About 250000 patients per year are seen in West Germany for inpatient treatment following suicidal actions. 14000 kill themselves, and it is estimated that this includes about 3000 patients with endogenous depression. 16% of those who survive their attempt at suicide, repeat this attempt in the following year. The likelihood of a repeated attempt is highest in the first year after the initial attempt. At least 85% of those attempting suicide could be released from intensive care within a very short time. 15% had to be admitted to a psychiatric ward or hospital due to further suicide attempts or endogenous depression (H.L. Wedler, M. Philipp, H.J. Bochnik).

Doctors and nurses regard suicide patients as the "most disliked patients". As a result, there is a great lack in the psychosocial care of suicidal patients. There are many reasons for this negative opinion as regards the suicidal patient. It is very often presumed that "he did not really mean it". It is usually only those who undertook the more serious attempt who have a chance of being taken seriously. The subjective side of the patient is completely dismissed during the clinical separation of the "tried-on" suicide attempt on the one hand and the "serious" attempt on the other. Many doctors find it very difficult to accept the attempt as a signal for help by which the patient is indicating that he is at present unable to go on with the resources at his disposal (C.H. Reimer).

There are several reasons for this unsatisfactory care of the suicidal patient. The way of dealing with the suicidal patient is rarely taught during the medical studies and in the training of nursing staff. Psychosocial care of suicidal patients is very often delegated to psychologists and to psychiatrists. This automatically leads to an emotional withdrawal from the patient with the inevitable negative effects on communication. Working with a suicidal patient raises a variety of anxieties, aggression, stresses and conflicts, as well as personal uncertainties about death. Problems raised by the frequent lack of compliance add to this. Many patients refuse to discuss the attempted suicide and demand immediate discharge. This raises the feeling in the helper that he is being rejected.

There are two major areas to consider when presented with a suicidal patient:

1.	Recognition and assessment of the likelihood of suicide. It is not possible to prevent suicide unless this is appreciated. This particularly difficult responsibility mostly falls to the doctor who is least trained in this area (general practitioner).
2.	Care after the attempt which is mainly in the hands of the hospital doctor.

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Recognition of the likelihood of suicide and the risk of suicide are one of the most important responsibilities which the doctor can be faced with. They can create major problems even for a doctor who has had a great deal of experience in the area. Testing by psychological, psychiatric or psychosocial methods cannot be used to assess the risk, as long as their reliability for prediction remains uncertain. Here it will be attempted to show what possibilities there are for the doctor who is not trained in psychology or psychiatry to use in his practice to estimate suicidal potential. Except in panic actions, attempts at suicide are, as a rule, preceded by a presuicidal development (W. Pöldinger). This can be broken down into three stages (figure):

Stages in presuicidal development (after W. Pöldinger)

In the first stage, suicide is considered as a possible way of solving a problem or conflict. There are psychodynamic factors such as aggression (which cannot be expressed and are turned inwards) which play a role, but there also may have been suggestive events (suicide in the environment). This explains the observation that the reports of suicide of prominent people can raise the suicide rate in the population. It was shown that the suicide rate fell markedly during a newspaper strike in Boston.

In the ambivalent stage, a battle develops between self-preserving and self-destructive forces. Direct or indirect warnings of suicide can appear in this stage (suggestions, threats, predictions), which are to be interpreted as cries for help and attempts for contact. The presumption that "those who talk about suicide don't do it, and those that do it, don't mention it" has not been shown to be valid. About 80% of all those who attempt suicide have given warnings of their intention. This is usually not taken seriously in cases where the person in question thereby puts pressure upon others.

The decision either for continuing life or for suicide is taken in the third stage. Those around are aware that the person has become "calm" and no longer mentions suicide. However it would be wrong to presume that there is no longer a risk of suicide. It is much more likely to be the "calm before the storm". It is particularly important to ask somebody who has mentioned or threatened to commit suicide why he now wants to live. Those who truly want to live will immediately be able to give a reason, whereas the person who has decided to commit suicide is not able to find a satisfactory answer.

If there is any suggestion that the patient is suicidal, even though he has not mentioned it (depression, life crisis), it is better to speak to him directly and confront him rather than fall into a false sense of security. This applies especially to the general practitioner who has known his patient for many years, who can be led astray by a false perception. Even though he has known the patient for many years, he only knows a few sides of the person, and if suicide is under consideration, this longstanding relationship is no substitute for such a discussion.

When trying to assess the suicidal behaviour, it is very important to take into account the fact that there are different psychodynamic's between suicide and attempted suicide. In the case of suicide, self-aggression and self-destruction are at the forefront. Although a suicide attempt can actually be a failed suicide, it can also be parasuicidal behaviour (N. Kreitmann W. Feuerlein, cit. W. Pöldinger). The parasuicidal gesture is not really an unsuccessful attempt at suicide, but rather an attempted suicide in which a cry for help is foremost. It is a form of non-verbal communication, which is used because verbal communication is no longer possible. This is the explanation of the fact that suicide attempts are observed more commonly in younger people, and suicide itself is more common in older people.

There is a rising number of young people in West Germany who commit and attempt suicide. Suicide is the second most common cause of death in those between 12 and 15. Suicide was the cause of death in 12% of those between 15 and 19 (1974 to 1983). Many patients committing suicide could not manage separation; many school systems no longer maintain an intact class from the age of 15, and the pupils have hardly any contact with others as they dash from one course to another. If there are family crises on top of this (such as divorce of the parents), the loss of a reference person can lead the young person to suicide.

The other group of those particularly at risk of suicide are old people. Statistics show that old people living on their own (widows or divorced) are particularly at risk of suicide, especially when they are faced with the loss of a life-long partner. Loneliness and isolation put the old person at much greater risk of suicide. Old people who live in an old people's home can also feel lonely and isolated, as it is not the number of social contacts but rather the quality of relationships which is decisive.

Doctors, too, are not immune to suicide, as shown by their suicide rate which is even higher than in the general population. This is probably a reason for inhibitions in speaking to a patient at risk of suicide.

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Distribution of suicide and suicide attempts according to age (after Dotzauer, 1963)

W. Pöldinger lists 4 points which should be used in the assessment of the likelihood of suicide:

1.	In any group with raised risk factors
2.	Crises, changes and pressures
3.	Suicidal development
4.	Pre-suicidal syndrome

The following groups are at risk of suicide (Kiev and Wilkins):

1.	Depressed patients
2.	Alcoholics, and those addicted to medication or drugs
3.	Old and lonely
4.	Those who have made it known, by mentioning or threatening attempts on their life
5.	Those who have already attempted suicide.

A crisis is often a precursor of the suicide. Crises are defined as stresses and experiences that the affected person can no longer work through and overcome (Häfner, 1974). Suicide is then one possible strategy available to solve the problem; acknowledgement of this reaction to such a crisis gives the doctor a chance of recognizing the risk of suicide. Nevertheless there are great individual variations. Crises can be seen as "normal" life-changes (leaving home, marriage, retirement) or as shaking experiences such as death of a loved-one, serious illness, social rejection etc. The majority of crises are probably satisfactorily resolved within the social circle. On the other hand, reactions to environmental crises can persist and become chronic. One of the most significant reasons for suicide however appears to be that those around do not react to a crisis.

The danger of the development of a presuicidal syndrome arises if the crisis remains unresolved (E. Ringel). This development occurs in three stages and offers an important chance for the assessment of a suicide risk (Ringel, 1969).

There is usually no difficulty in recognizing marked depression: it can be generally described as a ... lessness syndrome; uselessness, hopelessness, sleeplessness with loss of motivation and trust.

It is more difficult to recognize a masked depression, which by its very nature cannot be picked up by complaints or their content. Hints may be gleaned from the absence of an organic correlate to the complaint together with a dramatic description of the symptoms (i.e. "as if a bowl of gall were tipped over my tongue...") (P. Kielholz, 1973, L.S. Geisler, 1973).

Meerwein underlines that the affective reaction of the doctor can also be indicative of hidden depression. If the doctor becomes aware of a depressed feeling or mood in himself whilst the patient is describing his symptoms or problems, he should be aware that this may indicate depression in the patient.

If depression is likely to be present, the treatment with appropriate antidepressives (not however psychopharmaceuticals of the benzodiazepines groups) should be commenced as soon as possible. The severity of the depression and the experience of the doctor in dealing with depressed patients determine whether or not a consultant psychiatrist should take over the case. Where there is the slightest doubt, but especially where there is clear suicidal intent, psychiatric therapy should be requested.

There is a series of general rules for the medical dialogue with depressive patients. Tension can be reduced by the doctor clearly indicating to the patient that he understands such depression. It is usually ineffective to attempt to "console" the patient, as the depression itself is "hopeless" and the condition inconsolable. It is equally ineffective to attempt to try to animate the patient by suggesting obvious or superficial approaches ("completely relax at the weekend", "pull yourself together as much as possible"). The depressed person is neither able to completely relax nor to mobilize himself. "Pull yourself together" is understood in the literal meaning of the phase, as the injunction only increases the demands on him. Attempts at distraction (journeys, holidays, and visits to cinema or theatres) are equally useless. Similarly, "patting on the shoulder" is also likely to fail ("it will soon be better again" etc). The determining factor is that the depressive feels that his symptoms are accepted and understood. It can be a relief to the patient to hear that it is known that depression can resolve as quickly as it comes on.

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Experience has shown that the initial discussion after a suicide attempt takes on a decisive role. Every single word and every reaction that the recovering patient initially hears at the hospital bed can be decisive for the further course of his life. This is because the suicide patient perceives these first contacts as the reaction of the environment to his suicide attempt. It is for this reason that further working out of the conflict and attitude to his failed attempt at suicide depends on whether he receives friendly acceptance and readiness to help or rejections, judgement and indirect punishment. Hans Ludwig Wedler stated: "The type and quality of the first verbal as well as the non-verbal communication at the hospital bed is most likely to decide whether the patient once again accepts the reality from which he tried to escape, as well as his willingness to accept further help. A smile from the doctor and the nurse, a single friendly word are in themselves already 'positive crisis intervention.'"

The objective of crisis intervention after the suicide attempt is to create a correct approach for the future. Wedler gives 7 steps in the approach to the suicidal patient which act as crisis intervention.

1.	Contact as early as possible (bearing in mind the importance of the initial conversation)  Message: "I am prepared to accept you."
2.	Opportunity for self-examination Message: "I am prepared to listen to you."
3.	Re-establish social relationships (to nursing staff, doctors, other patients); Message: "Neutral atmosphere for practicing social contacts."
4.	One-to-one discussions, with analysis of the psychosocial situation and the way in which the crisis arose; discussions with close relatives; family and spouse discussions.
5.	Pointing in the right direction for further therapy and follow-up; motivation of the patient; arranging introductions.
6.	Attempt to integrate the suicidal behaviour into the psychosocial relationships of the patient (metacommunication).
7.	Putting the personal helping role into context.

It is not possible to achieve this form of crisis intervention without a considerable expenditure of time. Wedler estimated that a complete crisis intervention takes on average 5 to 6 one-to-one discussions and 1 or 2 discussions with relatives.

There are two psychological factors which can limit the effectiveness of crisis intervention (M. Philipp):

The majority of suicidal patients that survive the acute or intensive care ward have a transitional syndrome which lasts several hours or days after the phase of detoxification. This transitional phase is usually limited, and consists of slight attention disturbances and affective lability. This means that discussions, advice and suggestions are very often forgotten in the detoxification phase due to this amnesic component. This underlines the importance of several discussions.

A further psychological barrier in the intensive care unit is the tendency of repression and denial on the part of the suicidal patient. This mostly has its roots in a premorbid disturbed development of self-worth. This expresses itself as an excessive ego ideal and a increased tendency to feel injured. The failed suicide attempt along with surrendering to the intensive care unit act to increase damage to the ego which he attempts to resolve by means of repression and denial. This is also the reason why earlier suicide attempts are played down (also by relatives). This behaviour pattern is seen for example in the strong pressure for early discharge and refusal of psychological or psychiatric care.

In leading a discussion with suicidal patients, it is particularly important to avoid all disparaging comments and critical remarks about suicide. The importance of this must also be impressed upon the relatives. The objective of discussion with the suicidal patient is to build up a feeling of self-worth, and not only to work out the problems surrounding the patient. This can best be achieved by a basic approach, which accepts the patient without prejudice and gives him the feeling, by the way in which he is treated, that he is understood. "Taking the subjective experiences of the suicidal patient seriously is more helpful than lengthy discussions about the suicide intent and trivializing the problems" according to M. Philipp.

Most life crises run through the phases of shock, reaction, working out and new direction (Cullberg, 1978). The suicidal patient is in the shocked phase. The essence of every care of suicidal patients therefore can be summed up by the formula: "Depending on the phase of the crisis ... a personal presence is in the forefront at the time of shock, the 'just being there' and 'standing by' (the 'representation of hope')" (G. Sonneck). 

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