Clinical Manual for Management of the HIV-Infected Adult
2006 Edition

Section 8: Neuropsychiatric Disorders

Suicidal Ideation

Background

Transient suicidal thoughts are common in some people throughout the course of HIV disease and do not usually indicate significant risk of suicide. However, persistent suicidal thoughts with associated feelings of hopelessness and intent to die are very serious and must be assessed promptly and carefully. The risk of suicide is especially high for patients who are depressed and for those at pivotal points in the course of HIV infection.

Many events may trigger suicidal thoughts among persons with HIV. Such events may include learning about their positive HIV status, disclosing to family and friends, starting antiretroviral therapy, noticing the first symptoms, having a decrease in CD4 counts, undergoing a major illness or hospitalization, receiving an AIDS diagnosis, losing a job, experiencing major changes in lifestyle, requiring evaluation for dementia, and losing a significant relationship. A suicide assessment must always be included in the psychiatric evaluation.

Risk factors for suicide attempts include the following:

• Abandonment by, or isolation from family, friends, or significant others
• Age, especially teen years or >45 years of age
• Recent or current illness
• Any acute change in health status
• Fear of HIV-associated dementia
• Financial difficulty
• Hopelessness
• Multiple losses or recent stressors
• Pain
• Perception of poor prognosis
• Perception of poor social support
• Previous suicide attempts
• Substance abuse, especially alcohol
• Relapse into drug use after significant recovery
• Severe anxiety, depression, or other mental health disorder
• Social isolation (eg, being single, divorced, or alone, or experiencing the death of a spouse)
• Stigmatization due to illness, sexual orientation, substance use history, or other factors

S: Subjective

The patient expresses or exhibits, or a personal care giver discloses, the following:

• Active suicidal ideation with intent and plan, such as giving away significant personal belongings, saying goodbye, gathering the means (eg, gun, pills), writing a suicide note
• Passive withdrawal from therapy or medical care or decreased adherence (eg, stopping medications, missing appointments)
• A desire for HIV disease to progress more rapidly

History

Inquire about the following during the history:

• Previous suicide attempt(s)
• Friend or family member who has committed suicide
• Personal or family history of depression
• Previous episode of psychosis
• Presence of risk factors described above

Probe for other depressive symptoms and the immediacy of potential suicidal intent. Sample questions may include the following:

• "It sounds as if you're in great pain. Have you ever thought life is not worth living?"
• "Do you often think of death?"
• "Do you think about hurting yourself?"
• "How might you do that?"
• "Is this something you feel you might do?"

O: Objective

• Perform a mental status examination and suicide assessment.
• Look for signs of self-inflicted injuries such as wrist lacerations or neck burns.

A: Assessment

See chapter Depression for differential diagnosis of possible causes of depression and suicidality.

P: Plan

Evaluation

Evaluate the patient for depression, risk factors for suicide, and contributing psychiatric illnesses or situational stressors. Determine the immediacy of potential suicidal intent. If a mental health professional is available on site or can be summoned, an urgent consultation is often helpful in making these determinations.

Take the following actions as appropriate:

• If the patient exhibits active suicidal ideation with a plan, hospitalize the patient immediately, preferably in a psychiatric facility.
• If suicidal behavior is passive, refer for psychotherapy with an HIV-experienced mental health provider.
• Establish a contract with the patient not to inflict self-harm, to contact you or another specified clinician for help, or to go to hospital if suicidal ideations become active.
• Contact the patient between appointments. Enlist the help of significant others (if the patient agrees); invite them to accompany the patient on the next visit and see all of them together. Consider a support group or peer referral if available.
• Consider dispensing medications on a weekly basis for the purposes of:
  • Monitoring emotional status and treatment adherence
  • Preventing the availability of lethal doses of medications
• Perform appropriate follow-up. In consultation with a skilled mental health provider, be sure that the patient is receiving appropriate ongoing treatment for underlying or persisting psychiatric illness. Assess at each visit for adherence to mental health care and for reoccurrence of symptoms.

Patient Education

• Suicidal ideation and severe depression are not normal aspects of HIV infection, and usually can be treated effectively.
• Patients should report suicidal thoughts to their health care providers.
• Providers should inform patients about local suicide prevention resources, including suicide hotlines, emergency response (eg, 911), and local emergency departments.

References

• Gielen AC, McDonnell KA, O'Campo PJ, et al. Suicide risk and mental health indicators: Do they differ by abuse and HIV status? Women's Health Issues. 2005 Mar-Apr;15(2):89-95.
• Kelly B, Raphael B, Judd F, et al. Suicidal ideation, suicide attempts, and HIV infection. Psychosomatics. 1998 Sep-Oct;39(5):405-15.
• Komiti A, Judd F, Grech P, et al. Suicidal behaviour in people with HIV/AIDS: a review. Aust N Z J Psychiatry. 2001 Dec;35(6):747-57.
• New York State Department of Health AIDS Institute. Mental Health Care for People with HIV Infection: Clinical Guidelines for the Primary Care Practitioner. 2001. Accessed February 7, 2006.
• Roy A. Characteristics of HIV patients who attempt suicide. Acta Psychiatr Scand. 2003 Jan;107(1):41-4.