Suicidal Behaviour in Adult Psychiatry

Introduction

Suicidal behaviour is a critical topic for the MCCQE1 and a fundamental competency for any Canadian physician. Under the CanMEDS framework (specifically the Medical Expert and Communicator roles), you must be able to rapidly assess suicide risk, establish a therapeutic alliance, and implement immediate safety plans.

Suicide is a major public health issue in Canada. As a candidate, you must understand the nuances of risk assessment, the legal framework for involuntary admission (Mental Health Acts), and the specific epidemiological factors affecting Canadian populations, including Indigenous peoples.

Epidemiology in Canada

Understanding the demographics of suicide is essential for the MCCQE1, as it informs your pre-test probability and risk stratification.

Risk Assessment

Risk assessment is the cornerstone of managing suicidal behaviour. There is no single “test” for suicide; it is a clinical judgment based on static and dynamic factors.

The SAD PERSONS Mnemonic

While clinical judgment supersedes mnemonics, SAD PERSONS remains a useful checklist for MCCQE1 recall to ensure no major risk factor is missed.

S - Sex (Male)
A - Age (<19 or >45)
D - Depression (or Hopelessness)
P - Previous attempt (Strongest predictor)
E - Ethanol/Substance abuse
R - Rational thinking loss (Psychosis)
S - Social supports lacking
O - Organized plan
N - No spouse (Divorced, Widowed, Single)
S - Sickness (Chronic illness/Pain)

Risk Factors Categorization

Clinical Assessment Strategy

For the MCCQE1 Clinical Decision Making (CDM) or MCQs, follow a structured approach.

High-Yield Assessment Table

Management and Treatment

Management depends entirely on the risk stratification.

1. Immediate Safety (High Risk)

If a patient poses an immediate danger to themselves, they require hospitalization.

• Voluntary Admission: Preferred if the patient is cooperative and has insight.
• Involuntary Admission: Under the provincial Mental Health Act (e.g., Form 1 in Ontario).
  • Criteria: The patient must suffer from a mental disorder and present a danger to self, danger to others, or lack of ability to care for self (unintentional self-harm).

2. Pharmacological Management

Medication is used to treat the underlying disorder, not “suicidality” directly, with a few exceptions.

• Antidepressants (SSRIs): First-line for depression/anxiety. Note: Monitor for activation syndrome in the first few weeks (increased energy before mood improvement).
• Lithium: Key MCCQE1 Concept. Lithium is the only mood stabilizer proven to reduce suicide risk in Bipolar Disorder.
• Clozapine: Proven to reduce suicide risk in Schizophrenia.
• Ketamine: Emerging evidence for rapid reduction of acute suicidal ideation (specialist initiation).

3. Psychotherapy

• Dialectical Behaviour Therapy (DBT): Gold standard for Borderline Personality Disorder and chronic suicidality.
• Cognitive Behavioural Therapy (CBT): Effective for depression and hopelessness.

4. Safety Planning

For patients being discharged (Low/Moderate risk), a safety plan is mandatory.

Safety Plan Checklist:

• Identification of warning signs/triggers.
• Internal coping strategies (what can I do without contacting anyone?).
• Social contacts for distraction (friends/family).
• Family members/friends to ask for help.
• Professionals/Agencies to contact (Crisis lines, ER).
• Restriction of means (Removing firearms, locking up meds).

Canadian Guidelines & Key Points for MCCQE1

1. Restriction of Means

In Canada, physicians should specifically ask about firearms. Although less common than in the US, firearm ownership exists. If a patient is suicidal, you have a duty to ensure firearms are removed.

2. Duty to Warn/Protect

Based on the Supreme Court of Canada decision (Smith v. Jones), physicians may breach confidentiality if there is a clear, serious, and imminent threat of public safety or serious bodily harm to an identifiable person or group.

3. Indigenous Health

Recognize the role of intergenerational trauma (Residential Schools, Sixties Scoop) in the high rates of suicide among Indigenous peoples. Culturally safe care involves acknowledging these factors and integrating traditional healing practices where requested.

Summary of High-Yield Facts

• Strongest predictor of suicide: Past history of attempted suicide.
• Most common method in Canada: Hanging (suffocation), followed by poisoning and firearms.
• Protective factor: Pregnancy is generally considered a protective factor (though postpartum depression is a risk).
• Paradoxical risk: The period immediately following hospital discharge is the highest risk time (energy returns before mood improves).

Sample Question

Scenario

A 52-year-old man presents to the Emergency Department after being found by his wife holding a bottle of sleeping pills. He appears intoxicated. He admits that he “wanted to end it all” because he was laid off from his job of 25 years yesterday. He feels hopeless and believes his family would be better off with his life insurance money. He has no past psychiatric history. On exam, he is tearful, avoids eye contact, and smells of alcohol. He refuses voluntary admission, stating he “just needs to sleep it off at home.”

Question

Which one of the following is the most appropriate immediate management step?

• A. Discharge home with a prescription for an antidepressant and outpatient follow-up.
• B. Discharge home in the care of his wife with a safety plan.
• C. Administer intravenous thiamine and glucose and observe until sober.
• D. Formally admit the patient for involuntary psychiatric assessment.
• E. Refer to community addiction services for alcohol use disorder.

Explanation

The correct answer is:

• D. Formally admit the patient for involuntary psychiatric assessment.

Detailed Explanation: This patient presents with high acute risk for suicide. He has multiple risk factors (SAD PERSONS):

• Sex: Male
• Age: >45
• Depression/Hopelessness (Situational crisis)
• Ethanol use (Intoxication impairs judgment and increases impulsivity)
• Social support issues (Job loss - loss of role)
• Organized plan/Intent (Found with pills, states intent)

Crucially, he lacks insight (“family better off without me”) and refuses voluntary admission. Sending him home (Options A and B), even with family, is unsafe due to the immediacy of the threat, his intoxication, and his hopelessness. While he needs to sober up (Option C), the primary legal and clinical action is to secure his safety via admission. If he attempts to leave, he meets the criteria for involuntary admission (Form 1 or equivalent) as he is a danger to himself. Addressing the alcohol (Option E) is a long-term goal, not the immediate priority.

References

1. Public Health Agency of Canada. (2023). Suicide in Canada: Key Statistics. Retrieved from Canada.ca.
2. Soklaridis, S., et al. (2020). Mental health interventions and supports for Indigenous peoples in Canada. Canadian Family Physician.
3. Canadian Psychiatric Association. (2022). Clinical Practice Guidelines for the Management of Patients with Suicidal Behaviour.
4. Medical Council of Canada. (2024). MCCQE Part I Objectives: Suicide / Self-harm.
5. Royal College of Physicians and Surgeons of Canada. (2015). CanMEDS 2015 Physician Competency Framework.