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Assessing The Risk of Suicide

Scream

“The Scream” – Edvard Munch

Patients with depression may be at increased risk for suicide (Kahn, 1999. NYCDOH, 2006, Mann, 2005). Any patient that has a positive screening for depression should be evaluated for suicide risk. Asking about suicidal thoughts can save the patient’s life. Contrary to many physicians’ fear, asking about suicidal plans or ideation does not make patients more prone to commit suicide. Patients are usually relieved that they have been asked about their feelings and thoughts. Asking about suicidal ideation or plans conveys your interest in their well-being.

Questions in Assessing Suicidal Risk
  • Current thoughts of harming or killing self
  • Current plans to harming or killing self
  • Prior suicide attempts (critical indicator of future suicide risk)
  • Family history of mood disorder, alcoholism, or suicide
  • Actions or threats of violence to others
  • Access to firearms
  • Male
  • Elderly
  • Significant comorbid anxiety or psychotic symptoms and active substance abuse
  • Poor social support system or living alone
  • Recent loss or separation
  • Hopelessness
  • Preparatory acts (e.g., putting affairs in order, suicide notes, giving away personal belongings)

Physicians can initiate the topic of suicidal ideation with questions about the patient’s feelings about life.

Depending on the response, more specific questions about suicidal ideation can be asked.

If suicidal ideation is elicited, physicians should ask patients if they have a suicidal plan (e.g., how, when, where). A patient that is actively thinking about suicide and has a plan for suicide constitutes a medical emergency. This is especially true in patients with previous suicide attempts. 911 should be called for safe transport to the nearest emergency room for psychiatric care. Prediction of which patients with suicidal ideation will attempt or commit suicide is very poor.

The Institute of Mental Health has made recommendations for physicians who are assisting potentially suicidal patients. It is important to monitor your own reactions to a suicidal patient. Stay calm and don’t appear threatened so that the patient feels secure and maintains the doctor-patient dialogue. Listen attentively so that the patient feels validated about their distress and is not ignored. Avoid judgmental statements. Emphasize that suicidal feelings worsen with stress, but is a treatable condition. Also highlight that suicide causes family members and friends great pain that lasts for years. Make it clear to the patient that he or she will have input into their treatment along with you and the psychiatric team as part of a partnership.

Question 7:

Outpatients at risk for suicide should not receive large supplies of antidepressants in case of overdose. Which one of the following statements is true about antidepressants and suicide? (Choose the best answer.)

  1. Fluoxetine has been shown to lead to more suicide attempts in adolescents than use of placebo.
  2. Fluoxetine has been shown to lead to more suicide attempts in adolescents than use of placebo.
  3. Tricyclic antidepressants (TCAs) are more lethal in overdose than SSRIs.
  4. Suicide rates are higher with TCAs than with SSRIs.
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The correct answer is c. Tricyclic antidepressants are more lethal in overdose over selective serotonin reuptake inhibitors. The risk of suicide in all patients who are recovering from major depression may transiently increase during initial treatment, but whether antidepressants possibly cause increased suicide risk is extremely controversial. Increased energy to act on suicidal ideation is only one of the possible explanations currently under consideration. Monitoring patients closely during treatment is paramount and is part of “psychiatric treatment”. Fluoxetine is the only antidepressant found to be effective in children and adolescents, but close surveillance for suicidal ideation or plans is again warranted. The average risk of suicide in general was 4% with antidepressants and 2% on placebo.   (Sources: Jick SS, Dean AD, Jick H. Antidepressants and suicide. BMJ 1995; 310 (6974): 215-218; Simon GE. How can we know whether antidepressants increase suicide risk?  Am J Psychiatry 163:1861-1863, 2006.)

A link to a recent article on whether antidepressants increase suicide risk and the advent of “black box” warnings is available in the library.

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