Suicidal and Assaultive Behaviors
THE SUICIDAL PATIENT
Epidemiology
Reported suicides in the United States number 31,000 per year (12 per 100,000; 300,000 attempts annually).
Suicide is underreported and often is listed as accidental.
The attempted suicide/successful suicide ratio is 10 to 20:1.
Suicide increases with age; it is the third leading cause of death in male adolescents and college students.
The ratio of completers is 3:1 (M/F); that of attempters is 3:1 (F/M).
The most common attempt is by drug ingestion; most likely to be fatal is by shooting.
Most patients are not psychotic or incompetent; most are depressed.
All clinicians will encounter suicidal patients. Many will not recognize them. Some of those patients will kill themselves.
Identifying the Potentially Suicidal Patient
One fifth of suicides are unanticipated. Accurate prediction is difficult, if not impossible, with present knowledge. Entertain the possibility when (1)
The patient has made a suicide attempt [seen in the emergency department (ED), medical ward, etc.];
The patient makes overt or indirect suicide talk or threats: “You won’t be bothered by me much longer” (most often made to family members);
The patient is in a depressed or anxious mood due to an observable depression;
The patient has experienced a significant recent loss (e.g., spouse, job, self-esteem);
The patient demonstrates an unexpected change in behavior: making a will, intense talks with friends, giving away possessions;
The patient shows an unexpected change in attitude: suddenly cheerful, angry, or withdrawn.
Assessing Suicidal Risk
▪ Assessment Procedure
First, build rapport during a supportive nonjudgmental interview. If they are not volunteered, investigate suicidal thoughts by asking questions of increasing specificity (e.g., “Have you been feeling sad?” “Have you thought of doing away with yourself?” “How?”). Asking about suicide does not precipitate it. After a serious attempt, wait until the patient is alert enough to cooperate. Always ask about suicidality during a psychiatric assessment.
The following must be learned about all suicidal patients:
The patient’s intention: Why does he or she want to die?
Is a suicide plan made? The more specific the plan, the more likely the act.
Method: The more lethal the technique, the more serious the plan.
Presence of psychiatric or organic factors (e.g., psychotic depression, thought disorder, sedative self-medication, organicity).
Determine the role of impulsivity versus premeditation.
Is the precipitating crisis resolving?
Take an “inventory of loss.”
Does the patient have plans for the future?
Does the patient have caring family or other supports?
Does the patient think she or he is going to commit suicide?
▪ Population Risk Factors
Males
Elderly
Isolated individuals
Whites
American Indians
Policemen
▪ Individual Risk Factors
Sense of hopelessness [particularly in a patient with major depression (2)], helplessness, loneliness, exhaustion, “unbearable” psychological pain.
Psychiatric illness (3) (in 90% of suicide patients), mainly:
Major mood disorder (either first or second degree; 50% of all suicides), particularly with vegetative signs or constriction of thought; 15% lifetime suicide risk.
Alcoholism (suicide rate 50 times normal; 25% of all suicides) mostly those with chronic alcoholism, mostly men, often after interpersonal loss, 3% to 4% lifetime risk. Much higher if they also are depressed and with poor social supports (i.e., many patients). Drug addiction (10% die by suicide).
Schizophrenia, particularly when lonely, depressed, with chronic illness, or with persecutory delusions or self-destructive command hallucinations; 10% or more lifetime risk.
Other: Psychoses due to organic conditions; personality disorders (borderline, antisocial), panic disorder with comorbid depression.
Failing health, particularly if previously independent (5% of all suicides); chronic medical impairment; HIV/AIDS.
Intoxication; active use (abuse) of alcohol and other drugs.
Impaired impulse control for any reason; hostility.
History of suicide attempts, particularly serious attempts.
Nature of past or present suicide attempts (e.g., shooting or jumping more lethal than most ingestions or wrist cutting. Warning given? Help available at the time?
Family history of suicide; personal exposure to suicide; suicide itself may run in families genetically.
Widowed, divorced, separated, single, unemployed, retired.
Medical patients receiving renal dialysis.
Family stresses or instability; few external supports.
A change in status—up or down.
Recent loss or rejection.
Parental loss during childhood.
Initiating Appropriate Treatment
The first question often is “Should you hospitalize?” If the patient has pressing suicidal thoughts or decreased impulse control or both coupled with several risk factors, hospitalize, if only overnight. Be
conservative. Do not write off patients as “just manipulative”—all statements of suicide intent initially should be taken seriously (particularly from adolescents). Manipulative suicide patients (parasuicide) have “accidentally” killed themselves after being denied admission—60% of successful suicides have had previous suicide attempts. The most emotionally upset patient is not necessarily the most suicidal. The suicidal state is episodic; a patient may be “safe” just hours after a serious suicide attempt. Be very cautious of the patient who has trouble considering any alternative to suicide.
conservative. Do not write off patients as “just manipulative”—all statements of suicide intent initially should be taken seriously (particularly from adolescents). Manipulative suicide patients (parasuicide) have “accidentally” killed themselves after being denied admission—60% of successful suicides have had previous suicide attempts. The most emotionally upset patient is not necessarily the most suicidal. The suicidal state is episodic; a patient may be “safe” just hours after a serious suicide attempt. Be very cautious of the patient who has trouble considering any alternative to suicide.
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