Suicide in Physically Ill Populations

Adult studies have found associations between a variety of physical diseases and completed suicide (Hughes and Kleepsies 2001). Several studies sug gest associations of increased suicide risk in cancer (Luohovori and Hakam 1979), HIV/AIDS (Marzuk et al. 1997), and end-stage renal disease (Abrams et al. 1971). Because of limited data regarding the prevalence or risks for suicide among youngsters with physical illnesses, clinical practice is guided by the existing pediatric suicide studies and adult physically ill populations. A comprehensive evaluation with a focus on developmental, environmental, psychosocial, and biological risks or triggers is the best method for assessing the probability of suicide risks in physically ill children and adolescents (Hughes and Kleepsies 2001).

The presence of a life-threatening illness does not explain suicidal ideation. The majority of patients with chronic physical illnesses do not attempt suicide. Evidence from adult studies suggests that patients with physical illnesses who do attempt suicide have the same risk factors as healthy individuals. The Canterbury Suicide Project, a case-control study of individuals ages 13-24 years in New Zealand, studied 200 suicides, 302 medically serious suicide attempts, and 1,028 control subjects (Beautrais et al. 1997). Serious suicide attempters were equally distributed by gender; twice as many females as males ingested pills, whereas males tended to choose the more lethal means. Factors associated with serious attempts were sexual abuse, low parental care, poor parental relationships, poverty, residential mobility, mood disorders, substance abuse, conduct disorder, legal problems, and interpersonal relationship difficulties. Increasing severity of suicide attempts ap peared to be related to lower levels of self-disclosure (Beautrais et al. 1997). In another study seeking risk factors for suicide in adolescents, the presence of a DSM-IV Axis I diagnosis (predominately mood disorder) was identified in more than 90% of the suicides (Brent 1995). In other studies, identified risk factors have included previous suicide attempts, alcohol and substance abuse, conduct disorder (males), panic disorder (females), aggressive-impulsive behaviors, hopelessness, and pessimism (Shaffer 1998; Zalsman et al. 2008).

Management of suicidal risk begins with a thorough assessment, including open and frank queries about suicidal ideation, plans, and attempts. This evaluation should weigh the risk and protective factors for suicide so that a risk-rescue ratio can be determined (see Table 6-4). This ratio contrasts the relative strength of suicidal intent (risk) versus the wish for help (rescue) (Wharff and Ginnis 2007). Physically ill patients who are stable medically and deemed not to be at imminent risk for suicide can be discharged from the pediatric setting with outpatient mental health follow-up.

Youngsters with physical illnesses who are at significant suicidal risk should be admitted to an acute psychiatric setting as early as possible. Depending on the type and severity of the physical illness, the outside psychiatric facility may or may not accept the admission. Ideally, inpatient child psychiatric units that have expertise in managing co-occurring childhood physical illnesses—units that are often embedded within a medical hospital—should be

Table 6-4. Risk and protective factors for childhood suicide

Risk

Protection

Risk-taking activities

Peer social support

Friend or family member with prior attempt or completed suicide

Help-seeking behavior

Impaired thinking or judgment

Future-oriented thinking

Current social stressors and family conflict

Insight into problem

Substance abuse

Family support and adaptability

Access to firearms

Well-developed coping strategies

Male gender

Female gender

Peer victimization

Religion or spirituality

Sexual orientation conflicts

Hopefulness

Current psychiatric illness (especially depressive disorders)

Source. Reprinted from Wharff EA, Ginnis KB: "Assessment and Management of Suicidal Patients," in Comprehensive Pediatric Hospital Medicine. Edited by Zaoutis LB, Chang VW. Philadelphia, PA, Elsevier, 2007, p. I049. Copyright 2007, Elsevier. Used with permission.

identified ahead of time. At the time of referral, the patient's current medical status should be specifically described and clearly communicated to the accepting facility, with transfer occurring only in the context of clear medical stability.

For physically ill youngsters who are at significant risk of suicide and in need of continued medical treatment, the primary intervention goal is the creation of a safe environment in the pediatric setting through frequent assessment and monitoring, as well as the treatment of any contributory conditions. Intervention requires discussion with the family about the need for safety and support, consultation and planning with the health care staff, one-to-one observation by an assistant trained to recognize signs of potential harm and distress, removal of all objects that can be used for self-harm, and prevention of elopement. Any underlying physical conditions contributing to impulsive behaviors, such as delirium, psychosis, and intoxication or withdrawal syndromes, should be aggressively treated, because impulsivity has been associated with dangerous behaviors in the medical setting (Reich and Kelly 1976). Agitation and active suicide attempts in the hospital may require the use of physical and/or chemical restraints (Bostwick and Levinson 2005).

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