Assessing Suicidal and Homicidal Ideation
Essential Concepts
Suicidal Ideation
Learn the SAD PERSONS risk factors for suicide.
Use the CASE approach for assessing suicide risk.
Assess passive suicidality.
Assess active suicidality.
Assess imminent plan.
Homicidal Ideation
Learn the risk factors for homicide.
Ask about HI.
Know your Tarasoff duties.
We cannot tear out a single page from our life, but we can throw the whole book into the fire.
–George Sand
RISK FACTORS FOR SUICIDE
The reason an assessment of suicidality is necessary in every diagnostic interview is obvious enough: We hope to prevent suicide. However, the mental health field has not yet devised tools that allow prediction of suicidal behavior in a particular patient. On the other hand, researchers have discovered a number of factors that increase the statistical risk for suicide. It is important to be aware of these risk factors as you interview any potentially suicidal patient.
In evaluating suicidality during the initial interview, you have two goals. The first and most important is to assess whether an immediate risk of a suicide attempt exists. Your second goal is to determine current or past suicidality to help you formulate an accurate DSM-IV-TR diagnosis. You can achieve both of these goals with the same line of questioning.
Before reviewing the types of questions to ask, you should be familiar with the risk factors for suicide. An excellent
mnemonic for the major risk factors is “SAD PERSONS,” devised by Patterson et al. (1983).
mnemonic for the major risk factors is “SAD PERSONS,” devised by Patterson et al. (1983).
Mnemonic: SAD PERSONS (risk factors for suicide):
Sex: Women are more likely to attempt suicide; men are more likely to succeed.
Age: Age falls into a bimodal distribution, with teenagers and the elderly at highest risk.
Depression: Fifteen percent of depressive patients die by suicide.
Previous attempt: Ten percent of those who have previously attempted suicide die by suicide.
Ethanol abuse: Fifteen percent of alcoholics commit suicide.
Rational thinking loss: Psychosis is a risk factor, and 10% of patients with chronic schizophrenia die by suicide.
Social supports are lacking.
Organized plan: A well-formulated suicide plan is a red flag.
No spouse: Being divorced, separated, or widowed is a risk factor; having responsibility for children is an important statistical protector against suicide.
Sickness: Chronic illness is a risk factor.
Although useful for determining a patient’s long-term risk for committing suicide, these risk factors are less useful for assessing imminent risk, and imminent risk is the most important factor to assess during a diagnostic interview. One study helpful in identifying risk factors for short-term risk is the National Institute of Mental Health Collaborative Depression Clinical Study (Clark and Fawcett 1992). Researchers followed 954 patients with major affective disorders and found that clinical features associated with early suicide (i.e., within 1 year of assessment) included
Anxiety
Panic attacks
Anhedonia
Alcohol abuse
Clinical factors associated with a later attempt (at 5 years) included
High levels of hopelessness
SI
History of suicide attempts
ASSESSING SUICIDAL IDEATION: INTERVIEW STRATEGIES
KEY POINTSuicidality can be a difficult topic to broach, but you must ask about it in every diagnostic interview. Patients are rarely angry or embarrassed about suicidality questions. A majority of depressed patients have at least passing suicidal thoughts from time to time (Winokur 1981), and many patients are relieved when they are asked about suicidality, because it allows them to reveal the true depth of their depression. If they really have not thought about suicide, they will say something like, “Oh no, I could never do anything like that,” and will tell you why not.
Another common disincentive to asking about suicidality is the interviewer’s fear of a positive response. You may feel a sense of panic when first confronted with a suicidal patient, but with experience, you will realize that there are degrees of suicidality, and that not all suicidal patients require urgent hospitalization.
The CASE Approach
By far the best method of assessing suicide risk is the CASE approach, which was devised by one of my mentors, Dr. Shawn Shea, and published in his book The Practical Art of Suicide Assessment. I highly recommend that you read this book, as I have, because it provides much more detail regarding his technique and includes innumerable clinical examples.
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