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Suicidality and Violence in Patients With HIV/AIDS

January 2007

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IV. Management and Referral of Suicidal and Violent Patients

Recommendations:

Clinicians should maintain an up-to-date list of easily accessible mental health referral resources for patients who require either immediate mental health assessment or for whom assessment is less urgent.

Clinicians should attempt to involve people whom the patient perceives as supportive, such as friends and family, in treatment planning and management.

The management and referral strategies for suicidal and potentially violent patients depend on multiple factors, including the presence of risk factors, whether the risk factors indicate imminent danger, and acute versus chronic nature of suicidal or violent thoughts. Patients who present an imminent risk of harm to self or others represent a psychiatric emergency. Patients who are not imminently dangerous, but present with multiple risk factors and fail to respond to mental health treatment by the primary care clinician, require a complete evaluation by a mental health provider. Social support and referral to outpatient mental health services may also be necessary.


Key Point

Social support is fundamental to effective management of suicidal and potentially violent patients and can enable patients to accept help. Sources of support may include involvement of family, friends, or community-based services and the clinician's interest in understanding reasons for patients' wishes to harm themselves or others.


Involvement of people whom the patient perceives as supportive, such as friends and family, is essential for effective management of suicidal and potentially violent patients. For example, a patient who is not at immediate risk for suicide or violence might feel safer staying with a friend until he/she can see a psychiatrist for evaluation.


A. Imminent Suicidal or Violent Potential

Recommendation:

The clinician, or a member of the health care team, should escort a patient to the emergency department or call 911 when the patient expresses suicidal or violent thoughts accompanied by risk factors that indicate imminent danger (see Figure 1).

A patient who expresses actual intent to commit suicide or harm others needs urgent intervention and should receive immediate emergency department mental health assessment. A clinician's assessment that a patient is in imminent risk of harm to self or others overrules the patient's right to refuse treatment. In these cases, the clinician may need to call emergency services or the police.

New York State mental health laws provide legal procedures for the management of patients who are imminently suicidal and/or violent. Patients may be held against their will, for up to 72 hours, while a mental health assessment is performed to determine a patient's risk of harming self or others. If a mental health assessment, usually involving two psychiatrists, determines that a patient is at risk for suicide or violence, that person may be confined involuntarily beyond 72 hours for the purposes of mental health treatment. The clinician may also deem it necessary to warn any intended victim(s) of the violence. In this case, the clinician is permitted to overrule the patient's privacy privilege.


B. Non-Imminent Suicidal or Violent Potential With Accompanying Risk Factors

Recommendations:

Clinicians should refer patients who express suicidal or violent thoughts, but who are not at imminent risk, for a complete mental health evaluation when the mental health treatment by the primary care clinician does not result in successful stabilization of symptoms (see Figure 1).

Clinicians should discuss with patients the reasons why they think about suicide or violence and should develop a plan to modify risk factors.

Patients with serious suicidal and/or violent thoughts who are not imminently dangerous, but who possess risk factors, may be helped through modification of the risk factors listed in Table 1. The following are examples for addressing risk factors:

  • Treatment of underlying mental health disorder, particularly depression
  • Reduction of social isolation
  • Alleviation of physical pain, physical impairments, sleep disturbance
  • Removal of access to means of suicide or violence, such as medications and guns


Key Point

Patients with chronic suicidal and/or violent ideation often require long-term psychiatric treatment.


Suicidal thoughts can be amplified by HIV infection, particularly when suicide is consciously or unconsciously suggested to the patient by loved ones who cannot cope with the consequences of HIV/AIDS. Family, friends, and even healthcare workers who identify with a patient's hopelessness may further exacerbate suicidal thoughts by expressing ideas such as, Well, I might try to kill myself under these circumstances too. Rather than accept or reinforce such ideas, clinicians should explore with patients the reasons why they think about suicide or violence and explore means to modify risk factors. For example, a patient may fear physical pain and suffering, so a discussion of the treatment of the pain may markedly diminish the suicide potential.


C. Chronic Suicidal or Violent Ideation

Recommendation:

Clinicians should refer patients who express chronic wishes to harm self or others for a comprehensive outpatient mental health evaluation and then maintain ongoing communication with the mental health provider(s) involved in the patients' mental health care.

Some patients present with longstanding suicidal and/or violent thoughts that remain constant, although the thoughts may fluctuate in intensity over time. The level of risk may be less easily modified in the short term than among patients with more acute symptoms. Patients with chronic suicidal or violent ideation often require long-term psychiatric management. Treatment is usually designed to address underlying factors associated with their suicidal and/or violent thoughts (see Table 3). It is also important to recognize that patients with chronic suicidal and/or violent ideation may experience periods of acute worsening of symptoms that require a more aggressive treatment approach. For example, a patient with chronic suicidal and/or violent ideation who relapses to using alcohol or other drugs may require emergency evaluation. Similarly, increased suicidal ideation in a chronically suicidal patient may reflect new-onset depression that can be alleviated by treatment.


Table 3: Management Strategies for Chronic Suicidal and/or Violent Ideation
Type of Chronic Ideation Description Management Strategy
Chronic suicidal and/or violent ideation resulting from mental health disorders May be a feature of personality disorders, such as borderline or antisocial personality disorder, or a feature of chronic mental health disorder, such as schizophrenia. These patients usually require close coordination of treatment and communication between the primary care clinician and the mental health provider. Inpatient psychiatric hospitalization may be necessary during periods of acute crises.
Chronic suicidal ideation as a coping strategy May be a coping strategy for patients with chronic medical illness. For these patients, thinking about suicide may be an unconscious attempt to regain a sense of control over their lives. Patients may say or think, Well, if things get too overwhelming, I can always kill myself. Such thoughts may lend some sense of control to patients by providing a future option that never has to be acted on. When no other risk factors are present, most patients who express this type of suicidal thinking do not act on it. During acute crises or when other risk factors are present, these patients may be at more significant risk for suicide and require mental health assessment or inpatient hospitalization.
Chronic suicidal ideation among patients with desire for hastened death Some patients, usually those with more advanced disease, may request that their clinicians assist them in either suicide or hastened death. Additionally, some patients may wish to hasten their own deaths by refusing treatment. These patients may be suffering from a reversible mental health disorder, most notably depression, which could contribute to their wish to die. A mental health assessment should be performed to address any correctable problems, such as depression and poorly controlled anxiety, pain, or delirium.
Chronic suicidal ideation among self-injurious patients Patients may also present with chronic and repetitive self-injurious behaviors, such as cutting, that may or may not be associated with suicidal intent. These behaviors are more likely to occur in patients with borderline and antisocial personality disorders. In these patients, self-inflicted injury may be an expression of anger or frustration and serves to relieve internal tension. They may feel better after injuring themselves. These patients may benefit from ongoing specialized outpatient mental health treatment. They may also require brief mental health inpatient hospitalizations during crisis periods, when suicidal potential is heightened. See Personality Disorders in Patients With HIV/AIDS.


References

  1. Bellini M, Bruschi C. HIV infection and suicidality. Affect Disord 1996;38:153-164.
  2. Siegel K, Meyer IH. Hope and resilience in suicide ideation and behavior of gay and bisexual men following notification of HIV infection. AIDS Educ Prev 1999;11:53-64.
  3. Kalichman SC, Heckman T, Kochman A, et al. Depression and thoughts of suicide among middle-aged and older persons living with HIV-AIDS. Psychiatr Serv 2000;51:903-907.
  4. Kelly B, Raphael B, Judd F, et al. Suicidal ideation, suicide attempts, and HIV infection. Psychosomatics 1998; 39:405-415.
  5. Verheul R, Ball SA, van der Brink W. Substance abuse and personality disorders. In: Kranzler HR, Rounsavill BJ, eds. Dual Diagnosis and Treatment: Substance Abuse and Comorbid Medical and Psychiatric Disorders. New York: Marcel Dekker; 1998.
  6. Cooperman NA, Simoni JM. Suicidal ideation and attempted suicide among women living with HIV/AIDS. J Behav Med 2005;28:149-156.
  7. Komiti A, Judd F, Grech P, et al. Suicidal behaviour in people with HIV/AIDS: A review. Aust N Z J Psychiatry 2001;35:747-757.
  8. Roy A. Characteristics of HIV patients who attempt suicide. Acta Psychiatr Scand 2003;107:41-44.
  9. Marzuk PM, Tierney H, Tardiff K, et al. Increased risk of suicide in persons with AIDS. JAMA 1988;259:1333-1337.
  10. Coté TR, Biggar RJ, Dannenberg AL. Risk of suicide among persons with AIDS: A national assessment. JAMA 1992;268:2066-2068.
  11. Dannenberg AL, McNeil JG, Brundage JF, et al. Suicide and HIV infection. Mortality follow-up of 4147 HIV-seropositive military service applicants. JAMA 1996;276:1743-1746.
  12. Nestor P. Mental disorder and violence: Personality dimensions and clinical features. Am J Psychiatry 2002;159:1973-1978.


Further Reading

Cohen MA, Gorman JM, eds. Comprehensive Textbook of AIDS Psychiatry. New York: Oxford University Press; 2008.

Fazel S, Grann M. Psychiatric morbidity among homicide offenders: a Swedish population study. Am J Psychiatry 2004;161:2129-2131.

Fernandez F, Ruiz P, eds. Psychiatric Aspects of HIV/AIDS. 1st ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.

Marzuk PM, Tardiff K, Leon AC, et al. HIV seroprevalence among suicide victims in New York City, 1991-1993. Am J Psychiatry 1997;154:1720-1725.

Organization of AIDS Psychiatry. Bethesda, MD: Academy of Psychosomatic Medicine. Available at: www.apm.org/sigs/oap.

Perry S, Jacobsberg L, Fishman B: Suicidal ideation and HIV testing. JAMA 1990;263:679-682.

Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry 2003;160:(Suppl 11):1-60.

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This article was provided by New York State Department of Health AIDS Institute.
 
See Also
Suicide & HIV/AIDS

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