LOCAL FRONTIERS: Options for Preventing Suicide

Scott Barshack, MD

You get a call from a worried wife. Her husband is a 45-year-old executive who you’ve been treating for depression in your primary care practice for about two years. At his last visit, two months ago, he reported some “rough days” but otherwise said that things were going pretty well. Today, his wife reports that he came home early from work and went right to bed. In the past week, he has been withdrawn and has even made statements that the family would be better off without him. He suggested to his wife that he could stay at a hotel, so as not to be a burden.

Does this scenario raise any red flags? How would you respond?

When I was working on the inpatient unit at Marin General Hospital, we developed a profile of hospitalized psychiatric patients who committed suicide post discharge. These patients were mostly men in their forties to sixties. While on the psychiatric unit (Unit A), they were aloof. I distinctly remember one male patient, who later took his life, sitting in the dayroom with his laptop all day long and not mixing with the others. This patient and others like him would attend therapy groups but not really participate. There was often a superficial tone to their statements. In retrospect, they were disengaging from those around them.

Another risk factor in our profile was substance abuse, usually alcohol. One patient, who had recently separated from his wife and family, was living alone on a boat in Sausalito and drinking all day. After his hospitalization, he went back to the same lifestyle and eventually did kill himself. Patients with a recent loss of primary relationships or jobs were at high risk for suicide. They often felt overwhelming guilt about not being able to support their family.

Other risk factors we developed included a history of previous suicide attempts as well as the presence of a suicide note. Patients who came to Unit A after a significant suicide attempt, and had also left a note, had a much greater risk of actual suicide the next time around. One final risk factor is a recent diagnosis involving terminal or life-changing physical ailments. One such patient was found trying to buy a gun after he was diagnosed with a medical disorder that was slowly taking away his hearing.

What can we do about suicidal patients? In the wake of the Robin Williams suicide, that question has surfaced repeatedly in Marin County and elsewhere. Even hospitalized patients can’t be kept in the hospital forever. In fact, if a patient is intent on killing himself, he will often reassure staff and family that he is feeling much better, while at the same time plotting his next attempt.

If the 45-year-old male described above presented to your primary care office after his wife’s phone call, what would you do next? We all know the difficulty of finding a psychiatrist, especially one who’s available to see your patient within 24 hours. The most important thing you can do to help the patient is to listen and engage with him. Don’t be afraid to talk frankly about his suicidal thoughts, including any plan and any access to firearms, pills or other lethal means.

Don’t assume that the patient will volunteer all his thoughts about suicide; you need to ask specific questions. Ask if he has a history of previous attempts and if there is a family history of suicide. Contrary to myth, asking a lot of questions about suicide will not plant a seed in the patient’s mind that suicide is a good option. Also assess the patient’s support system and make sure his significant others know about it. Part of our protocol at Marin General was to not discharge a high-risk suicidal patient until we had conducted at least one family meeting and the family felt safe having the patient return home. Finally, assess whether the patient is “future oriented.” Have him commit to attending upcoming family events, such as birthday parties, holidays or outings.

If you still feel the patient is at risk after your discussion, the safest treatment is to send him to the hospital. In Marin, we have two points of entry for a suicidal patient: the MGH emergency room, where they will be seen by a psychiatric social worker, or the Marin County Crisis Unit, which is located next to Unit A and is staffed by county mental health workers. If the hospital is not an option, make sure someone will be able to watch the patient for at least the next 24 hours.

The hallmarks of treatment for depressed suicidal patients are psychotherapy, medication, family support and sobriety. Cognitive behavior therapy and dialectical behavior therapy help show patients that there are options to suicide and that the glass can be “half full.” Patients often feel stuck or even see suicide as a logical solution to their problems. The therapist’s job is to help patients understand that they won’t always be feeling this way and to help them address “fixable” issues in their life. Invoke the old adage, “Suicide is a permanent solution to a temporary problem,” attempting to show them that, with proper help, there is a light at the end of the tunnel.

In cognitive behavior therapy, therapists and patients work closely together to identify negative thoughts and behaviors and then change them. Change is effected by the therapist challenging the patient’s negative thoughts and collaboratively creating alternative and healthier ones. CBT is a short-term therapy, as it focuses immediately on the problem beliefs without necessarily exploring trauma or childhood and developmental issues. The therapist is active and is seen as a collaborator rather than an authority figure.

Dialectical behavior therapy focuses on ineffective patterns of coping, such as suicidal ideation. DBT helps patients learn their triggers to negative emotions and then develop a list of coping strategies. Again, the therapist is seen as an ally and is more active than in traditional psychotherapy. Patients are encouraged to keep a diary of their negative behavior. Individual DBT is often accompanied by group therapy that focuses on coping skills, such as meditation, mindfulness and stress reduction.

Medications are the cornerstone of treatment for depressed patients. Physicians not only need to treat mood, but also symptoms such as anxiety and insomnia. Medications for these latter symptoms tend to provide immediate relief, whereas antidepressants for mood can take several weeks to begin working. One fascinating new treatment for suicidal patients is IV administration of ketamine. This drug is thought to influence the glutamate system and relieve feelings of depression within minutes. Some emergency rooms are already providing ketamine as an emergency treatment for suicidal patients.

In addition to the above treatments, physicians and therapists should make every effort to stop suicidal patients from abusing substances. At least one-fourth of successful suicide victims have alcohol in their blood. If substance abuse is severe, consider a 30-day rehabilitation program. Entering such a program serves the purposes of sobriety, safety and psychopharmacologic intervention.

With regards to the suicidal patient discussed above, you should schedule an emergency appointment and have his wife come in with him. Engage him in a frank discussion of his suicidal thoughts, how strong they are and whether there is a clear plan. Confirm with his wife whether he has made suicidal statements, abused substances or has exhibited other worrisome behaviors. Then present them with recommendations for adjusting his medications.

You should also discuss using a therapist, preferably one that is hands-on and directive. Advise the patient’s wife that she should take her husband to the hospital if he doesn’t show improvement or if the situation worsens. Explain the step-wise approach to treatment, which begins with treating the patient as an outpatient while he continues working. If that isn’t enough, he should go on medical leave and enter a day treatment program. Also discuss the possibility of hospitalization and long-term residential treatment if all else fails.

In short, try to show both the husband and wife that there are still many options to treatment and that you’re going to be there to help him get through this. Try to present the options in a confident and organized way, demonstrating that physicians have been through this before with other patients and have had successful outcomes.

Sadly, even if you display a caring attitude and spend a lot of time with suicidal patients, some will still take their own life. In these cases, if you implemented the treatments discussed above, you will at least know that you did everything within your power to prevent suicide.

---

Dr. Barshack, an adolescent and adult psychiatrist with offices in Corte Madera and Petaluma, was previously medical director of behavioral health at Marin General Hospital.
Email: scottb246@mac.com