). Only one item on the SIAF differed significantly for the less and more serious groups on current suicidal thoughts. Current physical distress ratings, rated 0 (no distress) to 10 (would rather die), were statistically different for the less serious (mean 2.9, SD 2.2) compared with the more serious group on current suicidal thoughts (mean 7.0, SD 2.3) (t = 3.5, df = 25, p = 0.003). The less and more serious groups on current suicidal thoughts maintained these differences when compared for recent suicidal behavior. The less serious group (mean 1.6, SD 1.2) differed from the more serious group (mean 3.3, SD 1.9) (t = 2.9, df = 25, p = 0.01).

DISCUSSION

This was a pilot study that attempted to determine if a database such as the SIAF could be used as an effective means to characterize patients who are seen in consultation in the medical setting for suicide evaluation and to recommend areas that warrant further study. Some of the limitations of this study included a limited study duration and a small number of subjects. Items were rated by clinical impression rather than specific criteria sets and there were no interrater reliability checks. Study orientation meetings and discussion with the researchers may have helped limit clinician rating variance.

Results of this study that deserve further investigation include a possible trend towards high male representation among the suicidal subjects, high axis four stress ratings, and a large drop in GAF in the prior year. There was a trend towards acute medical conditions and acute suicidal ideation, few with prior attempts. Few required constant observation, but in our institution, 15-minute checks could also be recommended and were not recorded on the database.

The more serious recent suicidal behavior patients were those who tended to have poorer social supports and prior attempts compared with the less serious recent suicidal behavior patients. The more serious patients on current suicidal thoughts were those who had greater current physical distress ratings.

It may be that the more serious suicidal patients represent a different subgroup with different characteristics than the less serious group. Further clarification of these differences in a larger subject sample would be helpful. A more refined definition of physical distress also needs consideration.

Prior studies (5,6) of suicidal attempter/completer medical patients describe these patients as being demanding, angry and impulsive, personality disordered and psychotic, with precipitants of staff conflict and lack of emotional support. In contrast, this study found a trend towards acute changes in medical condition, loss of physical and role functions, and depression. There was minimal staff conflict and no psychosis. There was also only one subject with neoplasm compared with prior studies (8) that found a relation between neoplasm and suicidality. Our findings were consistent with prior studies, showing a correlation with maladaptive (emotional) reaction to illness and few patients with delirium or dementia (who might hurt themselves, but since they were not considered suicidal, would not have been included in the subject group).

By including patients with any suicidal ideation and not just attempters/completers of suicide in our study, we may have picked up a mixed population not comparable to the other studies (11). There could have been institutional patient population differences as well as differences in assessment methods that make comparison difficult. Further research needs to address these differences so that psychiatric consultants can begin to look at factors that correlate with more serious suicide risk when called to evaluate for suicidality. Interventions that could enhance social support and address high stress levels (family meetings, therapist support); diminish physical distress (medical or surgical interventions); treat depression (psychotherapy/pharmacotherapy); and improve physical and role functioning (physical therapy, interpersonal therapy) are important avenues that consultants should explore in their recommendations to the primary treating physician. Attention to patients' reaction to acute changes in their medical condition is also important.

The detailed study of suicidality in the medical setting is important to an understanding of the interplay of medical, psychological, and social factors in patients referred to psychiatrists for this reason. Studies using databases such as the SIAF and PCR are an effective and time-efficient means of acquiring data for this purpose. More research is needed to refine the database and to make recommendations to clinicians who evaluate suicidal patients in the general medical hospital.

References

1. Amen DG: Target theory of suicidal behavior. Resident and Staff Physician 33: 91-101,1987

2. Fawcett 1: Suicidal depression and physical illness. Jama 219:1303-1306, 1972

3. Osgood NJ: Suicide in the elderly. Carrier Foundation Letter 133:1-2, 1988

4.Hackett TP, Stern TA: Suicide and other disruptive states, In Hackett TP, Cassen NH (eds), Massachusetts General Hospital Handbook of General Hospital Psychiatry, 2nd ed. Massachusetts, PSG Publishing,1987

5. Reich P, Kelly MJ: Suicide attempts by hospitalized medical and surgical patients. N Engl J Med 294:298-301, 1976

6. Farberow NL, McKelligott JW, Cohen 5, Darbonne A:Suicide among patients with cardiorespiratory illnesses. JAMA 195:422-28,1966

7. Abram HS, Moore GL, Westervelt FB: Suicidal behavior in chronic dialysis patients. Am I Psychiatry 127: 1199-1204, 1971

8. Farberow NL, Ganzier 5, Cutter F, Reynolds D: An eight-year survey of hospital suicides. Life Threat Behav 1:184-202, 1975

9. Feinstein R, Pluchik R: Violence and suicide risk assessment in the psychiatric emergency room. Comp Psychiatry 31:337-343,1990.

10. McKegney FP, Schwartz CE, O Dowd MA, Salamon I, Kennedy R: Development of an optically scanned consultation-liaison data base. Gen Hosp Psychiatry 12:71-76, 1990

11. Linehan MM: Suicidal population: one population or two? Ann NY Acad Sci 487:16-33,1986

Appendix: Suicidal Ideation Assessment Form (SIAF)

PATIENT CHARACTERISTICS

NAME:_______________________________

Chart Number Occupational Status l) Working 2) Disability 3) Retired 4) Unemployed 5) Homemaker 6) Other

Living Arrangements: Before this Adm.__________________________ After d/c_____________________________________________________

l) Alone 2) With Family 3) Friends/Others 4) Nursing Home/Health-Related Facility 5) Hospice 6) Other Hospital 7) W/Home Attendant 8) Homeless 9) Other

CURRENT MEDICAL SITUATION

Primary Reason for Hospitalization (CHIEF COMPLAINT)

(l) Acute Is Condition Terminal? Is Death Imminent? (2) Chronic (l) Yes, (2) No (l) Yes, (2) No

Currently in pain? Rate: 0--------10 (10 = would rather die) (l) Yes, (2) No

Currently in physical distress? Rate: 0------10 (10 = Would rather die) (l) Yes, (2) No

Room Type: ___________________ l) Single 2) Double 3) Multiple 4) ICU 5) Single/lsolation 6.) Bioclean.

SUICIDAL CHARACTERISTICS

Time of day Sl was voiced or attempt was made l) Morning 2) Afternoon 3) Evening 4) Night 5) No Information 6) Ongoing.

Duration of hospitalization up to voicing Sl:

Days remaining until planned discharge (if known):

RATE/DEGREE OF SUICIDAL INTENT

Current Suicidal Thoughts (highest during current hospitalization)

(4) Expresses intense wish to kill self and has made a plan. (4) Reveals psychotic/delusional ideation or hallucination to kill/injure self. (3) Expresses intense wish to kill self but has made no plan. (2) Expresses ambivalent wish to kill self. (O) Reveals no suicidal ideas.

Recent Suicidal Behaviors (during the past several weeks)

(4) Made a serious suicide attempt (e.g., by gunshot/ingestion/hanging/jumping). (3) Made a suicide gesture (e.g., superficially cut wrist/ingested two pills). (3) Made a specific suicide plan. (3) Attempt made with little chance of discovery. (2) Had no interest or hope for the future. (O) Has made no suicidal plans or attempts.

Are suicidal ideas chronic? Affect associated with suicidal ideation (Sl) Prior attempt? Serious ___yes or____no

Social supports: none poor fair good excellent

Extreme use of denial in the face of hopeless reality?______

PRECIPITANT OF SUICIDALITY (check all that apply, write in details).

______Reaction to acute change in medical condition

_____New onset physical symptoms Patient informed of change in DX/PX, (which) for the worse? Patient perceived change in DX/PX (which) for the worse? Other, describe

_____Reaction to pain: Acute pain? Chronic Pain? Undertreated? Validity of pain denied by staff?

_____Related to Organic Brain Syndrome circle: Delirium/Dementia/Organic psychosis. If direct organic cause is known list:

_____Related to drug/Etoh use, specify drug Intoxicated during Sl? In withdrawal?

_____in order to get medication prescribed.

_____Related to psychosis, acute? chronic?

_____Related to depression, psychotic?

_____Related to maladaptive reaction to illness, acute? chronic?

_____Conflict with staff, specifics:

_____Patient overdependent on medical relationships for support.

_____Effort to obtain special care.

_____Specific staff were away or there was perceived/real rejection.

____Validity of medical symptoms challenged by staff.

_____Staff refusal to do procedure patient requests.

_____Patient refusal to comply with test/procedure. Is staff pushy?

_____Acute loss of emotional support. With who?

_____Reaction to relationship with other patients.

_____Interpersonal conflict.

_____ Change in medical status of another patient(s).

_____Family conflict, specifics related temporally to family visit/phone call.

_____Cry for help/attention, emotional support.

_____ Preventing interpersonal change (e.g., to keep a lover from leaving).

_____Provoking interpersonal change (e.g., to separate from parents; a way out for a battered wife)

_____ Loss of role function, at work? In the family? In society?

_____Loss of physical function, specify:

_____Shame/loss of face, real/perceived; in what aspect of psychosocial system?

_____Bereavement, acute? chronic? Who died?

_____Patient was attempting to manipulate his/her social situation (e.g., to obtain services; to cover an alcohol problem; to lessen the responsibility for a crime).

_____Other situation, specify: