In her doctoral thesis, clinical psychologist Bergljot Gjelsvik examines two aspects relevant to assessment of suicide risk: Access to prescribed medication and its role in deliberate self-harm (DSH), and characteristics of subjective experience of suicidal intent associated with an episode of DSH.
Adopting a longitudinal observational design, patients were included prospectively whilst hospitalised for a DSH episode, and subsequently completed questionnaire data at 3 (t2) and 12 (t3) months. Patient data were matched with data from the Norwegian Prescription Database and the Cause of Death Registry, and with hospital data about the lethality of the episode.
Gjelsvik investigated patients’ access to prescribed medication in the year prior to the DSH episode compared to the general population, and whether they used medication prescribed to them in the DSH episode. Findings showed that a much larger amount of psychotropic and non-psychotropic medication were prescribed to these patients compared to the general population. The majority of patients ingested drugs prescribed to them in the DSH episode, and this tendency increased with age.
Moreover, Gjelsvik investigated change in medication load following the DSH episode. The findings showed that prescribers did not curb prescribing to these patients in the year following the DSH episode. An overall increase was observed in both psychotropic and non-psychotropic medication load compared to the year prior to the episode.
Gjelsvik investigated the relationship between lethality of a deliberate self-harm episode and patient’s subjective experience of suicidal intent associated with the same episode, both at the time of the episode and retrospectively. Gjelsvik also investigated whether subjective experience of suicidal intent and lethality of the DSH episode predicted subsequent death by suicide. Apart from an association between lethality and perceiving the episode as a suicide attempt at t1, no association was found between subjective experience of suicidal intent and lethality at t1, t2 or t3. Lethality was significantly associated with subsequent death by suicide in the follow-up period.
Gjelsvik examined if and how re-appraised subjective experience of suicidal intent for a single index episode of DSH changes over time and factors associated with such change. The findings showed that current mood at the time of assessment, rather than the mere passage of time since the index DSH episode, was the most influential factor affecting the degree of suicidal intent attributed to an index episode of DSH when re-appraising it retrospectively. The only exception was re-appraised wish to die associated with the episode, which decreased over time independently of mood.
The findings challenge the notion that a single prescription bears significance in endangering vulnerable individuals to suicidal acts, and suggests that more focus should be directed to the total medication load for high risk subjects. This is particularly important given the high number of patients ingesting prescribed medication in a DSP episode in this study. The results suggest cautious and judicious prescribing to patients prone to DSP, and careful assessment of potential propensity for suicidality in the household.
Moreover, the study challenges the linearity between subjective experience of suicidal intent and lethality of DSH on which current terminology is premised, and emphasises the importance of assessing these two parameters separately in suicide risk assessment. Finally, the findings show that mood significantly influences re-appraisal of subjective experience of suicidal intent associated with a previous DSH episode. Clinically, this means that current mood provides a more helpful context in which to interpret appraisal of previous DSH regarding subjective experience of suicidal intent than the mere passage of time since the DSH episode in question. In suicide risk assessment, current degree of depressed mood must be taken into consideration as a factor that is likely to bias the information gathered. Health professionals need to be aware of the poor relationship between lethality and subjective experience of suicidal intent in risk assessments, and to be particularly vigilant for a history of near-fatal episodes when assessing suicide risk.