Three important assessments to complete with patients whom are suicidal are the 4p’s, MSE, and alcohol use screening.

A comprehensive risk assessment to monitor for suicidal ideation is the 4p’s:

Predisposing Factors: The factors that increase vulnerability to develop psychological problems.

  • Genetic factors: A history of mental illness in the family
  • Age, sex, ethnicity
  • Social/cultural determinants (Maori, male, low socioeconomics= high risk)
  • Child abuse/ traumatic childhood
  • Prenatal complications
  • Social isolation
  • Previous attempts

Precipitating Factors: The factors that trigger the onset or exacerbation of the psychological problems.

  • Substance abuse
  • Illness
  • Medication
  • Social stressors: financial, stress, grief and loss, abusive relationships

Perpetuating Factors: The factors that maintain the psychological problems and prevents its resolution.

  • Poor coping skills
  • A lack of support
  • A feeling of worthlessness/hopelessness
  • Traumatic events
  • Substance abuse

Protective Factors: The factors that prevent any deterioration in the condition.

  • Support system
  • Access to resources
  • Resilience
  • Strong cultural identity
  • Family/social responsibilities
  • Successfully overcoming previous mental illnesses/ depressive episodes

 

Nursing management

There is a need to be direct with questioning the patient about thought of dying, self harm, and harm to others:

  • Have you thought about killing yourself?
  • Have you thought about hurting somebody else?
  • Do you have a plan?
  • Do you have access to the means of suicide?
  • Have you attempted suicide in the past?   How many times?
  • At what times do the thoughts get worse?
  • Have you known anyone that has committed suicide?
  • What things stop you from acting on these thoughts?

The priority is to assess immediate risk to the patient or others. 

  • Initiate the MH act if there is imminent danger. Discuss with the patient whether they will voluntarily admit themselves to the MH ward.
  • Restrict access to means
  • Provide one on one nursing supervision
  • Develop a relapse prevention plan
  • Teach coping strategies
  • Provide drug and alcohol support
  • Provide support group information
  • Refer to a community mental health nurse
  • Discuss pharmalogical intervention for acute distress (benzos, antipsychotics)
  • Encourage family participation and education
  • Offer reassurance and hope

Other assessments to consider is a complete MSE

The link to access the full size versions of the MSE and article can be found here:  http://www.primaryissues.org/2013/03/mental-status-exam/

A mnemonic to help remember the categories of the MSE is:

A- Appearance and behaviour
S- Speech
E- Emotion [mood and affect]
P- Perception [Hallucination and illusion]
T- Thought content and process
I- Insight and Judgement
C- Cognition

An alcohol screening assessment is also recommended as alcohol use is a risk factor for suicide as it lowers inhibitions. A easy tool to use is the AUDIT-C tool. It consists of three questions to identify risky drinking behaviour.

The tool can be found here:  http://www.integration.samhsa.gov/images/res/tool_auditc.pdf

Depending on the results of the screening a brief intervention may be needed.

A useful guide for brief interventions can be found here:

http://www.matuaraki.org.nz/uploads/files/resource-assets/brief-intervention-guidelines.pdf

This video shows a clinical example of using brief interventions in practice:

 

 

References

Barker, P. (1988). Basic child psychiatry (5th ed.). Baltimore, MD: University Park Press.

Garand, L., Mitchell, A. M., Dietrick, A., Hijjawi, S. P., & Pan, D. (2006). Suicide in older addults: Nursing assessment of suicide risk. Issues in Mental Health Nursing, 27(4), 355–370. doi: 10.1080/01612840600569633

Granello, D. H. (2010). The process of suicide risk assessment: Twelve core principles. Journal of Counseling & Development, 88(3), 363–370. doi: 10.1002/j.1556-6678.2010.tb00034.x

 

 

 

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