Suicidal Risk
Suicidal Risk: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
Barbara A. Gawinski
Suicide is the eighth leading cause of death in the United States; every 15 minutes, someone successfully completes suicide. Almost all people who kill themselves carry a diagnosable mental or substance abuse disorder; 80% have depression, 10% have schizophrenia, and 5% have delirium. Because most patients see their primary care provider within a month of their suicide, recognition and treatment of depression is a promising way to prevent suicide (1–6).
Approach.
Suicide is the third leading cause of death between ages 15 and 24 years; it is the fourth leading cause among those aged between 25 and 44 years (7). Four times as many men die from suicide than women. Of people who kill themselves, 60% use firearms (1).
In the evaluation of every depressed patient, consider suicide. Almost every person has an occasional fleeting thought of suicide, but the suicidal patient ruminates about it. Appropriately prescribed serotonin-selective reuptake inhibitors can lessen suicidal tendencies and are markedly safer than the tricyclic antidepressants if taken in an overdose.
History.
The major risk factors for suicidal patients are being male, older, unemployed, unmarried, living alone, having a chronic illness, gay or lesbian, adolescent, and being in a socially alienated group (5). The two major risk factors for child suicide are conflict with parents and an undiagnosed psychiatric disorder. For youth, family and interpersonal conflict were the most prevalent reported precipitating event (4). Drinking alcohol, especially in combination with depression, increases the rate of death; 15% of alcoholics commit suicide. Patients with previous suicidal behavioral are at increased risk for subsequent suicide attempts. Is there a history of previous suicide attempts, explicit statement of suicidal ideas or feelings (such as, “I want to go to sleep and never wake up” or “I’m going away and you won’t have to worry about me anymore”), or development of suicidal plan? Some patients may also have a history of self-inflicted injuries, reckless behavior, and unexplained accidents. Clear indication of a suicide plan is the making of a will or distributing personal possessions. All these behaviors lead to increased suicide risk; it is important to assess for them.
Physical examination
Once a patient is identified as depressed (Chapter 3.3), the clinical interview and the mental status examination (MSE) are the primary methods for assessing severity of suicide risk. To assist the provider in assessing the risk of suicide, Table 3.2 identifies emotional and behavioral changes associated with suicide. When these finding are present, the clinician should assess the patient’s suicide risk.
Diagnostic assessment
All depressed patients need screening for conditions associated with increased suicide risk (Table 3.2). If the patient is depressed or has one or more conditions associated with increased suicide risk, ask specific questions for suicide assessment. These questions will not increase the patient risk of suicide, but rather will help guide development of a treatment plan. For patients with mild risk—experiencing passive or active suicidal ideation—contract for safety to establish a therapeutic relationship and identify the personal and professional resources for the patient and involved providers to contact if risk increases. The patient at medium risk—suicide plan without means to accomplish the plan—should return to the office frequently with a personal support person to continue to assess suicide risk, assess effectiveness of medication, and receive new prescriptions. Patients who have an active plan and means to carry out that plan are at high risk for suicide and should be transported to a hospital emergency room.
References
1. American Foundation for Suicide Prevention (1998). Suicide facts. www.afsp.org/
suicide
2. Beck AT, Kovacs M, Weissman A. Assessment of suicidal ideation: the scale for suicide ideation. J Consult Clin Psychol 1979;47:343–352.
3. Centers for Disease Control and Prevention. Suicide among children, adolescents, and youth: United States, 1980–1992. MMWR 1995a;44:289–291.
4. Centers for Disease Control and Prevention. Fatal and non-fatal suicide attempts among adolescents: Oregon, 1988–1993. MMWR 1995b;44:312–323.
5. Maxmen JS, Ward ND. Essential psychopathology and its treatment, 2nd ed. New York: WW Norton & Co, 1995:23–25.
6. American Foundation for Suicide Prevention. Suicide prevention resources (online). www.afsp.org
7. Ventura SJ, Anderson RN, Martin JA, Smith BL. Births and deaths: preliminary data for 1997. Natl Vital Stat Rep 1998;47(4):1–41.
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Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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