17 - Assessment and Treatment of Suicide Risk
Editors: Shader, Richard I.
Title: Manual of Psychiatric Therapeutics, 3rd Edition
Copyright 2003 Lippincott Williams & Wilkins
> Table of Contents > 17 - Assessment and Treatment of Suicide Risk
17
Assessment and Treatment of Suicide Risk
Richard I. Shader
As with other human behaviors, suicide, whether attempted or completed, can reflect many disparate determinants. By far the most important of these is depression. In states of depression, self-inflicted death is usually experienced as a release or relief from hopelessness or despair; a struggle that feels as if it cannot be favorably resolved; an intolerable dissatisfaction with oneself; overwhelming or intractable pain, especially when it is chronic; an incurable or stigmatizing illness, such as cancer or human immunodeficiency virus infection; old age; or a sense of a bleak and barren future. Such hopelessness and despair were poignantly captured in James Forrestal's suicide note (May 22, 1949), when he quoted the Chorus from Sophocles' Ajax, Better to die, and sleep the never waking sleep, than linger on and dare to live, when the soul's life is gone. Suicide can also be a response to the disordered thinking of a psychotic decompensation, particularly in patients suffering from depression or schizophrenia who may hear a voice directing them to die or saying that they do not deserve to live, or the result of a drug-induced (e.g., alcohol) or toxic state, which may result in stepping out of a window and falling or jumping to one's death in a false belief that one can walk on air or fly. Although self-immolation is much less frequent, nevertheless it is a well-known religious, nationalistic, or political phenomenon (a psychotic condition may cause some of these acts but may not be recognized). Some even see suicide as a means of rebirth. Suicide can also be experienced as revenge (e.g., You'll be sorry when I'm dead ) or as an attempt at reunification with a lost loved one. A few clinicians and ethicists use the term rational suicide for deaths involving unremitting pain and suffering that is not relieved by treatment or for which no treatment exists and in which no treatable mood disorder is present (see Chapters 18 and 19).
Precise incidence, prevalence, and other risk estimates for suicide are always difficult to establish. Because of the obvious difficulties in determining whether some deaths are accidental or if they are suicide or homicides (e.g., automobile accidents, poisonings, impulsive actions by adolescents who are neither depressed nor psychotic), available statistics likely underestimate the frequency of suicide. Population demographics and treated-prevalence figures for various illnesses also change, as do usage patterns and availability of alcohol and potentially lethal drugs (both licit and illicit). Working estimates of 25,000 to 35,000 suicide deaths per year appear to be reasonable. This figure is sometimes expressed as 10 to 13 deaths from suicide per year per 100,000 in the general United States population. The rates are about 18.6% for all men and 34.1% for men over 65; the comparable figures for women are 4.4% and 4.7%, respectively. Comparable figures for white males versus African-American males are 20.3% and 36.6% and 10.2% and 11.6%, respectively. About 10% of patients who have been diagnosed with schizophrenia will commit suicide, most likely when they are still young; when they are without strong supports from family, friends, or a job; or soon after a hospitalization that has not meaningfully changed their status.1 About 10% of patients who have been hospitalized for a mood disorder will also die from suicide. About 90% of suicide victims have a diagnosable psychiatric disorder, either as a current diagnosis or as one that can be made in retrospect, at the time of death. Suicide coupled with homicide occurs at an approximate rate of 0.2 to 0.3 per 100,000 person-years in the United States.
Firearms and explosives are by far the most frequently recorded means of suicide (57%); rates of suicide rise and fall to some extent based on the availability of firearms. Hanging, strangulation, and suffocation are less common, but these exceed the number of suicides linked to ingestions of solid or liquid poisons. All other methods are comparatively infrequent. Crashing a motor vehicle is estimated at 0.4%; this
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is obviously a difficult figure to establish because some single car deaths may be ruled accidental or alcohol related.
Physician-assisted suicide has received much attention in recent years. Because of the legal, moral, and philosophical issues involved in physician-assisted death, this topic deserves extensive discussion and is beyond the scope of this chapter.
I. Mental Status Examination Questions About Suicide
Just as vital signs are an elemental part of a physical examination, in the mental status examination or psychiatric interview, an assessment of suicidal risk is fundamental. Questioning should not be restricted to patients who appear depressed. Because suicidal impulses may wax and wane and as they may be more or less evident, continuing reassessment may also be required for some patients. Inquiry about suicidal concerns and impulses can be conducted systematically, progressing from more general to more specific questions in the following manner:
Are you happy (or satisfied) with your life?
How often does it really get you down?
How depressed do you feel?
Do you ever want to die?
Do you ever think about suicide?
What was going on in your life when you were thinking about dying?
Were there particular things upsetting you that connect to your wanting to die?
Do you think about injuring or killing yourself?
Do the feelings and thoughts last very long?
Has anyone close to you ever attempted suicide or succeeded?
Do you think about acting on your feelings?
Do you have a plan?
Were you ever on the verge of trying to kill yourself but then changed your mind before you acted on your feelings?
Did you ever try to kill yourself?
Did you ever start to kill yourself and then change your mind once you had started to do so?
Are there any guns, pills, or poisons in your house?
Do you have any reasons that would stop you, such as loved ones or religious beliefs?
The answers to these questions reflect the level of the motivation and intent of the potentially suicidal patient and the existence of a means or plan. Clinical experience does not support the fear that asking about suicide will put the idea into anyone's mind.
The assessment of an individual patient's potential for suicide is complex and difficult. Observation of the patient for facial, postural, and other nonverbal clues is important, as is questioning family members or other informants about their sense of the patient's suicide potential. Attention must be paid to what is said (and what is not), to what has happened (or not happened), to who is available to the patient (giving particular attention to patients who believe no one is available or who have just lost or been separated from their latest or only caring relationship); and to what has been done (or not done). The melange of suicidal variants attempts, failed attempts, attempts during which the patient changed his or her mind, manipulative gestures, thoughts, preoccupations and obsessive ruminations, and the act per se must be sorted out. Examples are the hurt and angry young child who says, You'll be sorry when I die myself; the young woman who tries to hold onto her lover by ingesting a nonlethal dose of aspirin; the recently widowed 60-year-old man who wants to die; the middle-aged man who shoots himself when he learns that he has an inoperable carcinoma; and perhaps even the persistent smoker who somewhat jokingly says, I wonder why I'm paying someone to kill me.
Learning how patients feel about the future is important. Do they have an orientation toward the future? Do they entertain realizable goals and realistic expectations, or are they setting themselves up for disappointment and loss?
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Assessment must be a continuing process, and one must remain alert to new stresses in patients' lives and to changes in patients' available interpersonal and material resources.
No single sign or set of signs is a reliable indicator of suicide potential. Attention must be paid to patients' appearance, mood, and thought content and to the overall significance of biographic elements (e.g., the fact that a patient is known to have recently put his or her affairs in order2 may be a clue to a plan for suicide). As was noted earlier, the recognized incidence of suicide is likely an underestimate that ignores the suicidal implications of numerous automobile accidents, home fires, and so on. At least transient suicidal thoughts are reported in some surveys to occur in about 15% to 20% of the general population. The following section details specific factors that may increase the clinician's index of suspicion. Assessing risk is often straightforward; predicting action is not. One should understand that risk factors and markers may not be identical for suicide attempters and completers. The high rate of false positives with many of these variables helps to explain why clinicians have difficulty predicting suicide.
II. Biographic Risk Factors Relevant to Suicide Assessment
A. History of Previous Attempts
A pattern of repeated threats or attempts is common. Depending on samples and methods of study, between 20% and 60% of patients who complete suicide have tried before. Attempts involving violent means (e.g., gunshots, hanging) or overdoses in the context of angry or hostile feelings are likely to be repeated. Failed attempts (i.e., the attempter expected to succeed) are more likely to be repeated and to lead to death than are manipulative attempts or gestures (i.e., the attempter did not expect to die and hoped the act would change the responses of others). So-called aborted attempts (i.e., the individual's intent was serious, but a change of mind immediately before the attempt halted the attempt) are common among those who make further attempts and those who succeed; aborted attempts are a clinically meaningful risk factor. Known attempts are about 10 times more frequent than completed suicides.
Those who have attempted suicide before are more likely to die than are the nonattempters.
Second attempts commonly come within 3 months after the first attempt.
B. Emotional and Diagnostic Factors
Depression (e.g., grief, hypochondriasis, insomnia, guilt) is a major factor in suicides, as are hopelessness and impulsivity. The presence of acute anxiety, especially panic attacks, and anhedonia (decreased capacity to experience pleasure and gratification) may be particularly ominous. The clinician should remember that having an unhappy or sad mood about having an illness is not equivalent to having a mood disorder and that mood disorders may be masked and that these may present as somatization. Suicidal thoughts occur for varying durations and in varying intensity, and they form in almost all patients suffering from major depressive disorder (see Chapter 18).
Psychosis, particularly with associated terror, suspiciousness, persecutory delusions, or hallucinations urging suicide or reasons for dying, may motivate suicide attempts. Patients with psychotic depressions and young catatonic patients are especially high-risk groups (see Chapters 18, 19, and 20).
Borderline Personality Disorder (BPD) patients, particularly during the first and second decades of life, are a high-risk group. The presence of recurrent suicidal behavior, gestures, or threats is one of the diagnostic criteria for the diagnosis of BPD in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition.
Acute and chronic alcoholism, other forms of drug dependency, and toxic delirium predispose some patients to self-destructive acts.
For women of childbearing age, postpartum months and the premenstrual week are times of higher risk.
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C. Occupational Status
The unemployed and the unskilled have higher suicide rates than do those who are skilled and employed.
By profession, higher suicide rates occur in policemen, musicians, dentists, insurance agents, farmers, physicians (especially psychiatrists, ophthalmologists, and anesthesiologists), air traffic controllers, and lawyers.
A sense of failure in fulfilling one's occupational role (e.g., in a job or as a wife or mother) is a common factor in suicides.
D. Marital Status and Other Supports
Single (never married) persons are at greatest risk for suicide, followed by persons who are widowed, separated and divorced, married without children, and married with children. Those who live all alone in the world or who feel alone (they are with no one who cares or they have no one to care about) and those who have recently lost a loved one or failed in a love relationship, particularly within the preceding 6 months to 1 year, must always be considered serious suicide risks. The anniversary of the loss of a loved one can be a particularly high-risk time.
E. Gender
Men commit suicide more frequently than women, perhaps up to three times as often. Probably those at highest risk for suicide are men over 75 and the middle-aged male with a recent life crisis (e.g., a health problem, such as myocardial infarction, carcinoma, or kidney disease; a major financial setback; a significant loss of a loved one) who makes use of alcohol and who tends to deny depression.
Women attempt suicide more often (from two to four times) than men do.
Gay, lesbian, and bisexual youth in the United States and in some other countries are at higher risk for suicide attempts than are other youth of comparable socioeconomic status. Some surveys suggest that the risk is highest among effeminate gay male youth.
F. Age
Suicides may occur in the young, but they are less common before adolescence. Over a quarter of a million high school students per year from 15 to 19 years of age make suicide attempts requiring medical attention. In this age cohort, girls attempt suicide more often than boys do, and the highest suicide attempt rate is found among teenaged girls of Hispanic origin (just over one in seven or about 15%). For the same age group, rates for white and African-American girls are about 10% and 8%, respectively.
A particularly high-risk situation involves the linkage of guns, alcohol, adolescent boys, and impulsivity. The suicide rate in the United States for white adolescent and young adult males from the ages of 15 to 24 years, although it was considerably lower than the rate for older men, increased alarmingly from the 1960s to the mid-1990s. Recent data suggest that this trend is now stabilizing and is possibly reversing.
About 12% of adolescent and young adult deaths in the United States are from suicide. In recent years, suicide has been the third highest cause of death among African-American males from the ages of 15 to 24 years, resulting in rates ranging from 16 to 18.5 per 100,000 persons. Firearms were the method of death in almost three out of four suicides in 15-year-old to 19-year-old white and African-American males.
The frequency of suicide increases with age for men from about the beginning of the fifth decade until the seventh decade. Some data suggest that suicide rates may now be increasing in the cohorts of those 75 years
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of age and older. Only about one in seven men in this age cohort who commit suicide will have had contact with a mental health professional, a fact consistent with the observation that the elderly make less use of mental health services than younger adults do. Recent estimates are that white men over the age of 64 have a suicide rate that ranges from 35 to 45 deaths per 100,000. For white women, this age cohort rate ranges from 5 to 7.5 per 100,000.In women, the frequency of suicide increases from the beginning of the fifth decade and peaks between 55 and 65 years of age.
G. Family History and Religion
Completed and attempted suicides are more common among people with a family history of attempts or suicides and among those with a close friend who committed suicide. Suicide rates tend to be low for persons from families that are Roman Catholic or Moslem.
H. Health Factors
Patients who have undergone recent surgery are at special risk, as are patients with intractable pain, chronic or protracted diseases, terminal illnesses, or incurable or stigmatizing illnesses. Although persons with human immunodeficiency virus infections have a 30-fold to 40-fold increase in suicide rates compared with age-matched and gender-matched control subjects, this increment appears to be proportionate to their greater levels of major depressive disorder as compared with control subjects. Non central nervous system cancer patients have suicide rates that are increased by two to four times over control subjects. Some data indicate that many illnesses directly affecting the brain, such as human immunodeficiency virus infection, Huntington disease, and epilepsy, are associated with increased suicide rates, thus suggesting that loss of restraint mechanisms may be involved.
I. Help Seeking
Although, in general, most persons who commit suicide have sought medical or psychiatric care within the year preceding the attempt, help seeking is not always a reliable indicator. One study of suicides among college students found that none had sought help nor had they appeared depressed to those who knew them. About half of high school suicide victims seek help before making an attempt.
J. Race
Within the United States, recorded suicide rates are higher, in general, for whites than for nonwhites. Young African-American males have a higher than expected rate of suicide. Similarly, rates are higher than expected for Native Americans and Eskimos.
K. Geographic Location and Seasonal Variation
In the United States, suicide rates are highest in Alaska, yet overall they are higher in urban areas than in rural settings. More suicides occur in the spring and summer, perhaps because people feel despair when the change of seasons does not bring relief from their winter depression or doldrums. Despite impressions to the contrary, no consistent evidence suggests a higher rate of suicide during the Christmas holidays. Methods of suicide may also vary by geography; in Hong Kong, for example, where many people live in tall buildings, jumping from a rooftop or window is the most common means reported.
L. Medication and Substance Abuse
Certain medications, such as reserpine and estrogen-containing oral contraceptives, may worsen mood disorders and may contribute indirectly to suicidal thoughts and acts. Various licit and illicit substances may increase suicide risk (e.g., alcohol through disinhibition and lysergic acid diethylamide [LSD] through toxic false beliefs).
M. Suicide After Homicide
Suicides following homicidal acts usually occur shortly after the homicide. Circumstances and motives vary, but dominant patterns include spousal murder for reasons of jealousy or failing health and the killing of
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one's children, the killing of one's entire family, and retaliation against another family member related either to suspected infidelity or to self-proclaimed altruism.
TABLE 17.1. SOME MYTHS ABOUT SUICIDE | ||||||||||||||
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N. Suicide Notes
The content of a note written during a failed or aborted attempt may provide clues as to the seriousness of the attempt. However, notes may also be written in attempts that are manipulative or that are a cry for help. When pens are used, finding ink on the correct writing hand of the deceased may be an important forensic clue.
O. Myths
Table 17.1 lists some commonly held myths about suicide that should be understood by clinicians.
III. Biologic Markers for Suicide
Although results from studies of the biologic basis for suicide vary considerably, some trends and generalizations are informative. People who commit suicide may have reduced concentrations of 5-hydroxyindoleacetic acid and serotonin in some brain regions, such as the brainstem. Reduced imipramine binding (or affinity) in brain tissue has also been observed. Reduced concentrations of 5-hydroxyindoleacetic acid in the cerebrospinal fluid have been found in some suicide attempters (e.g., in patients with unipolar major depressive disorder, personality disorders, and schizophrenia). In addition, some data suggest increased hypothalamic-pituitary-adrenal axis activity, including increased 24-hour urinary excretion of cortisol in this vulnerable group. A number of authors have suggested that, taken together, these findings may identify patients who are emotionally overwhelmed and vulnerable, as reflected by the overactivity of the hypothalamic-pituitary-adrenal axis, or those who are prone to impulsivity, as reflected in the low cerebrospinal fluid 5-hydroxyindoleacetic acid levels. When these alterations coincide with disordered mood, the potential for suicide may be high. These findings also point to a consistency between attempters and completers with regard to altered serotonin system functioning.
These and other lines of evidence have converged in ways that lead some experts to conclude that both suicidal behavior and major depression are independently
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related to alterations in serotonergic function and regulation (Mann et al., 2001). Additional findings that support this assessment are altered kinetics for ligand binding to the serotonin transporter on platelets and reduced ligand binding to 5-hydroxytryptamine-1A (5-HT1A) receptors in the prefrontal cortex; these changes occur independently of diagnosis. Moreover, a correlation is seen between blunted prolactin increases in response to oral fenfluramine and the occurrence and lethality of past suicide attempts in patients with major depression.
Twin and adoption studies also suggest genetic determinants for suicidal behavior, in both attempts and deaths. Possibly involved candidates that are supported by preliminary findings but that require further study are the genes for the 5-HT1B and 5-HT2A receptors, tryptophane hydroxylase, the serotonin transporter, and monoamine oxidase. One recent study revealed an elevation in RNA editing at a locus in the 5-HT2C receptor in the postmortem prefrontal cortex tissue of patients with major depression or schizophrenia who committed suicide; the comparator tissue was taken from psychiatrically normal persons who died in accidents or from homicide.
IV. Treatment
The proper assessment and treatment of suicide risk are extremely critical aspects of medical practice. Unfortunately, assessment of suicide risk and treatment planning can be influenced by the varied reactions of clinicians to suicidal patients. A few clinicians, for example, imply or openly state that they cannot take responsibility for someone else's life. This attitude often confuses the clinician's feelings of helplessness, anger, disappointment, and rejection with the civil liberties arguments or philosophical positions about individuals' rights. Important realizations are that, in all states, suicide has legal implications and that commitment laws may allow the hospitalization of people who are considered a danger to themselves.
Although this approach is not widely accepted, a few clinicians use a bantering interview style with suicide attempters, as a way to try to minimize or undercut the seriousness of the attempt; some restrict the bantering approach to those who have made repeated attempts. This controversial therapeutic style assumes a consciously manipulative aspect to the attempt. In the view of the author, the risks of adopting this approach outweigh any possible benefits.
Some clinicians hospitalize suicide attempters, and then they are reluctant to discharge them because they feel uncertain about judging their patients' freedom from suicidal impulses. In this era of managed care, keeping patients for more than limited stays as inpatients is particularly difficult. When a clinician feels unable to assess a patient's status, consultation with the ward team or other clinicians is essential.
Although offering guidelines for the treatment of individual patients is beyond the scope of this chapter, consideration of aspects of one approach to treatment may be helpful. The author approaches most suicidal patients with a bias based on clinical experience most suicidal patients change their minds. When patients have suicidal thoughts or behavior associated with major depressive disorder, effective treatment of the depression usually is sufficient. However, the clinician should keep in mind the fact that for currently available antidepressants to work rapidly is unusual.3 For acute exacerbations of suicidal feelings, the only effective treatment with a rapid onset of action is electroconvulsive therapy (see Chapter 24).
For suicidal behavior secondary to the hallucinations or delusions of schizophrenia, adequate treatment of the psychosis should be effective. Patients with BPD who have intense dysphoria may respond to treatment with monamine oxidase inhibitors or fluoxetine or to another specific selective serotonin reuptake
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inhibitor. Some clinicians believe that the early increases in anxiety or the occasional occurrence of akathisia that is associated with some selective serotonin reuptake inhibitors may pose special difficulties for the impulsive suicidal patient with a low tolerance for frustration or added distress. This concern must be weighed against data that show reductions in suicidal feelings in placebo-controlled studies of selective serotonin reuptake inhibitors. Because impulsivity is a central feature in many patients with BPD, the risks of medication use must be considered along with any potential benefits. The recently widowed patient may be helped to grieve (see Chapter 16) and may find support and companionship with others who are successfully handling widowhood.
With each suicidal patient, however, the aim is to come to understand and to have the patient understand why he or she wants to die, what might help to make life more worthwhile, and what adaptations can be made that would diminish the thought that suicide is the only or best solution. Some key elements in working with suicidal patients are (a) sympathetic listening, or being open to hearing their often ambivalently expressed cries for help and their deep despair or loneliness; (b) understanding and managing one's own countertransference reactions, such as helplessness, anger, or rejection; and (c) taking all threats of suicide seriously.
Providing a safe, nonrejecting environment is also important; this can range from helping a patient reveal feelings and impulses to family and friends so that they will spend more time with the patient to hospitalization with continuous observation. All obvious means of suicide should be removed from a patient's living areas, including, but not limited to, medications, poisons, knives, ropes, belts, shoelaces, and guns (note: separating bullets from guns is not sufficient). With the patient's permission, family members or close friends should be contacted and should be allowed to be involved in aftercare when this is assessed to be appropriate. Establishing a clear plan for the family or close friends to follow if the patient's condition worsens is important (see below).
Hospitalization, preferably voluntarily, should always be considered. The decision to hospitalize is based on an assessment of many factors, including the severity of the patient's stated suicidal thoughts and plans, the depth of any concomitant depression, the degree of available family or peer support, the presence of current and recent substance abuse, the presence of other comorbid medical complications or psychiatric disorders, or the presence of clear impulsivity with the availability of lethal means (Table 17.2).
TABLE 17.2. SOME IMPORTANT FACTORS INFLUENCING THE DECISION TO HOSPITALIZE PERSONS THREATENING OR PREOCCUPIED WITH SUICIDE | ||
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Once in the hospital, the patient's accessible environment may again require attention to minimize self-destructive opportunities. Sharp objects, belts, shoelaces, and other objects that could be used for self-harm must be removed because the patient may have picked these up in anticipation of being hospitalized. Safety screens for hospital windows must not be overlooked. Appropriate interpersonal and somatic therapies should be tried, while retaining the awareness that any improvement in a patient's mood may reflect his or her decision to try again. Continued support and involvement during this phase are essential. When one takes the crucial risk of reducing suicide precautions and permitting the patient more freedom, the timing of the shift must include a consideration of the amount of improvement in the patient's suicidal thoughts, depressed mood, or withdrawal; evidence of an orientation toward the future; and a sense that the patient is engaged with the staff in some form of therapeutic alliance. Family members, friends, and other key persons in the patient's life should be involved, when appropriate (within the constraints of confidentiality), so that the patient does not return to the same circumstances that contributed to his or her decision to die.
Before discharge, working out a plan for follow-up care with the patient is important. Planning should take into consideration the fact that some patients feel less suicidal when a therapist temporarily fills some void; this can lead to a reemergence of suicidal impulses when treatment termination or interruption is discussed. The plan for follow-up care should be explicit, with thoughtful preparation for any transition to a new therapist or to the referring therapist. Discharge assessment should include an estimate of the patient's capacity for self-care. The quality, absence, instability, or uncertainty of available object relationships must be considered; a component of treatment planning should include helping the patient to develop positive relationships. Group therapy or the involvement of community resource persons, such as a teacher, family member, physician or other trained clinician, or clergyman, may be beneficial. The benefits of a longer hospital stay (when this is actually possible) must be weighed against any other issues (e.g., regression, interruption of work or family ties, costs of continued care). Long-term planning must address the possibility of further suicide attempts.
A second bias has emerged from the author's clinical experience those suicidal patients who do not change their minds will usually find a way. Clinicians can delay death and can provide an opportunity for the patient to improve from a particular episode of depression, demoralization, grief, or psychosis. Some patients, however, find life so empty or painful that a second chance to them means a second chance to die, not a second chance to find something to live for or to have time to work out their disappointment in themselves. A word of caution is in order clinicians must not let their own feeling that they would not want to live under a particular set of conditions dictate their care of the patient. For example, avoiding the influence of one's own personal feelings about the value and meaning of life can be especially difficult when a clinician is treating a patient with inoperable and painful metastatic carcinoma.
Finally, some clinicians have had positive experiences with the use of formal no suicide contracts. In the author's view, the use of a contract may be reasonable when the patient is assessed as low risk, he or she has available people to call or stay with for support, and he or she has some stated reasons for wanting to live and when an alliance exists with the treating clinician. That a patient who refuses to discuss or sign a contract may be at high risk is also likely. In any contract, the patient must agree, preferably in writing and signing it in the presence of a witness, not to act on any self-destructive feelings when the wish to die becomes strong and to call the treating clinician and 911, a suicide or crisis hotline, a local emergency department, or a designated support person a person stipulated in the contract, along with that person's telephone number(s). The contract must also give the designated person the right to call the treating clinician or any other backup resources if the patient's condition worsens; the treating clinician must also have the right to call the designated person or the police if the patient fails to keep a scheduled appointment. In effect, the patient is agreeing to contain any suicidal impulses in between specified appointments or to call
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to arrange for a more immediate appointment. In the author's experience most impulsive, psychotic, substance abusing, or markedly depressed patients cannot be expected to do this, even when they agree to do so. That no suicide contracts have no legal standing must be remembered.
V. Comment and Caveats
Suicidal patients should be viewed as medical emergencies; treatment and program planning must recognize the need for 24-hour services. Suicide is a frequent basis for malpractice actions against psychiatrists. Careful documentation is essential, including recognition of the risk and past and present treatment and prevention efforts. The jeopardy for psychiatrists and other clinicians and their suicide-prone patients has increased in recent years with the higher threshold for hospitalization and the shortened lengths of stay that have resulted from managed care plans and increasing hospital costs. For example, the author has been consulted about managed care reviewers who have stated without seeing the patient that the suicidal concerns or behaviors of a patient were either not acute enough to require hospitalization or too chronic to benefit from hospitalization.
In the event of a suicide, immediate notification of one's malpractice insurance carrier is essential. An important early concern may be the issue of talking to the patient's family or to other staff. Unfortunately, the medicolegal aspects of suicide can become complicated when dealing with surviving family members. A delicate balance must be achieved between any natural desire to comfort the family, to help them understand, or to share one's own emotional responses and respecting the deceased patient's right to confidentiality. For a family to be irrational, to view the clinician as responsible for the death, and to interpret any caring responses as a manipulation to avoid a suit is also not uncommon. For clinicians and families to remember that suicide may be inextricably linked to certain disorders or to patients' responses to their suffering is not easy.
Many clinicians and other staff are devastated by the suicide of a patient. Although some may try to continue as if nothing has happened, the suicide will likely have an impact on the clinician's care of other patients, as well as on the self-concepts, self-esteem, and interpersonal lives of those involved. Review and supervision from a trusted and knowledgeable colleague can be beneficial to individual clinicians. Formal review in the form of a psychologic postmortem can also be useful for staff involved in the patient's care. The timing of such reviews may be affected by risk management and malpractice issues.
One possible method of suicide prevention or reduction limiting the widespread availability of handguns should be supported by clinicians. For clinicians to check for and urge the removal of lethal methods of suicide from their high risk patients is not sufficient (note: locking gun cabinets or separating guns from bullets is not sufficient): the participation of both them and their professional organizations in raising awareness among families, teachers, and other members of the community about the role of handguns and in encouraging injury prevention education is also essential.
VI. Useful Online Information
The American Association of Suicidology (AAS; see http://www.suicidology.org/) trains and certifies suicide hotline counselors and provides other valuable information on its website. For 24-hour nationwide hotline access, call 1-800-SUICIDE (1-800-784-2433) or visit the website (http://www.suicidehotlines.com/). Facts and statistics can be found at http://www.nimh.nih.gov/research/suifact.htm and at the AAS website.
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1Recent data suggest that the use of clozapine may significantly reduce suicide rates in schizophrenic patients.
2Some examples are the writing of or changes in a last will or testament, buying a burial plot, or making a plan for the disposition of one's remains or effects.
3Prescribing clinicians should keep in mind the potential for serious or even fatal overdosage with any antidepressants they prescribe; adjusting the number of pills dispensed and the timing and number of refills must be a consideration. The clinician should also remember that the tricyclic antidepressants and monamine oxidase inhibitors have a higher risk for more serious overdose consequences than the selective serotonin reuptake inhibitors and other newer agents do.
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