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Suicide Risk in The General Hospital

Douglas Berger, M.D.

Department of Psychiatry Einstein College of Medicine, Bronx New York U.S.A.; Visiting Researcher, Tokyo Institute of Psychiatry, Tokyo Japan

Psychiatry and Clinical Neurosciences, 49, suppl. 1, S85-89; 1995.

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Key Words: suicide, medical illness, medical patient

Abstract:

This paper reviews the relationship between physical illness and suicide, the studies of attempters and completers of suicide in general hospitals, and those studies that have investigated the characteristics of patients in the medical setting who have suicidal ideation. Study of suicidal ideation in a general hospital setting aimed at characterizing patients' suicidality may allow psychiatrists to better discriminate those patients who are at greater risk for completed suicide. Comparison of medical patients with suicidal ideation to those who had attempted or completed suicide, and recommendations to reduce suicidal impulses and treat these patients are discussed.

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 (2,8,11,17). Psychiatrists working in general medical hospitals often get called to evaluate patients for suicidality. Because of this and because these high-risk patients have not been well studied, we felt that characterizing this group would provide a more empirical foundation for evaluation and treatment recommendations. This paper will first give an overview of the relationship of physical illness to suicide, review the studies of attempted and completed suicides in medical patients, and then discuss some recent studies that have attempted to characterize and evaluate patients with suicidal ideation.

RELATIONSHIP OF PHYSICAL ILLNESS TO SUICIDE

Mackenzie (14), reviewed several studies on the relationship of suicide in physical illness. A meta-analysis of several studies over the years led Mackenzie to make the following conclusions. First, physical illness is reported to be involved in between 20%-70% of suicides, and felt to be important in from 11%-51%. Suicide attempts are more often lethal when related to physical illness than when not. Suicides related to physical illness are more often in older males leading to the speculation that men are less able to emotionally accept passivity and feelings of helplessness. Depression secondary to pain, changes in physical function and structure, and changes in appearance and social relationships are common themes.

Mackenzie also discussed ways that physical illness could affect suicidal impulsivity. These include, 1.) that of the illness itself causing the initiation or exaccerbation of a mental disorder (ie.-post MI depression), 2.) illness causing organic mental disorder (ie.-command suicidal hallucinations secondary to delirium), or 3.) the patient gives up on the treatment which leads to an effectual suicide. Studies to date suggest that the first cause is the most common. Suicides in patients with physical illness usually have a concomitant mental illness, most commonly depression and alcoholism. The terminally ill who suicide are least likely to have mental disorders. Organic brain syndrome was found in only 10%-20% of suicides in the medicall ill.

Certain diseases that were found to have higher incidences of suicide include cancer, head injury, Huntington's Chorea, peptic ulcer disease, and spinal cord injury. In cancer patients, males (but not females) with disseminated disease were at greatest risk especially soon after diagnosis. GI cancers as well as chemotherapy or no treatment compared with surgery or radiation therapy placed patients at higher risk. The increased risk with chemotherapy is thought to be related to greater disease severity and consequently poorer prognosis and hopelesness. Huntington's is thought to be related to affective symptoms, peptic ulcer to alcoholism, and spinal cord injury to the possibility that the personalities of these individuals are inherently impulsive and self-destructive. Interestingly, while increased disease severity increased suicide risk in cancer patients, partial injury in spinal cord injury victims was associated with increased risk, possibly reflecting a decreased ability for these patients to adapt mentally. Head injury and suicide is related to cognitive function loss, personality change, and alcohol use.

Other diseases with a questionable increased risk for suicide include epilepsy, rheumatoid arthritis, and multiple sclerosis. Increased suicide risk after improvement in temperal lobe epilepsy has been thought to be due to the possibility of depression emerging after cessation of recurrent convulsions and/or difficulty adjusting to life without a handicap. Rheumatoid arthritis may elevate suicide risk secondary to chronic pain, progressive disability, isolation from others, and steroid use. Multiple sclerosis may have an association with depression.

STUDIES OF ATTEMPTED AND COMPLETED SUICIDES IN MEDICAL PATIENTS

A number of retrospective studies have looked at completed suicides. One (19) found 10 of 11 related to jumping or falls, with 7 of 11 having symptoms of delirium. The authors speculate that these patients may have either been paranoid and jumped in order to escape something and/or had motoric impairment. Defining these patients as suicidal may be problematic as it seems unclear whether the patients in this study wanted to die or whether they died accidently due to OBS.

Another study (4) reviewed suicides at the Bronx VA and found a relationship to severe, chronic, terminal illness, with pain dyspnea and disfigurement. These investigators concluded that lonliness, loss of function, loss of physical and financial independence, and the prospect of certain death lead patients to make their own life-death risk/benefit analysis.

Other studies (7,18) characterized patients as having impaired relationships, high family stress, excess emotional stress over their illness, a low pain tolerance, and a need to control the treatment. These patients were anxious and depressed over their illnesses and had poor relationships with staff who in turn reacted to them in a less supportive fashion. A general lack of emotional support as well as prior suicide threats were also present. Impaired alertness or disorientation was not correlated. There were 32 suicides in this study (18) from 1955 to 1960 at the Bronx VA hospital, 56% suicided by jumping, with wrist cutting and hanging next most frequent.

In another study of 22 completers from 1967-1973 (10), delerium tremens was common, and from 1967-1973 at Brigham Hospital in Boston, a study (20) of 17 mostly female attempters found a relationship to imminent discharge or a change in social supports. This study found all attempts to be impulsive, associated with anger, and precipitated by loss of emotional support. These attempts were largely by patients with personality disorder and psychosis.

Dialysis (1) and malignancies (6) have also been associated with suicidal behavior. Reports differ from 30% to uncommon in the number who threaten suicide beforehand.

To summarize these studies, the suicide completion rate in general hospitals is low, usually in males who jump and leave no suicide note. Many are associated with alcoholism and OBS, cancer and dsypnea, often these patients are demanding and dissatisfied. Because the OBS patients may be better considered as accidental deaths, these reports may actually be describing more than one population of patients. No cases of murder-suicide were found in the literature. Protection from open stairwells, laundry chutes, and upper story windows, and removal of sharps and potentially harmful substances are important protective measures. Suicides that seem rational in medical patients were unusual.

STUDIES THAT HAVE ATTEMPTED TO CHARACTERIZE AND EVALUATE PATIENTS WITH SUICIDAL IDEATION

Very few studies have reported on suicidal ideation in medical patients and fewer have been a prospective attempt to characterize these patients. One study (16) over a two year period in Nova Scotia reported 24% of 692 consultations for suicidal ideation, 11.6% wishing to die imminently. More than 50% of suicidal patients were under 35 years of age, 42% dependent on alcohol, and many of those with abuse of street drugs. The report was in French and the English abstract did not specify whether the suicidal cases included those admitted for medical complications of a suicide attempt, which seemed likely due to the age distribution of the patients.

Hale et al. (12) reported on an analysis of patients in the general hospital with suicidal ideation. 116 patients admitted for suicide attempts as well as those consulted on for suicidal ideation were studied. This made up 13% of all consultations. 66% were patients admitted folowing an attempt and 34% had suicidal ideation during admission for a medical illness. The average age of the attempters (35.4 years) was significantly lower than those with suicidal ideation (45.5 years), and while the the vast majority (89%) of the attempters were transferred to a psychiatric ward, fewer of those with suicidal ideation (25%) were transferred to psychiatry. Medically ill patients were more likely to have an adjustment disorder whereas suicide attempters were more likely to have schizophrenia. Though there was no systematic attempt to identify the precipitants of suicide, the authors noted that suicidal ideation seemed to arise during periods when pain and suffering were intense and survival questionable.

We had recently published a prospective report on the characteristics of patients in the medical setting who have suicidal ideation (3). The purpose of this study was to formulate a data base that would allow psychiatrists to better discriminate those patients who are at greater risk for completed suicide. Comparison of medical patients with suicidal ideation with those who had attempted or completed suicide, and recommendations to reduce suicidal impulses and treat these patients were discussed.

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. Our study did not limit itself to a retrospective analysis of actual attempts or completed suicides as in previous studies. 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. These were patients who verbalized suicidal ideas to the treating clinicians, nursing staff, or family, who then relayed this information to staff. Approximately 9% of all psychiatric consultations at our institution were to evaluate suicidality.

Because of this study's focus on suicidality in the hospital, consults to evaluate patients admitted for medical consequences of suicide attempts were excluded. Psychiatric consultants completed the Suicidal Ideation Assessment Form (SIAF) (see Appendix), a consultant-rated questionnaire, during the course of a consultation for suicide evaluation. Degree of suicidal intent was rated by subscales from the Bronx Municipal Hospital Center Psychiatric Emergency Room Violence and Suicide Assessment Form (9). Other data was collected via the Patient consultation Record (PCR) described elsewhere (15).

The main findings included 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 average age of the patients with suicidal ideation was 55 years, and neither age nor any other demographic variable differed from the consultations as a whole. Interestingly this compares to a study by Collins et al. (5) who found more requests for suicide and depression evaluation in Hispanics and fewer such requests in Blacks.

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.

Prior studies (7,20) 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, minimal staff conflict and no psychosis. There was also only one subject with neoplasm compared with prior studies (6) that found a relation between neoplasm and suicidality. Our findings were consistent with prior studies, showing a correlation with maladaptive (emotional) reaction to illness, loss of physical and role functions, depression (though this was mentioned only briefly in one past study) (7), 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 in our study). While including patients with any suicidal ideation and not just attempters or completers of suicide in our study we may have picked up a population not comparable to the other studies (13), some of the prior studies which included OBS patients may have been studying accidental death rather than suicide.

Treatment for suicidal patients in the general hospital should include those that can enhance social support and address high stress levels (family meetings, therapist support), interventions to diminish physical distress (medical or surgical), treatment for depression (psychotherapy/pharmacotherapy), and interventions to improve physical and role functioning (physical therapy, interpersonal therapy). 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 between medical, psychological, and social factors in patients referred to psychiatrists for this reason. Further prospective study needs to be done in order to clarify those at risk for suicide and which interventions are most effective.

References

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

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

3. Berger D: Suicide evaluation in medical patients: a pilot study. Gen Hosp Psychiatry 15: 75-81, 1993

4. Brown W, Pisetsky JE: Suicidal behavior in a general hospital. Am J of Medicine 29:307-315, 1960

5. Collins D, Dimsdale JE, Wilkins D: Consultation/liaison psychiatry utilization patterns in different cultural groups. Psychosom Med 54:240-245, 1992

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

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

8.Fawcett J: Suicidal depression and physical illness. JAMA 219:1303-1306, 1972

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

10. Glickman LS: Psychiatric Consultation in the General Hospital, Marcel Dekker Inc., New York, pp. 181-202, 1980

11. 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

12. Hale M, Jacobson J., Carson R: Diagnostic characteristics and dispositions in suicidal hospitalized medical and surgical patients. Gen Hosp Psychiatry, 11:381-387, 1989

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

14. Mackenzie TB, Popkin MK: Suicide in the medical patient. Intl J Psych in Med 17:3-22, 1987

15. 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

16. Michalon M: La psychiatrie de consultation-liaison: une etude prospective en milieu hospitalier general. Can J Psychiatry (In French) 38:168-174,1993

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

18. Pitsetsky JE, Brown W: The general hospital patient, in L.D. Hankoff and B. Einsidler (eds), Suicide: Theory and Clinical Aspects, PSG Publishing Co. Inc., Littton Massachusetts, p.279, 1979

19. Pollack S: Suicide in a general hospital, in E.S.Schneidman and N.L.Farberow (eds), Clues to Suicide , Mcgraw-Hill, New York, p.152,1957

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

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: