Does Repeated Suicide Assessment Give Salience to Suicidal Behavior?

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Anecdotally, I avoid situations in which I am assessed for suicidality.  It’s intrusive, distressing, and the assessment isn’t used to provide relief from the distress.  For me, it’s a well known risk:harm without any benefit.

“Generally speaking, there is no history of providing psychiatric treatment in the emergency room setting,” says Elizabeth Wharff, director of the Emergency Psychiatry Service at Children’s Hospital Boston. “Since the late 1990s, we have seen a significant increase in the number of cases where an adolescent comes to our emergency room with suicidality and needs inpatient care, but there are no available psychiatric beds anywhere in the area.”

Given that the highest known demographic risk for suicide is that of previous suicide attempt, a couple of studies seem to lead to the notion that the current standard of practice of repeated and frequent assessment of suicidality without treatment to reduce the underlying distressors may actually be contributing to the development of suicidal behavior.

In the first study, demographics of suicide risk after the first hospitalization for a mental illness was explored.

Patients with any major psychiatric disorder are at significant risk for suicide after their first hospital visit, according to new research.
Dr. Caine noted that although rates of suicide were less than what other researchers have estimated in the past, they were still quite substantial.

“I think this study really teaches us that all those prior results were in the right direction, but we’re now seeing much more clearly what the proper magnitude is, and what the burden of suicide is.”

“You can also clearly see that the suicide risk continues to climb over years. Certainly there’s a steep climb in the first year after hospitalization, but it continues to climb. So, this isn’t something you think about just the first day or week or month. This is something you think about for years,” he concluded.

It would be reasonable to think that hospitalized patients would have been frequently assessed for suicidality and behavior without receiving any treatment to reduce distressors other than masking symptoms with psychotropic medications.  The overall hospital experience is so antitherapeutic and noxious that overwhelmingly, patients avoid rehospitalizations. But they may leave with heightened acclimation to suicidality by way of the concept discussed in the following study.

The second study deals with understanding mortality salience:

Why did the approval ratings of President George W. Bush— who was perceived as indecisive before September 11, 2001—soar over 90 percent after the terrorist attacks? Because Americans were acutely aware of their own deaths. That is one lesson from the psychological literature on “mortality salience” reviewed in a new article called “The Politics of Mortal Terror.”
The fear people felt after 9/11 was real, but it also made them ripe for psychological manipulation, experts say. “We all know that fear tactics have been used by politicians for years to sway votes,” says Cohen. Now psychological research offers insight into the chillingly named “terror management.”

The authors cite studies showing that awareness of mortality tends to make people feel more positive toward heroic, charismatic figures and more punitive toward wrongdoers.
Awareness of danger and death can bias even peaceful people toward war or aggression. Iranian students in a control condition preferred the statement of a person preaching understanding and the value of human life over a jihadist call to suicide bombing. But primed to think about death, they grew more positive toward the bomber. Some even said that they might consider becoming a martyr.

As time goes by and the memory of danger and death grows fainter, however, “morality salience” tends to polarize people politically, leading them to cling to their own beliefs and demonize others who hold opposing beliefs—seeing in them the cause of their own endangerment.

Isn’t that interesting! If thinking about mortality and death can induce salience, that would seem to be generalizable to suicidality outside of martyrdom.

In Joiner’s Interpersonal Theory of Suicide, he speaks to the idea that people get acclimated to the idea of suicide.  Frequent assessments of suicidality delve into all of the mechanics of committing suicide:  does the person have a plan, if so, describe it in detail, how will they access the supplies and resources necessary to carry out the plan, where will they do it, will they leave a note, do they have reasons for not doing it, etc.  Even when people deny any and all of these aspects, bringing them up over and over again (let’s call it externally applied rumination) promotes acclimation to the idea of suicide behavior, if not also reinforcing the suicidality (perceived burdensomness and thwarted belongingness). In other words, the assessments serve as mental rehearsing or practice without any treatment whatsoever outside of direct observation (not a treatment), incarceration/involuntary hospitalization (doesn’t treat anything, and increases distress), and removal of the stated intended means (TSA and box cutters, leading to shoe bombers, then underwear, then turban bombs – a moving target, NOT a treatment for suicidality).


What’s therapeutic about that?

The environment about where people are assessed and treated when experiencing a crisis of distress is critical.  Two bloggers recently addressed how much of a difference in help and harm leading to very different outcomes the physical treatment environment made here and here.

A recent post on the Bipolar Advantage blog discusses how to better help people during mental health crises, and proposes that “much of the hostility that [people who are part of the anti-psychiatry movement] have comes from bad experiences when in crisis.” I would absolutely agree.

When John had to enter the hospital a second time two weeks after his first, week-long stay, it was a real struggle to convince him to go because his first experience in the hospital had been such a negative one. I, on the other hand, have only gratitude for the people who helped me during my hospital stay.

It seems to me that mental hospitals could learn a lot about how to handle mental crises from the way general hospitals handle physical emergencies.

Many of the examples included actions by physicians and nurses that escalated and increasingly distressed patients already critically distressed.  In a comment on the Bipolar Advantage post, I summarized the desires of commenters in designing a helpful environment:

  Essential needs:

Dignity protected
Family/significant supporters’ unrestricted presence
Advocate present
Truthful and transparent information
Autonomy preserved
Planning for post-crisis self-management
Safe medication administration (right drug, right dose, right route,  right time, affordable, accessible, acceptable)
Tools for successful disease management and healthy living provided


Medically therapeutic
Eliminate law enforcement/incarceration/containment aspects
Clear written rules – same as hotel room/gym/spa rules of conduct –         NOT  punitive/control/power-based


Healthful foods served appealingly: open kitchen
Privacy for rest and sleep
Ability to get sun, green space/nature and fresh air as desired
Meeting rooms and lounges for care, socialization, quiet activities (meditation/exercise/reading/contemplation) and care planning
Clean, attractive and non-odiferous patient care areas

That doesn’t look like to much to ask. In fact, it looks like the run of the mill hospital quality standards for every other service except psychiatry.

Treatment As Usual: Case Report


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Submitted without comment:

Outpatient psychiatrist: Patient came to her routine psychopharm visit expressing profound hopelessness and a desire for her life to end. She described recent incidents at the shelter where she is staying, including one where another guest took an overdose of medication and she (the patient) was distraught that she hadn’t recognized this (clinically) sooner.  She repeatedly said, “I can’t survive this…I want it to end.”  In addition to feeling overwhelmed and anxious about her state of homelessness, she expressed concern that she “would never feel safe anywhere.”  She denied suicidal intent but was unable to find any reason to continue her life and made numerous self-disparaging remarks.  She became increasingly distraught, crying and almost moaning in her chair.


Since stopping her antipsychotic medication (intolerable EPS per patient) and decreasing her antidepressant medication on discharge from the hospital (to the street), the patient is faced with the reality of limited housing options and may likely face daily uncertainty about where she will sleep once she completes her time at current shelter – and is overwhelmed, panicked, despairing and hopeless about her life.  Her paranoid ideation has increased.  She sees no meaning in anything and wishes to die.  She denies immediate suicidal intent, but mostly due to lack of energy rather than lack of desire.


With much persuasion, patient walked with me to the A(cute)P(sychiatry)S(ervice) where she will be evaluated for inpatient hospital admission.

APS psychology fellow note 4 hours after arrival:

Patient was tearful, depressed with poor eye contact.  Patient refused to talk to writer stating “I can’t talk, go away.” Writer was unable to complete full exam due to patient refusing to be evaluated at this time.  Patient is intermittently sobbing uncontrollably, saying nothing more than “I can’t” and “you have to let me go”, refusing medication and refusing to participate in interview. Perseverating on “you have to let me go” “nothing will help”  TP – perseverative -Insight poor Judgment poor Patient requires ILOC to establish safety, containment, and aftercare planning.

36 hrs later – Psychiatry fellow and attending consultation note:

Fellow: This patient was admitted for altered mental state with bradycardia and a serum diphenhydramine level of 489 mcg/l (toxic range).  Psychiatric consultation was requested for ? suicide attempt. The patient reports that she left the hospital yesterday, returned to the shelter at which she was staying to discover that her belongings (aside from medications) had been removed.  Pt reports having felt more hopeless and ingested unspecified number of her prescribed medications.  She reports that she did not want to hurt herself but hoped that this ingestion would kill her.  She denies having anything to live for at this point, denies intent to harm herself but feels “regret” for the outcome of this medication ingestion and reportedly “want(s) to die.”   Pt does report that much of her feeling hopeless is related to lack of shelter and job.  She attributes her “life situation” to being ostracized “for being a whistleblower” (related to prior living and job situation per medical record review).

Attending: I have reviewed the events/notes of earlier this week.  At present, she explains to me that yesterday, when she left here, she wanted to die and took pills in order to bring about her death and thought the pills she took would effect that outcome.  When she realized she did not die, she felt regret.  She still feels regret because she still wants to die and kill herself. Asked why she did not acknowledge this yesterday before she left here, she said that she knew she would be hospitalized psychiatrically if she had and she didn’t want to be.  I explained to her that caretakers are able to help her only to the extent that she is honest with them.  She is pessimistic that pharmacotherapy and psychotherapy can help her deal better with her problems even if they cannot take them away.  I explained further that both can help her to be more optimistic.  She denies any thought of wanting to hurt anyone else.  She denies that anyone here is trying to hurt her.  She feels her thinking is clear and in its usual state.

Impression: Delusional and depressive disorders.  She is pessimistic, despondent, and suicidal at present and meets criteria for involuntary psychiatric admission.  Continue suicide precautions.  Continue 1:1 observation.




Comforting As A Treatment For Thwarted Belongingness

Comforting isn’t mentioned very much.  But it has powerful effects on people.

There is even a theory of comfort which has been used with people at the end of life.  Interestingly, people contemplating suicide are at a self defined end of life, so I wonder if the theory would work here?

What I’m not sure about is how people determine what is comforting when they perceive that they don’t, won’t, or can’t belong where they wish.

For me, it is about someone else’s deliberate and voluntary – as opposed to accidental and incidental- presence. It includes touching – a pat on the arm or shoulder or reaching out and holding my hand. It is sustained touch – not an air kiss and a phony hug.  It is action and not words.  It is especially not a phony, “is there anything I can do?” question which puts all of the support responsibility on me.  Of course, I always declined because that is the intended and correct response to that question.

But that comfort is totally out of reach for me.  I only imagine what is comforting, because I’ve never received it in my lifetime.  No one voluntarily interacts with me on any basis – except a slumlord who is harassing me in an to force me to move so he doesn’t have to make repairs to this falling apart attic oven.  No phone calls except robo appointment reminders.  No personal mail or email.  No face to face meetings.

What happens when a person presents at an emergency room for help with suicidality?  First, he is placed in a locked environment no different than a prison. Usually an untrained worker is assigned to continually observe, but not interact with, the distressed person. A variety of people – a social worker, a nurse, a physician or physician’s assistant, and students all may ask a battery of questions and become annoyed, angry and retaliatory when the distressed person can’t answer to their satisfaction.  At no point does the person receive comforting, reassurance or care.  Confinement, intense and intrusive scrutiny and the probability of being forcibly medicated, restrained and contained while being denied civil rights, basic humanity, respect and worth are what the distressed person faces. That’s the state of the art treatment for suicidal people.

Not only does this not help to de-escalate suicidality, it reinforces isolation, of being deemed the defective and unwanted “other”, and it intensifies despair.  It is cruel punishment, and it is not right.

What’s comforting when one is experiencing thwarted belongingness?  I can only imagine.