Risk factors and epidemiology
The highest number of suicide attempts occurs between the ages of 15 and 40, yet in elderly patients, attempts are significantly more likely to be fatal. The difference in completed suicide probability is clearly visible in statistics: while in adolescents (15–19 years) the ratio of attempts to completed suicide is 12:1 for males and 59:1 for females, by ages 70–74 these figures critically narrow down to 1.4:1 and 1.8:1, respectively.
In addition to chronic mental disorders, classic triggers include severe somatic illnesses, loneliness, breakup with a loved one, family quarrels, and commercial failures. According to the criteria of H.I. Kaplan and B.J. Sadock, the high-risk group also includes:
- Male gender and age over 45 years;
- Presence of depression, alcoholism, or episodes of inpatient psychiatric treatment in the anamnesis;
- Previous auto-aggressive actions by the patient themselves or their relatives;
- Tendency toward impulsivity, violence, aggression, and categorical refusal of help;
- Recent job loss or retirement.
Specifics in schizophrenia and demonstrative attempts
In the schizophrenic process, auto-aggression is often unpredictable and sometimes bizarre in nature. Patients with imperative hallucinations or hypochondriacal delusions may inflict severe mutilations upon themselves (e.g., amputation of the scrotum, inserting needles into the ear) trying to get rid of an imagined pursuer or an object inside the body. In catatonic syndrome, self-injuries are often stereotyped (gouging out eyes, skin burning). Against the background of apathy and mild personality changes, attempts may be committed purely out of "experimental" interest ("to see what happens"), which makes them extremely difficult to predict.
Demonstrative attempts, typical for adolescents and individuals with hysterical personality traits against the background of conflicts, are considered separately. Their goal is not death, but a cry for help or blackmail. However, in the heat of the moment, they cannot adequately assess the consequences, so the risk of death remains high. Any overt suicidal actions are an absolute indication for immediate hospitalization.
Principles of pharmacotherapy and psychological support
The main problem of medical treatment lies in the delayed effect of antidepressants. In the first days, it is critically important to prescribe strong sedatives to купировать (ameliorate) anxiety, reduce the risk of impulsive actions, and ensure quality night sleep. The regimens use:
- Levomepromazine (levomepromazine, 25–75 mg) or thioridazine (thioridazine, 30–75 mg);
- Quetiapine (quetiapine, 200–400 mg) or sulpiride (sulpiride, 400–600 mg);
- Tranquilizers (diazepam / diazepam, 15–30 mg);
- Normothimics (carbamazepine / carbamazepine, 400–600 mg; lithium carbonate / lithium carbonate, 900–1200 mg/day).
After an unsuccessful attempt, the patient often experiences a painful sense of guilt that intensifies their reluctance to live. A gross error by the doctor at this stage is to accuse the patient of selfishness, lack of foresight, or meticulously dissecting the motives of the act. The specialist's task is to create psychological defense, praise for cooperation, and demonstrate comprehensive support.
Food refusal as a form of auto-aggression
Food refusal in psychiatric patients can occur in both open (clenching teeth, spitting out food) and hidden forms (self-induced vomiting after eating). Causes include malignant schizophrenia with catatonia, poisoning delusions, severe depression, or anorexia nervosa. Weekly weighing is mandatory to monitor the condition. Symptoms of dangerous exhaustion include acetone breath odor, arterial hypotension, hypoglycemia, constipation, and decreased skin turgor.
Therapy includes bed rest and nutritional support. Preference is given to safe parenteral nutrition (glucose, amino acid, and vitamin solutions), which replaces laborious tube feeding. To stimulate appetite, subcutaneous administration of insulin (10–20 IU) followed by drinking sweet liquid, as well as anabolic hormones, is used. In psychotherapeutic talks, it is important to emphasize the physiological harm of starvation: hormonal disorders (amenorrhea) and irreversible cosmetic defects (wrinkles, increased body hair growth).
Briefly: answers to topical questions
On the basis of which article of the Law of the Russian Federation on Psychiatric Care is involuntary hospitalization carried out in the event of a suicide threat?
Involuntary hospitalization in the event of a suicide threat is carried out on the basis of Articles 23 and 29 of the Law of the Russian Federation on Psychiatric Care. Overt suicidal actions are an absolute indication for immediate hospitalization.
Involuntary intervention is permitted in the presence of a severe mental disorder causing one of the following criteria:
- direct danger to oneself or others;
- helplessness;
- substantial harm to health if left without psychiatric care.
Permission for compulsory detention and treatment of a patient in a psychiatric hospital is granted exclusively by a court.
Class and exam questions
How to properly communicate with a patient after a suicide attempt?
Judgment and discussion of motives should be avoided. The main goal is to reduce acute feelings of guilt, provide psychological support, help rationalize the act, and instill hope for the future.
Why is it impossible to rely solely on antidepressants when suicide risk is high?
Their therapeutic effect develops slowly, over 2–3 weeks. In the first days, it is necessary to prescribe strong sedatives (e.g., levomepromazine or diazepam) to manage the risk and normalize sleep.
How to manage food refusal in catatonic syndrome?
The disinhibition procedure is used: diazepam mixed with 40% glucose is administered very slowly intravenously, while the doctor constantly tries to establish verbal contact with the patient and offers them food.
What else to study on this topic
- Mechanisms of formation of imperative hallucinations in schizophrenia
- Differential diagnosis of types of delusions leading to food refusal
- Features of parenteral nutrition in depleted psychiatric patients
- Specifics of using normothimics in acute conditions
- Psychotherapeutic interventions in hysterical personality accentuation
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