Prevention Strategies

Suicide prevention starts with taking a suicide history of every patient with HIV. Clinicians need to feel comfortable discussing suicide in depth.

Countertransference reactions play a major role in being able to have a productive dialogue with the suicidal patient and establishing a therapeutic alliance. Feelings are contagious, and the overwhelming hopelessness of a suicidal individual may interfere with the clinician's ability to infuse hope and help the patient find alternatives to premature death. Far from harming the patient, being able to put feelings into words to express suicidal impulses is highly relieving and can prevent acting out aggressively. When a suicidal person verbalizes his or her suicidal ideas and plans, a different perspective can be attained as unendurable affects are expressed. Listening with empathy at a moment of crisis can begin to dissipate hopelessness and mobilize the will to live.

An adequate suicide history includes an assessment of present suicidal ideas and plans by asking direct and open-ended questions. Since past suicide attempts are, along with hopelessness, the strongest predictors of future completed suicide, the clinician must always ask about previous attempts and elicit a family history of suicide. Timely treatment of the psychiatric disorders associated with heightened suicide risk could prevent suicide in individuals at risk. Antidepressants should be prescribed to depressed and anxious suicidal patients, but it is important to remember that anhe-donia and psychomotor retardation lift first when these are prescribed, and hopelessness, dysphoria, and suicidal behavior take longer to improve (Mann, 2005). Psychotherapy can reduce a sense of alienation, provide symptomatic relief, increase networking, and promote conflict resolution. Psychotherapy modalities that can help suicidal patients include interpersonal, cognitive-behavioral, psychodynamic, and supportive, in both individual and group therapy settings.

Physical symptoms compound psychological distress and can precipitate death by suicide. Providing symptomatic relief and palliation of nociceptive and neuropathic pain, pruritus, diarrhea, nausea, emesis, and anorexia can avert a suicidal crisis in persons with HIV infection.

There is no treatment for suicide, only prevention. Thus there may be times when a person with HIV or AIDS is overwhelmed with suicidal feelings, and the person may or may not have a prior relationship with a psychiatrist or other mental health clinician. If there is a suicide attempt or an expression of suicidal ideation, primary physicians, psychiatrists, and other mental health professionals in an emergency setting, or psychosomatic medicine psychiatrists in general care may need to assess for suicidality. In such situations, an emergency psychiatric hospitalization may be indicated if the person is found to be actively suicidal and in the midst of a suicidal crisis. Close observation by staff is essential to ensure that the suicidal individual is safe during the process of the transfer. If the medical condition does not permit transfer, then one-on-one observation should be maintained until the suicidal crisis resolves or the transfer can be accomplished.

Since suicidal persons are ambivalent by definition and will oscillate from wanting to live and opting to die, it is important to identify family members or friends who can be called on to accompany and protect patients during a time of crisis. Family members or friends can also be of assistance in minimizing access to lethal means.

In order for the suicidal person with HIV infection to resolve a suicide crisis, it is important to establish trusting relationships, reconnect with family members and significant others, restore hope, find meaning in life, and develop goals to attain a sense of fulfillment and connectedness. With support, companionship, networking, conflict resolution, palliative care, adequate medical treatment, and alleviation of psychological distress, persons with HIV infection may realize that suicide is not the only option.

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Part V

Neuropathologic Manifestations of HIV Infection

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