Comprehensive Guide to Assessing Mental Capacity and Suicide Risk: Identifying and Managing Crisis Situations

If a person refuses assistance and there is doubt about his or her mental capacity, further medical intervention will be needed.

Mental Capacity

In determining mental capacity, undertake the two-stage test:

1. Does the person have an impairment or disturbance affecting the functioning of their mind/brain?
   • This can be temporary or permanent. Examples include:
     • Drug/alcohol intoxication, mind-altering substances.
     • Marked emotional distress (as per suicidal crisis).
     • Medical/physical conditions that cause confusion, drowsiness, or loss of consciousness (such as stroke, hypoglycemia, urinary tract infection, sepsis, concussion, heat exhaustion, migraine).
2. Does that impairment or disturbance prevent the person from making the decision that needs to be made at that time?
   • For a person to lack capacity, the impairment/disturbance must affect their ability to make a specific decision. A person must be given appropriate support to help them make a decision. If this support has not helped them to decide, then a lack of capacity may apply, meaning further medical assistance and intervention are most likely necessary.

A patient has capacity only if they can:

• Understand information about the decision to be made.
• Retain that information in their mind.
• Use or weigh the information as part of the decision-making process.
• Communicate their decision.

If they lack capacity in any of these areas, it represents a lack of capacity.

A suicidal crisis is an intense, dysregulated temporary state of active suicidal ideation, often occurring during a time of intense emotional distress. Importantly, this heightened distress usually passes, especially with support.

Suicidal exhaustion (emotional regulatory arrest) is a prolonged state where just having the energy to live can seem overwhelming. This may occur when a person feels they must make considerable effort to hide their feelings and “wear a mask” to enable them to act in a role they identify with. It is often connected with difficulties around self-worth and trust. For example, a male who identifies as a father, holding strong values about providing for his family, might hide inner fears about impending financial concerns, which cause him significant emotional distress, but outwardly he portrays his “usual” self. Life may feel “pointless and not worth the effort of continuing,” leading the person to believe that death is the only solution for emotional release and rest.

Both suicidal crisis and suicidal exhaustion may paradoxically present a surface calm. In these states, a person may appear to have a state of mind not dissimilar to their usual self, and they may even feel energized or express contentment. A return to normalcy should be regarded with extreme caution, as the person may have come to terms with the act of suicide that they intend to carry out. It is extremely unlikely that a person experiencing a suicidal crisis or exhaustion has mental capacity at that time, and they should not be left alone.

Suicide Risk Assessment (IPAP: Intent, Plan, Access to Means, Protective Factors)

Intent

• Explore the patient’s thoughts, and always ask the question about suicide:
  • Are the thoughts fleeting and nonspecific or intrusive and troubling?
  • Are there plans and intent?
  • How long and how often have they had these thoughts?
  • Is there evidence of any psychotic symptoms?

Plan

• Has the patient made previous attempts? If so, when and how?
• What method was used?
• How did they feel about surviving?

Access to Means

• Has the patient made a plan, and do they have the means to carry it out?
• What is the plan?
• Has it been rehearsed?
• Is the plan practical?
• Are the means readily available?
• Have they put their affairs in order?

Protective Factors or Lack of

• Consider the support available and any protective factors (e.g., family, friends, children, religious beliefs, health/social care services, pets, etc.).
  • Note that family isn’t always a protective factor, as sometimes patients feel their family would be “better off without them.”

Mental Disorders

The World Health Organization (WHO) defines mental health as a state of well-being in which every individual realizes their potential, copes with the normal stresses of life, works productively, and contributes to their community. When a person is unable to do this due to emotional difficulties, they are often said to be experiencing a mental disorder. The most common types include:

Anxiety
Anxiety is a normal feeling, typically experienced temporarily in a situation that is threatening or difficult. However, recurrent or persistent episodes of anxiety for no apparent reason can interfere with life and damage physical health.
ABC of Anxiety:

• Autonomic:
  • Increased respiration.
  • Increased heart rate/palpitations.
  • Sweating.
  • Nausea/gastrointestinal disturbances.
  • Frequent urination/urgency.
  • Shaking/tremor.
  • Dry mouth.
• Behavioral:
  • Rubbing palms/hands.
  • Pacing/restlessness.
  • Shouting.
  • Withdrawal.
  • Avoidance.
  • Increased consumption of alcohol or recreational drugs.
• Cognitive:
  • Fear (of the unknown): “What’s happening?”
  • Panic: “Something awful is going to happen.”
  • Inability to concentrate.
  • Loss of control: “I can’t control this.”
  • Thoughts of death: “I’m dying.”
  • Inability to focus on their current situation.

Depression and Severe Mood Changes
Depression is very common. One person in every five will experience an episode of depression in their lifetime, ranging from mild (low mood) to severe and life-threatening (with suicidal thoughts). Severe cases may include psychotic episodes.
ABC of Depression:

• Autonomic:
  • Decreased appetite.
  • Increased sensitivity to pain.
  • Reduced/weakened immune system.
  • Sleep disturbances (insomnia or oversleeping).
• Behavioral:
  • Tearfulness without apparent reason.
  • Anxiety or upset.
  • Withdrawal.
  • Poor eye contact.
  • Changes in sleep patterns.
• Cognitive:
  • Low self-esteem and confidence.
  • Reduced motivation.
  • Feelings of worthlessness.
  • Difficulty making decisions.
  • Suicidal ideation (not always).
  • Pessimism.
  • Impaired memory.

Assessment and Management

Key skills during assessment:

• Observation:
  • Consider the environment.
  • Is the person appropriately dressed for the time of year/day/venue? Clean or unkempt?
  • Are there non-verbal cues?
  • Are there any visible risks (e.g., weapons)?
• Communication:
  • Use simple, non-leading questions and avoid overwhelming the person with too many questions at once.
  • Gain an understanding of the patient’s situation (and their perception of it) to assess their immediate needs.
• De-escalation of Acute Distress:
  • Remain calm and non-judgmental.
  • Employ empathy, non-confrontation, threat minimization, compromise, and distraction techniques.

Screening

• Assess behavior, appearance, speech, rapport, mood/affect, cognition, thoughts, hallucinations/delusions, insight, and the risk to self/others.