Management in clinical practice

Given the paucity of firmly proven effective treatments for attempted suicide patients, how is the clinician dealing with this heterogeneous patient population to proceed? Before a treatment plan can be formulated a careful assessment must be carried out. The key factors that should be covered are listed in Tabled For the purpose of formulating a management plan it is particularly useful to draw up a problem list which summarizes the patient's current difficulties. This should be done in collaboration with the patient as far as possible.

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Table 2 The assessment of attempted-suicide patients

During the assessment it is crucial to estimate the risk of suicide or of another non-fatal attempt. However, accurate assessment is far from easy. One element of suicide risk is the degree of suicidal intent involved in the current attempt. Useful factors to consider are listed in Table.,3. Clinicians should consider the use of the valuable Beck Suicidal Intent Scale, (?°) which covers these items. Factors known to be associated with risk of a further attempt are listed in T§ble,,4. It should be noted that while individuals who score positive on several of these factors will have considerably increased risk of repetition, a substantial proportion of those who repeat will not show these characteristics, i.e. the predictive value of scales to predict repetition is modest.

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Table 4 Factors associated with risk of repetition of attempted suicide

Risk factors for suicide following attempted suicide are shown in Table5. Because suicide is less common than non-fatal repetition the predictive value of such items is even more limited.

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Table 5 Factors associated with risk of suicide after attempted suicide

The treatment plan should be drawn up on the basis of the patient's needs and risks. Inpatient psychiatric treatment will usually be indicated for patients with severe psychiatric disorders, especially where immediate risk of suicide appears to be high.

Major psychiatric disorders should be treated in the usual way, but with particular care about use of medication which might be toxic in overdose. Specific treatment should be provided for alcohol and drug abuse; indeed, a suicide attempt is sometimes the first occasion that abuse may come to the attention of the clinician.

The bulk of this patient population can be managed in the community. Brief problem-solving therapy will be appropriate for those patients who have clear problems such as in interpersonal relationships, employment, or social adjustment. This approach is readily taught to clinicians from different backgrounds and of varying levels of experience and can therefore be made readily available. Outreach programmes (e.g. home visiting) may be helpful to increase the proportion of patients who receive treatment, but are probably not necessary for all patients. This approach will often be an essential part of treatment in rural settings in developing countries. If possible there should be continuity of therapy in terms of the same person who saw the patient in hospital after their attempt providing aftercare as this is likely to result in better compliance with therapy. Provision of an emergency card to allow patients to avail themselves of emergency help may be useful for a subgroup of patients but not all. Longer-term cognitive-behavioural therapy or dynamic psychotherapy may be required for patients whose attempts are related to traumas such as sexual abuse or to personality disorder. People who are repeaters of suicide attempts may also require more intensive treatment, especially those who frequently repeat. If resources permit, the use of a programme based on dialectical behaviour therapy, possibly using a group format for at least part of treatment, might be considered. If frequent repeaters are willing to accept neuroleptic medication, low-dose oral or intramuscular phenothiazines may be worth trying.

Family therapy may be required for young adolescents, and also for patients with difficulties in relation to children. The needs of young children of attempters must be considered because there is a substantial association between parental attempted suicide and abuse or neglect of children.

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