Assessment, Evaluation, and Management of Suicidal Patients
Patients who are suicidal require careful assessment (see Table 7). In the assessment of suicide, it is important to recognize that the risk of suicide increases if the patient reports ideation (i.e., thoughts of suicide) plus a plan (i.e., description of the means). Risk continues to increase to the extent that the plan is lethal. Lethality is determined by an assessment of how likely death would follow, if the reported plan were carried out. Factors to consider in assessing lethality include availability of the means, reversibility of the means (once begun can it be stopped), and proximity to help. In the cancer patient reporting suicidal ideation, it is essential to determine whether the underlying cause is a depressive illness or an expression of the desire to have ultimate control over intolerable symptoms. Prompt identification and treatment of major depression is essential in lowering the risk for suicide in cancer patients. Risk factors, particularly hopelessness (which is an even stronger predictive factor for suicide than is depression) should be carefully assessed. The assessment of hopelessness is not straightforward in the patient with advanced disease with no hope of cure. It is important to assess the underlying reasons for hopelessness, which may be related to poor symptom management, fears of painful death, or feelings of abandonment. Of 220 Japanese patients who had cancer and who were diagnosed with major depression after being referred for psychiatric consultation, approximately 50% reported suicidal ideation. In a retrospective analysis of predictors of suicidal ideation, researchers found that those with more symptoms of major depression and poorer physical functioning were significantly more likely to report suicidal ideation.
Establishing rapport is of prime importance in working with suicidal cancer patients as it serves as the foundation for other interventions. The clinician must believe that talking about suicide will not cause the patient to attempt suicide. On the contrary, talking about suicide legitimizes this concern and permits patients to describe their feelings and fears, providing a sense of control. A supportive therapeutic relationship should be maintained, which conveys the attitude that much can be done to alleviate emotional and physical pain. (Refer to the PDQ summary on Pain for more information.) A crisis intervention–oriented psychotherapeutic approach should be initiated that mobilizes as much of a patient's support system as possible. Contributing symptoms (e.g., pain) should be aggressively controlled and depression, psychosis, agitation, and underlying causes of delirium should be treated. (Refer to the PDQ summary on Delirium for more information.) These problems are most frequently managed in the medical hospital or at home. Although uncommon, psychiatric hospitalization can be helpful when there is a clear indication and the patient is medically stable.