Download Update On Elderly Depression And Suicide

Update on Elderly Depression
and Suicide
Dr. E Cheung
Associate Consultant
Psychogeriatric Team
Castle Peak Hospital
Depression in the Elderly
Common
 Treatable
 Under-diagnosed & under-treated
 > 60% treated inappropriately
 Disease burden
 Morbidity & mortality

Prevalence of elderly depression
in different care settings
Care setting
Prevalence of
depressive
symptoms
Community
15%
Prevalence of
major
depressive
disorder
1-3%
Primary care
20%
10-12%
Acute hospital
20-25%
10-15%
Long term care
30-40%
16%
Prevalence of Depression (2)

In Hong Kong
 1034 elderly aged 70 and above living in
Shatin (Chiu et al, 1998):
 Major depression 1.54%
 Dysthymia 3.66%
 Adjustment disorder with depressed
mood 1.54%
Global burden of diseases (WHO)
1996
2020
Lower respiratory
diseases
Diarrhoeal diseases
Ischaemic heart disease
Perinatal conditions
Road traffic accidents
Unipolar major
depression
Ischaemic heart disease
CVA
Unipolar depression
COAD
Depression is associated with
increased mortality
Author
N
FU (months) Mortality (%)
Murphy,
1983
Rabins,
1986
Murphy,
1988
Baldwin,
1986
124
12
14
100
12
8
120
48
34
100
48
26
Risk factors of elderly depression
1. Female gender
2. Being widowed or divorced
3. Medical illness, e.g. stroke, neurological disorders
4. Functional disability
5. Family and personal history of depression
6. Social isolation
7. Life events
8. Medications, e.g. antihypertensives, steroids and
antiparkinsonian drugs
9. Caregiving, e.g. carers of people with dementia
Aetiology (1)
Social: reduced social networks, loneliness,
bereavement, poverty, physical ill health
 Psychological: low self-esteem, lack of
capacity for intimacy, physical ill health
 Biological: neuronal loss/neurotransmitter
loss, genetic risk, physical ill health

Aetiology (2)

Disease:
 Direct: CVA, Parkinson's disease, thyroid
disease, Cushing's disease, Hungtington's
disease
 Indirect: pain, disability, chronicity, poor
diet, decreased activity
Aetiology (3)

Drugs:
 Digoxin, L-dopa, steroid
 Beta-blockers, methyldopa
 Chronic benzodiazepine use
 Phenobarbitone
 Neuroleptics in chronic use
Diagnosis
A syndromal diagnosis
 Based on eliciting a specific cluster of
symptoms through careful history taking
and mental state examination, supplemented
by relevant physical examination
 No confirmatory laboratory tests
 ICD-10 or DSM-IV

International Classification of
Disease (ICD-10)


Cardinal symptoms: depressed mood, loss of
interest (anhedonia), loss of energy (anergia)
Additional symptoms: reduced concentration,
reduced self esteem (present), guilty feelings
(past), hopelessness and pessimism (future), self
harm or suicidal ideas, sleep disturbance,
decreased appetite, loss of libido, psychomotor
changes
Diagnostic and Statistical Manual
of Mental Disorders (DSM-IV)
• Depressed mood most of the day
• Marked diminished interest or pleasure in normal
activities
• Significant weight loss or weight gain
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness or excessive guilt
• Recurrent suicidal thoughts or attempts
• Reduced ability to concentrate
Diagnostic difficulties
Primary care physicians could identify no
more than 50% of patients with a
diagnosable depressive syndrome (Mulsant
& Ganguli, 1999)
 Presentation of depression in the elderly
may be modified by factors associated with
old age

Clinical presentation of elderly
depression

Compared with young depressives, older people
have (Weisman,1991):
 Less disturbed sleep
(19% vs 25%)
 Less appetite disturbance
(16% vs 27%)
 Less disturbed energy
(11% vs 18%)
 Less guilt
(5% vs 13%)
 Less diminished concentration (8% vs 16%)
 Fewer thought about death
(22% vs 31%)
Peculiar features of elderly
depression







Minimisation of sadness (Georgotas, 1983)
Somatisation or disproportionate complaints
associated with physical disorder (Sheehan et al,
2003)
"Neurotic" symptoms of recent onset
"Trivial" acts of deliberate self-harm
"Pseudodementia"
Depression superimposed on dementia
Accentuation of premorbid personality traits and
recent change in behaviour
Key questions to ask (1)
How is your mood?
 Have you lost interest in anything?
 Do you get less pleasure from things you
usually enjoy?
 How long have you had these symptoms?
 Have you been diagnosed before with a
depressive disorder?

Key questions to ask (2)
Any important health changes within the
past year?
 Any major changes in your life in the
preceding 3 months?
 Any symptoms to suggest underlying
physical illness?
 Have you ever thought you would be better
off dead?

Assessment
History
 Mental state examination
 Use of standardised instruments, e.g.
Geriatric depression scale (GDS)
 Cognitive assessment
 Physical examination
 Investigation

Geriatric Depression Scale (GDS)
Validated standardised scales available
locally for screening of depression: 15-item
Chinese Geriatric Depression Scale Short
Form (GDS) (Lee et al, 1993)
 Cut-off point of 8/15
 Can be applied by trained non-medical
personnel

老人憂鬱量表
以下列舉的問題是人們對一些事物的感受。在過去一星期內，你是否曾有
以下的感受，如有的話，請圈『是』
，若無的話，請圈『否』
。
1.
2.
3.
4.
5.
6.
你基本上對自己的生活感到滿意嗎？
你是否已放棄了很多以往的活動和嗜好？
你是否覺得生活空虛？
你是否常常感到煩悶？
你是否很多時感到心情愉快呢？
你是否害怕將會有不好的事情發生在你身上呢？
是
是
是
是
是
是
／
／
／
／
／
／
否
否
否
否
否
否
7. 你是否大部份時間感到快樂呢？
8. 你是否常常感到無助? (即是沒有人能幫助自己)
9. 你是否寧願晚上留在家裡，而不愛出外做些有新意的事情？
(譬如：和家人到一新開張酒樓吃晚飯)
10. 你是否覺得你比大多數人有多些記憶的問題？
11. 你認為現在活著是一件好事嗎？
12. 你是否覺得自己現在一無是處呢？
13. 你是否感到精力充沛？
14. 你是否覺得自己的處境無望？
15. 你覺得大部份人的境況比自己好嗎？
是 ／ 否
是 ／ 否
是 ／ 否
總分
________
是
是
是
是
是
是
／
／
／
／
／
／
否
否
否
否
否
否
Principles of management
1.
2.
3.
4.
5.
Monitoring the risk of self-harm
Educating the patient (and care givers) about depression
and involving him or her in treatment decisions
Treating the whole person - coexisting physical disorder;
attention to sensory deficits and other handicaps;
reviewing medication with a view to withdrawing those
unnecessary
Treating depressive symptoms with the aim of complete
remission (as residual symptoms are a risk factor for
chronic depression)
Prompt referral of patients requiring specialist mental
health services
When to refer for specialist
advice? (WPA, 1999)




When the diagnosis is in doubt (e.g. is this dementia?)
When depression is severe, as evidenced by:
 Psychotic depression
 Severe risk to health because of failure to eat or drink
 Suicide risk
Complex therapy is indicated (e.g. in cases with medical
comorbidity)
When first-line therapy fails (although primary care
physicians may wish to pursue a second course of an
antidepressant from a different class)
Treatment
Physical treatment
 Pharmacological treatment
 Electroconvulsive therapy
 Psychosocial treatment

The Monoamine Hypothesis
The 3 monoamines: noradrenaline,
serotonin and dopamine
 Depression believed to be the result of a
deficiency of monoamine neurotransmitters
 All known antidepressants act by increasing
the activity of these neurotransmitters in the
brain by various mechanisms

Special considerations in the
elderly
Pharmacokinetics (change in volume of
distribution , metabolism, elimination)
 Co-morbid physical illnesses
 Drug interactions
 Dosing

Pharmacological treatment

Information for patients and carers:
 Start low, go slow
 Typical side effect
 Delay in onset of therapeutic action
 Lack of dependence potential
 Need for continuation treatment
following initial response
The Five “R”s of antidepressant
treatment
Response
 Remission
 Recovery
 Relapse
 Recurrence

Recovery
Remission
Mood
Response
Relapse
Acute
Continuation
treatment treatment
Time
Recurrence
Maintenance
treatment
Principles of antidepressant
treatment
1.
2.
3.
4.
5.
Ascertain diagnosis
The ultimate aim of treatment is remission
Treatment has to be adequate in dosage,
duration and compliance has to be ensured
If there is no response after an adequate trial,
switch to another class of antidepressant
If there is partial response, further increase
dosage and/or persist for a longer duration or
augmentation
Principles of antidepressant
treatment
6.
7.
8.
Address psychosocial issues and
psychoeducation
Continuation treatment – at least 6 to 9 months
after remission, longer for elderly (12 to 24
months) at the same dose
Maintenance treatment – prophylactic
treatment for patients with multiple past
episodes, serious ill health, chronic social
difficulties and very severe depressive
symptoms. No consensus on length of
maintenance.
Risk factors for recurrence
(WHO, 1989)
1.
2.
3.
4.
5.
6.
7.
8.
Comorbidity
Chronic medical conditions
Chronic affective symptoms
Older age of onset of first episode
Severe functional impairment during depression
Psychotic depression
Previous suicide attempt
Family history of suicide and bipolar disorder
Tricyclic antidepressants (TCA)
Nortriptyline (Nortrilen), dothiepine
(Prothiaden), amitriptyline
 Anticholinergic S/E
 Anti-histaminergic S/E
 Anti-adrenergic S/E
 Cardiotoxicity

Mechanism of action of TCAs
Shown here is an icon of a tricyclic antidepressant (TCA). These drugs are actually five drugs
in one: (1) a serotonin reuptake inhibitor (SRI); (2) a noradrenaline reuptake inhibitor (NRI); (3)
an anticholinergic/antimuscarinic drug (M1); (4) an alpha adrenergic antagonist (alpha); and (5)
an antihistamine (H1).
Stephen M. Stahl: Essential
Psychopharmacology 1996
Therapeutic actions of TCAs
The serotonin reuptake inhibitor (SRI) portion of the TCA is
inserted into the serotonin reuptake pump, blocking it and
causing an antidepressant effect
Stephen M. Stahl, Essential
Psychopharmacology, 1996
Therapeutic actions of TCAs
The noradrenergic portion of the TCA is inserted into the noradrenaline reuptake
pump , blocking and causing an antidepressant effect
Stephen M. Stahl, Essential
Psychopharmacology, 1996
Side effects of TCAs
Side effects of the tricyclic antidepressants- part 1. In this diagram, the icon of the
TCA is shown with its H1 (antihistamine) portion inserted into histamine receptors,
causing the side effects of weight gain and drowsiness.
Stephen M. Stahl, Essential
Psychopharmacology, 1996
Side effects of TCAs
Side effects of the tricyclic antidepressants - part 2. In this diagram, the icon of
the TCA is shown with its M1 (anticholinergic/antimuscarinic) portion inserted
into acetylcholine receptors, causing the side effects of constipation, blurred
vision, dry mouth and drowsiness.
Stephen M. stahl, Essential
Psychopharmacology, 1996
Side effects of TCAs
Side effects of the tricyclic antidepressants - part 3. In this diagram, the icon of
the TCA is shown with its alpha (alpha adrenergic antagonist) portion inserted
into alpha adrenergic receptors, causing the side effects of dizziness, decreased
blood pressure and drowsiness.
Stephen M. Stahl, Essential
Psychopharmacology, 1996
Dose titration of TCA

Most commonly used TCA: dothiepine
(Prothiaden)
 Starting dose: 50mg nocte
 Then increase in increments of 25 to
50mg depending on side effects every
few days aiming at an initial target dose
of 150mg
 Maximum dose of 225mg nocte
Selective Serotonin Reuptake
Inhibitors (SSRIs)







Citalopram (Cipram), sertraline (Zoloft),
paroxetine (Seroxat), fluoxetine (Prozac),
escitalopram (Lexapro)
GI upset
Anorexia
Headache
Insomnia, anxiety, tremour
Sexual dysfunction
SIADH
Selective Serotonin Reuptake Inhibitor
(SSRI)
Shown here is the icon of a
selective serotonin reuptake
inhibitor (SSRI). In this case, 4
out of the 5 pharmacological
properties of the TCAs (tricyclic
antidepressants; Figure 6-13) are
removed. Only the serotonin
reuptake inhibitor (SRI) portion
remains; thus the SRI action is
selective, which is why these
agents are called selective SRIs.
Includes fluoxetine, fluvoxamine,
citalopram, paroxetine, sertraline and
escitalopram
Stephen M. Stahl, Essential
Psychopharmacology,1996
Mechanism of Action of SSRIs
In this diagram, the SRI
(serotonin reuptake
inhibitor) portion of the
SSRI molecule is shown
inserted in the serotonin
reuptake pump, blocking it
and causing an
antidepressant effect. This
is analogous to one of the
dimensions of the TCAs.
Stephen M. Stahl, Essential
Psychopharmacology, 1996
Serotonergic-Noradrenergic
Reuptake Inhibitor (SNRI)
Venlafaxine (Efexor/Efexor XR)
 Side effects similar to SSRI
 May cause hypertension at high doses

Serotonergic-noradrenergic Reuptake
Inhibitors (SNRI)
Shown here is the icon of a dual reuptake
inhibitor which combines the actions of both a
serotonin reuptake inhibitor (SRI) and a
noradrenaline reuptake inhibitor (NRI). In this
case, 3 out of the 5 pharmacological properties
of the TCAs (tricyclic antidepressants) were
removed. Both the SRI portion and the NRI
portion of the TCA remain; however the alpha,
antihistamine and anticholinergic portions are
removed. These serotonin/noradrenaline
reuptake inhibitors are called SNRIs or dual
inhibitors. A small amount of dopamine
reuptake inhibition (DRI) is also present in
some of these agents, especially at high doses.
e.g. Venlafaxine
Stephen M. Stahl, Essential
Psychopharmacology, 1996
Reversible inhibitors of
monoamine oxidase A (RIMA)
Moclobemide (Aurorix)
 Nausea
 Headache
 Insomnia
 Restlessness
 Agitation

Other antidepressants
SARI – nefazodone (Serzone)
 Sedation, lack of 5HT2 stimulation S/E
 NaSSA – mirtazapine (Remeron)
 Sedation, dry mouth, increased appetite,
weight gain
 NDRI – bupropion (Wellbutrin)
 Headache, dry mouth, agitation, nausea,
insomnia

Serotonin-2 Antagonist/reuptake Inhibitors
(SARI)
Shown here are icons for two of the
serotonin 2 antagonist/reuptake inhibitors
(SARIs). These agents also have a dual
action, but the two mechanisms are
different from the dual actions of the
SNRIs (serotonin noradrenaline reuptake
inhibitors). The SARIs act by potent
blockade both of serotonin 2 (5HT2)
receptors, combined with SRI (serotonin
reuptake inhibitor) actions. Nefazodone
also has weak NRI (noradrenaline reuptake
inhibition) as well as weak alpha
adrenergic blocking properties. Trazodone
also contains antihistamine properties and
alpha antagonist properties, but lacks NRI
properties.
Stephen M. Stahl, Essential
Psychopharmacology, 1996
Noradrenergic and Specific Serotonergic
Antidepressant (NaSSA)
e.g. Mirtazapine
Stephen M. Stahl, Essential
Psychopharmacology, 1996
Other antidepressants
Mianserin (Tolvon):
 Sedation, aplastic anaemia,
agranulocytosis
 Trazodone:
 Sedation, orthostatic hypotension,
priapism

Commonly used antidepressant drugs
Drug
group
Member
commonly used
in the elderly
Starting dose
Therapeuti
c dose
Common side effects
SSRI
Sertraline
50 mg OM
50 mg BD
Nausea, headache,
weight loss
Citalopram
10 -20 mg OM
TCA
Nortriptyline
10 -25 mg
nocte
40 mg
OM
75 - 100
mg nocte
SNRI
Venlafaxine XR
75 mg daily
150 - 225
mg daily
Hypertension
NaSSA
Mirtazapine
15 mg nocte
30 - 45
mg nocte
Weight gain, sedation,
dizziness
RIMA
Moclobemide
150 mg BD
300 mg
BD
Agitation, insomnia
and headache
Dizziness, sedation, dry
mouth, urinary retention,
postural hypotension,
cardiotoxicity
Other pharmacological treatment

Others:
 Antipsychotics
 Lithium augmentation
 Tri-iodothyronine (T3) augmentation
 Antidepressant combination
 Anticonvulsant augmentation
 Buspirone augmentation
 Pindolol augmentation
Electroconvulsive therapy (ECT)
Safe and effective
 Indication in food refusal, suicidal risk,
severe retardation and poor response to drug
treatment
 71-88% with good outcome
 Post ECT confusion 18-52%
 Twice or three times weekly for 6 to 12
sessions

Psychosocial interventions

Basic psychotherapeutic processes:
 Listening and talking
 Release of emotion
 Giving information
 Providing a rationale
 Restoration of morale
 Suggestion
 Guidance and advice
 The therapeutic relationship
Psychoeducation
Nature and pathogenesis of depression
 Use of a “Stress-diathesis” model
 Proposed treatment, expected side effects,
delay in onset of therapeutic response
 Expected duration of continuation and
maintenance treatment

Evidence-based psychosocial
treatments
Interpersonal therapy
 Cognitive behavioural therapy
 For moderate to severe depression, the
combination of pharmacotherapy and
psychological treatment has been found to
be superior to either treatment given alone
(Reynolds et al, 1999)

Elderly suicide
Elderly suicide in Hong Kong
Extent of the problem



High rate of elderly suicide:
 Two to three times higher in the elderly (25–35
per 100,000) than the general population (10-13
per 100,000)
 30% of all suicide deaths were aged 60 or
above
High rate of success
Ageing population
 Population aged 65 or above increased from
0.63 million in 1996 to 0.76 million in 2000
(21% increase)
Suicide rates by age group in
Hong Kong
Country
Number of
suicides
Rate per
100 000
Ranking by
suicide rate
China
195 000
16.1
24
India
87 000
9.7
45
Russia
52 500
41.5
3
USA
31 000
11.9
38
Japan
20 000
16.8
23
Germany
12 500
15.8
25
WHO, 1999 Ranking by number of suicides
Country
Lithuania
Number of Rate per
suicides
100 000
Ranking by
number of
suicides
1600
41.9
22
600
40.1
25
Russia
52 500
37.6
3
Latvia
850
33.9
23
Hungary
3000
32.9
16
Sri Lanka
5400
31.0
9
Estonia
WHO, 1999 Ranking by rates of suicide
What do we know about elderly
suicide in Hong Kong?
Characteristics of elderly suicide
completers
Low attempt to completion ratio – 4:1
 Greater determination as evidenced by:
 Lethal methods: 52% by jumping from
height, 36% by hanging (Chi & Yu, 1997)
 Fewer warning signs
 Greater planning and resolve
 Prevention after onset of a suicidal crisis
may be less successful for the elderly

Characteristics of elderly suicide
completers

Evidence from psychological autopsy studies:
 71-95% of suicide victims aged 65 or above
had a major psychiatric disorder (Conwell et al,
2002)
 86% of HK Chinese elderly suicide victims had
a diagnosable psychiatric disorder compared
with 9% in controls, with depression being the
most common diagnosis (Chiu et al, 2004)
Characteristics of elderly suicide
completers

Elderly suicide completion is also associated with:
 Past history of suicide attempt
 Physical illness and functional impairment
 Social isolation
 Recent life event
 Rigid, anxious and obsessional personality style
Risk factors
Psychiatric disorder
Social milieu
Personality
Genetics
Family Hx
Service utilisation of elderly
suicide completers




Locally, 77% of suicide completers had consulted
a doctor one month before death, compared to
39% in controls (Chiu et al, 2004)
Most were because of non-psychiatric problems
Only 37% of the suicide completers had a life time
history of consulting a psychiatrist although 86%
of them suffered from a psychiatric problem (Chiu
et al, 2004)
The rate of consulting a psychiatrist is 65% in a
Swedish psychological autopsy study (Waern et al,
2002)
Studies on suicidal ideations

Among 516 elderly aged 70 or above in
Berlin (Linden & Barnow, 1997):
 14.7% said that life is not worth living
(77.5% had depression)
 5.4% wished to be dead or thought about
suicide (95.7% had depression)
 1.0% showed suicidal ideas or gestures
(100% had depression)
Completer- 30/100,000
Attempter – 100/100,000
Suicidal Intentions – 1-5%
Life not worth living – 15-19%
Normal – 80%
Normal
Slightly
depressed
Life
Not
Worth
Living
Suicidal
Intentions
Attempters
Completers
TIME-LINE
Evidence-based means and tools


Gotland study (Rihmer et al, 1995):
 depression-related suicide rates decreased with
training programme for general practitioners on
the diagnosis and treatment of depression
TeleHelp-TeleCheck service (De Leo et al, 2002):
 reduction in elderly suicide rates after
introduction of tele-help service
What do we know about elderly
suicide?
1.
2.
3.
4.
Elderly suicides are characterised by a higher rate than
the general population, higher lethality, greater
determination and fewer warning signs
They are consistently associated with a number of risk
factors, e.g. past history of suicide, physical illness,
psychiatric illness and certain personality traits (Conwell
et al, 2002)
Some of these factors are modifiable, e.g. depressive
illness
The majority of elderly who eventually commit suicide
would make contact with a primary care physician one
month before their suicide (but not necessarily for a
mood problem) and most remain undetected (Chiu et al,
2004)
What do we know about elderly
suicide?
5.
6.
7.
8.
9.
Low utilisation rate of psychiatric service among elderly suicide
completers may reflect lack of awareness and stigmatisation in the
community (Chiu et al, 2004)
Suicidal ideations and intentions are highly correlated with
depressive disorder and are useful key markers for identification of
at-risk individuals (Linden & Barnow, 1997)
Programme aimed at educating primary care physicians about
depression has been shown to reduce suicide rate, e.g. Gotland study
(Rihmer et al, 1995)
Telecheck shown to be a useful tool in providing care for elderly at
risk of suicide and reduce suicide rate (De Leo et al, 2002)
Relevant and locally validated instruments are available, e.g. GDS
Strategies in suicide prevention
Universal prevention
 Selective prevention
 Indicated/targeted prevention

Elderly Suicide Prevention
Programme (ESPP)


A early detection and targeted intervention
programme
Two-tiered model:
 First tier comprises primary health care
practitioners, various listed NGOs and hotlines
coordinated by a regional committee
 Second tier comprises specialist psychogeriatric
service in the form of a Fast Track Clinic and
multidisciplinary treatment team
Important features of the twotiered model
Improved access: one-stop service for the
client
 Increased capacity for detection through the
use of standardised instruments and training
of non-medical personnel
 Free-flow of patients between the two tiers
according to needs assessment

Aims of ESPP
1.
2.
Early detection of elderly at risk of suicide
Effective and adequate management
Early detection
1.
Raising the awareness of target referrers and
general public:
a.
Promotional and bibliographic material
b.
Liaison with target medical referrers
c.
Liaison with non-medical target referrers
d.
Organise training sessions, lectures, publicity
activities
e.
Setting up of regional committee with local
NGOs
Early detection
2.
Improving access to service
a.
Setting-up of Fast Track Clinic (FTC) with an
aim of providing medical assessment in a
timely manner
b.
Early intervention service by CPNs within 7
days of referral with medical outreach in
exceptional cases
c.
Non-medical referral accepted, including
screening using the GDS and referrals from
listed NGOs
Effective and adequate
management
1.
2.
3.
4.
5.
6.
7.
Individual biopsychosocial assessment with
early intervention service
Multidisciplinary approach including
involvement of referrer
Regular case conference
Adequate biological and psychosocial treatment
Coordination of psychosocial support and
mobilising resources from the community
Intensive follow-up by home visits and/or
telecheck
In-patient facility
Service boundary
1.
2.
3.
Age 65 or above
Residing in the relevant catchment areas
Inclusion criteria
a.
Suicidal ideation/thoughts/talk/plan
b.
Previous attempt of suicide
c.
Suspected moderate to severe depression
(either by medical assessment or by screening
using the GDS)
Workflow of ESPP
NGO/hotlines
(Screening)
GP/DH/GOPD
TMH/POH
A&E, in-patient
Mood problem
Suicidal idea
Early
Intervention
(CPN)
Home visits/telecheck
Consultation
FTC
Suicide
attempt
Multidisciplinary
team
In-patient service
Clinical assessment and
management
Full psychiatric assessment
 Clear documentation
 Indicate rationale for decisions

Assessment of suicidal risk
Asking about suicidal inclinations does not
make suicidal behaviour more likely
 Willingness to make tactful but direct
enquiries about a patient’s intention
 Be alert to factors that signify an increased
risk of suicide

Assessment of suicidal risk
Consider known risk factors
 Assess current suicidal risk
 Assess suicidal intent – planning,
preparation, precaution against discovery,
final rite, verbal cues, suicide note
 Collateral information

Suggested questioning sequence

Whether the patient:
 hopes things turn out well
 gets pleasure out of life
 feels hopeful from day to day
 feels able to face each day
 ever despairs about things
 feels life to be a burden
 wishes it would all end
Suggested questioning sequence

Whether the patient:
 knows why he/she feels this way
 has thought of ending life
 has thought about the possible methods
 has ever acted on any suicidal thoughts or
intentions
 feels able to resist any suicidal thoughts
The End