Scenarios
Suicide attempt with suspected bipolar disorder
A 25-year-old woman with a doctorate is brought in by her parents after a suicide attempt by deliberately releasing gas in the living area. After initial somatic care, the psychiatric assessment takes place. Recently there have been aggressive outbursts and severe anxiety, accompanied by deep hopelessness and a pronounced wish to die.
According to the parents, she has expressed suicidal intentions repeatedly. She continues to have suicidal thoughts during the interview; a reliable distancing cannot be achieved. Due to depressive symptoms with simultaneous increased activation, a bipolar disorder with mixed features is suspected. There are no indications of psychotic symptoms or current substance use.
The patient is admitted to hospital and treated with olanzapine. In further interviews, previous depressive and hypomanic episodes are confirmed. Manic episodes are not known. This secures the diagnosis of bipolar II disorder. Within a few days the acute symptoms decrease; suicidality continues to be closely assessed.
Depressive disorder with increasing suicidal thoughts
A 44-year-old woman presents together with her husband. She reports that she is currently seriously considering ending her life. For the first time, neither her religious beliefs nor her attachment to close people sufficiently mitigate these thoughts.
For many years she has been predominantly sad and at times anxious. She has rarely felt joy. The husband describes recurring, multi-month depressive phases for about seven to eight years with pronounced withdrawal, frequent crying, early-morning awakening, loss of appetite and weight, and markedly reduced sexual interest. There are no indications of previous manic or hypomanic episodes or psychotic symptoms.
A recurrent depressive disorder is diagnosed. A current suicidal intent and concrete preparations are denied. The patient can understandably distance herself from an immediate implementation and accepts help. After psychiatric assessment, outpatient treatment with mirtazapine is started. The husband is involved; a safety plan and frequent check-in contacts are agreed. A first contact occurs within 48 hours.
At the check-up after one week, sleep and appetite have significantly improved. The mood is partially brighter; current suicidal thoughts are denied. Treatment and regular assessment of suicidality are continued.
Psychotic symptoms after a severe suicide attempt
A psychiatric consultation is requested for a 70-year-old man under emergency medical monitoring. There are blunt injuries in the area of the larynx and trachea.
The patient lives alone. In the morning a neighbor from the apartment below hears a loud impact. Since the patient does not respond to repeated knocking, the neighbor alerts the fire department. The forensic initial assessment suggests a hanging attempt with subsequent fall. A dens fracture is excluded by imaging.
Because the patient is unconscious at first contact, physical stabilization and necessary surgical care are the priority. The psychiatric examination is continued after regaining consciousness.
The patient states: “I know where I am. I am sure they are following me here too. They put a bugging device in my throat so they know my thoughts even before I say them.” There are no indications of delirium or a substance-related cause. A reliable distancing from further suicidal actions is not achieved.
Through further conversations, collateral history and previous treatment records, the diagnosis of schizophrenia is confirmed. Because of the persisting delusional experience of threat and the suicide risk, close monitoring and psychiatric co-treatment take place. After physical stabilization, the patient is transferred to a secure psychiatric ward. Treatment with clozapine is considered after reviewing previous therapies and the physical prerequisites.
Self-harm and acute suicidal crisis
A 19-year-old woman presents together with her boyfriend. There is alcohol and benzodiazepine dependence as well as repeated self-harm with visible scars. In the interview she appears emotionally very labile and cries repeatedly. Her parents separated during her childhood.
There are currently superficial cut wounds on the wrist. There are no nerve, vascular or tendon injuries. She reports that earlier self-harm did not always have a death wish. Currently, however, she expresses suicidal thoughts; a reliable distancing from further suicidal actions cannot be achieved.
After wound care, the patient is admitted for inpatient crisis treatment. A possible alcohol or benzodiazepine withdrawal is monitored and treated if necessary. In the further course, based on a longstanding pattern of emotional instability, fear of abandonment, unstable relationships and repeated self-harm, a borderline personality disorder is diagnosed. After acute stabilization, dialectical behavior therapy is initiated.
Practice
- Recognizing and assessing acute suicidality
- Outpatient or inpatient treatment?
- Medication treatment and follow-up care
After a suicide attempt, physical stabilization and treatment of possible injuries or poisoning are the initial priorities. At the same time a safe environment and appropriate care must be ensured.
In the conversation, a calm demeanor, sufficient time and respectful interaction are crucial. Suicidal thoughts are addressed directly and without reproach.
Asking openly about suicidality does not trigger suicidal thoughts. It can instead make it easier for those affected to talk about their distress.
Important questions include, for example:
- “Do you sometimes wish you wouldn’t wake up?”
- “Have you thought about taking your life?”
- “Do you intend to act on these thoughts?”
- “Have you already made preparations?”
- “Have there been similar crises or suicide attempts in the past?”
- “What has stopped you so far?”
- “Who can support you right now?”
Additionally, access to dangerous means, current stressors, psychotic symptoms, intoxication or withdrawal, and the ability to accept help and adhere to agreed next steps are examined.
Individual protective factors, such as religious beliefs or attachment to relatives, do not guarantee safety. Their actual significance must be assessed in the current crisis.
A questionnaire or a blanket classification into low, medium, or high risk cannot replace individualized clinical assessment.
The choice of treatment setting depends on the current level of danger, the mental state, and the available treatment options.
Not every passive wish to die automatically requires inpatient admission. However, in acute suicidality, inpatient treatment should be offered.
Inpatient care is particularly urgent with concrete intent to act, lack of ability to make agreements, pronounced psychotic experiences, or necessary medical treatment after a suicide attempt. Unclear risk that cannot be adequately assessed outpatiently may also make admission necessary.
Outpatient treatment may be an option if the professional assessment allows it and a reliable care plan is organized.
These particularly include:
- A jointly developed safety plan with concrete steps in case of deterioration.
- Binding and timely medical or psychotherapeutic contacts.
- Accessible professional help for crisis situations.
- The as safe as possible storage or restriction of access to dangerous means.
- Involvement of suitable significant others, insofar as this is possible and appropriate.
The presence of relatives alone is not sufficient. They must not bear sole responsibility for preventing a suicide. Blanket home monitoring rules do not replace necessary professional treatment.
A promise not to harm oneself is also not a sufficient basis for a discharge decision.
Medication choice is guided by the underlying disorder and the acute symptomatology. The aim is both short-term relief and effective longer-term treatment.
A sedative effect does not automatically mean that suicide risk has decreased sufficiently. Medications do not replace crisis intervention or necessary inpatient care.
When prescribing, toxicity in overdose and the amount of medication dispensed must also be considered.
The first days and weeks after an acute crisis or inpatient discharge require special attention. Continued treatment and follow-up appointments should be organized reliably to avoid gaps in care.
Foundation
It is assumed that genetic factors indirectly influence the development of suicidal thoughts and suicidal actions. Personality traits such as impulsivity, aggressiveness and a hostile basic attitude can be passed down across generations to some extent and steer thoughts and behaviour in a self-harming or risky direction. Genetic influences act in interaction with life events, social conditions and individual coping capacities.
Psychiatric disorders are important risk factors for suicidality. In particular, affective disorders such as unipolar depression as well as bipolar I and bipolar II disorders are associated with an increased risk of suicide attempts and suicide deaths.
Within this group, bipolar II disorder ranks first, followed by bipolar I disorder and unipolar depression.
An unrecognized or inadequately treated affective disorder can promote the development of suicidal crises. Because these illnesses also have a hereditary component, a genetic predisposition can indirectly influence the suicide risk.
After affective disorders, substance use disorders are named as another group of illnesses associated with suicidality. Repeated and persistent consumption of psychoactive substances can be related to suicide attempts in various ways:
– Impairment of the ability to solve problems and find ways out of crises.
– Intensification of existing psychiatric disorders.
– Destabilization of mood and triggering of anxiety.
– From a psychoanalytic point of view possibly (not established) a more pronounced desire for self-harm.
The particular significance of alcohol
Alcohol can reduce cognitive, emotional and behavioural inhibitions and impair judgment. In doing so, among other things, it enhances the inhibitory effect of GABA and inhibits excitatory signalling at certain glutamate receptors.
Especially in acute intoxication, this can promote impulsivity, risky behaviour and suicidal actions. Aggressive behaviour may also occur. However, paranoid or delusional jealous ideas are not an inevitable consequence of alcohol consumption and must be assessed diagnostically on their own merits.
Personality disorders can also be associated with an increased risk of suicidal behaviour, particularly borderline personality disorder. Marked emotional fluctuations, impulsivity, an unstable self-image, chronic feelings of emptiness and conflictual interpersonal relationships can promote the development of suicidal crises.
Suicidal acts in schizophrenia can be impulsive and carried out without lengthy preparation. However, this is not a fixed rule: both planned and impulsive actions occur in schizophrenia as well as in unipolar depression.
Suicidal acts can be associated with delusions or hallucinations. Depressive symptoms and hopelessness also play an important role. Pronounced apathy does not exclude emotional suffering or suicidality.