The American Psychiatric Publishing
Textbook of Suicide Assessment and Management
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The American Psychiatric Publishing
Textbook of Suicide Assessment and Management Edited by
Robert I. Simon, M.D. Robert E. Hales, M.D., M.B.A.
Washington, DC London, England
Note: The authors have worked to ensure that all information in this book is accurate at the time of publication and consistent with general psychiatric and medical standards, and that information concerning drug dosages, schedules, and routes of administration is accurate at the time of publication and consistent with standards set by the U.S. Food and Drug Administration and the general medical community. As medical research and practice continue to advance, however, therapeutic standards may change. Moreover, specific situations may require a specific therapeutic response not included in this book. For these reasons and because human and mechanical errors sometimes occur, we recommend that readers follow the advice of physicians directly involved in their care or the care of a member of their family. Books published by American Psychiatric Publishing, Inc., represent the views and opinions of the individual authors and do not necessarily represent the policies and opinions of APPI or the American Psychiatric Association. If you would like to buy between 25 and 99 copies of this or any other APPI title, you are eligible for a 20% discount; please contact APPI Customer Service at
[email protected] or 800-368-5777. If you wish to buy 100 or more copies of the same title, please email us at
[email protected] for a price quote. Copyright © 2006 American Psychiatric Publishing, Inc. ALL RIGHTS RESERVED Manufactured in the United States of America on acid-free paper 10 09 08 07 06 5 4 3 2 1 First Edition Typeset in Adobe’s The Mix and Palatino. American Psychiatric Publishing, Inc. 1000 Wilson Boulevard Arlington, VA 22209-3901 www.appi.org Library of Congress Cataloging-in-Publication Data The American Psychiatric Publishing textbook of suicide assessment and management / edited by Robert I. Simon, Robert E. Hales.—1st ed. p. ; cm. Includes bibliographical references and index. ISBN 1-58562-213-3 (hardcover : alk. paper) 1. Suicide—Risk factors. 2. Suicidal behavior—Diagnosis. 3. Suicidal behavior—Treatment. 4. Suicide—Prevention. [DNLM: 1. Suicide— psychology. 2. Mental Disorders—complications. 3. Risk Assessment— methods. 4. Suicide—prevention and control. WM 165 A5124 2006] I. Title: Textbook of suicide assessment and management. II. Title: Suicide assessment and management. III. Simon, Robert I. IV. Hales, Robert E. V. American Psychiatric Publishing. RC569.A74 2006 616.85'8445--dc22 2005032041 British Library Cataloguing in Publication Data A CIP record is available from the British Library.
We dedicate this book to all those who have committed themselves to saving the lives of persons struggling with mental illness
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Contents Contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xix Stuart C. Yudofsky, M.D. Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxvii Robert I. Simon, M.D. Robert E. Hales, M.D., M.B.A.
Assessment Principles
1
Suicide Risk: Assessing the Unpredictable . . . . . . . . . . . . . . . 1 Robert I. Simon, M.D.
P A R T
I
Special Populations
2
Children and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Peter Ash, M.D.
3
The Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Yeates Conwell, M.D. Marnin J. Heisel, Ph.D.
4
Suicide and Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Liza H. Gold, M.D.
5
Social, Cultural, and Demographic Factors in Suicide . . . 107 Leslie Horton, M.D., Ph.D.
6
Suicide Prevention in Jails and Prisons . . . . . . . . . . . . . . . 139 Jeffrey L. Metzner, M.D. Lindsay M. Hayes, M.S.
P A R T
I I
Suicide Risk Assessment: Special Issues
7
Cultural Competence in Suicide Risk Assessment . . . . . . 159 Sheila Wendler, M.D. Daryl Matthews, M.D., Ph.D.
8
Psychological Testing in Suicide Risk Management . . . . 177 Glenn R. Sullivan, Ph.D. Bruce Bongar, Ph.D., ABPP, FAPM
P A R T
I I I
Treatment
9
Psychopharmacological Treatment and Electroconvulsive Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . 199 H. Florence Kim, M.D. Lauren B. Marangell, M.D. Stuart C. Yudofsky, M.D.
10 Psychodynamic Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . 221 Glen O. Gabbard, M.D. Sara E. Allison, M.D.
11 Split Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235 Donald J. Meyer, M.D. Robert I. Simon, M.D.
P A R T
I V
Major Mental Disorders
12 Depressive Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255 Jan Fawcett, M.D.
13 Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277 Ross J. Baldessarini, M.D. Maurizio Pompili, M.D. Leonardo Tondo, M.D.
14 Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301 Jong H. Yoon, M.D. Cameron S. Carter, M.D.
15 Anxiety Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313 Daphne Simeon, M.D. Eric Hollander, M.D.
16 Personality Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329 Maria A. Oquendo, M.D. Juan Jose Carballo, M.D. Barbara Stanley, Ph.D. Beth S. Brodsky, Ph.D.
17 Substance-Related Disorders . . . . . . . . . . . . . . . . . . . . . . . . . 347 Avram H. Mack, M.D. Hallie A. Lightdale, M.D. P A R T
V
Treatment Settings
18 Outpatient Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367 John T. Maltsberger, M.D.
19 Emergency Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381 Laura J. Fochtmann, M.D.
20 Inpatient Treatment and Partial Hospitalization . . . . . . 401 Gregory Sokolov, M.D. Donald M. Hilty, M.D. Martin Leamon, M.D. Robert E. Hales, M.D., M.B.A.
P A R T
V I
Patient Safety
21 Patient Safety Versus Freedom of Movement: Coping With Uncertainty . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423 Robert I. Simon, M.D.
22 Safety Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441 John A. Chiles, M.D. Kirk D. Strosahl, Ph.D.
P A R T
V I I
Aftermath of Suicide and Psychiatrist Reactions
23 Aftermath of Suicide: The Clinician’s Role . . . . . . . . . . . . . 459 Frank R. Campbell, Ph.D., L.C.S.W., C.T.
24 Psychiatrist Reactions to Patient Suicide . . . . . . . . . . . . . . 477 Michael Gitlin, M.D.
P A R T
V I I I
Special Topics
25 Combined Murder-Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . 495 Carl P. Malmquist, M.D., M.S.
26 Legal Perspective on Suicide Assessment and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 511 Daniel W. Shuman, J.D.
27 Patient Suicide and Litigation . . . . . . . . . . . . . . . . . . . . . . . . 527 Charles L. Scott, M.D. Phillip J. Resnick, M.D.
28 Clinically Based Risk Management of the Suicidal Patient: Avoiding Malpractice Litigation . . . . . . 545 Robert I. Simon, M.D. Appendix APA Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors: Executive Summary of Recommendations. . . . . . . . . . . . . 577 Work Group on Suicidal Behaviors Douglas G. Jacobs, M.D., Chair Ross J. Baldessarini, M.D. Yeates Conwell, M.D. Jan A. Fawcett, M.D. Leslie Horton, M.D., Ph.D. Herbert Meltzer, M.D. Cynthia R. Pfeffer, M.D. Robert I. Simon, M.D. With commentary and case examples by Douglas G. Jacobs, M.D. and Margaret Brewer, R.N., M.B.A. Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 599
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Contributors Sara E. Allison, M.D. Resident in Psychiatry, Department of Psychiatry, Baylor College of Medicine, Houston, Texas Peter Ash, M.D. Chief, Child and Adolescent Psychiatry; Director, Psychiatry and Law Service; and Associate Professor, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia Ross J. Baldessarini, M.D. Professor of Psychiatry and in Neuroscience, Department of Psychiatry, Harvard Medical School; Director, Psychopharmacology Program and International Consortium for Bipolar Disorder Research, McLean Division of Massachusetts General Hospital, Belmont, Massachusetts Bruce Bongar, Ph.D., ABPP, FAPM Calvin Professor of Psychology, Pacific Graduate School of Psychology, Palo Alto, California; Consulting Professor of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California Margaret Brewer, R.N., M.B.A. Consultant to the Suicide Education and Research Division, Screening for Mental Health Inc., Wellesley Hills, Massachusetts Beth S. Brodsky, Ph.D. Department of Neuroscience, New York State Psychiatric Institute and Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York Frank R. Campbell, Ph.D., L.C.S.W., C.T. Adjunct Faculty, Louisiana State University, Baton Rouge, Louisiana Juan Jose Carballo, M.D. Alicia Koplowitz Fellow, Division of Child Psychiatry, New York State Psychiatric Institute, New York, New York xiii
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Cameron S. Carter, M.D. Professor of Psychiatry and Director, Imaging Research Center, University of California, Davis School of Medicine, Sacramento, California John A. Chiles, M.D. Clinical Professor of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Sound Psychiatry Consulting Group, Port Townsend, Washington Yeates Conwell, M.D. Professor, Department of Psychiatry, University of Rochester Medical Center, Rochester, New York Jan Fawcett, M.D. Professor of Psychiatry, University of New Mexico School of Medicine, Albuquerque, New Mexico Laura J. Fochtmann, M.D. Professor, Departments of Psychiatry and Behavioral Sciences, Pharmacological Sciences, and Emergency Medicine, Stony Brook University School of Medicine, Stony Brook, New York Glen O. Gabbard, M.D. Brown Foundation Chair of Psychoanalysis, Professor of Psychiatry, and Director, Baylor Psychiatry Clinic, Department of Psychiatry, Baylor College of Medicine, Houston, Texas Michael Gitlin, M.D. Professor of Clinical Psychiatry, Geffen School of Medicine at University of California—Los Angeles, Los Angeles, California Liza H. Gold, M.D. Clinical Associate Professor of Psychiatry and Associate Director, Program in Psychiatry and Law, Georgetown University Medical Center, Washington, D.C. Robert E. Hales, M.D., M.B.A Joe P. Tupin Professor and Chair, Department of Psychiatry and Behavioral Sciences, University of California, Davis School of Medicine; Medical Director, Mental Health Services, County of Sacramento, Sacramento, California
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Lindsay M. Hayes, M.S. Project Director, National Center on Institutions and Alternatives, Mansfield, Massachusetts Marnin J. Heisel, Ph.D. Department of Psychiatry, University of Rochester Medical Center, Rochester, New York Donald M. Hilty, M.D. Associate Professor of Clinical, Psychiatry and Behavioral Sciences, University of California, Davis School of Medicine, Sacramento, California Eric Hollander, M.D. Professor of Psychiatry and Director of Clinical Psychopharmacology, Department of Psychiatry, Mount Sinai School of Medicine, New York, New York Leslie Horton, M.D., Ph.D. Assistant Professor of Clinical Psychiatry, Keck School of Medicine, University of Southern California, Los Angeles, California Douglas G. Jacobs, M.D. Associate Clinical Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts; Executive Director, Screening for Mental Health Inc., Wellesley Hills, Massachusetts H. Florence Kim, M.D. Assistant Professor of Psychiatry, Menninger Department of Psychiatry, Baylor College of Medicine, Houston, Texas Martin Leamon, M.D. Associate Professor of Clinical Psychiatry and Behavioral Sciences; Medical Director, Mental Health Treatment Center; University of California, Davis School of Medicine, Sacramento, California Hallie A. Lightdale, M.D. Assistant Professor of Psychiatry, Georgetown University School of Medicine, Washington, D.C. Avram H. Mack, M.D. Assistant Professor of Psychiatry, Georgetown University School of Medicine, Washington, D.C.
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Carl P. Malmquist, M.D., M.S. Professor of Social Psychiatry, University of Minnesota, Minneapolis, Minnesota John T. Maltsberger, M.D. Associate Clinical Professor of Psychiatry, Harvard Medical School, Boston; Clinical Associate, McLean Hospital, Belmont; Boston Psychoanalytic Society and Institute, Boston, Massachusetts Lauren B. Marangell, M.D. Brown Foundation Chair of the Psychopharmacology of Mood Disorders; Associate Professor of Psychiatry, and Director of Mood Disorders Research, Menninger Department of Psychiatry, Baylor College of Medicine, Houston, Texas Daryl Matthews, M.D., Ph.D. Professor and Director, Forensic Psychiatry Program, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii Herbert Meltzer, M.D. Bixler/Johnson/Mays Professor of Psychiatry and Professor of Pharmacology, and Director, Psychopharmacology Division, Vanderbilt University Medical Center, Nashville, Tennessee Jeffrey L. Metzner, M.D. Clinical Professor of Psychiatry, University of Colorado School of Medicine, Denver, Colorado Donald J. Meyer, M.D. Senior Associate, Program in Psychiatry and Law at Massachusetts Mental Health Center; Associate Director, Forensic Psychiatry, Beth Israel Deaconess Medical Center; Assistant Clinical Professor, Harvard Medical School, Boston, Massachusetts Maria A. Oquendo, M.D. Professor of Clinical Psychiatry at Columbia University, New York, New York Cynthia R. Pfeffer, M.D. Professor, Department of Psychiatry, Joan and Sanford I. Weill Medical College, Cornell University, New York, New York
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Maurizio Pompili, M.D. Research Fellow, Department of Psychiatry, Harvard Medical School and International Consortium for Bipolar Disorder Research, McLean Division of Massachusetts General Hospital, Belmont, Massachusetts; Clinical Fellow, Department of Psychiatry, University of Rome (La Sapienza), Rome, Italy Phillip J. Resnick, M.D. Professor of Psychiatry and Director, Fellowship in Forensic Psychiatry, Case Western Reserve University School of Medicine, Cleveland, Ohio; Adjunct Professor, Case Western Reserve University School of Law, Cleveland, Ohio; and Director of the Court Psychiatric Clinic, Cleveland, Ohio Charles L. Scott, M.D. Chief, Division of Psychiatry and the Law; Associate Professor of Clinical Psychiatry; and Director, Forensic Psychiatry Fellowship, University of California, Davis Medical Center, Sacramento, California Daniel W. Shuman, J.D. Professor of Law, Dedman School of Law, Southern Methodist University, Dallas, Texas Daphne Simeon, M.D. Associate Professor, Department of Psychiatry, Mount Sinai School of Medicine, New York, New York Robert I. Simon, M.D. Clinical Professor of Psychiatry and Director, Program in Psychiatry and Law, Georgetown University School of Medicine, Washington, D.C.; Chairman, Department of Psychiatry, Suburban Hospital, Bethesda, Maryland Gregory Sokolov, M.D. Medical Director, Jail Psychiatric Services, Sacramento; Assistant Clinical Professor of Psychiatry and Behavioral Sciences; University of California, Davis School of Medicine, Sacramento, California Barbara Stanley, Ph.D. Department of Neuroscience, New York State Psychiatric Institute and Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York—John Jay College of Criminal Justice
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Kirk D. Strosahl, Ph.D. Mountainview Consulting Group Inc. Moxee, Washington Glenn R. Sullivan, Ph.D. Veterans Affairs Medical Center, Salem, Virginia Leonardo Tondo, M.D. Lecturer, Department of Psychiatry, Harvard Medical School and International Consortium for Bipolar Disorder Research, McLean Division of Massachusetts General Hospital, Belmont, Massachusetts; Associate Professor, Department of Psychology, University of Cagliari, Centro Lucio Bini Mood Disorders Research Center, Cagliari, Sardinia Sheila Wendler, M.D. Assistant Clinical Professor of Psychiatry, Fellow, Forensic Psychiatry, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii Jong H. Yoon, M.D. Assistant Professor of Psychiatry, University of California, Davis School of Medicine, Sacramento, California Stuart C. Yudofsky, M.D. D.C. and Irene Ellwood Professor and Chairman, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine; Chief of Psychiatry Services, The Methodist Hospital, Houston, Texas
Foreword
The very day that Robert I. Simon, M.D. and Robert E. Hales, M.D. graciously called to invite me to write the foreword to the The American Psychiatric Publishing Textbook of Suicide Assessment and Management, which they have edited, I received another phone communication from the chief of staff of one of training institutions affiliated with the Menninger Department of Psychiatry of Baylor College of Medicine: I regret to have to tell you this, Stu, but one of our inpatients has just committed suicide while in the hospital. As you can understand, not only is the family highly upset, but many of our staff are also severely distressed. I am particularly concerned about the patient’s primary clinician, who is a new faculty member, just having completed her residency training in June.
Unfortunately, in my role as chairman of a department of psychiatry in a large metropolitan area, I am regularly and frequently called upon to lend support to psychiatrists and other mental health professionals in our community who have recently lost patients to suicide. When I meet with these professionals, they invariably express three primary concerns. First, the clinicians confide in me about their gnawing fear that they may have “missed something” that might have alerted them to the impending suicide. Second, they express concern that “I may have done something wrong, or not done something required, in my treatment of the patient.” Third, they solicit my opinion about whether they might be vulnerable to a lawsuit related to the suicide, and ask what they should do to prepare for this potentiality. The prevailing themes of these meetings are thus tripartite and summarized by their following questions to me: “What did I miss?” “What could I have done to have prevented this tragedy?” “What are the implications of the suicide to me as a professional?” In reviewing this textbook in preparation to write this introduction, I decided to use these three questions as a measure of the book’s utility and contribution to our profession and the patients whom we serve.
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“What Did I Miss?” As reviewed in this textbook, suicide is an unfortunate reality of the human condition, with approximately 11 people in the United States per 100,000 completing suicide annually. The risk for suicide in individuals with bipolar and other mood disorders is estimated to be 193 per 100,000, a startling 18 times greater than that for the general population! Notwithstanding these data, the concept of suicide is surreal to many psychiatrists and physicians of other disciplines of medicine. Inherent to our medical training is an appreciation of the overwhelming biological complexity of the “human organism,” all elements of which have been honed through gene–environment interactions for survival of the individual and the species. Just one example of the biological complexity of the human organism derives from the Human Genome Project. This project has revealed that about half of the 23,000 human genes are expressed in the human brain; thus, given that most genes code for numerous proteins, there are likely more than 100,000 different proteins in the human central nervous system (Insel and Quirion 2005). As opposed to the fang, claw, or sinew in other mammals, the human brain is our species’ primary tool of survival. The realization that our moods, our thoughts, and even our perceptions can result in our “turning against” all of this extraordinary biological complexity—all designed for survival—and attempt to kill ourselves is difficult to comprehend and accept. Like the presence of fever in the care of a surgical patient, suicidal ideation demands immediate attention, understanding and intervention by the clinician. For example, not infrequently, fever of unknown origin (so-called FUO) is the presenting problem of patients referred to surgeons by other physicians. In these instances, the referring physicians have not been able to determine the exact source of the fever of a patient, and they are concerned that an unknown, potentially treatable, life-threatening condition might be the source of the fever. In the context of the uniqueness of every patient and clinical situation, the surgeon must be aware of, and carefully review (and “rule out”), the considerable menu of potential etiologies. Two considerations haunt the surgeon’s mind: “What don’t I know?” (i.e. Are there any etiologies that I am failing to consider?) and, of even greater concern, “What I don’t know can result in the imminent death of my patient.” Similarly, when a patient presents with suicidal ideation to a psychiatrist or a mental health professional of another discipline, a seemingly fathomless vault of innumerable etiologic possibilities looms before the practitioner. One senior psychiatrist confided to me that at the instant a patient reveals suicidal
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ideation or intent to him, he feels overwhelmed: “I feel as if I am at the base of an unstable, mountainous snowbank. I know that I must rapidly assess my therapeutic options and rapidly develop a treatment plan. However, I am also fearful that something I do, or fail to do, will trigger an avalanche that could be fatal to my patient and, consequently, devastating to me and my practice. I know that I must be both well informed and very careful.” The avalanche to which the psychiatrist referred comprises a nearly infinite, snowflakelike quantity of potential causalities of his or her patient’s suicidal ideation. Specific and interacting elements from the entire bio-psycho-social-spiritual spectrum must be rapidly assayed, and the relevant elements must be addressed. Important questions—such as “Where should I start in my information gathering?” “What should I ask my patient and his or her family, and what shouldn’t I ask at this time?” “What are the best ways to gather this information while enhancing my patient’s therapeutic engagement?” “Are there interventions that might actually increase the suicidal potential of my patient?”—simultaneously cascade down upon the clinician. In helping the clinician to answer the first question—or, more importantly, not to have to pose this question at all because of the prevention of a suicidal act—I believe that The American Psychiatric Publishing Textbook of Suicide Assessment and Management is the best available single source for the clinician to help him or her manage and master the avalanche of requisite information, knowledge, and skills required when assessing and treating patients with suicidal ideation, intent, or behaviors.
“What Could I Have Done to Have Prevented This Tragedy?” Much is known about the risk factors of suicide, and these are indispensable, bedrock data with which to guide the mental health professional’s assessment of a patient’s potential for suicide. How appropriate that the editors chose “Suicide Risk: Assessing the Unpredictable” as the first chapter for their textbook. In this chapter, Robert I. Simon, M.D., eloquently points out, “Only the risk of suicide is determinable. The prediction of suicide is opaque, but there is reasonable visibility for assessing suicide risk.” Dr. Simon emphasizes the necessity of systematic risk assessment in order to identify modifiable and treatable risk and protective factors that will help the clinician forge the overall safety management and treatment plan for patients at risk for suicide. He notes, as well, that it is easy to overlook important risk and protective factors in the absence of a systematic assessment, and, through the body of his
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chapter, he “walks the reader through” how such a systematic assessment is best conducted. Consistent with the entirety of this textbook, Dr. Simon’s chapter is suffused with relevant and applicable facts—gems that are immediately applicable to the clinical context of assessing and treating a patient at high risk of suicide. For example, he notes that “approximately 25% of patients at risk for suicide do not admit having suicidal ideation to the clinician but do tell their families.” The implication is clear: “Just asking the patient at risk for suicide about the presence of suicidal ideation, intent, and plan and receiving a denial cannot be relied upon by itself. If possible, family members or others who know the patient should be consulted.” Another example of the great value and clinical application of this chapter is Dr. Simon’s adroit review of the seminal prospective studies by Jan Fawcett, M.D., of short-term suicide risk factors in which the key role of severe anxiety disorders, especially panic disorder, is highlighted. Dr. Simon concludes the chapter by emphasizing that suicide risk assessment is “a process, not an event.” In addition, he offers a comprehensive series of figures that outline a conceptual approach to systematic suicide risk assessment. The content of these figures not only enables the reader to organize his or her assessment and therapeutic management of patients with suicidal potential, but also provides a skeletal framework of the textbook that is “fleshed out” in the ensuing chapters. The constraints of space afforded for this introduction do not permit me to review for the reader the plethora of useful information found in each chapter of this textbook that have immediate applicability to clinicians desiring to identify and prevent suicidal behavior in their patients. Nonetheless, as a neuropsychiatrist who almost daily treats patients at significant suicide risk, I will comment on several points that I found to be singularly helpful in my practice. Like fever for surgeons, suicidal ideation and intent may also be the consequence of psychiatric treatment. For example, during surgery a patient may become infected as an unavoidable consequence of removing a subdiaphragmatic abscess or as a result of physician error, such as leaving a gauze sponge in the patient after surgical closure. Similarly, much has been made recently of the possibility that certain selective serotonin reuptake inhibitors, or SSRIs, may increase suicidal ideation in children and adolescents. Peter Ash, M.D., in his chapter on children and adolescents (Chapter 2), adroitly dissects the factual elements of this controversy in a fashion that equips the child psychiatrists to make the decisions in the best interest of their child and adolescent patients, and H. Florence Kim, M.D., Lauren B. Marangell, M.D., and I (Chapter 9) endeavor to do the same for the treatment of adult patients. Importantly, the requisite data
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to inform our patients and their families about treatment risks are also provided in these chapters. Similarly, psychodynamically-oriented clinicians are also aware that accessing, in treatment, a patient’s long-repressed, highly conflicted memories and feelings can lead to deep feelings of depression and selfdirected anger that can be manifested by suicidal ideation, intent, and behavior. This outcome can be the unfortunate result of exploration that is required for insight and ultimate symptom reduction, or therapeutic error, such as a premature interpretation. Glen O. Gabbard, M.D., and Sara E. Allison, M.D., eloquently describe this circumstance in their chapter on psychodynamic treatment (Chapter 10): “Treatment of the suicidal patient may be likened to negotiating the perils of a minefield— with each step, one is terrifyingly aware of the potential lethality underfoot..” They also advance the following encouraging counsel: “A psychodynamically informed road map may be helpful to both strengthen the clinician’s footing and identify hazards on the path to recovery.” While acknowledging the dearth of validated research of the efficacy of psychodymically informed psychotherapy in reducing the suicidality of depression, the authors review several studies that document significant reductions in suicidality in patients with borderline personality disorder. They also note that the published literature indicates that experiential factors leading to specific psychodynamic themes can play an important role in suicidality, such as a recent history of important losses in the context of important childhood losses. For example, many readers may be surprised to learn that empirical studies consistently link suicidal ideation with high levels of perfectionism. These data provide the clinician exploratory and therapeutic openings to help assess and reduce suicidal risk in our patients. Gabbard and Allison’s review of clinicians’ coutertransference pitfalls is particularly helpful: When the therapist assumes the role of savior or omnipotent rescuer who will go to all forms of self-sacrifice to save the patient, countertransference hate and resentment are often the unfortunate by-products. This may take the form of aversion, leading the therapist to abandon the patient in subtle ways (forgetting appointments, withdrawing emotionally), or malice, filling the therapist with impulses to respond to the patient in overtly hostile or sarcastic ways. Therapists may fear that a patient’s suicide will make them look bad to their colleagues, and this recognition of the patient’s power over them may breed resentment.
The individual chapters in this textbook identify and address special clinical situations (such as suicide in children and the elderly, in incarcerated individuals, and in patients with depression, bipolar disorder, schizophrenia, anxiety disorders, personality disorders, substance use
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disorders, and so forth) in ways that prepare and fortify the clinician’s assessment and treatment of patients with suicidal ideation or intent. Chapters on outpatient treatment, emergency treatment, inpatient treatment, safety interventions, somatic treatments, psychodynamic psychotherapeutic treatment, and other specialized therapeutic regimens inform the reader about optimal care of patients at risk for suicidal. Although I have herein provided only samplings—tips of gigantic icebergs of information and skill—I believe that this textbook is the best available resource to help clinicians answer the question “What could I have done to have prevented this tragedy?”
“What Are the Implications of the Suicide to Me as a Professional?” In his outstanding chapter “Psychiatrist Reactions to Patient Suicide” (Chapter 24) Michael Gitlin, M.D., correctly notes, “The suicide of a patient in ongoing treatment is surely among the most traumatic events in the professional life of a psychiatrist.” He continues, “This is especially noteworthy given that more than 30,000 individuals commit suicide yearly in the United States...and that more than half of these individuals have received care for their psychiatric problems in the year prior to their suicide ...” The implication of these data is painfully clear: thousands of mental health professionals each year undergo the trauma of the loss of one of their patients to suicide. In addition, Dr. Gitlin notes that fully one-third of psychiatric trainees have experienced a patient suicide, with 5% of residents having more than one patient suicide during their training. Further, Dr. Gitlin provides studies that document that patient suicides are the most common cause of professional anxiety in psychiatrists and that the degree of their distress is often very high. He notes one survey of British psychiatrists that reveals that one-third of those who experience a patient suicide describe the event as having affected their personal lives (irritability and poor coping in family situations) and 15% reported having considered taking early retirement. Anxiety, depression, and acute posttraumatic stress symptoms have been reported as “classic symptoms” in psychiatrists who have lost patients to suicide. Initial clinicians’ responses to suicide are often shock, disbelief, denial, and depersonalization, and later, grief, shame, guilt, and fear of blame become manifest. Paradoxically, a mental health professional may experience relief after the suicide of a chronically suicidal patient who has made many threats or attempts; and of course, such feelings eventually give rise to guilt and self blame. Thus, the psychological implications to the mental health professional after a patient’s
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suicide can be profound and should be the first consideration of the professional following the suicide of a patient. Dr. Gitlin admonishes that isolation from colleagues and family are common, disabling, and dangerous sequelae. Fortunately, the author provides excellent suggestions to the practitioner for anticipating and coping with untoward psychosocial responses to the suicide of a patient. Among the many stresses with which a practitioner must cope following the suicide of a patient is the threat or actuality of a malpractice suit. Professor of Law Daniel W. Shuman begins his extraordinary chapter (Chapter 26) with the following advice: “If the occurrence of a patient suicide is an inevitability for most clinical psychiatrists..., then it is prudent for psychiatrists in a litigious society like ours to be concerned about the risk of a malpractice claim that the suicide could have been prevented if they had done their job properly.” He goes on to declare, “The practice of evidence-based psychiatry is the best defense on the merits to a psychiatric malpractice claim.” Professor Shuman’s chapter is a guide to the manner in which the courts assess claims for malpractice arising out of patient suicide and suicide attempts. He reveals that most malpractice claims against psychiatrists arise out of negligence claims, which means that harm to the patient is the result of professional carelessness or mistakes. Stated in legal terms, “The prima facie case of negligence ...consists of evidence from which a reasonable juror could find, by a preponderance of the evidence, a breach of a duty proximately causing harm.” In the clearest fashion the author then reduces the legal components of negligence to four critical elements: a) duty; b) breach; c) cause; and d) harm. He devotes the large portion of his chapter to explicating each of these elements in a fashion that enhances the clinician’s understanding of the fundamentals of negligence law suits—knowledge that aids us in reducing the risk of malpractice suits from multifarious sources, including patient suicide. Professor Shuman’s chapter dovetails seamlessly with Dr. Simon’s chapter “Clinically Based Risk Management of the Suicidal Patient: Avoiding Malpractice Litigation.” In this chapter, Dr. Simon notes, “Patient suicides account for numerous malpractice suits filed against psychiatrists and the highest percentages of settlements and verdicts covered by professional liability insurers.” In surgical fashion, he then dissects the four critical elements of negligence expounded on by Mr. Shuman to expose the common sources suicide-related liability and the abundant opportunities of risk management and prevention. Elusive legal conceptualizations, including standard of care, quality of care, and preponderance of evidence, are lucidly explicated. Especially applicable are several lists condensing risk management suggestions for sui-
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cidal patients in critical phases of their treatment: outpatients, inpatients, and emergency services. Another excellent table highlights key components of and issues related to suicide prevention contracts. I anticipate that the reader will especially appreciate and benefit from the section of this chapter devoted to “the aftermath” of suicide (also discussed in detail by Frank R. Campbell, Ph.D., L.C.S.W., C.T., in Chapter 23, “Aftermath of Suicide: The Clinician’s Role”). For example, the clinician is informed that “the duty to maintain confidentiality of the patient’s record continues, unless a court decision or statute provides otherwise.” Similarly, Dr. Simon reminds us that “the physician–patient privilege that protects confidentiality does not end with the patient’s death. It may be claimed by the deceased patient’s next of kin or a legal representative,” and that the psychiatrist should “obtain written authorization from the executor or administrator of the deceased patient’s estate before a copy of the medical record is released.” The author’s point is that (avoidable) legal errors are often made by mental health professionals in the aftermath of a patient’s suicide. Like so many of my colleagues, I currently care for, and over the years have treated, many patients at high risk of suicide. I am no stranger to many unsettling moments, hours, and days when I have worried about the safety of each of these patients, the wisdom (or lack thereof) of my treatment plan, and, I confess, the legal, professional, and personal implications if my patient were to attempt or complete suicide. Reading through The American Psychiatric Publishing Textbook of Suicide Assessment and Management, I became aware of a progressive reduction of my anxiety and an increased level of confidence about my treatment of patients at high suicide risk. The source of this transformation is the unprecedented body of knowledge and skills imparted by this textbook regarding so many relevant aspects of the evaluation and treatment of the suicidal patient. I know that many lives will be spared as a result of this book. I also know that this revolutionary textbook will help many of my fellow mental health practioners avoid upsetting and potentially damaging aftermaths of patient suicide. Stuart C. Yudofsky, M.D.
References Insel TR, Quirion R: Psychiatry as a clinical neuroscience discipline. JAMA 294:2221–2224, 2005
Preface
No textbook of suicide can encompass the immense professional literature relating to suicide assessment and management. The problem is that there is too much information, not too little. Since this is a clinical textbook, we asked ourselves, “What information would be clinically useful for the mental health practitioner treating the patient at risk for suicide?” Suicide risk assessment is a core competency that psychiatrists and other mental health professionals are expected to acquire during their training. The first chapter focuses on overall assessment principles and is complemented by, in the appendix to this volume, the Executive Summary of Recommendations from the American Psychiatric Association Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors. The reader will note that most of the members of the American Psychiatric Association Workgroup on Suicidal Behaviors, who developed this practice guideline, have written chapters for this book. We have enlisted recognized experts for each of the chapters. To the extent possible, the authors rely on evidence-based medicine. Expert opinion, though unquestionably valuable, usually plays a secondary role. To maintain a clinical focus, nearly all the chapters contain clinical cases, followed by a discussion that seeks to integrate the clinical finding with the material presented in the text. Each chapter ends with “Key Points” so that the reader will have a clear understanding as to what the chapter authors felt were the major learning objectives. Part I (Chapters 2 through 6) focuses on special populations: children and adolescents; the elderly; the importance of gender; social, cultural, and demographic factors; and issues involving suicide in jails and prisons. Part II (Chapters 7 and 8) addresses special issues in suicide risk assessment: cultural competence and psychological tests and scales. Treatment—psychopharmacological, psychodynamic, and collaborative (since the last-mentioned type of treatment is increasingly being xxvii
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used in today’s managed care environment)—is systemically reviewed in Part III (Chapters 9 through 11). Major mental disorders that are frequently associated with suicide— depressive disorders, bipolar disorders, schizophrenia, anxiety disorders, personality disorders, and substance use disorders—are also addressed in Part IV (Chapters 12 through 17). We felt that it was also important to address, in Part V, suicide assessment and management in various practice settings: outpatient, emergency services, and inpatient and partial hospitalization. In addition, we included, in Part VI, two chapters that address general concerns relevant to all three settings: patient safety (vs. freedom of movement) and safety interventions. It has been observed that there are three kinds of mental health clinicians: those who have had patients commit suicide, those whose patients will commit suicide, and those who have experienced more than one patient suicide. Included in the book, in Part VII, are discussions of the clinician’s role following a patient’s suicide, the psychiatrist’s reactions to patient suicide, and forensic issues that clinicians should keep in mind when responding to a patient’s suicide. The final chapters, in Part VIII, address four diverse areas: murdersuicide, the legal issues involving the standard of care and potential liability for clinicians, forensic psychiatry, and clinically based risk management as a way to avoid malpractice litigation. The reader will note a wide range of clinical and forensic expertise in our authors. Although each chapter was carefully reviewed and edited by us (and the authors responded in a gracious and constructive manner), we wanted the writing style and approach to the topic to reflect the authors’ own style and perspective. In addition, we allowed overlap among selected chapters, since people rarely read a book cover to cover but instead select particular chapters of special importance to them, usually because of pressing clinical situations or teaching needs. We are fortunate to have attracted a number of distinguished academicians, some of whom collaborated with more junior colleagues, to craft up-to-date yet authoritative chapters. The primary goal for this book is to assist clinicians who daily face the often daunting, sometimes frustrating, and always worrisome task of clinical assessment and management of the patient at risk for suicide. We hope to have achieved this goal, and we welcome your feedback on the book. Robert I. Simon, M.D. Robert E. Hales, M.D., M.B.A.
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Suicide Risk Assessing the Unpredictable Robert I. Simon, M.D.
The purpose of systematic suicide risk assessment is to identify modifiable and treatable risk and protective factors that inform the patient’s overall treatment and management requirements (Simon 2001). Suicide risk assessment is a core competency that psychiatrists are expected to acquire during their residency (Scheiber et al. 2003). A standard of care does not exist for the prediction of suicide (Pokorny 1983, 1993). Suicide is a rare event. Efforts to predict who will commit suicide lead to a large number of false-positive and false-negative predictions. No method of suicide risk assessment can reliably identify who will commit suicide (sensitivity) and who will not (specificity). Suicide is the result of multiple factors, including diagnosis (psychiatric and medical), psychodynamic, genetic, familial, occupational, environmental, social, cultural, existential, and chance factors. Furthermore, stressful life events have a significant association with completed suicides (Helia et al. 1999). Patients are at varying risk for suicide that can change rapidly. Thus, unless speaking generally, the term patient at risk for suicide is preferred to the generic “suicidal patient.” Standardized suicide risk prediction scales do not identify which patient will commit suicide (Busch et al. 1993). Single scores of suicide risk assessment scales and inventories should not be relied on by clinicians as the sole basis for clinical decision making. Structured or semistructured suicide scales can complement, but are not a substitute for, systematic suicide risk assessment (American Psychiatric Association 2003). Malone et al. (1995) found that semistructured screening instruments improved 1
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routine clinical assessments in the documentation and detection of lifetime suicidal behavior. Oquendo et al. (2003) have discussed the utility and limitations of research instruments in assessing suicide risk. Self-administered suicide scales are overly sensitive but lack specificity. Suicide risk factors occur in many depressed patients who do not commit suicide. Checklists cannot encompass all the pertinent suicide risk factors present in a given patient. A plaintiff’s attorney will point out the omission of pertinent suicide risk factors on the checklist used to assess the patient who later commits suicide. The standard of care does not require that specific psychological tests or checklists be used as part of the systematic assessment of suicide risk (Bongar et al. 1992). Actuarial analysis reveals that most depressed patients do not kill themselves. For instance, the 2002 national suicide rate in the general population was 11.0 per 100,000 (Kochanek et al. 2004). The suicide rate or absolute risk of suicide for individuals with bipolar and other mood disorders is estimated to be 193 per 100,000, which represents a relative risk 18 times greater than that of the general population (Baldessarini 2003). Thus, 99,807 patients with these disorders will not commit suicide in a single year. The same actuarial analysis can be applied to other psychiatric disorders. The suicide rate for schizophrenia and alcohol and drug abuse is also 18 times the 2002 national suicide rate. On an actuarial basis alone, the vast majority of patients will not commit suicide. Suicide is a rare event. Actuarial analysis is more useful in identifying diagnostic groups at higher risk than trying to predict the suicide of a specific patient (Addy 1992). Actuarial analysis does not identify specific treatable risk and modifiable protective factors. The clinical challenge is to identify those depressed patients who are at high risk for suicide at any given time (Jacobs et al. 1999). The standard of care does require that psychiatrists and other mental health professionals adequately assess suicide risk when such assessment is indicated. Although open to interpretation, risk assessments that systematically evaluate both risk and protective factors should meet any reasonable definition of “adequate” (see Figure 1–1). Systematically, suicide risk assessment is an inductive process in which the clinician reasons from specific patient data to arrive at a clinical judgment that informs appropriate treatment and management. Suicide risk assessment based on current research that identifies risk and protective factors for suicide enables the clinician to make evidence-based treatment and safety management decisions (Fawcett et al. 1987; Linehan et al. 1983). Professional organizations recognize the need for developing evidencebased and clinical consensus recommendations to be applied to the management of various diseases, including such behavioral states as suicide (Gray 2004; Simon 2002). The American Academy of Child and Adolescent
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Psychiatry has published practice parameters for assessing and treating children and adolescents with suicidal behavior (Shaffer et al. 1997). The American Psychiatric Association Work Group on Suicidal Behaviors has developed a practice guideline for assessing and treating patients with suicidal behaviors (American Psychiatric Association 2003; see Appendix to this textbook for executive summary of recommendations).
Case Example A 32-year-old single woman, a computer specialist, is brought to an urban community hospital emergency department after ingesting an unknown quantity of aspirin tablets and then slashing her arms with a knife. She is severely agitated, responding to command hallucinations to kill herself. The patient became acutely depressed and agitated following the breakup of a brief relationship with another woman, her first “serious” intimate relationship. At age 16, the patient made a few superficial scratches on her wrist with a razor after a “disappointment” with a young woman she idolized from afar. During the week prior to admission, she abused alcohol and methamphetamine. An admission drug screen is positive for these substances. The salicylate level is markedly elevated. Upon admission to the psychiatric unit, the patient is placed on one-toone safety management. Her agitation and disruptive behaviors require placement in open-door seclusion with an attendant sitting by the door. Nursing staff protocol requires that all patients be encouraged to verbally agree to or to sign a suicide prevention contract. Although the patient does not understand the purpose of the contract, she signs it. Psychiatric examination reveals a thought disorder, severe agitation, bizarre facial grimaces and mannerisms, confusion, hopelessness, command hallucinations, flat affect, insomnia, and inability to interact with the psychiatrist, unit staff, and other patients. The psychiatrist and the psychiatric unit’s social worker speak with the patient’s mother and siblings at the time of admission. The psychiatrist relies on the emergency exception to consent in speaking to family members without the patient’s authorization. He learns that the patient’s parents were divorced when she was 7 years old. She sees her father infrequently. The patient has a close relationship with her mother, older brother, and younger sister. There is no history of physical or sexual abuse. The mother reveals that her daughter was a good student, excelling in mathematics. Her relationship with coworkers is good. However, she has had few friends. The patient holds strong religious beliefs. She is described by her siblings as creative, artistic, and a loner. The patient has reacted to major disappointments with depression and suicidal thoughts, sometimes accompanied by “strange” facial movements and grimaces. The family history is positive for mental illness. A paternal uncle, diagnosed as a “manic-depressive,” committed suicide with a shotgun 10 years ago. A reclusive maternal aunt has been diagnosed as a “chronic schizophrenic.”
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Systematic Suicide Risk Assessment Assessment factorsa
Risk
Protective
Individual Distinctive clinical features (prodrome) Religious beliefs Reasons for living Clinical Current attempt (lethality) Therapeutic alliance Treatment adherence Treatment benefit Suicidal ideation Suicidal intent Suicide plan Hopelessness Prior attempts (lethality) Panic attacks Psychic anxiety Loss of pleasure and interest Alcohol/drug abuse Depressive turmoil (mixed states) Diminished concentration Global insomnia Psychiatric diagnoses (Axis I and Axis II) Symptom severity Comorbidity Recent discharge from psychiatric hospital Impulsivity Agitation (akathisia) Physical illness Family history of mental illness (suicide) Childhood sexual/physical abuse Mental competency
FIGURE 1–1. Source.
Systematic suicide risk assessment: a conceptual model.
Adapted from Simon 2004. Used with permission.
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Interpersonal relations Work or school Family Spouse or partner Children Situational Living circumstances Employment or school status Financial status Availability of guns Managed care setting Demographic Age Gender Marital status Race Overall risk ratingsb a
Rate risk and protective factors present as low (L), moderate (M), high (H), nonfactor (0), or range (e.g., L–M, M–H). b Judge overall suicide risk as low, moderate, high, or a range of risk.
FIGURE 1–1. (continued).
Systematic suicide risk assessment: a conceptual model
The patient is living at home. The psychiatrist asks about guns in the home. The patient’s brother states that there is a shotgun at home used for skeet shooting. The brother agrees to remove the gun from the home. A follow-up call by the social worker confirms that the gun was removed from the home and secured in a safe place. The psychiatrist’s systematic suicide risk assessment of the patient on admission is rated as high (Figure 1–2). The psychiatrist makes a diagnosis of schizophrenia, disorganized type, and substance abuse disorder (alcohol and methamphetamine). He prescribes an atypical antipsychotic medication, a benzodiazepine for control of severe agitation, and a sleep medication. In his initial suicide risk assessment, the psychiatrist evaluates both acute and chronic risk factors as well as current preventive factors. He continues to assess the patient’s acute suicide risk factors over the course of the hospitalization. On the day after admission, the patient is less agitated. She does not require seclusion. On the third hospital day, command hallucinations are indistinct. The patient is more communicative with the hospital staff and other patients. By the fifth hospital day, the patient states the command hallucinations “have gone away.” She is not agitated. Suicidal ideation continues but without intent or plan. The patient’s bizarre fa-
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cial grimaces and mannerisms observed on admission are no longer present. Hopelessness and confusion diminish. The patient attends all the assigned group therapies. She benefits from individual and group supportive therapies. The patient develops a therapeutic alliance with the psychiatrist and the treatment team. Her affect, however, remains flat. Her thought processes are logical, but her abstracting ability for proverbs is impaired. Mild insomnia is present. Concentration is poor. The patient willingly takes her medication, although she experiences mild to moderate side effects. Using evidence-based studies, the psychiatrist assesses the risk factors associated with an increased risk of suicide in schizophrenic patients. These include a previous suicide attempt (robust “predictor” of eventual completed suicide), substance abuse, depressive symptoms (especially hopelessness), male sex, early stage in illness, a good premorbid history and intellectual functioning, and frequent exacerbations and remissions (Meltzer 2001). The psychiatrist has read the InterSePT study, which found significant risk factors for suicide in schizophrenic patients to include the diagnosis of schizoaffective disorder, current or lifetime alcohol/substance abuse or smoking, hospitalization in the previous 3 years to prevent a suicidal attempt, and the number of lifetime suicidal attempts (Meltzer et al. 2003a). A systematic suicide risk assessment is performed on hospital day 6 (Figure 1–3). It is compared with the admission suicide risk assessment (Figure 1–2). Although most of the acute psychotic symptoms have improved or remitted, suicidal ideation continues. The overall risk of suicide is assessed as moderate. The psychiatrist determines that the patient needs an additional week of inpatient treatment. Because of the patient’s overall improvement, however, the managed care organization authorizes insurance coverage for only 2 additional days after a doctor-to-doctor appeal. The psychiatrist’s experience is that most patients at moderate suicide risk can be treated as outpatients, so he crafts an outpatient treatment plan based on the patient’s clinical and safety needs. He understands that the decision to discharge a patient is his responsibility and should not be based on a managed care organization’s denial of benefits. The denial of benefits is not allowed to place the patient at increased risk for suicide. The patient’s postdischarge plan recommends once-per-week supportive psychotherapy and medication management with the psychiatrist. The patient is also referred to the hospital’s partial hospitalization and substance abuse programs, which she will attend the day after discharge. The patient is eager to return to work but agrees to remain on sick leave for another 3 weeks. She recognizes the importance of adhering to the follow-up care plan. The patient plans to pursue her artistic interests. Her mother and siblings are very supportive, a major protective factor. The psychiatrist assesses other protective factors, including the patient’s ability to form a therapeutic alliance, adherence to treatment, treatment benefit, strong religious values, positive reasons for living, and commitment to the follow-up care plan. The psychiatrist’s discharge diagnosis is schizophrenia, single episode in partial remission, and substance abuse (alcohol and methamphetamine).
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Standard of Care Each state defines the standard of care required of physicians. For example, in Stepakoff v. Kantar (1985), a suicide case, the standard applied by the court was the “duty to exercise that degree of skill and care ordinarily employed in similar circumstances by other psychiatrists.” The duty of care established by the court was that of the “average psychiatrist.” In an increasing number of states, the standard of care is the “reasonable, prudent practitioner” (Peters 2000) (see Chapter 28, “Clinically Based Risk Management of the Suicidal Patient”). The legal standard must be distinguished from the professional standard of “best practices” (Simon 2005). In a suicide case, the courts evaluate the psychiatrist’s management of the patient who attempted or committed suicide to determine whether the suicide risk assessment process was reasonable and the patient’s attempt or suicide was foreseeable. An “imperfect fit,” however, exists between medical and legal terminology. Foreseeability is a legal term of art. It is a commonsense, probabilistic concept, not a scientific construct. Foreseeability is defined as the reasonable anticipation that harm or injury is likely to result from certain acts or omissions (Garner 1999). Foreseeability is not the same as predicting when a patient will attempt or commit suicide. It should not be confused with predictability, for which no professional standard exists. It also must be distinguished from preventability; a patient’s suicide may be preventable in hindsight, but it was not foreseeable at the time of assessment. Only the risk of suicide is determinable. The prediction of suicide is opaque, but there is reasonable visibility for assessing suicide risk. Contemporaneously documented systematic suicide risk assessments help provide the court with guidance. When suicide risk assessments are not performed or documented, the court is less able to evaluate the clinical complexities and ambiguities that exist in the assessment, treatment, and management of patients at risk for suicide. In malpractice litigation the failure to perform an adequate suicide risk assessment is often alleged along with other claims of negligence. It is rarely asserted as the only complaint.
Systematic Suicide Risk Assessment Systematic suicide risk assessment identifies acute, modifiable, and treatable risk and protective factors essential to informing the psychiatrist’s treatment and safety management of patients at risk for suicide
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Assessment factorsa
Risk
Protective
Individual Distinctive clinical features (prodrome)
H
Religious beliefs
0
Reasons for living
0
Clinical Current attempt (lethality)
H
Therapeutic alliance
H
Treatment adherence
L
Treatment benefit
0
Suicidal ideation (command hallucinations)
H
Suicidal intent
H
Suicide plan
0
Hopelessness
M–H
Prior attempts (lethality)
L
Panic attacks
0
Psychic anxiety
0
Loss of pleasure and interest
H
Alcohol/drug abuse
H
Depressive turmoil (mixed states)
0
Diminished concentration
H
Global insomnia
M–H
Psychiatric diagnoses (Axis I and Axis II)
H
Symptom severity
H
Comorbidity
H
Recent discharge from psychiatric hospital Impulsivity
0 (within 3 months) M–H
Agitation (akathisia)
H
Physical illness
0
Family history of mental illness (suicide)
H
Childhood sexual/physical abuse
0
Mental competency
M
FIGURE 1–2. ample. Source.
Admission systematic suicide risk assessment: case ex-
Adapted from Simon 2004. Used with permission.
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9
Interpersonal relations Work or school
L
Family
M
Spouse or partner
H
Children
0
Situational Living circumstances
M
Employment or school status
L
Financial status
L–M
Availability of guns
H
Managed care setting
0
Demographic Age
M
Gender
H
Marital status
L
Race
0
Overall risk ratingsb a
b
High
Rate risk and protective factors present as low (L), moderate (M), high (H), nonfactor (0), or range (e.g., L–M, M–H). Judge overall suicide risk as low, moderate, high, or a range of risk.
FIGURE 1–2. Admission systematic suicide risk assessment: case example (continued). (see Table 1–1). It is easy to overlook important risk and protective factors in the absence of systematic assessment. Systematic suicide assessment helps the clinician piece together risk factors that construct a clinical mosaic of the suicidal patient. Suicide risk assessment is an integral part of the psychiatric examination, yet it is rarely performed systematically, or when it is performed, it is not contemporaneously documented. It is evident from the review of quality assurance records and the forensic analysis of suicide cases in litigation that the extent of suicide risk assessment usually is no more than “Patient denies HI, SI, CFS” (homicidal ideation, suicidal ideation, contracts for safety). Frequently one finds no documentation of suicide risk assessment or an inadequate documentation such as the “Patient denies suicidal ideation.” Often, relying on a talismanic “no-
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Discharge Suicide Risk Assessment Assessment factorsa
Risk
Protective
Individual Distinctive clinical features (prodrome)
0
Religious beliefs
H
Reasons for living
M
Clinical Current attempt (lethality)
H
Therapeutic alliance
M
Treatment adherence
H
Treatment benefit
M
Suicidal ideation (command hallucinations)
M
Suicidal intent
0
Suicide plan
0
Hopelessness
L
Prior attempts (lethality)
L
Panic attacks
0
Psychic anxiety
0
Loss of pleasure and interest
L
Alcohol/drug abuse
M
Depressive turmoil (mixed states)
0
Diminished concentration
H
Global insomnia
L
Psychiatric diagnoses (Axis I and Axis II)
H
Symptom severity Comorbidity Recent discharge from psychiatric hospital Impulsivity
L–M H 0 (within 3 months) L
Agitation (akathisia)
0
Physical illness
H
Family history of mental illness (suicide)
H
Childhood sexual/physical abuse
0
Mental competency
L
FIGURE 1–3. Source.
Discharge suicide risk assessment: case example.
Adapted from Simon 2004. Used with permission.
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11
Interpersonal relations Work or school
H
Family
H
Spouse or partner
L–M
Children
0
Situational Living circumstances
M
Employment or school status
H
Financial status
M
Availability of guns
0 L–M
Managed care setting Demographic Age
M
Gender
L
Marital status
L
Race
0
Overall risk ratings
b
Moderate
a
Rate risk and protective factors present as low (L), moderate (M), high (H), nonfactor (0), or range (e.g., L–M, M–H). b Judge overall suicide risk as low, moderate, high, or a range of risk.
FIGURE 1–3.
Discharge suicide risk assessment: case example (continued).
harm contract” replaces performing an adequate suicide risk assessment. Laypersons could just as easily ask these same questions and obtain a no-harm contract. Moreover, there is no evidence that suicide safety contracts decrease or prevent suicide (Simon 2004). The road to patient suicides is often strewn with safety contracts. In the case example, systematic suicide risk assessment supplants a reliance on a suicide prevention contract. Suicide risk assessment is a core clinical skill that informs the treatment and management of patients at risk for suicide (Simon 2001). Why do so many psychiatrists, whether they have been sued or not, fail to perform and document adequate suicide risk assessments? When this question is posed to colleagues, a variety of answers are given: the clinician does not know how to perform a systematic suicide risk assessment; the clinician simply does not do suicidal risk assessments,
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TABLE 1–1.
Textbook of Suicide Assessment and Management Modifiable and treatable suicide risk factors: some examples
Depression Anxiety Panic attacks Psychosis Sleep disorders Substance abuse
Impulsivity Agitation Physical illness Situation (e.g., family, work) Lethal means (e.g., guns, drugs) Drug effects (e.g., akathisia)
Source. Adapted from Simon RI: Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management. Washington, DC, American Psychiatric Publishing, 2004. Used with permission.
usually delegating it to others; the clinician performs systematic risk assessments but does not document them, usually in a high-volume practice; the anxiety produced by patients at substantial risk for suicide creates denial and minimization of the risk, causing a failure to perform an adequate assessment; the clinician fears that documenting the risk assessment process creates legal exposure if the assessment is wrong and the patient commits suicide. In inpatient settings, short lengths of stay and the rapid turnover of seriously ill patients may distract the clinician from performing adequate risk assessments. A combination of these and other reasons are at play. Approximately 25% of patients at risk for suicide do not admit having suicidal ideation to the clinician but do tell their families (Robins 1981). Hall et al. (1999) found that 69 of 100 patients had only fleeting or no suicidal thoughts before they made a suicide attempt. None of these patients reported a specific plan before their impulsive suicide attempt. This was the first attempt for 67% of these patients. Patients who are determined to commit suicide regard the psychiatrist and other mental health professionals as the enemy (Resnick 2002). Therefore, just asking the patient at risk for suicide about the presence of suicidal ideation, intent, and plan and receiving a denial cannot be relied upon by itself. If possible, family members or others who know the patient should be consulted. Even when the patient is telling the truth, it is unwise to equate the patient’s denial of suicidal ideation with an absence of suicide risk. The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry (American Psychiatric Association 2001) states: “Psychiatrists at times may find it necessary, in order to protect the patient or community from imminent danger, to reveal confidential information disclosed by the patient” (section 4, annotation 8). Management
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of patients at high risk for suicide may require breaking patient confidence and involving the family or significant others (e.g., to obtain vital information, to administer and monitor medications, to remove lethal weapons, to assist in hospitalization). Statutory waiver of confidential information is provided in some states when a patient threatens selfharm (Simon 1992). If the severely disturbed patient lacks the mental capacity to consent, a substitute health care decision-maker should be interviewed. In a number of states, proxy consent by next of kin is not permitted for patients with mental illnesses. If an emergency exists, the emergency exception to patient consent may be invoked (Simon 2004). Just listening to others without divulging information about the patient does not violate confidentiality. It may be possible to speak with others once a therapeutic alliance develops and the patient consents. Observational information obtained from the psychiatric examination may provide objective information about the suicide risk factors, thus avoiding total reliance on the patient’s reporting. For example, slash marks on the arms or neck, burns, or other wounds may be apparent. The mental status examination may reveal diminished concentration, bizarre ideation, evidence of command hallucinations, incapacity to cooperate, restlessness, agitation, severe thought disorder, impulsivity, and alcohol or drug withdrawal symptoms. The degree of irritability can be rapidly assessed in patients with major depressive disorder and is correlated with depression severity and suicide attempts (Perlis et al. 2005). Suicidal ideation is a key risk factor. In the National Comorbidity Survey, the probability of transitioning from suicidal ideation to suicidal plan was 34%, and the probability of transitioning from a plan to attempt was 72% (Kessler et al. 1999). The probability of transition from suicidal ideation to an unplanned attempt was 26%. In this study, approximately 90% of unplanned and 60% of planned first attempts occurred within 1 year of the onset of suicidal ideation. Systematic suicide risk assessment should be performed when the patient reports passive rather than active suicidal ideations (e.g., “I hope God takes me” versus “I’m going to kill myself”). Passive ideation can quickly become active. Also, the patient may be minimizing or hiding active suicidal ideation. When evaluating a patient’s suicidal ideation, the clinician should consider specific content, intensity, duration, and prior episodes. Mann et al. (1999) found that the severity of an individual’s ideation is an indicator of risk for attempting suicide. Beck et al. (1990) found that when patients were asked about suicidal ideation at its worst point, patients with higher scores were 14 times more likely to commit suicide compared with patients with lower scores.
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Suicide risk assessment bears some analogy to weather forecasting (Monahan and Steadman 1996; Simon 1992). Astronomical events such as eclipses can be predicted with 100% accuracy. Prediction is an actuarial or scientific concept. Weather forecasts can be made only within certain probabilities. Suicide risk assessments are “here and now” determinations whose clinical usefulness diminishes over time. Psychological and environmental risk factors that influence future occurrences can be specified with more precision in the short term. Similar to weather forecasts, suicide risk assessments should be frequently updated. The analogy, however, is imperfect. Weathermen can predict the weather with reasonable accuracy, but they cannot change it. Psychiatrists cannot predict who will commit suicide, but they can reduce or eliminate suicide risk. The purpose of suicide risk assessment is to identify and treat acute risk factors and to identify and mobilize protective factors in the management of the suicidal patient. Suicide risk assessment is an essential clinical tool, not a prediction instrument. As with weather forecasting, determining the clinician’s level of confidence in the available patient data is essential for the treatment and management of suicide risk. Table 1–2 contains a suicide risk assessment data checklist that can be used by clinicians. The standard of care requires that the clinician gather sufficient information on which to base an adequate suicide risk assessment. The checklist can alert the clinician to deficiencies in the data collection. Systematic risk assessment itself is an impetus to gather essential clinical information about the patient. The checklist reminds the clinician to consider multiple data sources. When the clinical situation turns stormy, clinicians, like pilots, must rely on their instruments. Systematic suicide risk assessment is an instrument for managing the suicidal patient.
Suicide Risk Factors There is no pathognomonic risk factor for suicide. A single suicide risk factor does not have adequate statistical power on which to base an assessment. Suicide risk assessment cannot be predicated on any one factor (Meltzer et al. 2003b); the assessment of suicide risk is multifactorial. Moreover, a number of retrospective, community-based psychological autopsies and studies of psychiatric patients who have committed suicide have identified general risk factors (Fawcett et al. 1993). These factors must then be applied to the clinical presentations of individual patients. Short-term suicide risk factors derived from a prospective study of patients with major affective disorders were statistically significant
Suicide Risk: Assessing the Unpredictable TABLE 1–2.
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Suicide risk assessment data checklist: hospital admission
Identify distinctive individual suicide risk factors Identify acute suicide risk factors Identify protective factors Evaluate medical history and laboratory studies Obtain treatment team information Interview patient’s significant others Speak with current or prior treaters Review patient’s current and prior hospital records Note. Modify for outpatient use. Source. Adapted from Simon RI: “Suicide Risk Assessment in Managed Care Settings.” Primary Psychiatry 7:42–43, 46–49, 2002.
within 1 year of assessment (Fawcett et al. 1990). These risk factors included panic attacks, psychic anxiety, loss of pleasure and interest, moderate alcohol abuse, depressive turmoil (mixed states), diminished concentration, and global insomnia. Short-term risk factors were predominantly severe, anxiety driven, and treatable with a variety of psychotropic drugs (Fawcett 2001). Patients with major depression and generalized anxiety disorder (GAD) have higher levels of suicidal ideation when compared with depressed patients without GAD (Zimmerman and Chelminski 2003). Comorbid anxiety and depression occur in more than 50% of nonbipolar major depressive disorders (Zimmerman et al. 2002). The combination of severe depression and anxiety or panic attacks can prove lethal. A patient may be able to tolerate depression. When anxiety or panic is also present, however, the patient’s life may become unbearable, making suicide a devoutly desired escape. Anxiety (agitation) symptoms should be treated aggressively while antidepressant medications are given an opportunity to work. Some patients demonstrate a significant antidepressant response within the first 1–2 weeks of treatment (Posternak and Zimmerman 2005). Time is on the side of patients at risk for suicide who are treated rapidly and effectively. Conversely, time works against patients when treatment is delayed or ineffective. The mental disorder often progresses and becomes entrenched. Secondary effects such as work impairment and disrupted relationships lead to despair, demoralization, and an increased risk of suicide. Long-term suicide risk factors in patients with major affective disorder are associated with suicides completed 2–10 years after assessment (Fawcett et al. 1990). Long-term suicide risk factors are derived from
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community-based psychological autopsies and the retrospective study of psychiatric patients who have committed suicide (Fawcett et al. 1993). Long-term suicide risk factors include suicidal ideation, suicidal intent, severe hopelessness, and prior attempts. Suicide risk increases with the total number of risk factors, providing a quasi-quantitative dimension to suicide risk assessment (Murphy et al. 1992). Patients with disorders from diagnostic groups such as major affective disorders, chronic alcoholism and substance abuse, schizophrenia, and borderline personality disorder (BPD) are at increased risk for suicide (Fawcett et al. 1993). Roose et al. (1983) found that delusional depressed patients were five times more likely to commit suicide than depressed patients who were not delusional. Busch et al. (2003) also found that 54% of 76 inpatient suicides had an association between psychosis and suicide. In the Collaborative Study of Depression, no significant difference in suicide was found between depressed and delusionally depressed patients. Patients who had delusions of thought insertion, grandeur, and mind reading, however, were significantly represented in the suicide group (Fawcett et al. 1987). A number of follow-up studies did not find that patients with psychotic depression are more likely to commit suicide than patients with nonpsychotic depression (Coryell et al. 1996; Vythilingam et al. 2003). Suicide risk likely increases with the severity of psychosis. Patients often display distinctive individual suicide risk and preventive factor patterns. Suicide patterns may be identified from prior exacerbations of suicidal ideation, suicidal crises, or actual attempts. Understanding a patient’s psychodynamics and psychological responses to past and current life stressors is important. In the case example presented earlier in this chapter, when the patient was depressed and at risk for suicide, she displayed bizarre facial mannerisms. Some unusual prodromal suicide risk factors can emerge when the patient becomes suicidal, as, for example, in the stuttering patient whose speech clears, the patient who compulsively whistles, and the patient who selfinflicts facial excoriations. Most patients experience more common suicide risk patterns, such as suicidal ideation within a few hours or days after the onset of early morning awakening. Knowing a patient’s distinctive prodromal suicide risk factors along with his or her psychodynamics is very helpful in treatment and safety management. Strongly held values such as religious beliefs and reasons for living can be significant protective factors. Demographic suicide risk factors include age, sex, race, and marital status. The suicide rates for white males 65 years of age and older are elevated. White males older than 85 have the highest suicide rates.
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Males commit suicide at a rate three to four times greater than the rate among females. Females make suicide attempts at a rate three to four times greater than the rate among men. Divorced individuals are at significantly increased risk for suicide compared with married individuals. The suicide rate is higher among white individuals, with the exception of young adults (National Institute of Mental Health 2003). Demographic suicide risk factors, although significant, supplement the assessment of individual risk factors. A family history of mental illness, especially of suicide, is a significant suicide risk factor. A genetic component exists in the etiology of affective disorders, schizophrenia, alcoholism and substance abuse, and Cluster B personality disorders. These psychiatric disorders are associated with most suicides (Mann and Arango 1999). Genetic and familial transmission of suicide risk is independent of the transmission of psychiatric illnesses (Brent et al. 1996). Psychiatric illnesses are the necessary but not necessarily the sufficient cause of patient suicides. Patients with intractable, malignant psychiatric disorders that end in suicide often have strong genetic and familial components to their illnesses. In schizophrenia, the completed lifetime suicide rate is between 9% and 13% (Mortensen and Juel 1993). The estimated number of suicides annually in the United States among patients with schizophrenia is 3,600 (12% of total suicides). The lifetime suicide attempt rate is between 20% and 40%. Suicide is the leading cause of death among persons with schizophrenia who are younger than 35 years. Suicide is a risk in schizophrenia throughout the individual’s life cycle (Helia et al. 1997; Meltzer and Okaly 1995). However, suicide tends to occur in the early stages of illness and during an active phase (Meltzer 2001). In the case example, the patient’s suicide attempt was directed by command hallucinations. The earlier psychiatric literature indicated that command hallucinations accounted for relatively few suicides in schizophrenic patients (Breier and Astrachan 1984; Roy 1982). Nonetheless, an auditory hallucination that commands suicide is an important risk factor requiring careful assessment. The patient needs to be asked: Are the auditory hallucinations that are commanding suicide acute or chronic? Syntonic or dystonic? Are they familiar or unfamiliar voices? Is the patient able to resist the hallucinatory commands, or has the patient attempted suicide in obedience to the voices? Juninger (1990) reported that 39% of patients with command hallucinations obeyed them. Patients were more likely to comply with hallucinatory commands if they could identify the voices. Kasper et al. (1996) found that 84% of psychiatric inpatients with command hallucinations had obeyed them within the previous 30 days. The resistance to com-
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mand hallucinations that dictate dangerous acts appears to be greater than the resistance to commands to perform nondangerous acts (Juninger 1995). This is not as true for patients who have obeyed command hallucinations dictating self-destructive behaviors. In a study of command hallucinations for suicide, 80% of suicide attempters reported at least one attempt in response to command hallucinations (HarkavyFriedman et al. 2003). Hellerstein et al. (1987) studied the content of command hallucinations and found that 52% involved suicide, 14% involved nonviolent acts, 12% involved nonlethal injury to self or others, 5% involved homicide, and 17% were unspecified. Thus, 57% of command hallucinations dictated violence. Patients with auditory hallucinations that command suicide should be presumptively assessed as being at high risk for suicide, requiring immediate psychiatric treatment and management. Harris and Barraclough (1997) abstracted 249 reports from the medical literature regarding the mortality of mental disorders. They compared observed numbers of suicides in individuals with mental disorders with those expected in the general population. The standardized mortality ratio (SMR)—a measure of the relative risk of suicide for a particular disorder compared with the expected rate in the general population (SMR of 1)—was calculated for each disorder by dividing observed mortality by expected mortality (Table 1–3). The authors concluded, “If these results can be generalized, then virtually all mental disorders have an increased of risk for suicide excepting mental retardation and dementia” (p. 222). Harris and Barraclough also calculated the SMR for all psychiatric diagnoses by treatment setting. The SMR for inpatients was 5.82 and for outpatients was 18.09. Prior suicide attempts by any method had the highest SMR of 38.36. Suicide risk was highest in the 2 years after the first attempt. A correct diagnosis is essential. The SMR for psychiatric, neurological, and medical disorders can be helpful to the psychiatrist in assessing the risk of suicide for a specific diagnosis. Baldessarini (2003) and colleagues found that the overall SMR for bipolar disorder was 21.8. The SMR was 1.4 times higher for women than for men. Most suicide acts occurred within the first 5 years after onset of the illness. The SMR for bipolar II disorder was 24.1, compared with an SMR of 17.0 for bipolar I disorder and 11.8 for unipolar disorders. The high SMR for prior suicide attempts is supported by other studies (Fawcett 2001). Between 7% and 12% of patients who make suicide attempts commit suicide within 10 years, thus making it a significant chronic risk factor for suicide. Suicide rehearsals are common. Recent near-lethal attempts are frequently followed within days by a completed
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Suicide Risk: Assessing the Unpredictable TABLE 1–3.
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Mental and physical disorders: standard mortality ratio
Disorder Eating disorders Major depression Sedative abuse Mixed drug abuse Bipolar disorder Opioid abuse Dysthymia Obsessive-compulsive disorder Panic disorder Schizophrenia Personality disorders AIDS Alcohol abuse Epilepsy Child and adolescent Cannabis abuse Spinal cord injury Neuroses Brain injury Huntington’s chorea Multiple sclerosis Malignant neoplasms Mental retardation
SMRa 23.14 20.35 20.34 19.23 15.05 14.00 12.12 11.54 10.00 8.45 7.08 6.58 5.86 5.11 4.73 3.85 3.82 3.72 3.50 2.90 2.36 1.80 0.88
aStandard mortality ratio (SMR) is calculated by dividing observed mortality by expected
mortality. SMR for the general population is 1. Source. Adapted from Harris and Barraclough 1997.
suicide. Most suicides, however, occur in patients with no history of prior attempts. The majority of patients who committed suicide did not communicate their suicide intent during their last appointment (Isometsa et al. 1995). In a retrospective study of 76 inpatient suicides, Busch et al. (2003) found that 77% of the patients denied suicidal ideation as their last recorded communication. Mann et al. (1999) found that prior suicide attempts and hopelessness are the most powerful clinical “predictors” of completed suicide. More males than females (62% vs. 38%) died at their first suicide attempt (Isometsa and Lonnqvist 1998). Previous attempters (82%) used at least two different methods in attempts and completed suicides.
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No annual national data are available on attempted suicide. It is estimated that 8–25 suicide attempts occur for every completed suicide (National Institute of Mental Health 2003). Reliable research finds, however, that high risk factors associated with attempted suicide in adults are depression, prior suicide attempt(s), hopelessness, suicidal ideation, alcohol abuse, cocaine use, and recent loss of an important relationship (Murphy et al. 1992). In youths, the strongest factors associated with suicide attempts are depression, alcohol or other drug use disorder, and aggressive or disruptive behaviors (National Institute of Mental Health 2003). Weisman and Worden (1972) devised a risk-rescue rating in suicide assessment as a descriptive and quantitative method of determining the lethality of suicide attempt.
Populations at Risk for Suicide Practice parameters exist for the assessment and treatment of children and adolescents with suicidal behavior (Shaffer et al. 1997). Risk factors for adolescents include prior attempts, affective disorder, substance abuse, living alone, male sex, age 16 years or older, and a history of physical and/or sexual abuse. Adverse childhood experiences—for example, emotional, physical, and sexual abuse—are associated with an increased risk of attempted suicide throughout the life span (Dube et al. 2001). More suicidal women than suicidal men have experienced childhood abuse (Kaplan et al. 1995). Brent (2001) provided a framework for the assessment of suicide risk in the adolescent that can be used to determine immediate disposition, intensity of treatment, and level of care (see Chapter 2, “Children and Adolescents”). In adults older than 65 years of age, important correlates of late-life suicide are depression, physical illnesses, functional impairment, personality traits of neuroticism, social isolation, and loss of important relationships (Conwell and Duberstein 2001). The suicide rate for men 85 years and older rises substantially (60 per 100,000; Loebel 2005). Affective disorder is the risk factor with the strongest correlation. Forty-one percent of older adults saw their primary care physician within 28 days of committing suicide (Isometsa et al. 1995). Thus, primary care is an important point of suicide prevention for elders at high risk (see Chapter 3, “The Elderly”). Personality disorders place a patient at increased risk for suicide (Linehan et al. 2000). Patients with personality disorders are at seven times greater risk for suicide than the general population (Harris and Barraclough 1997). In patients who commit suicide, 30%–40% have personality disorders (Bronisch 1996; Duberstein and Conwell 1997; see
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Chapter 16, “Personality Disorders”). Cluster B personality disorders, especially BPD and antisocial personality disorder, place patients at increased risk for suicide (Duberstein and Conwell 1997). Personality disorders, when comorbid with bipolar disorder, are an independent suicide risk factor that increases lifetime risk of suicide (Garno et al. 2005). In patients with BPD, impulsivity was associated with a high number of suicide attempts after controlling for substance abuse and a lifetime diagnosis of depressive disorder (Brodsky et al. 1997). In a longitudinal study of personality disorder, a combination of BPD, major affective disorder, and alcoholism was found in a subgroup of completed suicides (Stone 1993). Personality disorder, negative recent life events, and Axis I comorbidity were identified in a large sample of individuals who commited suicide (Heikkinen et al. 1997). Recent stressful life events, including workplace difficulties, family problems, unemployment, and financial trouble, were highly represented among patients with personality disorders. Personality disorders and comorbidity, such as depressive symptoms and substance abuse disorders, are frequently found among patients who commit suicide (Isometsa et al. 1996; Suominen et al. 2000). Gunderson and Ridolfi (2002) estimated that suicide threats and gestures occur repeatedly in 90% of patients with BPD. The clinician’s suicide risk assessment of the borderline patient should pay attention to comorbidity, especially mood disorder and substance abuse; prior suicide attempts or self-mutilating behaviors; impulsivity; and unpleasant recent life events. Self-mutilating behaviors that commonly occur in borderline patients include cutting (80%), bruising (34%), burning (20%), head banging (15%), and biting (7%). Although self-mutilation is considered to be parasuicidal behavior (without lethal intent), the risk of suicide among individuals with selfmutilating behavior is doubled (Stone 1987). Retrospectively, it may be difficult or impossible to distinguish a nonlethal suicide gesture from an actual suicide attempt. The clinician must consider intent, not just behavior. For example, a patient takes 10 aspirin tablets with the intent that it will result in death. Suicidal intent is defined as the subjective expectation and desire to die by a self-destructive act (American Psychiatric Association 2003). A patient taking 6 mg/day of a benzodiazepine who takes an overdose of 180 1-mg tablets may not have any intention to commit suicide and may know that death will not likely occur. An aborted attempt occurs when the intent to harm is interrupted and no physical harm results. Lethality refers to the danger to life by a suicide method or act. O’Carroll et al. (1996) have provided definitions for a variety of suicidal behaviors.
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Psychiatrists have difficulty gauging the imminence of suicide. No suicide risk factors identify imminence. Imminence defies definition; it is not a medical or psychiatric term. Imminence is another word for prediction. The patient who points a loaded gun at his or her head or perches on a bridge is a high-risk psychiatric emergency. However, individuals have been “talked out” of pulling the trigger or jumping. Individuals intent on committing suicide are usually ambivalent to the last moment. Suicide risk is in constant flux. Less extreme examples of patients who may be at high risk for suicide include patients who are found hiding lethal instruments or who are vocal about committing suicide at their first opportunity. It is imperative to identify, treat, and manage a patient’s acute risk factors driving a suicide crisis than to undertake the impossible task of trying to predict whether or when a suicide attempt may occur. Imminent suicide creates the illusion of shortterm prediction (Simon, submitted for publication). Impulsivity, usually a trait factor or predisposition often associated with alcohol and substance abuse, is an important suicide risk factor requiring careful assessment (Moeller et al. 2001). Impulsivity also has been found in many suicide attempters with major depressive disorder, panic disorder, and aggressive behaviors linked to the serotonergic system (Pezawas et al. 2002). Patients who harm themselves are more impulsive than the general population. Patients who repeatedly harm themselves are found to be more impulsive than patients who have harmed themselves for the first time (Evans et al. 1996). Impulsivity can be both acute and chronic. Chronic impulsivity can become acute when heightened by life stress, loss, and anxiety. Suicide attempts or violent suicide often result (Fawcett 2001). Mann et al. (1999) found that suicide attempters with major depressive disorder have higher levels of aggression and impulsivity than nonattempters. Impulsivity can be assessed clinically by asking the patient questions about violent rages, assaultive behaviors, arrests, destruction of property, spending sprees, speeding tickets, sexual indiscretions, and other indicators of poor impulse control. “Shame suicides” can occur in individuals faced with intolerable humiliation (e.g., scandal, criminal charges). A shame suicide may be an impulsive act in a narcissistically vulnerable person. It may not be associated with a diagnosable mental disorder (Roy 1986). A patient’s suicide risk may be exacerbated by problems that arise from the treater. Examples include physical or psychological impairment, incompetence, indifference, patient exploitation, negative countertransference, fatigue (“burnout”), and deficient language skills (Simon and Gutheil 2004). To perform an adequate suicide risk assessment, the
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clinician must be able to understand idiomatic phrases and slang expressions. In one instance, a severely depressed suicidal patient with opioid dependence told the psychiatrist that she had “gone cold turkey.” The psychiatrist, who had limited English language skills, proceeded to ask the patient if she had an eating disorder.
Suicide Risk Assessment Methodology A number of suicide risk assessment models are available to the clinician (Beck et al. 1998; Clark and Fawcett 1992; Jacobs et al. 1999; Linehan 1993; Mays 2004; Rudd et al. 2001; Shea 2004). Only a few methods can be cited here. No suicide risk assessment model has been empirically tested for reliability and validity (Busch et al. 1993). Clinicians can also develop their own systematic risk assessment methods based on their training, clinical experience, and familiarity with the evidence-based psychiatric literature. The example of suicide risk assessment illustrated in Figure 1–1 represents just one way of conceptualizing systematic assessment. Figure 1–1 is a teaching tool designed to encourage a systematic approach to suicide risk assessment. It should not be used as a form or protocol to be applied in a robotic fashion. The use of stand-alone suicide risk assessment forms is not recommended. Suicide risk factors vary in number and importance according to the individual patient. The clinician’s judgment is central in identifying and assigning clinical weight to or establishing a hierarchy of risk and protective factors. It is also important to assess protective factors against suicide to achieve a balanced assessment of suicide risk. Each patient has a distinctive suicide risk factor profile that should receive a high priority for identification and assessment. The risk factor profile or prodrome tends to reappear during subsequent recurrence of psychiatric illness. Malone et al. (2000) assessed inpatients with major depression for severity of depression, general psychopathology, suicide history, reasons for living, and hopelessness. The Self-Report Reasons for Living Inventory was used to measure beliefs that may act as preventive factors against suicide (Linehan et al. 1983). The total score for reasons for living was inversely correlated with the sum of the scores for hopelessness, subjective depression, and suicidal ideation. The authors recommended including reasons for living in the clinical assessment and management of suicidal patients. Protective factors against suicide may include family and social support, pregnancy, children at home, strong religious beliefs, and cultural sanctions against suicide (Institute of Medicine 2001). Religious affiliation was associated with less suicidal behavior in depressed patients
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(Dervic et al. 2004). Severely depressed patients, however, may feel abandoned by God or believe that God will understand and forgive, increasing their risk for suicide. Survival and coping, responsibility to family, and child-related concerns are protective factors (Linehan et al. 1983). A therapeutic alliance between clinician and patient can be an important protective factor against suicide (Simon 1998). The therapeutic alliance, however, is influenced by a number of factors, especially the nature and severity of the patient’s illness. Thus, it can change quickly from session to session. It cannot be assumed, therefore, that a therapeutic alliance will be present and protective between sessions. Clinicians have been shocked and bewildered when a patient with whom they felt a strong therapeutic alliance existed attempts or commits suicide between sessions. The absence of a therapeutic alliance in a patient at risk for suicide should be considered a significant risk factor. Protective factors, like risk factors, vary with the distinctive clinical presentation of the individual patient at suicide risk. An ebb and flow exists between suicide risk and protective factors. Protective factors are especially important for discharge planning. Protective factors are usually easier for patients to talk about, thus tending to be overvalued by the patient or the clinician. Protective factors can be overcome by the acuteness and severity of mental illness. Figure 1–1 divides assessment factors into five general categories: individual, clinical, interpersonal, situational, and demographic. The practitioner ranks the risk and protective factors according to the patient’s distinctive clinical presentation. Acute suicide risk factors are a focus of current clinical attention and should be monitored closely. A dimensional scale of low, moderate, high, or nonfactor, reflecting the continuum of suicide risk, is used. A final risk rating is an informed clinical judgment call based on the overall assessment of the risk and protective factor pattern. The overall risk assessment informs safety management and discharge decisions. The purpose of Figure 1–1 is to provide a conceptual model that encourages systematic suicide risk assessment. Assessments can be made in a time-efficient manner after thorough psychiatric examination and during continuing patient care. A concise contemporaneous note that describes the clinician’s suicide risk assessment and clinical decision-making process is adequate (Table 1–4). Assessment factors may be rated according to a variety of clinical dimensional parameters in suicide risk assessment (Table 1–5). For example, assessment factors may be rated as acute (recent onset, severe) or chronic (longstanding, usually static risk factors). After initial psychiatric examination and systematic suicide risk assessment, the clinician can evaluate the course of acute suicide risk factors that brought the pa-
Suicide Risk: Assessing the Unpredictable TABLE 1–4.
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Sample suicide risk assessment note
Suicide risk factors identified and weighed (low, moderate, high) Protective factors identified and weighed (low, moderate, high) Overall assessment rated (low, moderate, high, or range) Treatment and management intervention informed by the assessment Effectiveness of interventions evaluated Source. Adapted from Simon RI: Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management. Washington, DC, American Psychiatric Publishing, 2004. Used with permission.
tient to treatment. Modifiable and treatable suicide risk factors should be identified early and treated aggressively. For example, anxiety, depression, insomnia, and psychosis may respond rapidly to medications as well as to psychosocial interventions. Impulsivity may respond to treatment with anticonvulsants (Hollander et al. 2002). The clinician should also identify, support, and, when possible, enhance protective factors. Psychosocial interventions can help mitigate or resolve interpersonal issues at home, work, or school. At discharge, a final systematic suicide risk assessment allows comparison with the initial office visit or hospital admission assessment (Simon 1997).
Conclusion Suicide risk assessment is a process, not an event. Suicide risk exists along a continuum that can vary from minute to minute, hour to hour, and day to day. Thus, assessments need to be performed at a number of clinical junctures, for example, change of safety status, removal from seclusion and/or restraint, ward changes, and passes. A suicide risk assessment process that follows the course of acute risk factors is illustrated in the case example presented earlier in this chapter. For outpatients, systematic suicide risk assessment is critical to clinical decision making, especially regarding voluntary or involuntary hospitalization. Patients with Axis I psychiatric disorders such as schizophrenia, anxiety disorders, major affective disorders, and substance use disorders often present with acute (state) suicide risk factors. Patients with Axis II disorders often display chronic (trait) suicide risk factors. Exacerbation of an Axis II disorder or comorbidity with an Axis I disorder (including substance abuse) may exacerbate and transform a chronic suicide risk factor, such as impulsivity, into an acute risk factor. A family history of mental illness, especially associated with suicide, is an important chronic (static) risk factor. The offspring of mood-disordered patients
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TABLE 1–5.
Textbook of Suicide Assessment and Management Dimensional parameters in suicide risk assessment
Risk–Protective Acute–Chronic Necessary–Sufficient Individual–Situational State (Axis I)–Trait (Axis II) Source. Reprinted from Simon RI: Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management. Washington, DC, American Psychiatric Publishing, 2004. Used with permission.
who attempt suicide are at a markedly increased risk for suicide (Brent et al. 2002). In the case example, the patient’s aunt was diagnosed as a “chronic schizophrenic,” and a “manic-depressive” uncle committed suicide. Comorbidity significantly increases the patient’s risk for suicide (Kessler et al. 1999). As noted earlier, suicide risk increases with the total number of risk factors, providing a quasi-quantitative dimension to suicide risk factor assessment (Murphy et al. 1992). Necessary (e.g., depression) and sufficient (e.g., situational) factors provide another assessment parameter. For example, the patient with major depression who also is experiencing a personal loss or work-related crisis may present with both necessary and sufficient suicide risk factors. Evaluating individual (e.g., distinctive or atypical suicide risk factors) and situational (e.g., loss) parameters can also be useful in suicide risk assessment. This parameter is a variant of the necessary and sufficient analysis. Systematic suicide risk assessment encourages the gathering of relevant clinical information. Malone et al. (1995) found that at admission, clinicians performing routine clinical assessments failed to document a history of suicidal behavior in 12 of 50 patients who were identified by research assessment to be depressed and having attempted suicide. Fewer suicide attempts were reported clinically than were reported with use of a comprehensive research assessment. Documentation of suicidal behavior was most accurate on hospital intake admission using a semistructured format than on discharge documentation by clinical assessment alone. The authors suggested that the use of semistructured screening instruments may improve documentation and the detection of lifetime suicidal behavior. Systematic suicide risk assessment of the patient’s risk and protective factors is a clinical process that also provides an improved means of gathering information and informing the identification, treatment, and management of patients at risk for suicide.
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❏ Key Points ■
Fully commit to the ongoing assessment, treatment, and management of the patient at suicide risk.
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Be aware of personal factors that can adversely affect the care of the suicidal patient. Conduct a realistic self-appraisal regarding the number of suicidal patients you can competently treat at any one time.
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Conduct systematic suicide risk assessment to inform treatment and management of patients at risk for suicide.
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Identify treatable and modifiable suicide risk and protective factors early, and treat aggressively. Delayed or ineffective treatment can result in a psychiatric condition becoming entrenched, leading to patient demoralization, hopelessness, and adverse life consequences.
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Do not use suicide prevention contracts in place of conducting systematic suicide risk assessments. Suicide risk assessment is a process, not an event.
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Contemporaneously document suicide risk assessments. Such documentation facilitates good clinical care and is standard practice.
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If necessary, contact significant others to facilitate hospitalization, mobilize support, and acquire information of importance. Just listening does not violate patient confidentiality. Whenever possible, obtain the patient’s consent.
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Do not delegate suicide risk assessment of the patient to others. It is the responsibility of the psychiatrist.
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Do not allow managed care limitations of benefits to become a risk factor for suicide. Clinicians have a professional, ethical, and legal duty to provide adequate assessment and management of patients, regardless of managed care protocols and restrictions.
References Addy CL: Statistical concepts of prediction, in Assessment and Prediction of Suicide. Edited by Maris RW, Berman AL, Maltsberger JT, et al. New York, Guilford, 1992, pp 218–232 American Psychiatric Association: Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry. Washington, DC, American Psychiatric Association, 2001 American Psychiatric Association: Practice guidelines for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry 160(suppl): 1–60, 2003 Baldessarini RJ: Lithium: effects on depression and suicide (visuals). J Clin Psychiatry 64:7, 2003
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Beck AT, Brown G, Berchick RJ, et al: Relationship between hopelessness and ultimate suicide: a replication with psychiatric outpatients. Am J Psychiatry 147:190–195, 1990 Beck AT, Steer RA, Ranieri WF: Scale for suicidal ideation: psychometric properties of a self-report version. J Clin Psychol 44:499–505, 1998 Bongar B, Maris RW, Bertram AL, et al: Outpatient standards of care and the suicidal patient. Suicide Life Threat Behav 22:453–478, 1992 Breier A, Astrachan BM: Characterization of schizophrenic patient who commits suicide. Am J Psychiatry 141:206–209, 1984 Brent DA: Assessment and treatment of the youthful suicidal patient. Ann NY Acad Sci 932:106–131, 2001 Brent DA, Bridge J, Johnson BA, et al: Suicidal behavior runs in families. Arch Gen Psychiatry 53:1145–1152, 1996 Brent DA, Oquendo M, Birmaher B, et al: Familial pathways to early onset suicide attempt. Arch Gen Psychiatry 59:801–807, 2002 Brodsky BS, Malone KM, Ellis SP, et al: Characteristics of borderline personality disorder associated with suicidal behavior. Am J Psychiatry 154:1715–1719, 1997 Bronisch T: The typology of personality disorders: diagnostic problems and their relevance for suicidal behavior. Crisis 17:55–58, 1996 Busch KA, Clark DC, Fawcett J, et al: Clinical features of inpatient suicide. Psychiatr Ann 23:256–262, 1993 Busch KA, Fawcett J, Jacobs DG: Clinical correlates of inpatient suicide. J Clin Psychiatry 64:14–19, 2003 Clark DC, Fawcett J: An empirically based model of suicide risk assessment of patients with affective disorders, in Suicide and Clinical Practice. Edited by Jacobs D. Washington, DC, American Psychiatric Press, 1992, pp 55–73 Conwell Y, Duberstein PR: Suicide in elders. Ann NY Acad Sci 932:132–150, 2001 Coryell W, Leon A, Winokur G, et al: Importance of psychotic features to longterm course in major depressive disorder. Am J Psychiatry 153:483–489, 1996 Dervic K, Oquendo MA, Grunebaum MF, et al: Religious affiliation and suicide attempt. Am J Psychiatry 161:2303–2308, 2004 Dube SR, Anda RF, Felitti VJ, et al: Childhood abuse, household dysfunction and the risk of attempted suicide throughout the lifespan: findings from the adverse childhood. JAMA 286:3089–3096, 2001 Duberstein P, Conwell Y: Personality disorders and completed suicide: a methodological and conceptual review. Clin Psychol Sci Pract 4:359–376, 1997 Evans J, Platts H, Liebenau A: Impulsiveness and deliberate self-harm: a comparison of “first-timers” and “repeaters.” Acta Psychiatr Scand 93:378–380, 1996 Fawcett J: Treating impulsivity and anxiety in the suicidal patient. Ann NY Acad Sci 932:94–105, 2001 Fawcett J, Scheftner WA, Clark DC, et al: Clinical predictors of suicide in patients with major affective disorders: a controlled prospective study. Am J Psychiatry 144:35–40, 1987 Fawcett J, Scheftner WA, Fogg L, et al: Time-related predictors of suicide in major affective disorder. Am J Psychiatry 147:1189–1194, 1990 Fawcett J, Clark DC, Busch KA: Assessing and treating the patient at suicide risk. Psychiatr Ann 23:244–255, 1993 Garner BA (ed): Blacks Law Dictionary, 7th Edition. St. Paul, MN, West Group, 1999 Garno JL, Coldberg JF, Ramirez PM, et al: Bipolar disorder with comorbid cluster B personality features: impact on suicidality. J Clin Psychiatry 66:339–345, 2005
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Gray GE: Evidence-Based Psychiatry. Washington, DC, American Psychiatric Publishing, 2004 Gunderson JG, Ridolfi ME: Borderline personality disorder: suicide and selfmutilation. Ann NY Acad Sci 932:61–77, 2002 Hall RC, Platt DE, Hall RC: Suicide risk assessment: a review of risk factors for suicide in 100 patients who made severe suicide attempts: evaluation of suicide risk in a time of managed care. Psychosomatics 40:18–27, 1999 Harkavy-Friedman JM, Kimhy D, Nelson EA, et al: Suicide attempts in schizophrenia: the role of command auditory hallucinations for suicide. J Clin Psychiatry 64:871–874, 2003 Harris CE, Barraclough B: Suicide as an outcome for mental disorders. Br J Psychiatry 170:205–228, 1997 Heikkinen ME, Henriksson MM, Erkki T, et al: Recent life events and suicide in personality disorders. J Nerv Ment Dis 185:373–381, 1997 Helia H, Isometsa ET, Henriksson MM, et al: Suicide and schizophrenia: a nationwide psychological autopsy study on age-and-sex specific clinical characteristics of 92 suicide victims with schizophrenia. Am J Psychiatry 154:1235–1242, 1997 Helia H, Heikkinen ME, Isometsa ET, et al: Life events and completed suicide in schizophrenia: a comparison of suicide victims and without schizophrenia. Schizophr Bull 25:519–531, 1999 Hellerstein D, Frosch W, Koenigsbert HW: The clinical significance of command hallucinations. Am J Psychiatry 144:219–225, 1987 Hollander E, Posner N, Cherkasky S: Neuropsychiatric aspects of aggression and impulse-control disorders, in American Psychiatric Publishing Textbook of Neuropsychiatry and Clinical Neurosciences, 4th Edition. Edited by Yudofsky SC, Hales RE. Washington, DC, American Psychiatric Publishing, 2002, pp 579–596 Institute of Medicine: Reducing Suicide: A National Imperative. Washington, DC, National Academies Press, 2001, pp 2–4 Isometsa ET, Lonnqvist JK: Suicide attempts preceding completed suicide. Br J Psychiatry 173:531–535, 1998 Isometsa ET, Heikkinen ME, Martunen MJ, et al: The last appointment before suicide: is suicide intent communicated? Am J Psychiatry 152:919–922, 1995 Isometsa ET, Henriksson MM, Heikkinen ME, et al: Suicide among subjects with personality disorders. Am J Psychiatry 153:667–673, 1996 Jacobs DG, Brewer M, Klein-Benheim M: Suicide assessment: an overview and recommended protocol, in Guide to Suicide Assessment and Intervention. Edited by Jacobs DJ. San Francisco, CA, Jossey-Bass, 1999, pp 3–39 Juninger J: Predicting compliance with command hallucinations. Am J Psychiatry 147:245–247, 1990 Juninger J: Command hallucinations and the prediction of dangerousness. Psychiatr Serv 46:911–914, 1995 Kaplan M, Asnis GM, Lipschitz DS, et al: Suicidal behavior and abuse in psychiatric outpatients. Compr Psychiatry 36:229–235, 1995 Kasper ME, Rogers R, Adams PA: Dangerousness and command hallucinations: an investigation of psychotic inpatients. Bull Am Acad Psychiatry Law 24:219–224, 1996
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Kessler RC, Borges G, Walters EE: Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry 55: 617–626, 1999 Kochanek KD, Murphy SL, Anderson, RN, et al: Deaths: Final Data for 2002. National Vital Statistics Reports 53 (5) (DHHS Publ No PHS 2005-1120). Hyattsville, MD, National Center for Health Statistics, 2004 Linehan MM: Cognitive Behavioral Treatment of Borderline Personality Disorder. New York, Guilford, 1993 Linehan MM, Goodstein JL, Nielsen SL, et al: Reasons for staying alive when you are thinking of killing yourself: the reasons for living inventory. J Consult Clin Psychol 51:276–286, 1983 Linehan MM, Rizvi SL, Welch SS, et al: Psychiatric aspects of suicidal behaviour: personality disorders, in The International Handbook of Suicide and Attempted Suicide. Edited by Hawton K, Van Heeringen K. New York, Wiley, 2000, pp 147–178 Loebel JP: Completed suicide in late life. Psychiatr Serv 56:260–262, 2005 Malone KM, Katalin S, Corbitt E, et al: Clinical assessment versus research methods in the assessment of suicidal behavior. Am J Psychiatry 152:1601–1607, 1995 Malone KM, Oquendo MA, Hass GL, et al: Protective factors against suicidal acts in major depression: reasons for living. Am J Psychiatry 157:1084–1088, 2000 Mann JJ, Arango V: The neurobiology of suicidal behavior, in Guide to Suicide Assessment and Intervention. Edited by Jacobs D. San Francisco, CA, JosseyBass, 1999, pp 98–114 Mann JJ, Waternaux C, Haas GL, et al: Toward a clinical model of suicidal behavior in psychiatric patients. Am J Psychiatry 156:181–189, 1999 Mays D: Structured assessment methods may improve suicide prevention. Psychiatr Ann 34:367–372, 2004 Meltzer HY: Treatment of suicidality in schizophrenia. Ann NY Acad Sci 932: 44–60, 2001 Meltzer HY, Okaly G: Reduction of suicidality during clozapine treatment of neuroleptic-resistant schizophrenia: impact of risk-benefit assessment. Am J Psychiatry 152:183–190, 1995 Meltzer HY, Alphs L, Green AI, et al: Clozapine treatment for suicidality in schizophrenia: international suicide prevention trial (InterSePT). Arch Gen Psychiatry 60:82–91, 2003a Meltzer HY, Conley RR, de Leo D, et al: Intervention strategies for suicidality (audiograph series). J Clin Psychiatry 6(2):1–18, 2003b Moeller FG, Barratt ES, Dougherty DM, et al: Psychiatric aspects of impulsivity. Am J Psychiatry 158:1783–1793, 2001 Monahan J, Steadman HJ: Violent storms and violent people: how meteorology can inform risk communication in mental health law. Am J Psychol 51:931– 938, 1996 Mortensen PB, Juel K: Mortality and causes of death in first admitted schizophrenic patients. Br J Psychiatry 163:183–189, 1993 Murphy GE, Wetzel RD, Robins E, et al: Multiple risk factors predict suicide in alcoholism. Arch Gen Psychiatry 49:459–462, 1992 National Institute of Mental Health Suicide Facts. Available at: http://www. nimh.nih.gov/suicideprevention/suifact.cfm. Accessed October 14, 2005. O’Carroll PW, Berman AL, Maris RW, et al: Beyond the Tower of Babel: a nomenclature for suicidology. Suicide Life Threat Behav 26:237–252, 1996
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Oquendo MA, Halberstam, Mann JJ: Risk factors for suicidal behavior: the utility and limitations of research instruments, in Standardized Evaluation in Clinical Practice (Review of Psychiatry Series, Vol 22, No 2; Oldham JO and Riba MB, Series Editors). Edited by First MB. Washington, DC, American Psychiatric Publishing, 2003, pp 103–130 Perlis RH, Fraqvas R, Fava M, et al: Prevalence and clinical correlates of irritability in major depressive disorder: a preliminary report from the Sequenced Treatment Alternatives to Relieve Depression Study. J Clin Psychiatry 66:159–116, 2005 Peters PG: The quiet demise of deference to custom: malpractice law and the millennium. Wash Lee Law Rev 57:163, 2000 Pezawas L, Stamenkovic M, Reinhold J, et al: A longitudinal view of triggers and thresholds of suicidal behavior in depression. J Clin Psychiatry 63:866–873, 2002 Pokorny AD: Predictions of suicide in psychiatric patients: report of a prospective study. Arch Gen Psychiatry 40:249–257, 1983 Pokorny AD: Suicide prediction revisited. Suicide Life Threat Behav 23:1–10, 1993 Posternak MA, Zimmerman M: Is there a delay in the antidepressant effect? A meta-analysis. J Clin Psychiatry 66:148–158, 2005 Resnick PJ: Recognizing that the suicidal patient views you as an adversary. Curr Psychiatry 1:8, 2002 Robins E: The Final Months: Study of the Lives of 134 Persons Who Committed Suicide. New York, Oxford University Press, 1981 Roose SP, Glassman AH, Walsh BT, et al: Depression, delusions, and suicide. Am J Psychiatry 140:1159–1162, 1983 Roy A: Suicide in chronic schizophrenia. Br J Psychiatry 141:171–177, 1982 Roy A: Suicide. Baltimore, MD, Williams & Wilkins, 1986, pp 6, 93–94 Rudd MD, Joiner T, Rajab MH: Treating Suicidal Behavior: An Effective, TimeLimited Approach. New York, Guilford, 2001 Scheiber SC, Kramer TSM, Adamowski SE: Core Competence for Psychiatric Practice: What Clinicians Need to Know. Washington, DC, American Psychiatric Publishing, 2003 Shaffer DA, Pfeffer CR, Bernet W, et al: Practice parameters for the assessment and treatment of children and adolescents with suicide behavior. J Am Acad Child Adolesc Psychiatry 36(10), 1997 Shea SC: Delicate art of eliciting suicidal ideation. Psychiatr Ann 34:385–400, 2004 Simon RI: Clinical Psychiatry and the Law, 2nd Edition. Washington, DC, American Psychiatric Press, 1992 Simon RI: Discharging sicker, potentially violent psychiatric inpatients in the managed care era: standard of care and risk management. Psychiatr Ann 27:726–733, 1997 Simon RI: The suicidal patient, in The Mental Health Practitioner and the Law: A Comprehensive Handbook. Edited by Lifson LE, Simon RI. Cambridge, MA, Harvard University Press, 1998, pp 329–343 Simon RI: Psychiatry and Law for Clinicians, 3rd Edition. Washington, DC, American Psychiatric Publishing, 2001 Simon RI: Suicide risk assessment: what is the standard of care? J Am Acad Psychiatry Law 30:340–344, 2002 Simon RI: Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management. Washington, DC, American Psychiatric Publishing, 2004
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Simon RI: Standard of care testimony: best practice or reasonable care? J Am Acad Psychiatry Law 33:8–11, 2005 Simon RI, Gutheil TG: Clinician factors associated with increased risk for patient suicide. Psychiatr Ann 330:1–4, 2004 Stepakoff v Kantar, 473 N.E.2d 1131, 1134 (Mass 1985) Stone M: Natural history of borderline patients treated by intensive hospitalization. Br J Psychiatry 10:185–206, 1987 Stone M: Long-term outcome in personality disorders. Br J Psychiatry 162:299– 313, 1993 Suominen KH, Isometsa ET, Henriksson MM, et al: Suicide attempts and personality disorder. Acta Psychiatr Scand 102:118–125, 2000 Vythilingam M, Chen J, Bremmer JD, et al. Psychotic depression and mortality. Am J Psychiatry 160:574–576, 2003 Weisman AD, Worden JW: Risk-rescue rating in suicide assessment. Arch Gen Psychiatry 26:553–560, 1972 Zimmerman M, Chelminski I: Generalized anxiety disorder in patients with major depression: is DSM-IV’s hierarchy correct? Am J Psychiatry 160:504–512, 2003 Zimmerman M, Chelminski I, McDermut W: Major depressive disorder and Axis I diagnostic comorbidity. J Clin Psychiatry 63:187–193, 2002
Appendix: Definition of Terms1 Aborted suicide attempt Potentially self-injurious because the person intended to die but stopped the attempt before physical damage occurred. Deliberate self-harm Willful self-inflicting of painful, destructive, or injurious acts without intent to die. Lethality of suicidal behavior Objective danger to life associated with a suicide method or action. Note that lethality is distinct from and may not always coincide with an individual’s expectation of what is medically dangerous. Suicidal ideation Thoughts of serving as the agent of one’s own death. Suicidal ideation may vary in seriousness depending on the specificity of suicide plans and the degree of suicidal intent. Suicidal intent Subjective expectation and desire for a self-destructive act to end in death. Suicide Self-inflicted death with evidence (either explicit or implicit) that the person intended to die Suicide attempt Self-injurious behavior with a nonfatal outcome accompanied by evidence (either explicit or implicit) that the person intended to die.
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Reprinted from “Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors.” American Journal of Psychiatry 160(suppl): 1–60, 2003. Copyright 2003, American Psychiatric Association. Used with permission.
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Children and Adolescents Peter Ash, M.D.
Suicide is the third leading cause of death in 15- to 19-year-olds, after accidents and homicide, and accounts for approximately 1,500 deaths in the United States per year (7.4 per 100,000; Anderson and Smith 2005). In early adolescents, suicide is much less common (1.2 per 100,000 in 10to 14-year-olds) and rare in prepubertal children. Many of the principles pertinent to the assessment and treatment of adults detailed elsewhere in this volume are relevant to the assessment and treatment of suicidal adolescents, but because of developmental differences, different living circumstances, and different legal status, approaches to younger patients are somewhat different from those used with adults. Key differences are shown in Table 2–1.
Epidemiology and Demographics Adolescent suicide rates have been quite variable: rates for white males tripled from 1964 to 1991, and then over the next 10 years fell back to rates comparable to those in the 1970s (National Center for Health Statistics 2004). The changes in youth suicide rates roughly parallel the directions of changes in youth homicide rates and rates of suicide and homicide in young adults and are fairly similar to suicide rates in the elderly, although rates in the elderly began dropping several years earlier (National Center for Health Statistics 2004). Also, it appears that although firearms
This work was supported in part by a grant from The Pew Charitable Trusts.
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TABLE 2–1.
Textbook of Suicide Assessment and Management Suicidal adolescents: key differences from suicidal adults
Category
Difference(s) from suicidal adults
Risk factors
Suicide accounts for a higher proportion of all deaths. Suicidal ideation is more common. Suicide attempts are more common. Disruptive behavior disorders increase risk. Contagion effects are more powerful.
Diagnostic differences
Psychotic disorder is much less common.
Symptoms
Although more common, suicidal ideation is more likely to be denied when asked about. Lethality of means is more commonly misjudged.
Treatment
SSRIs require more monitoring. Family involvement in treatment is more important.
Legal status
Legal consent for treatment needs to be provided by someone other than patient. Hospitalization over patient’s objection can often be accomplished without resorting to civil commitment. Patient’s responsibility for treatment compliance is reduced.
Aftermath of completed suicide
Full discussion with parents is less constrained by confidentiality limitations because parents control record release.
are still the most common means of suicide, among older adolescents suicides with firearms have been decreasing along with overall suicide rates, whereas suicides by hanging are increasing (Lubell et al. 2004). Increased prescribing of antidepressant medication may also have contributed to the decreasing suicide rates (Olfson et al. 2003). Suicide rates increase with age from childhood through adolescence and continue to increase through early adulthood. Boys are about five times more likely to commit suicide than girls (Anderson and Smith 2005), although girls are considerably more likely to make nonlethal suicide attempts (Grunbaum et al. 2004). Although sex differences are
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explained in part by the means of suicide employed—teenage boys tend to use more lethal methods, such as firearms and hanging, rather than the less dangerous methods often used by girls, such as poisoning (e.g., carbon monoxide or pill overdose) or wrist cutting (Brent and Kolko 1990; Trautman and Shaffer 1989)—the difference more clearly reflects the nature of suicidal intent. There are significant racial differences as well: Native Americans have the highest rates of completed suicide, followed by whites, and African Americans have the lowest rates, although the gap has narrowed because of a large jump in the rates among African American youth in the 1980s (Gould et al. 2003). Suicidal thinking and suicide attempts are fairly common in late adolescence. The Youth Risk Behavioral Surveillance (YRBS) study, conducted annually by the Centers for Disease Control and Prevention, surveys U.S. high school students regarding a variety of risky behaviors. In 2003, according to YRBS results, 16.9% of high school students had seriously considered suicide in the previous 12 months, 16.5% had made plans, 8.5% had attempted suicide, and 2.9% had made an attempt that required medical attention (Grunbaum et al. 2004). When these rates are compared with the completed suicide rate of approximately 0.007%, it is clear that the ratio of suicidal ideation to completed suicide is very high (more than 2,000:1). This high ratio contributes to low specificity when ideation is used as a risk factor, and this complicates clinical risk assessment. The YRBS showed that girls are more likely than boys to have suicidal ideation, make plans, and carry out attempts (Grunbaum et al. 2004). Although completed suicide is rare in prepubertal children, selfdestructive thoughts and behavior are frequent in this young age group, and those children who express suicidal ideation are more likely to have symptoms of psychiatric illness and to evidence suicidal behavior later in adolescence (Pfeffer et al. 1997). Like rates for completed suicide, rates for suicide attempts increase through adolescence (Gould et al. 2003). Of concern, about one-third of suicidal youth think they should be able to handle problems on their own and avoid seeking help, and one-quarter think they should keep their suicidality a secret (Gould et al. 2004).
Case Examples Case Example 1: Girl in the Emergency Department Fifteen-year-old Stephanie is brought to the emergency department after an overdose of an undetermined number of aspirin tablets. She has no history of psychiatric treatment, and her parents say that she has been functioning fairly well, although she is sometimes moody, which they have attributed to “being a teenager.” She was found difficult to
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arouse in her room around 9 P.M., when her parents went to tell her that two girlfriends had stopped by to pick her up to go to a party. After being medically stabilized in the emergency department, she tells the examining psychiatrist that earlier that evening her boyfriend of 8 months broke up with her over the phone and that she “couldn’t bear to face anyone” that night but just “wanted to get some sleep” and “didn’t want to die.” She does not recall any plans to go to a party, but her girlfriends told Stephanie’s parents that the plan to attend the party together had been made 2 days earlier.
Case Example 2: Indirect Threat by an Outpatient John, a 16-year-old boy, had been removed from his biological mother at age 6 for neglect and has been in a series of foster homes and group homes since that time. He reports that he gets along well with the family he is currently living with but thinks, “They like me OK, but they know I’ll be gone as soon as I turn 18.” He has been in and out of outpatient psychiatric treatment at a community mental health center for 3 years for depression. Antidepressant medication has been tried but has done little to relieve his depressive symptoms, which appear to derive from feeling unwanted and vary widely in severity in response to current stressors. Two years ago, after he was removed from a foster placement for disruptive behavior and placed in a group home, he tried to hang himself with a belt tied to the clothes bar in his closet, but his weight broke the bar, and he saw this as “a sign I should go on.” He did not tell anyone about this attempt until asked about suicidal thinking at his regular medication check a month later. John has been associating with a delinquent crowd, engaging in occasional vandalism and some burglary, and regularly gets stoned on marijuana with his friends. After witnessing a nonfatal shooting at a club, John started carrying a handgun he’d obtained in a burglary “for protection” when he goes to the club. Last week, after his girlfriend called him “a loser” and broke up with him, he went out with some friends, got drunk, got into a fight with some other youths on the street, and was arrested for assault. He is now quite upset about the prospect of incarceration and told his Protective Services worker, “There’s no way I’m going to prison. No way.” She relayed this to his therapist.
Assessment The key to effective intervention is a careful assessment of suicidal risk. Asking about suicidal ideation and a history of attempts at self-harm, depressive feelings and symptoms, family problems, and recent stressors should be a routine part of the initial evaluation of any adolescent or depressed child. As with adults, there are no studies to identify factors that will allow a clinician to predict accurately which adolescents will commit suicide. Research has therefore focused on risk factors. The
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suicide risk factor literature is complex, because a variety of factors, including age, sex, and race, affect the potency of various factors. Risk factors have been reviewed in a practice parameter of the American Academy of Child and Adolescent Psychiatry (AACAP) on the assessment and treatment of suicidal behavior (American Academy of Child and Adolescent Psychiatry 2001) and in other reviews (Brent 2001; Cavanagh et al. 2003; Evans et al. 2004; Fergusson et al. 2000; Gould et al. 2003). Risk factors commonly cited in the literature appear in Table 2–2. Of these factors, a history of a previous attempt is the strongest predictor of completed suicide, an effect that is considerably stronger for boys. Boys with a previous attempt are at 30 times the risk of nonattempters, whereas girls with a previous attempt are at 3 times the risk for non-attempters (Brent et al. 1999; Shaffer et al. 1996). Asking about a history of previous suicidal ideation and attempts should always be a component of an adolescent’s or depressed child’s assessment.
Intent in a Recent Attempt Clinically, suicidal ideation or recent attempt, especially when coupled with a plan involving lethal means, is most often the trigger to a judgment of imminent danger requiring hospitalization. Multiple past attempts increase the risk. Individuals who attempt suicide make further attempts at a rate of 6%–15% per year. The time of greatest risk for another suicide attempt is within the first 3 months to 2 years after an initial attempt. Suicidal intent needs to be differentiated from nonsuicidal self-harm, such as repetitive cutting. Kingsbury (1993), using the Beck Suicide Intent scale, identified four factors that are useful to consider in assessing intent in a recent attempt: belief about intent, preparation, prevention of discovery, and communication (Table 2–3). Because adolescents often minimize their intent after an attempt, it is important to obtain corroborative data about what occurred. Assessing risk in children and adolescents is complicated by the fact that completed suicide is rare when compared with clinical presentations of suicidal ideation and suicide attempts. Stephanie, the adolescent described in the first case example, presents a common picture. In interviewing Stephanie, it would be important to elucidate what she remembers thinking in the time leading up to taking the pills. Beginning with open-ended questions may reveal more information than beginning with direct questions about whether the adolescent wished to die, especially because adolescents not uncommonly minimize their intent when seen in the emergency department because of repression, a wish to avoid embarrassment, or a wish to avoid hospitalization. Youth, es-
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TABLE 2–2.
Textbook of Suicide Assessment and Management Leading risk factors for completed suicide in adolescents
Individual factors Explicit suicidality Stated intent with or without plan Previous suicide attempt High intent/lethality of method Psychopathology Diagnoses Major depression Bipolar disorder Substance abuse comorbid with other psychopathology Schizophrenia Conduct or personality disorder, especially with impulsive characteristics Symptoms Helplessness and hopelessness Impulsivity Conflicts over same-sex or bisexual orientation Demographic factors Increased risk with age (over age 14) Male White Unwed/Unwanted pregnancy Family and environmental factors Family history of suicidal behavior Parental psychopathology Family pathology/discord Abuse (physical or sexual) History of violence Firearm in the home Recent stressors Interpersonal loss Arrest/legal problems
pecially younger adolescents and preadolescents, are more likely than adults to misjudge the lethality of means. The clinician must consider that an attempt involving an overdose that was not pharmacologically dangerous might have seemed likely to cause death to the adolescent and that some potentially lethal attempts (such as an aspirin overdose) might have seemed like a gesture to a youth who thought she was ingesting a fairly benign medication.
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Assessing lethal intent of a recent suicide attempt
Clinical component
Example issues
1. Belief about intent
Purpose of the attempt Expectation of dying Lethality of means Saving up pills for overdose Saying good-bye Planning Planning attempt to avoid discovery: Timing so no one will find soon Choosing an isolated place Telling others, directly or indirectly, about suicidal thinking Suicide note
2. Preparation
3. Concealment
4. Communication
Source.
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Adapted from Kingsbury 1993.
Planning and concealment may be revealed by the adolescent after an attempt, but information from other sources, such as parents or friends who found the victim, is invaluable in achieving a comprehensive picture of what occurred. Information such as whether the attempt was carried out in a way that was likely to be discovered, or whether a note was left, should be given higher weight than a retrospective account of intent provided by the patient. In the case example, Stephanie took the pills at home, and it would be useful to understand whether she might reasonably have expected her parents to check on her at some point in the evening. It would also be important to clarify whether she knew that her friends would be stopping by. Asking others who know the patient about whether the patient has communicated suicidal thinking can also provide important data about the duration of suicidal intent. The initial assessment is also a good time to alert family and others to be on the lookout for suicidal thinking in the future, to urge them to take such communications seriously, and to encourage them to inform treatment providers of their observations. One of the key principles of intervention is to improve the interpersonal surveillance network that surrounds the patient.
Intent in Reported Suicidal Ideation Brent (2001) suggests that when an outpatient reports suicidal ideation, the severity and pervasiveness of the ideation are key dimensions to assess. Severity refers to the continuum from passive thoughts of wanting
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to die, through an active wish to die, to an active wish with a plan involving lethal means. Pervasiveness refers to the intensity and frequency of the suicidal thinking. In the case example of John, the arrested boy with a history of attempted hanging who makes an indirect threat by saying he will not go to prison, it would be important to obtain a detailed picture of just what his current threat entails, at what time (pretrial? postconviction?) he anticipates acting, and the likelihood of incarceration. His history suggests that when stressed, he is at significant risk for making an attempt with lethal means.
Psychopathology Adolescent suicide completers have very high rates of psychiatric disorder (around 90%) (Brent 1993; Brent et al. 1993b; Brent et al. 1999; Shaffer et al. 1996). Affective disorder appears to pose a risk of more than 11 times that of the normal population (Gould et al. 2003). Major depressive disorder is the most prominent finding and poses the most risk. One follow-up study (Rao et al. 1993) found that 4.4% of children who had been diagnosed with major depression committed suicide in the following 10 years. Although the majority of completers had long-standing symptoms, in one study (Brent 1993) about one-third of the depressed group had developed symptoms in the previous 3 months. Bipolar disorder also elevates risk. Comorbid substance abuse significantly increases the risk of affective illness (Brent et al. 1993b; Shaffer et al. 1996) and disruptive disorders (Renaud et al. 1999). Conduct disorder appears to be a potent risk factor for boys but not for girls. Like adults, youths with schizophrenia are at increased risk for suicide, but schizophrenia has a low incidence in children and adolescents. Axis II psychopathology is also found in many suicide completers, particularly Cluster B types (histrionic, borderline, narcissistic, antisocial) (Brent et al. 1990; Low and Andrews 1990; Marttunen et al. 1991) and Cluster C types (avoidant–dependent) (Brent et al. 1994a). High school suicide attempters, both boys and girls, are approximately four times as likely to have been in physical fights in the preceding year (Swahn et al. 2004). Females with learning disabilities have been found to have twice the risk for suicidal behavior and violence in comparison with peers (Svetaz et al. 2000). In the minority of youth who do not evidence clear psychopathology, suicide is associated with recent legal or discipline problems, interpersonal loss or conflicts, and the presence of firearms (Brent et al. 1993c; Marttunen et al. 1994). In many respects, the assessment of underlying psychopathology in suicidal youth is very similar to the assessment in nonsuicidal youth.
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AACAP has developed practice guidelines for the assessment and treatment of depression (American Academy of Child and Adolescent Psychiatry 1998a), bipolar disorder (American Academy of Child and Adolescent Psychiatry 1997), substance use disorders (American Academy of Child and Adolescent Psychiatry 1998b), and conduct disorder (Steiner 1997). Symptoms that deserve particular emphasis in assessing suicidality include hopelessness, impulsiveness, poor problem solving, social skills deficits, and aggressiveness, because these characteristics play directly into lowering the threshold for suicidal behavior. Treatment of underlying psychopathology is clearly indicated, but only 30%–50% of adolescent suicide victims have had prior contact with a mental health professional (Blumenthal 1990). Relatively few victims are in active treatment at the time of a suicide, and noncompliance with outpatient treatment is correlated with increased risk for a recurrence of suicidality (Greenhill and Waslick 1997). Worsening suicidal ideation while in ongoing treatment, particularly when not related to identifiable stressors, is a worrisome risk factor.
Family and Social Factors A number of family stressors have been found to be risk factors for suicide, including family member suicide attempts (Agerbo et al. 2002; Brent et al. 1996), not living with both parents (Groholt et al. 1998), family history of depression and substance abuse (Brent et al. 1994b), and parent–child discord (Brent et al. 1994b; Gould et al. 1996). Parental divorce does not appear to be a significant risk factor (Gould et al. 1998), and intrafamilial abuse, although associated with suicide, is only a weak factor when other factors are controlled for (Fergusson et al. 1996; Johnson et al. 2002). Children and adolescents also commonly react to the suicide of a family member with posttraumatic stress disorder and suicidal ideation (Pfeffer et al. 1997). Family cohesion also functions as a crucial protective factor (Rubenstein et al. 1998). Once a family is alerted to a child’s or adolescent’s difficulties, the family can be of great assistance in supervising and supporting a suicidal youth, making the home safe, monitoring medication, and ensuring treatment compliance. Conversely, families who cannot provide these functions complicate treatment and will likely need to be a focus of intervention. There is some evidence that religiosity functions as a protective factor, but the studies have not controlled for possible confounding variables, such as substance abuse (Gould et al. 2003).
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In both case examples, the motivation and ability of the families to support and monitor the suicidal adolescent will need to be assessed carefully. The assessment of John, the boy in foster care who is already involved in illegal and secretive behaviors, is likely to be the more problematic, because the foster family may have less influence with or control over him and because his affective ties to them appear weak. His social support network extends beyond the foster family and includes workers from protective services and the juvenile court who are in a position both to anticipate stressors and to affect their nature (through formulating recommendations for disposition of his assault charge).
Environmental Factors Low socioeconomic status appears to have little effect on adolescent suicidality (Agerbo et al. 2002; Brent et al. 1988). There is considerable evidence that personal contact with a suicide or high media coverage of suicides can lead to increased suicidal behavior in adolescents (Gould et al. 2003). Contagion effects appear to be inversely related to age: they are strongest among younger adolescents (Holinger 1990) and much weaker after age 24 (Gould et al. 1994). Imitation seems most likely to occur among adolescents with preexisting risk factors (Shaffer et al. 1990). Firearms are the most common method of committing suicide, and firearms, particularly handguns, in the home are associated with a fourfold increase in risk for suicide (Brent et al. 1993a).
Precipitants Most, but by no means all, suicides and suicide attempts have a clearly identified precipitant. However, a stressor alone, in the absence of preexisting vulnerability, likely does not lead to suicide. Marttunen et al. (1993) found a precipitating stressor in 70% of a series of completed suicides of Finnish adolescents. Half the stressors occurred in the 24 hours preceding the suicide. Thus, it appears that many adolescent suicides are impulsive responses to stressors, which leaves a very brief window between the time when an adolescent develops suicidal ideation and the time when he or she carries out a suicidal act. Separation and loss issues are the most common stressors. Parent–child conflict is the more common precipitant for younger adolescents, whereas separation issues among peers (such as romantic difficulties) predominate among older adolescents (Brent et al. 1999; Groholt et al. 1998). Incarcerated adolescents are at particularly high risk for suicide (Penn et al. 2003; Sanislow et al. 2003).
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Biological Factors There are intriguing data regarding the effects of serotonin dysregulation and genetic factors on suicidality, but at the present time these findings have little impact on clinical practice. Homosexual or bisexual orientation is associated with significantly increased risk, but much of the risk is attributable to other comorbid risk factors, and the independent contribution from sexual orientation appears fairly small (Russell and Joyner 2001).
Questionnaire Assessments A variety of questionnaires and scales have been developed for assessing suicidality in adolescents in clinical samples (reviewed by Winters et al. 2002) or for screening community samples (Shaffer et al. 2004). The scales suffer from either limited psychometric data or low specificity. Therefore, at present, such scales may be used either as an adjunctive measure or as a screening instrument but should not replace a psychiatric interview for high-risk youth.
Treatment Treatment of children and adolescents at risk for suicide encompasses four major components: protecting the patient, continuing to assess risk, ameliorating risk factors, and enhancing protective factors (Table 2–4).
Protect the Patient Protection of the patient is the first consideration. The decision about whether to discharge from the emergency department a patient who recently made an attempt turns on a careful balancing of the risk and protective factors discussed earlier. The AACAP guidelines note that although there have been no randomized studies to determine whether hospitalization actually saves lives, attempters who express a persistent wish to die or have a clearly abnormal state, such as major depression with psychotic features or rapid cycling with impulsive behavior and irritability, should be admitted and continued in inpatient treatment until they are stabilized (American Academy of Child and Adolescent Psychiatry 2001). Furthermore, before discharging the patient, the clinician must be convinced that the living situation to which the patient is returning will provide adequate support, monitoring, and supervision of the patient and that parents or family will eliminate the patient’s access to firearms and lethal medications. A plan for follow-up treatment should be devised, preferably with a
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Textbook of Suicide Assessment and Management Components of the treatment of suicidal children and adolescents
1. Protect the patient. 2. Continue to assess risk. 3. Ameliorate risk factors. 4. Enhance protective factors.
scheduled appointment. The patient and family should be given information about an available care provider who can be contacted if help is needed prior to the appointment. If the appointment cannot be scheduled in the emergency department, a follow-up mechanism should be in place for contacting the family to make sure outpatient treatment was sought. In outpatient treatment, when new or worsening risk is elucidated, the decision similarly turns on whether the protective factors are sufficiently strong to feel confident the patient is safe. As with the decision to discharge, the family must feel comfortable with the outpatient plan and agree to accept some of the responsibility for the patient’s safety. In assessing a patient’s capacity to be treated as an outpatient, it may be helpful to ask what the patient would do if stressors recurred. As with adults, “no-suicide contracts” in which the patient promises to tell an adult if he or she is feeling suicidal have not been shown to be effective and should not be relied on to protect the patient, although discussions about these agreements may be useful in assessing and fostering the therapeutic alliance (Simon 2004).
Continue to Assess Risk It is important to emphasize that assessment of suicidality is a process that continues throughout treatment. Suicidality changes over time, both in response to the severity of underlying pathology and in the patient’s response to external events. Any treatment modality employed with suicidal youth should include ongoing, repeated, and documented assessments of suicide risk.
Ameliorate Risk Factors Treatment should include addressing and diminishing dynamic risk factors. Central in this is the treatment of underlying psychopathology. A recent large-scale, multisite study showed that a combination of fluoxetine and cognitive-behavioral therapy resulted in significant improvement in 71% of moderately to severely depressed adolescents (March et al. 2004). Drug treatment alone and therapy alone also showed positive, although
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somewhat weaker, effects. Suicidal thinking was also significantly reduced in all groups, including the placebo group, although treatment effects in comparison with the response seen with placebo were weak for this symptom. The clinician should consider the possibility that a suicidal adolescent patient might overdose and either arrange for parental control of the medication or prescribe nonlethal quantities. The use of selective serotonin reuptake inhibitors (SSRIs), the mainstay pharmacological treatment for depression, has become more problematic since 2004, when the U.S. Food and Drug Administration (FDA) began requiring a black-box warning for SSRIs that includes the language, “Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with Major Depressive Disorder (MDD) and other psychiatric disorders” (U.S. Food and Drug Administration 2005). The FDA based its decision on a pooled analysis that found that reports of suicidal thinking increased from 2% on placebo to 4% on active drug (Hammad 2004). The meaning of this increase remains controversial. In drug-prescribing information, the FDA, in 2005, recommended “at least weekly face-to-face contact with patients or their family members or caregivers during the first 4 weeks of treatment, then every other week visits for the next 4 weeks, then at 12 weeks, and as clinically indicated beyond 12 weeks” (U.S. Food and Drug Administration 2005). The American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry (2005), in association with a number of other professional organizations, believe that clinical grounds support a position that monitoring should be individualized to the needs of the child and family. However, until the FDA changes its formal position, if there is an adverse event, a clinician will have a difficult time in court defending a lower level of monitoring than what the FDA recommends. The publicity and more stringent prescribing guidelines have generated anxiety in many parents and in prescribing physicians, especially pediatricians, which may lead to decreased use of these medications in depressed adolescents who might well benefit from them. The use of SSRIs in suicidal youth remains an evolving area of practice, and it is hoped that future research will clarify what are reasonable precautions. Psychotherapy plays an important role in treatment in providing information about continuing risk, delineating how the youth thinks about suicide, addressing underlying psychopathology, correcting cognitive distortions involved in hopelessness, improving social skills, helping the adolescent cope with such stressors as may be present, and enhancing protective factors such as more adaptive defenses or coping strategies. Although a number of psychotherapies have been shown to
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be efficacious for depression and other underlying psychopathology, there are very limited data demonstrating effectiveness in reducing suicide attempts in adolescents when compared with control subjects. Multisystemic therapy (Huey et al. 2004) has been shown to reduce repeat attempts when compared with hospitalization. Most studies of psychosocial treatments have been of fairly brief duration (up to 20 weeks), and it may well be that longer treatments are necessary to improve what is often a chronic condition. Despite the limited research base for adolescents, research on adults has demonstrated effectiveness of psychosocial treatments in ameliorating underlying psychopathology and family problems, and the need to address suicidal youths’ distorted thinking and interpersonal conflicts has led to a general consensus that psychosocial treatment for suicidal adolescents is indicated.
Enhance Protective Factors Some factors, including ameliorating disruptive or stressful family patterns and eliminating access to firearms, are best dealt with in a family context. Unfortunately, parental compliance with a recommendation to remove firearms is fairly low, even when parents are provided with considerable information about the risks and strong recommendations (Brent et al. 2000). Working to increase family support is an important component of enhancing protective factors, and the family’s role in monitoring the youth’s condition is very important.
Legal and Risk Management Considerations Consent to Treatment In most jurisdictions, children and adolescents are legally incompetent to consent to treatment except under special circumstances. Emancipated minors—those who live separately from their parents, are selfsupporting, and have been declared emancipated by a court, and minors who are married or in the military—are able to make health care decisions as though they were adults. Some states provide exceptions for certain actions, such as seeking outpatient treatment, or have “mature minor” rules that allow defined classes of youth to seek health care as though they are adults. Youth can generally obtain treatment for substance abuse, sexually transmitted diseases, pregnancy, and contraception independently of their parents, although parent notification issues can get complex depending on the type of intervention and laws of the local jurisdiction, especially with abortion. However, for most
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minors who come to psychiatrists, the parent or guardian needs to provide informed consent for treatment and controls the release of information. For these reasons, family members are key participants in the treatment in a manner different from the treatment of adults. The U.S. Supreme Court has found that a physician’s recommendation and the consent of a parent are sufficient for hospitalizing a minor over the minor’s objections (Parham v. J.R. and J.L. 1979). State law varies as to the age at which an adolescent may file a formal objection to hospitalization, the procedures available to an objecting minor, and what happens following an objection (usually a court hearing on the question of continuing hospitalization). If the parents are unavailable or refuse to consent to hospitalization, then involuntary hospitalization is available provided the youth meets the state’s involuntary commitment criteria.
Confidentiality A dilemma that can arise during the treatment of a depressed child or adolescent patient is the clinical need to break the patient’s confidentiality without his or her assent and inform parents of the patient’s status, such as when an adolescent becomes suicidal and parents need to be involved in management. Adolescents usually prize treatment confidentiality, and breaking it, even when clinically indicated and legally allowable, runs the risk of negatively affecting the treatment alliance. It is therefore important at the outset of the treatment of a suicidal patient to discuss with the minor patient the conditions under which the therapist will communicate information to the parents. When the clinician needs to discuss a management issue with parents, for example, when a youth becomes more depressed and the therapist wishes to advise the parents to remove firearms from the home, it is preferable to raise the need to talk to the parents with the adolescent patient and obtain his or her assent. If the adolescent objects, but the therapist has significant concerns about the youth’s safety, the therapist generally may discuss these issues with the parents over the adolescent’s objections, because in most cases the parents legally speak for the child and control access to information about treatment. In those rare instances in which the minor patient legally controls release of information, such as when the minor is emancipated or has “mature minor” status in a state that recognizes such a status, such a breach may not be legal, and the clinician then has fewer options and is in essentially the same dilemma as when treating an adult. If the opportunity to involve the adolescent’s support system is limited, the threshold for hospitalization is lowered.
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Aftermath of a Completed Suicide The tragic outcome of a completed suicide by a patient in treatment generates strong feelings in family members and friends of the patient and in the treating clinician. It may also give rise to a malpractice action against the treating psychiatrist. The clinician is faced with the tasks of grieving, helping the patient’s family with their grief, and limiting legal liability. An important first step following a suicide is to notify one’s malpractice carrier and obtain suggestions from their risk management unit. It is appropriate for the clinician to meet with the family and discuss the patient’s condition. Because the parents generally control the release of information, there are not usually the confidentiality problems that may attend discussing the suicide of an adult patient. In such a discussion, it is generally appropriate for the clinician to express his or her own grief and to be relatively open about the patient’s condition. Most risk management units will caution a clinician not to express guilt or fault for the suicide. It is generally appropriate for the clinician to attend the funeral if he or she wishes to, but permission from the family should be obtained beforehand. Although informing the family and participating in the grieving process are the humane things to do, there are few data to suggest they significantly lessen the likelihood of a malpractice suit. In a malpractice case involving an outpatient suicide, a threshold question is whether the suicide was reasonably foreseeable. If suicide was reasonably foreseeable, the psychiatrist had a duty to take reasonable steps to protect the patient, most commonly by hospitalizing him or her. If the suicide was not reasonably foreseeable, then the duty to protect the patient is much reduced. Many issues in adolescent suicide cases are similar to those in malpractice cases involving adult suicides (see Chapter 28, “Clinically Based Risk Management of the Suicidal Patient”). Issues that tend to be different from adult malpractice cases include whether informed consent was obtained from the parents for certain components of the treatment, whether the parents were sufficiently informed and involved in managing the patient, and the level of responsibility attributed to the minor patient (Ash 2002). In malpractice litigation involving an adult who committed suicide, the degree to which the adult was responsible for his or her own acts, and thus a contributor to the outcome, is often important. When a minor commits suicide, the presumption that minors are not as competent as adults reduces the responsibility of the minor for his or her actions and tends to increase the blame attributable to responsible adults, such as the clinician or parents.
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As in adult malpractice cases, the psychiatrist’s documentation of treatment will be carefully scrutinized. It is therefore very important to document carefully the assessment process, noting which risk factors and protective factors for suicide were assessed and how they were weighed. The assessment process is an ongoing one, and later assessments should also be documented. One of the effects of managed care has been to increase the threshold of severity necessary to justify inpatient hospitalization, so the presence of some suicide risk factors is quite common among inpatient adolescents. Malpractice cases arising out of the tragedy of an adolescent committing suicide on an inpatient psychiatric unit tend to follow the general pattern of cases involving the suicide of an adult inpatient (see Chapter 20, “Inpatient Treatment and Partial Hospitalization”). The two most common issues are the adequacy of the assessment of the patient’s suicidality by the doctor and hospital staff and the reasonableness of the measures instituted to protect the patient. The attending psychiatrist needs to be aware of clinical findings by the staff. As in outpatient cases, good documentation is critical. When the level of suicide precautions is decreased, the notes should reflect the basis for making the change.
❏ Key Points ■
Completed suicide is rare in preadolescents. Risk increases with age through adolescence and is higher for boys, whereas suicide attempts are more common in girls.
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Suicidal ideation is quite common among high school students (1 in 6 per year), as are suicide attempts (1 in 12 per year), although only 1 in 1,000 attempts results in death. Assessing the lethality of suicidal intent is complex but is nevertheless a key to planning intervention.
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Affective disorder is the most common underlying psychopathology and is frequently responsive to combined medication and psychosocial treatments.
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Use of SSRIs remains one of the mainstays of treatment of depressed youth, although the FDA black-box warning for SSRIs prescribed to adolescents requires more monitoring of the effects of these medications in early phases of treatment.
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The social and legal status of adolescents as more immature and less competent than adults requires that parents be very involved in treatment and treatment decisions of suicidal children and adolescents.
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References Agerbo E, Nordentoft M, Mortensen PB: Familial, psychiatric, and socioeconomic risk factors for suicide in young people: nested case-control study. BMJ 325: 74, 2002 American Academy of Child and Adolescent Psychiatry: Practice parameters for the assessment and treatment of children and adolescents with bipolar disorder. J Am Acad Child Adolesc Psychiatry 36:138–157, 1997 American Academy of Child and Adolescent Psychiatry: Practice parameters for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry 37:63S–83S, 1998a American Academy of Child and Adolescent Psychiatry: Practice parameters for the assessment and treatment of children and adolescents with substance use disorders. J Am Acad Child Adolesc Psychiatry 36:140S–156S, 1998b American Academy of Child and Adolescent Psychiatry: Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. J Am Acad Child Adolesc Psychiatry 40:24S–51S, 2001 American Psychiatric Association, American Academy of Child and Adolescent Psychiatry: ParentsMedGuide: The Use of Medication in Treating Childhood and Adolescent Depression. Information for Patients and Families. Available at: http://www.parentsmedguide.com/parentsmedguide.htm. Accessed March 5, 2005. Anderson RN, Smith BL: Deaths: leading causes for 2002. Natl Vital Stat Rep 53:1– 90, 2005 Ash P: Malpractice in child and adolescent psychiatry. Child Adolesc Psychiatr Clin North Am 11:869–886, 2002 Blumenthal SJ: Youth suicide: risk factors, assessment, and treatment of adolescent and young adult suicidal patients. Psychiatr Clin North Am 13:511–556, 1990 Brent DA: Depression and suicide in children and adolescents. Pediatr Rev 14:380–388, 1993 Brent DA: Assessment and treatment of the youthful suicidal patient. Ann N Y Acad Sci 932:106–128, 2001 Brent DA, Kolko DJ: The assessment and treatment of children and adolescents at risk for suicide, in Suicide Over the Life Cycle: Risk Factors, Assessment, and Treatment of Suicidal Patients. Edited by Blumenthal SJ, Kupfer DJ. Washington, DC, American Psychiatric Press, 1990, pp 253–302 Brent DA, Perper JA, Goldstein CE, et al: Risk factors for adolescent suicide: a comparison of adolescent suicide victims with suicidal inpatients. Arch Gen Psychiatry 45:581–588, 1988 Brent DA, Kolko DJ, Allan MJ, et al: Suicidality in affectively disordered adolescent inpatients. J Am Acad Child Adolesc Psychiatry 29:586–593, 1990 Brent DA, Perper JA, Moritz G, et al: Firearms and adolescent suicide: a community case-control study. Am J Dis Child 147:1066–1071, 1993a Brent DA, Perper JA, Moritz G, et al: Psychiatric risk factors for adolescent suicide: a case-control study. J Am Acad Child Adolesc Psychiatry 32:521–529, 1993b Brent DA, Perper J, Moritz G, et al: Suicide in adolescents with no apparent psychopathology. J Am Acad Child Adolesc Psychiatry 32:494–500, 1993c
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Brent DA, Johnson BA, Perper J, et al: Personality disorder, personality traits, impulsive violence, and completed suicide in adolescents. J Am Acad Child Adolesc Psychiatry 33:1080–1086, 1994a Brent DA, Perper JA, Moritz G, et al: Suicide in affectively ill adolescents: a casecontrol study. J Affect Disord 31:193–202, 1994b Brent DA, Bridge J, Johnson BA, et al: Suicidal behavior runs in families: a controlled family study of adolescent suicide victims. Arch Gen Psychiatry 53: 1145–1152, 1996 Brent DA, Baugher M, Bridge J, et al: Age- and sex-related risk factors for adolescent suicide. J Am Acad Child Adolesc Psychiatry 38:1497–1505, 1999 Brent DA, Baugher M, Birmaher B, et al: Compliance with recommendations to remove firearms in families participating in a clinical trial for adolescent depression. J Am Acad Child Adolesc Psychiatry 39:1220–1226, 2000 Cavanagh JT, Carson AJ, Sharpe M, et al: Psychological autopsy studies of suicide: a systematic review. Psychol Med 33:395–405, 2003 Evans E, Hawton K, Rodham K: Factors associated with suicidal phenomena in adolescents: a systematic review of population-based studies. Clin Psychol Rev 24:957–979, 2004 Fergusson DM, Horwood LJ, Lynskey MT: Childhood sexual abuse and psychiatric disorder in young adulthood, II: psychiatric outcomes of childhood sexual abuse. J Am Acad Child Adolesc Psychiatry 35:1365–1374, 1996 Fergusson DM, Woodward LJ, Horwood LJ: Risk factors and life processes associated with the onset of suicidal behaviour during adolescence and early adulthood. Psychol Med 30:23–39, 2000 Gould MS, Petrie K, Kleinman MH, et al: Clustering of attempted suicide: New Zealand national data. Int J Epidemiol 23:1185–1189, 1994 Gould MS, Fisher P, Parides M, et al: Psychosocial risk factors of child and adolescent completed suicide. Arch Gen Psychiatry 53:1155–1162, 1996 Gould MS, King R, Greenwald S, et al: Psychopathology associated with suicidal ideation and attempts among children and adolescents. J Am Acad Child Adolesc Psychiatry 37:915–923, 1998 Gould MS, Greenberg T, Velting DM, et al: Youth suicide risk and preventive interventions: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 42:386–405, 2003 Gould MS, Velting D, Kleinman M, et al: Teenagers’ attitudes about coping strategies and help-seeking behavior for suicidality. J Am Acad Child Adolesc Psychiatry 43:1124–1133, 2004 Greenhill LL, Waslick B: Management of suicidal behavior in children and adolescents. Psychiatr Clin North Am 20:641–666, 1997 Groholt B, Ekeberg O, Wichstrom L, et al: Suicide among children and younger and older adolescents in Norway: a comparative study. J Am Acad Child Adolesc Psychiatry 37:473–481, 1998 Grunbaum JA, Kann L, Kinchen S, et al: Youth risk behavior surveillance— United States, 2003. Morb Mortal Wkly Rep 53:1–96, 2004 Hammad TA: Results of the analysis of suicidality in pediatric trials of newer antidepressants. Presentation at the FDA Center for Drug Evaluation and Research (CDER), Bethesda, MD, September 2004. Available at: http:// www.fda.gov/ohrms/dockets/ac/cder04.html#PsychopharmacologicDrugs. Accessed March 26, 2005.
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Holinger PC: The causes, impact, and preventability of childhood injuries in the United States: childhood suicide in the United States. Am J Dis Child 144: 670–676, 1990 Huey SJJ, Henggeler SW, Rowland MD, et al: Multisystemic therapy effects on attempted suicide by youths presenting psychiatric emergencies. J Am Acad Child Adolesc Psychiatry 43:183–190, 2004 Johnson JG, Cohen P, Gould MS, et al: Childhood adversities, interpersonal difficulties, and risk for suicide attempts during late adolescence and early adulthood. Arch Gen Psychiatry 59:741–749, 2002 Kingsbury SJ: Clinical components of suicidal intent in adolescent overdose. J Am Acad Child Adolesc Psychiatry 32:518–520, 1993 Low BP, Andrews SF: Adolescent suicide. Med Clin North Am 74:1251–1264, 1990 Lubell KM, Swahn MH, Crosby AE, et al: Methods of suicide among persons aged 10–19 years—United States, 1992–2001. Morb Mortal Wkly Rep 53: 471–473, 2004 March J, Silva S, Petrycki S, et al: Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial. JAMA 292:807–820, 2004 Marttunen MJ, Aro HM, Henriksson MM, et al: Mental disorders in adolescent suicide: DSM-III-R Axes I and II diagnoses in suicides among 13- to 19-yearolds in Finland. Arch Gen Psychiatry 48:834–839, 1991 Marttunen MJ, Aro HM, Lonnqvist JK: Precipitant stressors in adolescent suicide. J Am Acad Child Adolesc Psychiatry 32:1178–1183, 1993 Marttunen MJ, Aro HM, Henriksson MM, et al: Psychosocial stressors more common in adolescent suicides with alcohol abuse compared with depressive adolescent suicides. J Am Acad Child Adolesc Psychiatry 33:490–497, 1994 National Center for Health Statistics: Health, United States, 2004 (DHHS Publ No 2005-0152). Hyattsville, MD, National Center for Health Statistics, 2004 Olfson M, Shaffer D, Marcus SC, et al: Relationship between antidepressant medication treatment and suicide in adolescents. Arch Gen Psychiatry 60: 978–982, 2003 Parham v J.R. and J.L., 442 U.S. 584 (1979) Penn JV, Esposito CL, Schaeffer LE, et al: Suicide attempts and self-mutilative behavior in a juvenile correctional facility. J Am Acad Child Adolesc Psychiatry 42:762–769, 2003 Pfeffer CR, Martins P, Mann J, et al: Child survivors of suicide: psychosocial characteristics. J Am Acad Child Adolesc Psychiatry 36:65–74, 1997 Rao U, Weissman MM, Martin JA, et al: Childhood depression and risk of suicide: a preliminary report of a longitudinal study. J Am Acad Child Adolesc Psychiatry 32:21–27, 1993 Renaud J, Brent DA, Birmaher B, et al: Suicide in adolescents with disruptive disorders. J Am Acad Child Adolesc Psychiatry 38:846–851, 1999 Rubenstein JL, Halton A, Kasten L, et al: Suicidal behavior in adolescents: stress and protection in different family contexts. Am J Orthopsychiatry 68:274– 284, 1998 Russell ST, Joyner K: Adolescent sexual orientation and suicide risk: evidence from a national study. Am J Public Health 91:1276–1281, 2001
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Sanislow CA, Grilo CM, Fehon DC, et al: Correlates of suicide risk in juvenile detainees and adolescent inpatients. J Am Acad Child Adolesc Psychiatry 42:234–240, 2003 Shaffer D, Vieland V, Garland A, et al: Adolescent suicide attempters: response to suicide-prevention programs. JAMA 264:3151–3155, 1990 Shaffer D, Gould MS, Fisher P, et al: Psychiatric diagnosis in child and adolescent suicide. Arch Gen Psychiatry 53:339–348, 1996 Shaffer D, Scott M, Wilcox H, et al: The Columbia Suicide Screen: validity and reliability of a screen for youth suicide and depression. J Am Acad Child Adolesc Psychiatry 43:71–79, 2004 Simon RI: Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management. Washington, DC, American Psychiatric Publishing, 2004 Steiner H: Practice parameters for the assessment and treatment of children and adolescents with conduct disorder. J Am Acad Child Adolesc Psychiatry 36:122S–139S, 1997 Svetaz MV, Ireland M, Blum R: Adolescents with learning disabilities: risk and protective factors associated with emotional well-being. Findings from the National Longitudinal Study of Adolescent Health. J Adolesc Health 27: 340–348, 2000 Swahn MH, Lubell KM, Sinmon TR: Suicide attempts and physical fighting among high school students—United States, 2001. Morb Mortal Wkly Rep 53:474–475, 2004 Trautman PD, Shaffer D: Pediatric management of suicidal behavior. Pediatr Ann 18:134–143, 1989 U.S. Food and Drug Administration: Class suicidality labeling language for antidepressants. Available at: http://www.fda.gov/cder/drug/antidepressants/ PI_template.pdf. Accessed March 5, 2005. Winters NC, Myers K, Proud L: Ten-year review of rating scales, III: scales assessing suicidality, cognitive style, and self-esteem. J Am Acad Child Adolesc Psychiatry 41:1150–1181, 2002
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The Elderly Yeates Conwell, M.D. Marnin J. Heisel, Ph.D.
In recent years suicide has come to be recognized as a major public health concern and a target for prevention. Publication of the Office of the Surgeon General’s National Strategy for Suicide Prevention was a landmark in that process (U.S. Public Health Service 2001). Older adults tend to be less visible than younger adults in the United States, where the predominant cultural values are youth, beauty, and a vigorous lifestyle. It often goes unrecognized, therefore, that older adults have the highest suicide rate of any segment of the population. In this chapter, we use the case history of an influential older American to illustrate the characteristics of, and risk factors for, suicide in this age group. We then review the evidence base for management of acutely suicidal elders and recommendations for approaches to prevention in this rapidly growing segment of the population.
Death by Suicide of George Eastman On March 14, 1932, George Eastman, founder of the Eastman Kodak Company, visited with his organist, personal secretary, and Kodak executives in his Rochester, New York, mansion and signed an updated copy of his will. After his visitors left, Eastman smoked a final cigarette, put a gun to his chest, and fatally wounded himself. His secretary found a note on his night table that read, “To my friends. My work is done. Why wait? GE.” Eastman, a generous philanthropist who had once been con57
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sidered the wealthiest bachelor in America, was dead at 77 years of age. Although his great wealth and success set him apart from most who die by suicide, Eastman’s death was in many respects predictable because the events and circumstances surrounding it exemplify so well the common risk factors for late-life suicide: multiple losses, personality vulnerability, physical illness, functional impairment, social isolation, and depression. Eastman was born on July 12, 1854, in Waterville, New York, into a distinguished family. His ancestors had immigrated to the United States from Wales in 1635. His father, an industrious self-made man who founded and ran a local business college, died of neurological impairment associated with “inflammatory rheumatism” when George was only 7. Younger brother to two sisters, one of whom died from polio at age 8, Eastman stepped early into the role of young caregiver, actively contributing to the household income. He was hardworking, serious, and conscientious. As an adolescent, Eastman paid for his sister’s body to be transported from Rochester to a cemetery in Waterville; as an adult, he lived with and cared for his ailing mother until her death. Even after his photographic plate company started achieving success, Eastman continued working in a bank during the day to ensure a stable income, dedicating the evenings to painstaking work on his fledgling business. A robust and self-determined individual, Eastman was a firm believer in eugenics and euthanasia. His philosophy of life and death was likely fueled, in part, by multiple painful losses of close family, friends, acquaintances, and business associates to debilitating physical illnesses. In addition to losing his father and sister at a young age, Eastman witnessed many other examples of once-vibrant individuals slowly succumbing to painful disease processes, including his beloved mother, who spent the final days of her life confined to a wheelchair. After her death in 1907, a dejected Eastman told friends, “I don’t want to live that long” (Brayer 1996, p. 515). As his own physical illness, most likely spinal stenosis, made walking and functioning more difficult and painful, Eastman began expressing a longing for death and even for self-destruction. As the once robust and adventuresome entrepreneur grew dependent on others for assistance with basic bodily functions, Eastman confided to friends that he felt that there was nothing left to live for and occasionally talked of suicide. In one portentous conversation with a personal friend, Eastman spoke in favor of suicide in the case of a hypothetical “man with an incurable disease who has discharged all his obligations and has no one dependent on him,” asking “What is there ethically against his committing suicide?” (p. 516). He had similar con-
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versations with his doctors, once asking his personal physician about the lethality of strychnine and later asking that he outline the precise location of Eastman’s heart. As his physical pain increased and his functioning grew increasingly impaired, Eastman withdrew from society and from the company of all but his closest friends and acquaintances, a self-imposed isolation characterized by painful loneliness and growing dependency on visitors and members of his personal staff. During the final months of his life, Eastman corresponded with close family and friends, expressing his devotion to them and stating that his work was done. After his death Eastman’s business associates and members of his staff recounted with pity the sadness of his final months, noting he “shuffled along in great pain, inexplicably weepy and depressed, dragging one foot behind” him (Brayer 1996, p. 517). Eastman began pitying himself as well, once stating, “When a man is alone and hasn’t anybody interested in him, there’s no reason for getting old” (p. 516). Statements like “There isn’t much to live for” (p. 519) further speak to Eastman’s growing despair. Only after Eastman revised his will did his demeanor change; he grew more cheerful, his mind apparently made up. Eastman’s legacy consists of making photography accessible and popular to the public as well as his philanthropic contributions to Rochester and the world. As well, however, he has contributed to our understanding of late-life suicide. His is an example of the potentially lethal combination of multiple losses, personality vulnerability, physical illness, functional impairment, social isolation, and depression. Eastman’s story additionally exemplifies the many potential points of entry for suicide intervention, from family and friends whom he longed to be with but was embarrassed to see to his physician to whom he expressed suicidal despair. Perhaps only after learning from his example how we might intervene to prevent suicide among at-risk older adults can we agree that his work is truly done.
Characteristics of and Risk Factors for Suicide in Older Adults Scope and Nature of the Problem Suicide rates rise with age for both men and women in most countries that report death statistics to the World Health Organization (Pearson and Conwell 1995). The United States, however, shows a somewhat different pattern, as illustrated in Figure 3–1. Increased rates among older adults are largely explained by elevated risk for white men over the age
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Suicide rate per 100,000
80 70 60
Black female
White female
Black male
White male
50 40 30 20 10
5− 10 9 − 14 15 − 1 20 9 − 24 25 − 2 30 9 − 34 35 − 3 40 9 − 44 45 − 4 50 9 − 54 55 − 5 60 9 − 64 65 − 6 70 9 − 7 75 4 − 7 80 9 − 84 85 +
0
Age groups
FIGURE 3–1.
U.S. suicide rates, by age, sex, and racial group, 2002.
Source. National Institute of Mental Health data, Centers for Disease Control and Prevention, National Center for Health Statistics.
of 65. Black men show a bimodal distribution, with peaks in younger adulthood and older age. Rates among women are generally lower, peaking at midlife and declining or remaining stable throughout the remainder of the life course. Reasons for this apparent interaction between age, race, and gender in determining suicide risk remain speculative. The prevalence of suicide attempts among older people is less well established because there is no systematically administered surveillance mechanism for the behavior. It is clear, however, from epidemiologic data that older adults report a history of suicide attempts less often than do their younger counterparts (Moscicki 1997). Suicidal ideation shows a similar pattern in which elders consistently report lower rates than middle-aged and younger adults (Gallo et al. 1994). Table 3–1 lists prevalence rates of suicidal ideation and/or death ideation (thoughts of death without suicidal intent) from epidemiologic studies in a range of industrialized nations (Callahan et al. 1996; Crosby et al. 1999; Forsell et al. 1997; Jorm et al. 1995; Linden and Barnow 1997; Rao et al. 1997; Scocco et al. 2001; Shah et al. 2000; Skoog et al. 1996). The wide variation is explained by the varying measures and definitions used, including the time frames and age ranges of the populations sampled.
Studies of suicide ideation (SI) and death ideation (DI) among older adults
Age, y
Sample size, N
Time frame
Prevalence
Indiana, U.S.
≥ 60
301b
1 week
SI: 4.6%
Crosby et al. 1999 Forsell et al. 1997
United States Kungsholmen, Sweden
≥ 65 ≥ 75
760 969
1 year 2 weeks
Jorm et al. 1995
Canberra, Australia
≥ 70
923
2 weeks
Linden and Barnow 1997 Rao et al. 1997
Berlin, Germany
≥ 70
516
1 week
Cambridge, U.K.
≥ 81
125
2 years
Scocco et al. 2001
Padua, Italy
≥ 65
611
1 month 1 year Lifetime
Studya
Location
Callahan et al. 1996
Correlates
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TABLE 3–1.
Depressive illness, functional impairment SI: 1.0% Older age SI: 10.1 fleeting, Major depression (50% of those 2.5% frequent with frequent SI), institutionalization, functional disability, visual problems SI/DI: 2.3% Depressive disorder, poor health, disability, vision and hearing impairments, unmarried, in residential care SI: 1% Major depressive disorder DI: 21.1% (50%–75%) SI: 7% Female gender, depression DI: 20% symptoms and diagnosis, dementia Depression, anxiety, hostility, hypnotic use
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SI/DI: 6.5% 9.2 17.0
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Studies of suicide ideation (SI) and death ideation (DI) among older adults (continued)
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TABLE 3–1.
❘
Sample size, N
Time frame
Location
Shah et al. 2000
West Middlesex, U.K.
≥ 65
55c
1 month
Skoog et al. 1996
Göteborg, Sweden
≥ 85
345
1 month
aAll
Age, y
Prevalence
Correlates
SI: 36% DI: 33% SI/DI: 15.9%
Depressive symptoms and diagnosis, antidepressants Major depression, psychotic disorders, heart and peptic ulcer disease, anxiolytics, and neuroleptics
studies used in-person interviews except Crosby et al. 1999, which used a nationwide telephone survey. Depressed persons in primary care. c Medical inpatients. b
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Studya
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The presence of a history of either suicide attempts or suicidal ideation increases risk for subsequent suicidal behavior and completed suicide in elders, just as at earlier points in the life course. However, the lethality of suicide attempts increases with age. Whereas there may be from 8 to 40 or more suicide attempts per completed suicide in the general population, that ratio may be 4:1 or lower in older adults (Crosby et al. 1999; McIntosh et al. 1994). Intentional self-destructive acts are more likely to result in death among older adults because they have increased physical illness burden and therefore less ability to withstand the physical insult. Furthermore, older people who attempt suicide are more likely to live alone than younger people and thus escape timely detection and rescue. Equally important is another characteristic illustrated so well by Mr. Eastman: older people in suicidal states tend to plan more, are more determined to die, and use more immediately lethal means such as firearms (Conwell et al. 1998). Almost three-quarters of older adults who take their own lives do so with a gun, compared with approximately 55% of younger people. Like Mr. Eastman, the modal elder who commits suicide is a man who carefully considers and plans his actions but is, at best, indirect with others about his intent before ending his life with a self-inflicted gunshot wound.
Psychiatric Illness Much of our knowledge about the correlates and risk factors for suicide in older people is derived from “psychological autopsy” studies in which the mental, physical, and social circumstances are reconstructed from records and interviews with next of kin and other knowledgeable informants. Comparison with similar data obtained from carefully selected control groups enables identification and quantification of risk factors. Such studies have repeatedly and consistently demonstrated that psychiatric illness is present in the great majority of older adults who take their own lives and in proportions far greater than in comparison groups of older adults who do not die by suicide. Table 3–2 shows the distribution of psychiatric diagnoses in psychological autopsy studies conducted throughout the world (Barraclough 1971; Beautrais 2002; Carney et al. 1994; Chiu et al. 2004; Conwell et al. 1996; Harwood et al. 2001; Henriksson et al. 1995; Waern et al. 2002b). Affective illness—and in particular major depressive disorder—is the predominant mental illness present in 54%–87% of cases. Substance use disorders also appear to confer increased risk, although less so than affective illness. The data from controlled studies are inconclusive regarding the contribution of anxiety disorders or nonaffective psychoses to late-life suicide. Curiously,
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even the most carefully conducted research has yet failed to show that a diagnosis of dementia or delirium increases risk for suicide. The lack of association of dementia with increased suicide risk is counterintuitive, given the devastating impact of the illness, its close association in its early phases with mood disorder, and association of decreased cognitive functioning with elevated suicide ideation. These findings no doubt reflect the limitations of retrospective and informant report data. The few available prospective cohort studies of suicide in later life, however, reinforce the central role played by mood disorders and hopelessness (Ross et al. 1990; Turvey et al. 2002). Although psychiatric illness is the rule among elders who take their own lives, it more often than not goes undiagnosed (Wells et al. 2002). As with George Eastman, the symptoms of depression, demoralization, and hopelessness may be easily masked by comorbid physical illness and a reluctance to acknowledge emotional pain. These characteristics of mood disorders in older adults, and among men in particular, make the detection—and therefore the prevention—of suicide particularly challenging.
Physical Illness Another domain in which George Eastman’s death is typical of elder suicides is physical health status: he had a painful and debilitating physical condition that greatly impaired his ability to function independently. For a man of such power and authority, such dependency must have been particularly noxious. Of course, ill health and functional impairments are common in later life, making their specific associations with suicide difficult to prove. Record linkage studies coupling physical illness registries with death registries have shown significantly increased relative risk for suicide associated with disorders of the central nervous system such as multiple sclerosis, Huntington’s disease, seizure disorders, spinal cord injury, and stroke; systemic lupus erythematosus; HIV/AIDS; and malignant neoplasms (with the exception of skin cancer), among other conditions (Harris and Barraclough 1994; Quan et al. 2002; Whitlock 1986). Results are mixed in case-control psychological autopsy studies of older adult suicides in which some (Duberstein et al. 2004b; Waern et al. 2002a) but not other investigators (Beautrais 2002) report serious physical illness to be an independent risk factor for suicide after controlling for psychiatric illness. This latter point is important because of the close association between so many physical disorders, functional impairments, and affective illnesses. In many instances, including perhaps that of Mr. Eastman, the older person may become suicidal in the face of physical illness and decline
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TABLE 3–2.
Axis I diagnoses made by psychological autopsy in studies of late-life suicide Diagnosis, %
Study
Location
Barraclough 1971 Beautrais 2002
West Sussex, U.K. New Zealand
Carney et al. 1994 San Diego, California, U.S. Chiu et al. 2004 Hong Kong Conwell et al. 1996 Monroe County, New York, U.S. Harwood et al. Central England, 2001 U.K. Henriksson et al. Finland 1995 Waern et al. 2002b Göteborg, Sweden
Sample size, N
Major depression
≥ 65 ≥ 55
30 31
87 86
3 14
0 —
13 9
≥ 60
49
54
22
—
14
≥ 60 55–74
70 36
53 47
26 17
3 43
— 3
9 6
14 8
75–92
14
57
21
27
7
0
29
≥ 60
100
63
5
5
4
23
≥ 60
43
44
21
25
5
12
9
≥ 65
85
46
36
27
8
5
Age, y
Other Alcohol Other Nonmood use substance affective No disorder disorder use disorder psychosis diagnosis
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only if depression intervenes. Our own group compared physical health and functional status among adults age 60 years and older enrolled in primary care practices who had taken their own lives with matched primary care elders who had not (Conwell et al. 2000). Physical health and functional measures significantly distinguished the two groups. However, after controlling for the presence of mood disorders, the physical health and functional variables were no longer associated with suicide status. Furthermore, studies of individuals with terminal illness have repeatedly demonstrated that suicidal ideation is rare in the absence of depression (Chochinov et al. 1995). The complex relationships between physical health, functional status, and psychiatric disorders, in particular depression, require additional study. It is most prudent at this stage, however, to assume that although real, perceived, or anticipated physical decline may place an older adult at increased risk for suicide, its impact is greatly exacerbated by the advent of comorbid depressive symptomatology.
Stressful Life Events In the life of George Eastman, physical illness and functional decline may have served as powerful stressors precipitating his demoralized state, and possibly a major depressive episode, preceding his suicide. A range of other life circumstances common to older adulthood have been associated with suicide as well. Although bereavement clearly increases risk for suicide for several years after the loved one’s death, the impact may be greater on middle-aged and younger adults who lose a spouse than in later life, when such tragic events are more often expected (Duberstein et al. 1998). Retirement and other forms of life transition have been implicated in late-life suicide, particularly for older men, with George Eastman as one possible example. However, studies to date do not provide empirical support for retirement itself as a risk factor, and functional decline may be the best approximation for other role changes examined in the literature. Two case-controlled psychological autopsy studies examined the associations of other specific stressors with suicide in older adults. Both Beautrais (2002) and Rubenowitz et al. (2001) found that financial and relationship problems distinguished elder suicides from matched community control subjects. When other factors such as medical and psychiatric illness, age, and sex were taken into account, financial stressors were no longer predictive. However, family discord remained significantly associated with suicide case status. The powerful contribution of interpersonal relationships and social support to suicide risk in older
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adults is supported by other findings as well. Turvey et al. (2002) found in secondary analyses of data from a prospective cohort study of older adults that those who had more friends and relatives in whom to confide were less likely to take their own lives. Miller (1978) reported in a psychological autopsy study that elderly men who took their own lives were less likely to have had a confidant than were age-matched community control subjects. Finally, our group also found that those over 50 years of age who died by suicide had significantly fewer social contacts than a living comparison sample matched for age, sex, race, community residence, and history of psychiatric illness (Duberstein et al. 2004a). Again, George Eastman is an instructive example. Unmarried, without children, facing the loss of friends and professional colleagues, and increasingly restricted to his home by his functional limitations, Mr. Eastman was isolated from the people and activities that gave meaning to his life.
Other Factors to Consider Psychiatric illness, physical health problems, and other stressful life circumstances affect individuals in myriad ways. Because the vast majority of older people with any of these problems do not take their own lives, other factors must be involved that help explain who would have suicidal thoughts under those circumstances and who would act on them. Personality traits are normally distributed across the older adult population, so none has value as an independent predictor of suicide. However, studies have identified several traits that are associated with suicidal behaviors in later life and therefore help us understand who may be at risk in the face of other “more potent” suicide risk factors. Descriptive studies have linked suicide in older adults with the characteristics of hypochondriasis, hostility, shy seclusiveness, and a rigid, independent style. Harwood et al. (2001) found in a case-controlled psychological autopsy study that older adults who died by suicide had significantly more anxious and obsessive traits than did control subjects. Duberstein (1995) used reliable and valid measures of personality traits derived from the Five-Factor Model to yield similar findings. Specifically, high levels of Neuroticism and low scores on the Openness to Experience (OTE) factor of the NEO Personality Inventory (Costa and McCrae 1992) distinguished persons age 50 years and older who took their own lives from matched control subjects. Low OTE scores are characteristic of individuals best described as having a constricted range of interests and muted affective and hedonic responses to their environ-
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ment. They prefer the familiar to the novel. Duberstein (2001) and colleagues also found that individuals low in OTE were less likely to endorse suicidal ideation. They went on to propose a model in which elders with low OTE score are at increased risk both because they are less well equipped socially and psychologically to manage the challenges of aging and because their inability to express suicidal ideation makes them more likely to escape detection and life-saving interventions. At the same time, the low OTE trait may be adaptive for younger and middle-aged men able to exercise power over their environments. It is only when illness-related changes conspire to rob them of that power that these traits may contribute to risk for suicide. An exciting and rapidly expanding body of research is examining the role that neurobiological factors may play in the pathogenesis of suicide (Mann et al. 1999). The associations between measures of central serotonin functioning and impulsive, aggressive behaviors have received the most attention, although many other systems have been implicated as well. The distinctive pattern of suicide rates depicted in Figure 3–1 raises the possibility that aging-related changes in neurobiological systems may contribute. However, studies of neurobiological mechanisms in older people are greatly complicated by their high rates of comorbid physical illness and medication prescription. At this stage, theories about neurobiological contributions to late-life suicidal behavior remain largely untested. Finally, we know from both ecological and case-control studies that access to lethal means increases risk for suicide and that restriction of that access has been associated with the reduction in suicide rates (see, for example, Hawton et al. 2001). As previously noted, access to firearms is the means for suicide used by almost three-quarters of older people in this country. In a psychological autopsy study of older men in Arizona, Miller (1978) found that suicides were significantly more likely than living control subjects to have acquired a weapon within the past year. Our group, using the same method, found that having access to a firearm in the home was a significant predictor of suicide in men, but not women, older than 50 years. Furthermore, we found that the effect was specific to handguns; having a long gun in the home did not appear to confer additional risk (Conwell et al. 2002b).
Management of Suicide Risk in Late Life The observation that suicidal behavior in older people is highly malignant and more often results in death than in younger people has important implications for management and prevention.
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Assessment and Intervention When an older person is recognized as being suicidal, aggressive action must be taken to intervene. The initial step should be more detailed assessment to determine the extent and specificity of current and past suicidal thoughts, including the degree of planning undertaken, reasons for considering suicide, current and previous history of self-harm behavior, and the physical and interpersonal outcomes of such behavior. One should also assess the older patient’s reasons for living and perceived sources of meaning in life, because these may indicate sources of ambivalence and potential avenues for preventive intervention. If an older suicidal person has lethal intent (e.g., determination to end one’s life and specific plans about how to do so) or is unable or unwilling to share his or her thoughts with the evaluator, hospitalization to ensure the person’s safety and enable further evaluation may be indicated. Assessment should further include determining whether the individual has access to potentially lethal means, in particular firearms. If so, the most responsible course would be to contact trusted family members, friends, or local law enforcement, with the patient’s consent, and ask them to remove the weapons. They may give them to the police for temporary safe keeping. Every effort should be made to provide a safe environment for the person to return to. If the patient refuses to relinquish the gun or make accommodations to ensure safety from other potential means of self-harm, then hospitalization should again be considered. Given the integral role played by social supports in late-life suicide, assessment and mobilization of the at-risk older person’s formal and informal social networks are critical and may serve to defuse the acute crisis as well. Family members and friends may be invited to provide instrumental support and supervision, but only if their relationship with the patient is a trusted and comfortable one. Education of the involved support system is important with regard to risk assessment and the need for consistent follow-up and sustained treatment. Beyond assessment and management of the acute suicidal crisis, the treating provider should conduct a thorough multiaxial diagnostic evaluation that incorporates consideration of major psychiatric diagnoses, including personality disorders, as well as pertinent traits and characteristic coping styles, physical health and functional status, sources of stress in the person’s life, and resources that he or she has (intra- and interpersonal as well as social and economic) to manage them. On this basis, a treatment plan can then be formulated that addresses not only the intolerable pain driving the acute suicidal crisis but also the underlying factors that promote it.
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Prevention of Suicide in Later Life A second implication of the apparent lethality of late-life suicidality is that high priority should be placed on preventing the development of suicidal states in older people because once established, they are so difficult to detect and treat. A spectrum of prevention efforts—indicated, selective, and universal approaches to intervention—may be necessary to address mental disorders in a comprehensive fashion (Institute of Medicine 1994) (see Table 3–3). Because suicide is a relatively rare outcome (and even more so in a subgroup of the population such as older adults), few studies have examined the impact of specific preventive interventions on late-life suicidal behaviors. However, the few whose results have been reported show promise for further development as elements of a comprehensive late-life suicide prevention strategy.
Indicated Approaches Indicated approaches for the reduction of late-life suicide are designed to support the detection and effective treatment of suicidal ideation and the associated psychiatric illnesses that place seniors at immediate risk. As prescription rates for antidepressants, and selective serotonin reuptake inhibitors in particular, have risen in recent years, suicide rates have declined, including those among older adults. Although unable to establish a causal relationship between antidepressant prescriptions and suicide prevention, correlational studies support the notion that wider access to effective treatment for depression results in fewer deaths by suicide (Gibbons et al. 2005). Up to three-quarters of older adults who took their own lives had been in the office of a primary care provider within the previous 30 days; approximately one-third had been in their provider’s office within the last week of life (Conwell et al. 2002a). These observations suggest that improved detection and treatment of depression by primary care physicians should be a prime target for late-life suicide preventive interventions. The most rigorous test of this hypothesis thus far is provided by work from the Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) (Bruce et al. 2004). In this study, 598 older patients with depressive disorders were recruited from primary care practices and randomized to receive either care as usual or a multi-component intervention based on a collaborative, stepped-care model. The treatment condition included the use of treatment guidelines applied in the primary care setting with support of a depression care specialist who worked in close collaboration with the primary care physician, patient, and family to optimize compliance, tailoring care to the patient’s needs and preferences. Treatment
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The Elderly TABLE 3–3.
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Approaches to preventive intervention
Approach
Target population
Description
Indicated
High-risk individuals
Interventions to prevent full-blown disorders or adverse outcomes; emphasis on proximal risk factors
Selective
Individuals or subgroups at higher than average risk
Prevention through reducing characteristics that may place individuals at risk; emphasis on more distal factors
Universal
Entire population irrespective of risk status
Broadly directed initiatives to reduce prevalence of risk factors in a population and enhance health
may have included medications, interpersonal psychotherapy, and education/family support. Bruce et al. (2004) found that rates of suicidal ideation declined significantly faster in intervention patients than control subjects. Intervention patients also had significantly better outcomes with regard to depressive symptoms. The incidence of suicide attempts was too small to judge the intervention’s impact on that outcome. Nevertheless, the consistent associations observed among depression, suicidal ideation, and completed suicide on the one hand and between treatment of depression and reduced rates of suicidal ideation and suicide on the other provide powerful reinforcement for further study and implementation of preventive approaches targeting depression in late-life primary care.
Selective Approaches Selective preventive interventions target groups of older adults at risk for developing suicidal states as a result, in particular, of social isolation and impaired social supports, physical illness and functional impairment, and the presence of mild or subsyndromal depressive symptomatology. Within this framework, many existing medical and social services could be considered selective suicide prevention strategies. For example, comprehensive geriatric assessment clinics that provide thorough multidisciplinary diagnostic and treatment services to older adults may have that additional benefit. Social services that provide outreach to isolated elders in the community and care management services that address their other social needs may lower suicide risk as well. De Leo and colleagues (2002) provided some support for this hypothesis. The Telehelp/Telecheck service in Padua, Italy, provided telephone-based outreach, evaluation, and support services to more than
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18,000 frail elders. The authors observed that over 11 years of service delivery there were significantly fewer than expected suicides among their clients in the elder population of that region. Unfortunately, few social services have the expertise or resources to conduct the rigorous evaluations necessary to show their impact on suicidal ideation and behavior in the populations that they serve.
Universal Approaches Finally, a comprehensive late-life suicide strategy should include approaches that target the entire population regardless of any individual’s risk status. Although not typically the purview of health care providers, universal prevention strategies are becoming increasingly recognized as integral components of public health and population-oriented health care delivery. Such approaches to late-life suicide may include, for example, educational programs to decrease ageism and stigmatization among older adults about receiving mental health care or educational or legislative approaches to lethal means restriction. An example of the latter was provided in Great Britain when in 1998 legislation took effect limiting the size of packs of paracetamol (or acetaminophen) and salicylates (aspirin) sold over the counter (Hawton et al. 2001). As the number of tablets per pack decreased, so did the annual number of deaths from overdose by these commonly used medications. A second example that pertains more directly to older adults is the introduction of gun control through the Brady Handgun Violence Prevention Act of 1994. Known as the “Brady Act,” it requires licensed firearms dealers to observe a waiting period and initiate a background check prior to each handgun sale. Ludwig and Cook (2000) examined the patterns of change in suicide and homicide rates before and after the act went into effect to determine whether specific changes in rates may have been associated with implementation of its policies. Eighteen states already had equivalent legislation in place, which the investigators called “control states”; 32 states were required to newly implement the Brady Act’s procedures (the “intervention states”). The authors found no difference between intervention and control states in patterns of change in homicide rates for either the population age 21 years or older or adults age 55 years or older, and no difference for suicide rates among younger adults. However, after implementation of the act, the rate of suicide by firearm among individuals older than 55 years of age declined significantly more in the intervention states than in the control states. This finding is of particular interest because it appears to suggest that handgun control may be a relatively more effective suicide prevention strategy for older adults and especially for older men.
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Conclusion Older adults are at higher risk for suicide than any other age group, although in the United States it is older men who particularly bear that risk. The detection and management of suicidal older adults present special challenges to the health care and social services systems. They are less likely than younger adults to endorse suicidal ideation or to make attempts, yet they have substantially higher rates of completed suicide. The self-destructive acts that an older person implements are likely to be far more lethal in planning, implementation, and outcome. Therefore, clinical interventions must be aggressively made when an older patient is recognized to be suicidal. They should include immediate comprehensive assessment of the nature and extent of suicidal thoughts and plans, access to means, past history of suicidal behavior, and a systematic review of risk and protective factors. On that basis an acute management plan can be articulated to help maintain the patient’s safety while assessing and treating the patient’s underlying pathology. Recent case-controlled psychological autopsy studies, supplemented by prospective cohort and record linkage studies, have helped to identify factors that place older adults at risk for suicide. Chief among them is psychiatric illness, in particular mood disorders. Medical illness and functional impairment, social isolation, and life stressors (especially bereavement and family discord) also are major contributors. Hopelessness and the personality traits of neuroticism and low OTE should also be considered as vulnerabilities to development of suicidal states. Finally, access to lethal means, and in particular handguns, appears to be a factor contributing to suicide in later life. In addition to aggressive intervention for elders recognized to be suicidal, we must implement and test strategies designed to prevent elders with more “distal” risk factors from deteriorating into a suicidal state. These strategies should include a coordinated combination of indicated (e.g., primary care–based models to improve detection and treatment of late-life depression), selective (e.g., outreach and support for socially isolated elders in the community), and universal approaches (e.g., restricted access to lethal means). George Eastman’s suicide note—“My work is done. Why wait?”— suggests that he had choices to make about how and when his life would end. However, like most suicidal persons, he most likely saw little alternative to death other than a period of intolerable psychic pain and suffering. The clinician’s duty is to recognize that intolerable pain and to help create more desirable alternatives to death by one’s own
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hand. Treatment and prevention strategies provide us the tools to create those alternative solutions and thereby provide elders with the choice to live.
❏ Key Points ■
Older adults are at greater risk for suicide than other segments of the population.
■
Mental illnesses, in particular affective disorders and a history of attempted suicide, are the most powerful determinants of risk.
■
Physical illness and functional impairment, social isolation, family discord, other life stressors, and a rigid coping style also contribute to risk for suicide in later life.
■
For elders with suicidal ideation, especially those with a plan and access to means, intervention must be aggressive and may include acute hospitalization to provide for their safety, evaluation, and treatment.
■
Development and implementation of interventions designed to prevent onset of the acutely suicidal state are particularly high priorities.
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Specific indicated, selective, and universal interventions have shown promise independently as means to reduce suicide mortality in later life.
References Barraclough BM: Suicide in the elderly: recent developments in psychogeriatrics. Br J Psychiatry Suppl 6:87–97, 1971 Beautrais AL: A case control study of suicide and attempted suicide in older adults. Suicide Life Threat Behav 32:1–9, 2002 Brayer E: George Eastman: A Biography. Baltimore, MD, Johns Hopkins University Press, 1996 Bruce ML, Ten Have T, Reynolds CF III, et al: Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial. JAMA 291:1081–1091, 2004 Callahan CM, Hendrie HC, Nienaber NA, et al: Suicidal ideation among older primary care patients. J Am Geriatr Soc 44:1205–1209, 1996 Carney SS, Rich CL, Burke PA, et al: Suicide over 60: the San Diego study. J Am Geriatr Soc 42:174–180, 1994 Chiu HF, Yip PS, Chi I, et al: Elderly suicide in Hong Kong: a case-controlled psychological autopsy study. Acta Psychiatr Scand 109:299–305, 2004 Chochinov HM, Wilson KG, Enns M, et al: Desire for death in the terminally ill. Am J Psychiatry 152:1185–1191, 1995
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Conwell Y, Duberstein PR, Cox C, et al: Relationships of age and Axis I diagnoses in victims of completed suicide: a psychological autopsy study. Am J Psychiatry 153:1001–1008, 1996 Conwell Y, Duberstein PR, Cox C, et al: Age differences in behaviors leading to completed suicide. Am J Geriatr Psychiatry 6:122–126, 1998 Conwell Y, Lyness JM, Duberstein P, et al: Completed suicide among older patients in primary care practices: a controlled study. J Am Geriatr Soc 48:23– 29, 2000 Conwell Y, Duberstein PR, Caine ED: Risk factors for suicide in later life. Biol Psychiatry 52:193–204, 2002a Conwell Y, Duberstein PR, Connor K, et al: Access to firearms and risk for suicide in middle-aged and older adults. Am J Geriatr Psychiatry 10:407–416, 2002b Costa PT, McCrae RR: Revised NEO Personality Inventory and NEO Five Factor Inventory: Professional Manual. Odessa, FL, Psychological Assessment Resources, 1992 Crosby AE, Cheltenham MP, Sacks JJ: Incidence of suicidal ideation and behavior in the United States 1994. Suicide Life Threat Behav 29:131–140, 1999 De Leo D, Dello BM, Dwyer J: Suicide among the elderly: the long-term impact of a telephone support and assessment intervention in northern Italy. Br J Psychiatry 181:226–229, 2002 Duberstein PR: Openness to experience and completed suicide across the second half of life. Int Psychogeriatr 7:183–198, 1995 Duberstein PR: Are closed-minded people more open to the idea of killing themselves? Suicide Life Threat Behav 31:9–14, 2001 Duberstein PR, Conwell Y, Cox C: Suicide in widowed persons: a psychological autopsy comparison of recently and remotely bereaved older subjects. Am J Geriatr Psychiatry 6:328–334, 1998 Duberstein PR, Conwell Y, Conner KR, et al: Poor social integration and suicide: fact or artifact? A case-control study. Psychol Med 34:1331–1337, 2004a Duberstein PR, Conwell Y, Conner KR, et al: Suicide at 50 years of age and older: perceived physical illness, family discord and financial strain. Psychol Med 34:137–146, 2004b Forsell Y, Jorm AF, Winblad B: Suicidal thoughts and associated factors in an elderly population. Acta Psychiatr Scand 95:108–111, 1997 Gallo JJ, Anthony JC, Muthen BO: Age differences in the symptoms of depression: a latent trait analysis. J Gerontol 49:251–264, 1994 Gibbons RD, Hur K, Bhaumik DK, et al: The relationship between antidepressant medication use and rate of suicide. Arch Gen Psychiatry 62:165–172, 2005 Harris EC, Barraclough BM: Suicide as an outcome for medical disorders. Medicine 73:281–296, 1994 Harwood D, Hawton K, Hope T, et al: Psychiatric disorder and personality factors associated with suicide in older people: a descriptive and case-control study. Int J Geriatr Psychiatry 16:155–165, 2001 Hawton K, Townsend E, Deeks J, et al: Effects of legislation restricting pack sizes of paracetamol and salicylate on self poisoning in the United Kingdom: before and after study. BMJ 322:1203–1207, 2001 Henriksson MM, Marttunen MJ, Isometsa ET, et al: Mental disorders in elderly suicide. Int Psychogeriatr 7:275–286, 1995
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Institute of Medicine: Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC, National Academy Press, 1994 Jorm AF, Henderson AS, Scott R, et al: Factors associated with the wish to die in elderly people. Age Aging 24:389–392, 1995 Linden M, Barnow S: 1997 IPA/Bayer Research Awards in Psychogeriatrics: the wish to die in very old persons near the end of life: a psychiatric problem? Results from the Berlin Aging Study. Int Psychogeriatr 9:291–307, 1997 Ludwig J, Cook PJ: Homicide and suicide rates associated with implementation of the Brady Handgun Violence Prevention Act. JAMA 284:585–591, 2000 Mann JJ, Waternaux C, Haas GL, et al: Toward a clinical model of suicidal behavior in psychiatric patients. Am J Psychiatry 156:181–189, 1999 McIntosh JL, Santos JF, Hubbard RW, et al: Elder Suicide: Research, Theory, and Treatment. Washington, DC, American Psychological Association, 1994 Miller M: Geriatric suicide: the Arizona study. Gerontologist 18:488–495, 1978 Moscicki EK: Identification of suicide risk factors using epidemiologic studies. Psychiatr Clin North Am 3:499–517, 1997 Pearson JL, Conwell Y: Suicide in late life: challenges and opportunities for research. Int Psychogeriatr 7:131–136, 1995 Quan H, Arboleda-Florez J, Fick GH, et al: Association between physical illness and suicide among the elderly. Soc Psychiatry Psychiatr Epidemiol 37:190– 197, 2002 Rao R, Dening T, Brayne C, et al: Suicidal thinking in community residents over eighty. Int J Geriatr Psychiatry 12:337–343, 1997 Ross RK, Bernstein L, Trent L, et al: A prospective study of risk factors for traumatic death in the retirement community. Prev Med 19:323–334, 1990 Rubenowitz E, Waern M, Wilhelmsson K, et al: Life events and psychosocial factors in elderly suicides: a case control study. Psychol Med 31:1193–1202, 2001 Scocco P, Meneghel G, Caon F, et al: Death ideation and its correlates: survey of an over-65-year-old population. J Nerv Ment Dis 189:210–218, 2001 Shah A, Hoxey K, Mayadunne V: Suicidal ideation in acutely medically ill elderly inpatients: prevalence, correlates and longitudinal stability. Int J Geriatr Psychiatry 15:162–169, 2000 Skoog I, Aevarsson O, Beskow J, et al: Suicidal feelings in a population sample of nondemented 85-year-olds. Am J Psychiatry 153:1015–1020, 1996 Turvey CL, Conwell Y, Jones MP, et al: Risk factors for late-life suicide: a prospective, community-based study. Am J Geriatr Psychiatry 10:398–406, 2002 U.S. Public Health Service: National Strategy for Suicide Prevention: Goals and Objectives for Action. Rockville, MD, U.S. Department of Health and Human Services, U.S. Public Health Service, 2001 Waern M, Rubenowitz E, Runeson B, et al: Burden of illness suicide in elderly people: case-control study. BMJ 324:1355–1358, 2002a Waern M, Runeson B, Allebeck P, et al: Mental disorder in elderly suicides. Am J Psychiatry 159:450–455, 2002b Wells KB, Miranda J, Bauer MS, et al: Overcoming barriers to reducing the burden of affective disorders. Biol Psychiatry 52:655–675, 2002 Whitlock FA: Suicide and physical illness, in Suicide. Edited by Roy A. Baltimore, MD, Williams & Wilkins, 1986, pp 151–170
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Suicide and Gender Liza H. Gold, M.D.
Suicide is a gendered phenomenon. About 80% of all suicides are committed by males. The gendered nature of suicide has been recognized since the earliest studies of this behavior. Emile Durkheim, who provided the first systematic and statistical study of suicide in his 1897 work Suicide, observed that suicide “happens to be an essentially male phenomenon” (Durkheim 1897/1952, p. 72). Modern statistical data consistently demonstrate that deaths by suicide among males exceed those among females in every country except China. In the United States, males commit suicide at a rate three to four times that of females (Brockington 2001; Maris et al. 2000; Moller-Leimkuhler 2003; Simon 2004). The highest suicide rates for women occur among white females in the range of 40 to 44 years (Moscicki 1999). Yet even these rates are lower than the suicide rates for men of any age (Kaplan and Klein 1989). Despite women’s low suicide mortality rates, women have consistently higher rates of two of the most significant suicide risk factors, depression and suicide attempts. Approximately 90% of individuals who commit suicide have a diagnosable psychiatric disorder. Affective illness (major depression, bipolar disorder, and schizoaffective disorder) is the most common diagnosis among completers, accounting for up to 60%–70% of suicide deaths (Carroll-Ghosh et al. 2003; Maris et al. 2000; Moscicki 1999; Simon 2004). Epidemiological studies have consistently shown that depression is about twice as common in women as in men (Kessler et al. 1996; Regier et al. 1988). The incidence of major depression ranges from 2.6% to 5.5% in men and from 6.0% to 11% in women. 77
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This almost 2:1 ratio has been well documented across countries and ethnic groups (Dubovsky et al. 2003; Kornstein and Wojcik 2002; Kung et al. 2003; Sloan and Kornstein 2003). A history of nonfatal attempts is also a well-recognized risk factor for suicide. As has been noted, “The best clinical indicator of a future suicide attempt is a prior suicide attempt” (Simon 2004, p. 45). In the United States, women attempt suicide at a rate three to four times that of men. The relationship between nonfatal attempts and eventual suicide completion is complex. Considerable comorbidity and interaction of multiple factors in the etiology of suicide exist. Nevertheless, 7%–12% of patients who make attempts commit suicide within 10 years, making attempts a significant chronic risk factor for suicide. For each attempt, the risk of another attempt occurring during a 2-year follow-up period increases by 30%. Between 18% and 38% of persons who commit suicide had made previous attempts (Jacobs et al. 1999; Maris et al. 2000; Moscicki 1999; Skogman et al. 2004; Zahl and Hawton 2004). One recent study found an approximately 30-fold increase in the risk of suicide among individuals who had made a suicide attempt in the 4 years following that attempt when compared with the general population (Cooper et al. 2005). Given women’s increased incidence of depression and suicide attempts, women’s suicide mortality rates are remarkably low. This inverse relationship has been referred to as “the gender paradox of suicidal behavior” (Skogman et al. 2004) and has been recognized for almost 200 years (Kushner 1995). Despite an awareness of this phenomenon, the gendered nature of suicide and the paradox it presents have not been adequately investigated or explained. Most theories regarding suicidal behavior have been developed on the basis of the experiences and behavior of men. Studies tend to focus on risk factors for suicide mortality, a low base rate phenomenon (1.3% of the population in 2002) occurring primarily among white males (approximately 70%; National Institute of Mental Health 2003). Conclusions drawn from such studies are then often generically applied to women and other ethnic groups (Canetto and Lester 1995). Nevertheless, “[I]t is a myth that conceptual categories developed from studying suicidal behavior in white European-American men can be automatically generalized to women and people of other cultures” (Canetto and Lester 1995, p. 4). Certainly, the gender gap in suicide mortality rates between men and women cannot be explained by differences in these male-oriented demographic risk factors. The gender paradox observed in suicide behavior and mortality suggests questions that require the adoption of alternative perspectives for
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investigation. It requires using approaches that move away from the perspective of the centrality of the white male experience and focuses instead on the characteristics of other groups. Why are other populations less vulnerable to suicide than white males, despite having many of the recognized demographic risk factors associated with suicide mortality? Which factors or behaviors protect women (and other ethnic and racial groups) from the high suicide mortality rates of white males? The answers to these questions could lead to insights that expand our understanding of suicide as well as therapeutic interventions that could decrease suicide risk. Gender is one of many static demographic factors that influence suicide mortality. Multiple static and dynamic risk factors contribute to any individual’s attempted or completed suicide. Although gender can be examined as a factor in and of itself, it is inextricably intertwined with other static risk factors, such as age, race, and culture. For example, 90% of all suicides in the United States are committed by white persons. African Americans commit suicide much less frequently than whites, and African American women “are remarkably resistant to suicide compared to other demographic groups” (Garlow et al. 2005, p. 321). Suicide rates also change relative to age across and within ethnic and racial groups. Suicide rates for white men peak at midlife and again around age 80. Rates for white women peak in mid-life, whereas rates for nonwhite men and women peak in young adult life (Garlow et al. 2005; Good and Sherrod 2001; Maris et al. 2000; Moscicki 1995; National Institute of Mental Health 2003; Simon 2004; Webster Rudmin et al. 2003; Willis et al. 2003). A complete investigation of these interrelated demographic factors is beyond the scope of this discussion, but elements of these issues will inevitably arise in the course of a discussion of gender.
Case Examples Case Example 1: Mr. Taylor Mr. Taylor was a white, divorced, 58-year-old chief executive officer of a major corporation. He had lived alone since his divorce a number of years earlier. He had a history of escalating alcoholism, which had begun to impair his functioning. He sought psychiatric treatment with the encouragement and support of friends and family. He was able to discontinue alcohol use and responded well to antidepressant medication. After 2 years, he discontinued treatment because he felt he was doing well. Soon after ending treatment, Mr. Taylor’s company came under federal investigation for financial fraud. Mr. Taylor was forced out of the company, became a target of investigation, and possibly faced criminal
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charges. Mr. Taylor did not tell his family or friends about his work problems. He became increasingly isolative, spent his days at home, and rarely left his house. He began drinking again. Mr. Taylor’s family found out about the investigation after it made headlines in the local papers. Mr. Taylor’s adult son called and spoke with his father after reading the papers. Mr. Taylor did not sound upset. He told his son not to worry and that once the whole truth came out, everything would turn out well. Later in the day, Mr. Taylor’s son tried to call again, but no one answered the phone. He went to his father’s house and found Mr. Taylor dead from a gunshot wound to the head, with his handgun lying next to him. The death was ruled a suicide. A blood alcohol level revealed that Mr. Taylor had been intoxicated at the time he shot himself.
Case Example 2: Ms. Smith Ms. Smith was a white 48-year-old woman who worked in law enforcement. She had just made an appointment with a psychiatrist, Dr. Black, for a medication consultation. Ms. Smith had a history of two suicide attempts by over-the-counter medication, one at age 15 and another at age 28. The first was precipitated by problems with her physically abusive father, and the second followed a painful divorce. Both resulted in hospitalization and successful treatment with medication. Although she stopped taking her medication some years after her first hospitalization, Ms. Smith had remained on medication since the time of her second suicide attempt. Ms. Smith reported that both of these attempts were serious and her intent had been to die. Three years before making the appointment with Dr. Black, Ms. Smith’s job required that she relocate to a new state, leaving behind supportive family and friends. Since moving, she had been isolated and lonely but had remained on her medication, which she received from her internist. Despite taking her medication, Ms. Smith began experiencing more symptoms of depression and hopelessness. She had become involved in a relationship, and after 1 year, she and her boyfriend began living together. However, their relationship began to deteriorate. At the same time, Ms. Smith’s mother was diagnosed with terminal cancer. Because of the distance and her job responsibilities, Ms. Smith was not able to see her mother as much as she would have liked and felt increasingly guilty about this. Ms. Smith had begun seeing a psychotherapist before contacting Dr. Black. Ms. Smith and her therapist had a good therapeutic alliance. Both Ms. Smith and her therapist were concerned that Ms. Smith’s medication needed to be adjusted. The therapist referred Ms. Smith to Dr. Black. In the week prior to the scheduled consultation, Ms. Smith and her boyfriend began talking about separating. Ms. Smith developed acute suicidal ideation 3 days prior to the consultation with Dr. Black. Given her experience of surviving two previous overdose attempts, Ms. Smith wanted to make sure that if she tried to kill herself, she would succeed. She loaded her employment-issued firearm and put it to her head.
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After sitting for some time with the loaded gun, Ms. Smith decided not to shoot herself. The main reason for this decision was her concern the effect of her suicide would have on her mother, although she mentally reserved the option of killing herself after her mother died. In the meantime, Ms. Smith decided to go through with the consultation to see if medication might help. Ms. Smith responded honestly to Dr. Black’s questions about suicidal ideation and plans but revealed that she had not told anyone else, including her therapist, about her suicidal intent or plan.
Mr. Taylor, in the first case example, exemplifies the “typical” suicide completer: an older white male who is depressed, maybe alcoholic; lives alone or is socially isolated; uses a highly lethal irreversible method (most often a gunshot to the head); dies after his first suicide attempt; has grown increasingly hopeless; has recurring work, sexual, and marital problems; has experienced a series of stressful negative life events; and often sees suicide as the only permanent resolution to his persistent life problems (Maris et al. 2000). Ms. Smith, in the second case example, has a history consistent with elements of the stereotypical nonfatal suicide attempter. As a younger female, she made two suicide attempts but used less lethal methods— those having lower medical certainty of resulting in death. She was perhaps ambivalent about dying. Such attempts are often motivated by interpersonal dynamics, including changes in an important relationship. These attempts may be more impulsive and may be related to either Axis I or Axis II disorders, although those who make nonfatal suicide attempts, like those who complete suicide, tend to be depressed and abuse alcohol and other substances (Maris et al. 2000). The degree of Ms. Smith’s current intent was indicated by her choice of a new and more lethal method based specifically on her previous experiences of failure to kill herself by overdose. Her current presentation is consistent with a high risk of suicide mortality, despite her history of lower lethality attempts.
Demographic Risk Factors Most of the demographic factors commonly acknowledged to increase suicide risk do not explain the differences in suicide mortality rates among groups other than white males (Canetto and Lester 1995). Indeed, much of what we believe we know about risk factors for suicide applies primarily to older, white men. Demographic risk factors, such as marital status, increasing age, or physical illness, are not as significant for groups other than white males or do not explain the lower or higher rates of suicide mortality in other groups.
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For example, the association of age and suicide is almost exclusively a white-male phenomenon. The frequency of suicide among females changes relatively little across middle and late life (Maris et al. 2000; Steffens and Blazer 1999). Elderly women do not enjoy any particular advantages over elderly men in regard to the suicide risk factors most commonly mentioned in the literature. In fact, elderly women are more likely than elderly men to be exposed to conditions such as limited financial resources, loss of spouse, living alone, and poor health that in elderly men have been thought to precipitate suicidal behavior (Canetto 1995, 2001). Yet the mortality rates of elderly women are significantly lower than those of elderly men. Moreover, African Americans, particularly African American women, typically commit suicide at much younger ages than do whites. One large urban study found that the vast majority of African American women committed suicide between ages 20 and 45, and virtually no suicides in this group occurred above or below this age range (Garlow et al. 2005). Similarly, risk factors such as single marital status, lower socioeconomic status, and unemployment are as common or more common among African American women as white men. Indeed, African American women are likely to be among the most socioeconomically disadvantaged groups in the United States. Yet rates of suicide mortality for African American women are the lowest of all race-by-gender groups in the United States (though their rates of death by violence at the hands of others are among the highest of any subgroup; Alston and Anderson 1995). In 2000, only 1.1% of all suicides in the United States were committed by African American females; African American males accounted for 5.6%, white females for 17.7%, and white males for 72.4% (Garlow et al. 2005). Other studies have confirmed that suicide among women generally is less associated with adversity and single status (Oates 2003). Thus, some factors associated with suicide and suicidal behaviors among the general American public do not apply to African American women (Alston and Anderson 1995).
Standard Explanations for the Gender Gap Explanations for the gender paradox in suicide often reflect traditional gender stereotypes. Explorations of gender-related issues begin from the understanding that gender refers to the socially constructed roles of men and women implicating different norms and cultural expectations for both sexes. These norms and expectations define characteristics typical and desirable for males and females. These characteristics are transmitted and reinforced by early socialization as well as by social in-
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stitutions. Substantial disparities not supported by biological distinctions continue to exist in the construction of gender roles, myths, and stereotypes. These distinctions structure acceptable social roles as well as access to personal, social, and material resources. Both roles and access to resources differ significantly for men and women. For this reason, gender is a significant determinant of health and illness, including psychiatric illness (Moller-Leimkuhler 2003). Early suicidologists attributed women’s lower suicide mortality rates to their stereotypical character traits, such as mental dullness, passive natures, or the effects of gender-based social roles. Beginning in the nineteenth century, male suicide was characterized as a result of the grave stresses inherent in men’s roles and responsibilities, such as impotence, business embarrassments, losses, and ungratified ambition. Women, in contrast, were said to commit suicide because of domestic unhappiness, loss of honor or purity (illicit love affairs), or disappointed love. Durkheim (1897/1952) theorized that women were less prone to suicide than men because of their greater emotional attachments to home and family, greater religious faith, greater patience, and less developed intellectual capacity. As outdated as such explanations may sound, they were held well into the mid–twentieth century (Canetto and Lester 1995; Kushner 1995; Maris et al. 2000). Explanations about women and suicidal ideation and plans based on gender stereotypes have been discredited and disavowed. Nevertheless, on close examination, current explanations of the gender gap in suicide mortality rates still reflect the persistence of gender stereotypes of both men and women to various degrees. Perhaps even more significantly, they fail to provide much-needed insight into the gendered nature of suicide.
Substance Abuse or Dependence Substance abuse is also a gendered disorder, occurring primarily in men. It has been suggested that the higher incidence of substance abuse, particularly alcohol abuse, accounts for the gender gap in suicide mortality. Alcohol abuse or dependence occurs three to four times more frequently among men than women, with overall male-to-female ratios varying from approximately 2:1 to 5:1. (Brady and Randall 1999; Canterbury 2002; Maris et al. 2000; Regier et al. 1990). Could the risk of suicide associated with the use of alcohol in men outweigh the gendered risk factors of depression and suicide attempt? Alcohol abuse is the second most frequent diagnosis associated with suicide, following mood disorders (Moscicki 1999). In one large study, 18%
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of alcoholics eventually committed suicide. Toxicology data for individuals who complete suicide indicate that between 40% and 60% of these individuals were legally intoxicated at the time of death (Maris et al. 2000; Simon 2004). Some support for this theory of substance abuse as the basis of the gender gap in suicide mortality rates can be found in studies that have demonstrated a higher rate of alcoholism in males who commit suicide than in females who commit suicide (Kung et al. 2003). In one such study, alcohol was detected in 28.9% of individuals who committed suicide; of these, 81.8% were male and 18.2% were female (Garlow 2002). Gendered patterns of substance abuse in regard to comorbid illness, however, indicate that this Axis I diagnosis and risk factor in and of itself does not explain the gender gap, although it may play some role. Major depression is often a primary diagnosis in women who abuse alcohol. In contrast, the majority of men who abuse alcohol demonstrate alcoholism as a primary diagnosis (Brady and Randall 1999; Canterbury 2002). Moreover, females with alcoholism have significantly more depression and anxiety disorders than do their male counterparts, and the onset of these disorders precedes the onset of substance use disorders more often in women than in men (Kessler et al. 1996; Table 4–1). In addition, one recent study found that differential patterns of substance abuse did not account for the lower age at suicide of African Americans, indicating that substance abuse also cannot account for other demographic differences in suicide mortality (Garlow et al. 2005). Male stereotypes play a role in explanations involving alcohol abuse. Although substance use disorders in general are stigmatized, substance use is more stigmatized in women than in men. This may result in the lower levels of alcohol abuse among women (Brady and Randall 1999; Maris et al. 2000). Nevertheless, when women exhibit alcohol abuse as a comorbid disorder, they exhibit higher rates of suicidal behavior and mortality (Kornstein and Wojcik 2002). In the 1993 National Mortality Followback Survey, which used natural deaths as a control group, both male and female suicide decedents were more likely to have used marijuana and alcohol (Kung et al. 2003).
Lethality of Method The higher suicide rate among males is commonly explained at least in part by males’ more frequent use of lethal methods, particularly the use of firearms. Overall, men reportedly choose relatively limited, highly lethal methods to commit suicide, whereas women use a much greater variety of methods, many of which are of relatively low lethality (Kung et al. 2003; Maris et al. 2000; Slaby 1998). Men do indeed commit the ma-
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General patterns found in alcohol abuse/dependence relative to gender Men
Primary diagnosis
Alcohol abuse/ dependence Anxiety disorder present Less often Depressive disorder present Less often Onset of non–substance More often follows abuse disorders onset of substance abuse
Women Major depression More often More often More often precedes onset of substance abuse
jority of firearm suicides: in 1998, the rate of suicide by such a method was more than 6.5 times the rate in women (11.4 and 1.7 per 100,000 respectively; Romero and Wintemute 2002). Nevertheless, epidemiological data demonstrate that suicide by firearms has become the most common method of suicide for both men and women across all age groups, notwithstanding females’ lower absolute rates (Brent 2001; Canetto 2001; Jacobs et al. 1999; Kaplan et al. 1997; Moscicki 1999). Each year, approximately 55% of all suicide deaths are due to firearms (Table 4–2). Of these, approximately 60% are males and 40% are females (Table 4–3). Firearms are responsible for three times the number of suicides as the next leading methods. Access to a firearm increases risk for suicide for both males and females (Kung et al. 2003), even in individuals with no identifiable psychopathology (Brent 2001). Women who purchased handguns were at particularly high risk for suicide with a firearm. In a broad community-based study whose cohort represented all causes of death, suicide by firearm accounted for 31.2% of all deaths during the first year of gun ownership among women who purchased handguns. This rate stood in marked contrast with 0.2% of all deaths among all women in the cohort (Wintemute et al. 1999). Sixteen to nineteen percent of the U.S. population own a handgun, and 26%–30% of men and 7%–8% percent of women own such weapons (Wintemute et al. 1999). The higher proportion of men committing suicide with firearms may be an artifact of higher rates of gun ownership among men rather than a reflection of men’s greater preference to commit suicide using a firearm. The 1.7:1 proportion of men versus women who use firearms to commit suicide is very similar to the gender distribution of firearm ownership (1.9:1) and handgun ownership (1.7:1) in the general population (Conner and Zhong 2003). Thus, lethality of method, although one possible factor, does not itself explain the gender gap in suicide mortality.
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TABLE 4–2.
Suicide methods, 2002
Method Firearms All except firearms Suffocation/Hanging Falls Drowning Poisoning Source.
Percentage of total suicides 54.0 46.0 20.4 2.3 1.2 17.3
Data from American Association of Suicidology 2004.
Explanations such as those offered in regard to lethality of methods also reflect gender stereotypes. Men are said to be more familiar and comfortable with guns. Women’s lower rates of gun ownership, however, may reflect social roles and norms that discourage aggression in women. In addition, women are often said to avoid more violent methods because they might cause unsightly disfigurement (Maris et al. 2000), implying that concerns over appearance after death may be more important to suicidal women than concerns regarding death itself. This explanation reflects stereotypic beliefs regarding vanity about appearance in women and does not take into account that firearms are now the preferred method of suicide for both genders.
Neurobiology of Aggression, Violence, and Suicidal Ideation and Plans In recent years, the presence of the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) in the cerebrospinal fluid (CSF) and its relationship to suicide, especially violent suicide, have been explored and offered as a possible explanation for various aspects of suicidal behavior, including gender differences in suicide mortality rate (Mann and Arango 1999; Maris et al. 2000). One of the most consistent findings in the suicide literature, reported in both postmortem studies of suicide completers and clinical studies of suicide attempters, has been evidence of decreased brain stem levels of serotonin or 5-HIAA. More lethal suicide attempts have also been associated with lower CSF 5-HIAA levels (Arana and Hyman 1989; Carroll-Ghosh et al. 2003; Mann and Arango 1999; Moscicki 1999). Nevertheless, these findings do not as yet form the basis of a complete explanation of gender-based differences in suicide mortality rates.
Suicide methods, United States, 1996–2002, by gender (%)
Firearms, total Firearms, male Firearms, females All othera All other, male All other, female
1996
1997
1998
1999
2000
2001
2002
58.8 63.2 39.9 41.2 36.8 60.1
57.5 62.0 39.3 42.5 38.0 60.7
57.0 61.6 38.4 43.0 38.4 61.6
56.8 61.7 36.9 43.2 38.3 63.1
56.5 61.2 37.2 43.5 38.8 62.8
55.1 No data No data 44.9 No data No data
54.0 No data No data 46.0 No data No data
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TABLE 4–3.
a
Includes suffocation/hanging, falls, drowning, poisoning, cutting/piercing, fire/flame. Source. Data from American Association of Suicidology 2004.
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CSF 5-HIAA determinations, particularly those done postmortem, are an imprecise way to measure serotonin levels and activity in the living brain. Many of these studies also had small numbers of subjects. Moreover, like many types of suicide studies, most of this research on spinal fluid concentrations of 5-HIAA has focused on male subjects (Maris et al. 2000), raising the question of whether these results can be generalized to women. Biochemical explanations that link aggression, suicide, and gender are still incomplete. Numerous other neurotransmitters, as yet unexplored, are likely to be implicated in any complex behavior such as suicide (Carroll-Ghosh et al. 2003). In addition, other biochemical differences exist between men and women. These do not of themselves indicate a connection with greater or lesser rates of suicide mortality. Women, for example, have lower concentrations of testosterone than do men. The link between testosterone and aggression is well recognized, but there is no known direct relationship between testosterone and suicidal behavior (Maris et al. 2000).
Help-Seeking Behaviors Women are also said to have decreased rates of suicide mortality because they are more likely than men to seek help when depressed. Multiple studies have demonstrated that emotions such as weakness, uncertainty, helplessness, anxiety, and sadness are considered common female stereotypical characteristics. A woman’s identity is therefore not threatened by acknowledgment of such symptoms or the seeking of support. Women are thus believed to be more likely to seek medical or mental health services (Chrisler 2001; Kung et al. 2003; Maris et al. 2000; Moller-Leimkuhler 2003). In contrast, male stereotypes that encourage emotional isolation and suppression of distress do not promote help-seeking or acknowledgment of depression. Such behaviors are considered signs of weakness and dependence and imply loss of control, autonomy, and competence. These are not consistent with perceptions of masculine identity and thus may be avoided, resulting in higher rates of suicide mortality (Good and Sherrod 2001; Maris et al. 2000; Moller-Leimkuhler 2003). Studies support the observation that women use health services more often than do men, even when visits for pregnancy and birthrelated services are factored out (Chrisler 2001). One study found that a greater number of female suicide decedents were more likely than their male counterparts to have had contact with mental health services (Luoma et al. 2002). The effect of this gendered utilization of health ser-
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vices, however, has not been consistently demonstrated to directly correlate with suicide mortality. For example, the 1993 National Mortality Followback Survey found that both male and female suicide decedents were more likely to have used mental health services in the year prior to the suicide (Kung et al. 2003). Older studies found that 75% of individuals who completed suicide had had contact with a physician within 6 months prior to their death (Blumenthal 1990). Because the majority of suicide victims are men, a large proportion of the individuals who contacted physicians were also likely to be men, indicating a willingness to seek help for either a somatic or emotional problem. Even if found to be statistically significant, gender differences in help-seeking behavior seem unlikely to fully explain lower mortality rates in women. In regard to mental health services in general, fewer than a third of people with mental disorders seek treatment, and among those who do, a significant number are misdiagnosed or suboptimally treated (Blehar and Norquist 2002). Moreover, there is evidence that physicians do not take women’s complaints as seriously as men’s. This perspective hinders accurate diagnoses of women’s illnesses, leads to overprescription of psychotropic medications to women, and contributes to the lesser likelihood that women will be referred to specialists for medical services (Chrisler 2001). Thus, even when seeking help, many women are not adequately treated.
Motivation and Intent Another explanation of gender differences in the suicide mortality rate that plays on gender stereotypes focuses on beliefs regarding differences in motivation and intent in suicidal behavior. Research during the 1960s served to sharpen distinctions between fatal and nonfatal suicidal behavior and portrayed the latter as being less aimed at ending life than at changing life. It is now widely believed that a majority of suicidal women have little or no intent to die, resulting in low mortality rates. The nonlethal suicidal acts of women are often interpreted as maladaptive aggressive or affiliative strategies employed to solve interpersonal problems or to influence relationships rather than as a desire to end life (Stephens 1995). It is not uncommon to see suicide attempts by women described pejoratively as manipulative or passive aggressive. Gendered differences in patterns and outcomes of suicide attempts and repeated episodes of deliberate self-harm have been observed (Skogman et al. 2004; Zahl and Hawton 2004). Nevertheless, the issue of lethal intent in women’s suicidal behaviors is unresolved. The model
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that dismisses female nonfatal suicidal acts, particularly in multiple attempters, as spurious “is premature and awaits empirical verification” (Stephens 1995, p. 92). Self-destructive behavior occurs on a continuum of lethality and intent. It can be difficult to determine which behaviors may be gestures without true lethal intent and which behaviors, however minimal in actual lethality, are truly intended to result in death. Indeed, the interpretation of suicide attempts as “gestures” can result in the minimization of behavior that may have profound significance in terms of suicide assessment. In the second case example, an evaluation that focused on Ms. Smith’s past attempts and use of less lethal methods to conclude that her current risk of suicide was low would have been erroneous. Multiple authors have cautioned that the evaluation of lethality of female suicide attempters should consider the severity of the suicidal intent rather than the lethality of the method (Jacobs et al. 1999; Simon 2004; Skogman et al. 2004). Explanations that invoke character traits rather than assessment of intent both reflect and reinforce some of the most negative elements of female gender stereotypes. Help-seeking behavior is considered a female characteristic, closely equated with the negative, less mature, and less valued personality trait of dependency. Similarly, suicide attempts and gestures interpreted as manipulative or controlling behavior are closely related to both dependency and passive aggressiveness, other negative traits strongly associated with women. Perhaps most indicative of the pejorative gender stereotypes that influence gendered perspectives of suicidal behavior is the language used to describe suicide attempts in contrast to that used to describe suicide completions. Suicidal behaviors or attempts that do not result in death—those more commonly associated with women— are often characterized as “failed suicides” or as reflecting passivity or lack of imagination, despite the fact that such attempts are in fact associated with survival. In contrast, the “male pattern” of killing oneself may be characterized as “successful suicide,” despite the fact that it results in death and ends all possibility of adaptation (Canetto and Lester 1995).
Protective Factors in Women The influence of gender stereotypes and gendered approaches to suicide research have obscured perspectives regarding suicide that deserve more extensive study. In the case examples, both Mr. Taylor and Ms. Smith were at high risk for suicide. A focus on risk factors such as those easily recognized in the case of Mr. Taylor leads to overlooking what may be the most clinically significant question related to gender
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(and race, ethnicity, and culture) and suicide: Why did Mr. Taylor kill himself and Ms. Smith choose to continue living? What protects groups other than white males who demonstrate similar demographic risk factors from the high suicide mortality rates demonstrated by white males? As Kaplan and Klein (1989) noted, “Perhaps the most revealing question to look at, especially in terms of future suicide prevention, is ‘What keeps women alive?’” (p. 267). The gender stereotypes noted earlier may indeed provide some protection from suicide for women, although not in the way suggested by traditional explanations based on negative female stereotypes. As noted, completed suicide is viewed as a masculine phenomenon and is considered more permissible for men. Attempted but “failed” suicide is more often identified as a feminine behavior characteristic (Canetto 1995, 2001; Kushner 1995). Researchers have found that both males and females who committed suicide were rated as more masculine and more potent than males and females who simply attempted suicide. Surviving a suicidal act is culturally perceived as inappropriate for males. Older European-American men’s suicides are narrated as acts of independence and courage in the face of adversity. Studies have demonstrated less empathy toward suicidal men. Nevertheless, they have also rated suicide in males less wrong, less foolish, and less weak than suicide in females (Moller-Leimkuhler 2003). Because stereotypes influence behavior, women may be more inhibited from lethal suicidal behavior on the basis of cultural norms. If nonfatal suicide behavior is viewed as weaker and less masculine, males might be more likely to structure any suicidal act in such a way as to reduce the likelihood of surviving. Females, however, might feel less stigma from surviving an attempt and might therefore be likely to engage in less lethal suicidal actions (Stillion 1995). The example of the exception to the low suicide mortality rate of women may support this hypothesis. Chinese American women, who have high suicide rates, come from a culture in which suicide is considered a female behavior. China is the one country where suicide is more common among women than among men, especially in rural areas. As Canetto (2001) concluded, “The cross-cultural data suggest that it is the association of suicide with masculinity that protects most U.S. older women from suicide. Once that association is reversed, as appears to be the case in Chinese communities, women are counted among the suicidal” (pp. 192–193). Conversely, gender stereotypes encourage men to be “tough,” which means suppressing all emotions potentially associated with vulnerability. This cultural male identity often results in dysfunctional health consequences. The relative vulnerability of males to a variety of physical
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and emotional problems may arise from maladaptive coping strategies associated with adhering to masculine stereotypes: emotional inexpressiveness, lack of help-seeking, aggressiveness, risk-taking behavior, violence, alcohol and drug abuse, and suicide. The irony inherent in the ultimate effect of such stereotypes, aimed at producing “strong men,” is the evidence that “stoicism does not produce emotional strength. Indeed, rather than producing strong men, stoicism produces brittle men” (Good and Sherrod 2001, p. 205). Other explorations of the factors that decrease suicide mortality in women look to psychological theory, which has proposed alternative models of healthy female psychological development and mental health (Gilligan 1993; Jordan 1997; Jordan et al. 1991; Miller 1987). This model, based on the centrality of relationships, posits a continuous path of relational development that moves beyond traditional psychodynamic focus on individual psychological development. Interdependency, reciprocity, and mutual empathy are seen as characteristics of healthy relationships. Although members of both sexes can and do engage in such an exchange, our society especially supports this model for women. Powerful cultural norms tend to reinforce relational development in girls to a greater extent than in boys (Kaplan and Klein 1989). The significance of relatedness to others and the importance of social supports appear to serve women both as protection against suicidal urges and as precipitant for nonfatal suicidal behavior (Maris et al. 2000). One of the qualities that stands out in a comparison of female attempters and male completers is the relatively greater interpersonal embeddedness of female attempters. Suicide attempts in women are often precipitated by relational loss, rupture, conflict, or impasse. The women are deeply connected with others, albeit conflictually, and reaching out, albeit dysfunctionally, whereas the men appear much more isolated (Kaplan and Klein 1989). Relational theorists propose that both women and men experience increased psychological difficulties when opportunities to enter into and sustain healthy relationships are unavailable (Kaplan and Klein 1989, p. 257). Within more traditional psychodynamic frameworks, women’s strengths and the positive growth-enhancing aspects of their development remain obscure. These models interpret the need for and attempts to maintain relationships in negative terms such as dependency, passivity, or manipulativeness. From the perspective of relational theory, the context in which suicidal action occurs becomes a central aspect of suicidal behavior. Suicidal action becomes a mode by which the woman makes a desperate plea for mutual engagement: “When a woman’s rela-
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tional priorities and needs are so blocked or distorted that she perceives no further possibilities for growth within relationships[,] her vulnerability to suicide will be greater” (Kaplan and Klein 1989, p. 259). Women may also be protected from suicide by an adherence to ethics based on the centrality of relationships and principles of interdependence, mutuality of caretaking, and responsibility for the well-being of others. These ethics differ from the predominantly male ethic of justice, which centers on principles of right and wrong (Gilligan 1993). This proposed female “ethic of care” defines a moral responsibility to avoid hurting others. This may prevent women from taking actions such as suicide that would cause pain to others, particularly to dependent children (Canetto 2001; Kushner 1995). For a woman to make the decision to kill herself, and to therefore abandon her relationships with or to hurt others, “stands in direct opposition to the values most central to her core identity as a relational being” (Kaplan and Klein 1989, p. 260). The importance of relationships and relatedness to others (including childbearing and child care) may provide a core framework for understanding suicidal behavior in women (Maris et al. 2000). Epidemiological data indicate that having a child in the home under age 18 has been found to reduce the risk of suicide in women but not in men (Kung et al. 2003; Maris et al. 2000; Young et al. 1994). Clinical observations indicate that the psychological experience of a seriously suicidal woman often includes feeling torn by an anguished struggle between the need to alleviate her own unbearable pain and her sense of responsibility to avoid hurting those who would be affected by her death (Kaplan and Klein 1989). The clinical implications of these protective factors are profound. In the case examples presented earlier in this chapter, Ms. Smith ultimately chose not to kill herself because of the effect her death would have on her mother. Should Ms. Smith’s mother die, and Ms. Smith’s level of depression (and access to a firearm) remain unchanged, her risk for suicide would increase considerably. It is possible that had Mr. Taylor been more engaged with his adult children, the risk of his committing suicide in response to his problems would have been decreased. Women also demonstrate more adaptational and flexible coping styles than do men. Many women demonstrate a willingness to try to resolve problems in a variety of ways and in ways that include connecting with others. Studies of suicide prevention center utilization confirm the significantly greater tendency for women to seek and benefit from contact with these helping facilities, although as noted, they cannot entirely explain the gender gap in mortality rates. Nevertheless, gender differences in suicidal behavior may reflect a tendency for males to respond
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with a more rigid position to stress, conflict, and frustration. Females may have a greater tendency to adopt flexible positions, such as seeking help, thus maximizing their chances for attachment and assistance (Canetto 1995; Maris et al. 2000). In contrast, men “tend to move more readily to a position of giving up and ending a perceived intolerable state of being” (Maris et al. 2000, p. 157), increasing their risk of suicide. The relational model may also explain the differential effects of more traditionally recognized suicide risk factors. For example, marriage without reference to gender is commonly cited as a protective factor against suicide (Maris et al. 2000; Slaby 1998). Nevertheless, it appears that marriage protects men from suicide more than it does women (Kposowa 2000). The relational model provides insight into how the social and psychological benefits provided by marriage differ for men and women. Males are less socially integrated and report fewer sources of support. Often the only source of support is their spouse, who may also mediate their relationships with children, other family members, and friends. When men lose their spouses, their social relationships are more disrupted. Women, on the other hand, seem to form greater supportive networks, such as meaningful friendships, regardless of their marital status. Accordingly, even when a marriage ends in divorce or death, women can fall back on resources of social bonds and support often unavailable to men (Kposowa 2000; Moller-Leimkuhler 2003).
Gendered Issues in Suicide Exploration of the role of gender in suicide has included a number of speculative investigations. For example, several studies have reported that women with cosmetic breast implants have a two to three times higher rate of death from suicide than similar-age women in the general population. These studies are flawed, and no conclusions can be drawn from their findings (McLaughlin et al. 2003). Some researchers have proposed the existence of a “male depressive syndrome,” a subtype of depression clinically limited to men (Walinder and Rutz 2001). The validity of this concept has limited support. Other explorations of gender have included investigations of whether male and female suicides jump from different heights (apparently not; Lester 2003) and whether suicide notes written by men and women differ (maybe; Maris et al. 2000). Certain gendered issues related to suicide have been explored to at least some degree with research that demonstrates some clinical significance or epidemiological validity. These gender-related issues are worth reviewing both in and of themselves and for their ability to elucidate gender-related protective as well as risk factors for suicide.
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Childhood Sexual Abuse A history of childhood sexual abuse is another recognized suicide risk factor. Childhood sexual abuse is associated with a higher rate of adult psychopathology generally, including adult suicide behaviors (Maris et al. 2000; Martin et al. 2004; Simon 2004). This factor is also more commonly associated with women than with men, because childhood sexual abuse is more common among women. Approximately 20%–25% of women report such experiences, compared with 5%–10% of men (Finkelhor 1994). Nevertheless, although more common among girls, the experience of childhood sexual abuse carries more consequences for boys in regard to alcohol and drug use, aggressive behavior, truancy, and suicidal ideation and plans. Community-based studies have found the risk of suicide in abused boys to be markedly elevated not only when compared with nonabused boys but also when compared with the increased risk among abused girls (Martin et al. 2004; Molnar et al. 2001). The possibility that gender-related protective factors might mitigate the risk of suicide in sexually abused girls must be considered but remains to be investigated.
Women Physicians and Suicide Studies examining rates of suicide in women physicians consistently report substantially higher rates of suicide for this professional group, four times higher than for the national female rate. Research into the association of specific occupations and suicide has been marked by methodological problems and inconsistencies (Frank and Dingle 1999; Stack 2000). Research on the incidence of suicide among physicians is marked by considerable debate over the extent to which physicians generally are at risk for suicide or whether the high rates noted reflect the demographics associated with white males, who make up the majority of this profession (Stack 2000). A meta-analysis reviewing the research in this area noted that both male and female physicians show elevated suicide ratios when compared with the general population. Although the male physicians’ rate was modestly elevated, at 1.41, the female physicians’ rate was highly elevated, at 2.27. However, the issue of the bias of the studies regarding female physicians and suicide was also noted, especially in regard to creating an appearance of elevated rates that may in fact not be accurate (Schernhammer and Colditz 2004). A number of groups of professionals are noted to have elevated suicide rates. These include physicians, nurses, pharmacists, veterinarians, chemists, lawyers, and psychologists (Stack 2000). High suicide rates
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have been found among female chemists, psychologists, and university professors as well as physicians (Yang and Lester 1995). Researchers have also observed the preponderance of professions that have access to lethal methods of suicide in these groups. Thus, studies that have found elevated risk of suicide in female members of these professions may indeed reflect the elevated risk in these occupations due to such access (Brockington 2001; Frank and Dingle 1999; Stack 2000). This implies that whatever protective factors may be associated with gender can be outweighed by access to lethal means of suicide. The prevalence of suicide among women physicians in the United States and the presence of associated factors such as psychiatric disorders and suicidal behavior have actually received little systematic investigation. Available studies are methodologically flawed in a variety of ways, including the problems associated with small sample sizes (Frank and Dingle 1999; Schernhammer and Colditz 2004; Yang and Lester 1995). Depression, drug abuse, and alcoholism are often associated with suicides of physicians. Women physicians in particular have been shown to have a higher frequency of alcoholism and a higher incidence of depression than women in the general population (Schernhammer and Colditz 2004). Nevertheless, although the suicide completion rate of female physicians seems to be higher than that of other women and higher than the rate of male physicians, their suicide attempt rate may be lower. One study found that 1.5% of women physicians reported having attempted suicide, and 19.5% reported a history of depression. Those with a history of depression were substantially more likely to have attempted suicide than were those without a history of depression (7% and 0.2% respectively). The rate of 1.5% for suicide attempts is low even compared with the rate of attempts—approximately 4%—reported generally among U.S. women. Women physicians may therefore have lower rates of suicidal intent and/or higher rates of completion than women in the general population (Frank and Dingle 1999). Various hypotheses have been advanced to explain physician suicide generally and higher rates in women physicians in particular. Affective disorders and substance abuse are the most common psychiatric diagnoses noted, and as in other gender subgroups, the risk associated with these disorders appears to outweigh any protective factors. The possibility of higher rates of completion relative to data about occupational access to lethal methods and increased incidence of drug and alcohol abuse may decrease some of the association of gender-related issues. Other explanations take social and cultural perspectives. Many believe that the practice of medicine poses additional stresses for
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women, including prejudice and discrimination, the lack of women role models, role conflict, and inadequate family and institutional support (Bowman and Allen 1985; Frank and Dingle 1999; Stack 2000; Yang and Lester 1995). Gender stereotypes both suggest and support such explanations. However, gendered beliefs also have their own effect on assumptions underlying research and thus may be a source of distortion in both results and interpretation of data. Most of the research on women, employment, and suicide mortality has focused on those occupations with the highest prestige, such as women physicians, whereas research on men has considered the full range of occupational types (Yang and Lester 1995). This may be an artifact of the practice, persistent since the nineteenth century, of barring or limiting women from professional types of employment. Women were believed to be suited only for domestic labor, and education and paid employment outside the home were believed detrimental to their mental and physical health. In fact, evidence on suicide mortality generally does not support the assumption that working outside the home, regardless of type of occupation, leads to more psychopathology and suicide in women. At the aggregate level, participation in the labor force is associated with a lowered risk of death from suicide for women, even though some groups of professional women do appear to have an increased risk of death from suicide. In addition, suicidal behavior in women demonstrates the same pattern in response to employment as that found in men: for both, unemployment, as well as certain professional careers, seems to increase the risk of suicide (Yang and Lester 1995).
Personality Disorders Patients with personality disorders are at seven times greater risk for suicide than the general population. Of all patients who commit suicide, 30%–40% have personality disorders (Simon 2004). Cluster B diagnoses, and especially borderline personality disorder (BPD), are associated with suicidal acts. Studies have found rates of suicide in BPD ranging from 4% to 9.5% (Jacobs et al. 1999). BPD is in fact the only personality disorder in which recurrent suicidal threats, gestures, or behavior or self-mutilative behaviors are one of the formal diagnostic criteria. The comorbidity of Axis I disorders makes suicidal acts more likely (Jacobs et al. 1999; Maris et al. 2000; Simon 2004). BPD is also a diagnosis primarily associated with women. The rate of BPD in the general population is 2%–3%, but the ratio of women to men who meet the criteria for BPD is 2:1 or even higher (Phillips et al.
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2003). The influence of gender stereotypes in the construction of this diagnosis has been extensively discussed and is the subject of ongoing debate (Hensley and Nurnberg 2002). The association of female stereotypical characteristics as criteria for this diagnosis of psychopathology, including suicide gestures and attempts, has been well documented. Also consistent with female gender stereotypes, the incidence of suicide attempts outnumbers that of suicide completions. Actual suicide attempts (as opposed to suicide threats or gestures) occur in 60%–70% of borderline patients, and this group usually makes multiple attempts, with an average of three. In contrast, the rate of suicide in clinical samples of BPD is about 9%—about 400 times the rate of suicide in the general population and more than 800 times the rate in young females. Still, when contrasted with the 60%–70% of borderline patients who make multiple suicide attempts, the 9% figure actually reflects the high frequency with which borderline patients make suicide attempts that do not result in death (Gunderson and Ridolfi 2001). Because depression is a common comorbid diagnosis, and given the number of suicide attempts, higher rates would be expected. These findings again raise questions about protective factors associated with women that have not yet been elucidated. Antisocial personality disorder is another gendered Cluster B diagnosis, one found more frequently in men than in women. About 3% of men and 1% of women meet criteria for this diagnosis (Phillips et al. 2003). It is associated primarily with externally directed violence but is also associated with a suicide rate of 5% (Perry 1999). Relatively little research is available in regard to the association of antisocial personality and suicide. The 5% rate of completed suicides cited may include persons with concurrent Axis I depressive disorders, substance use disorders, or personality disorders that themselves increase the risk of suicide (Jacobs et al. 1999). More serious attempts appear to be associated with substance abuse, depression, and comorbid BPD. Thus, the risk of suicide associated specifically with antisocial personality disorder is unknown and remains to be explored (Jacobs et al. 1999; Perry 1999; Weiss and Hufford 1999).
Suicide During Pregnancy and the Postpartum Period Despite high rates of psychiatric morbidity, including elevated levels of depression, during childbearing years as well as postpartum depression and psychosis (Nonacs and Cohen 2003; Sloan and Kornstein 2003), studies have found a low risk of fatal self-harm in childbearing women. Pregnancy
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and recent motherhood appear to protect against suicidal behavior, consistent with research indicating that having a child in the home under age 18 decreases the risk of suicide. The suicide rates for women during pregnancy and up to 2 years postpartum are fractions of those expected after adjustment for age (Appleby 1996; Oates 2003). In one Canadian study (Turner et al. 2002), only 0.02%–0.2% of maternal deaths resulted from suicide in the period between 20 weeks of gestation and 42 days postpartum. In the period of 43 days to 225 days postpartum, 0.5%–1.0% of deaths were due to suicide. The researchers concluded, “Although postpartum depression clearly affects many women, it apparently does not result in an increased incidence of suicide” (Turner et al. 2002, p. 35). Notably, the risk of suicide associated with severe psychiatric illness, particularly psychosis, appears to outweigh the protection conferred by pregnancy and childbirth. Although postnatal women in general may have a low rate of suicide, those who develop severe postpartum illness are at high risk, particularly during the first year after childbirth (Appleby et al. 1998). In one study in which suicide was the leading cause of all maternal deaths either during pregnancy or up to 1 year postdelivery, 85% of the women had identified psychiatric problems and were receiving treatment. At least 68% were psychotic or had severe depressive illness (Oates 2003). In another study, suicides that did occur were by committed by psychotic women (Appleby 1996). One group of researchers found that the overall risk of suicide in women admitted to psychiatric hospitals in the year following childbirth increased 70-fold. This figure was consistent with the elevated suicide rates found within the first year of discharge of individuals hospitalized for psychosis (Appleby et al. 1998) and in particular in the first week after discharge (Qin and Nordentoft 2005).
Murder-Suicide Gendered patterns are also prominent in the rare but tragic incidence of murder-suicide. This event occurs much less frequently than either simple suicide or homicide. Roughly 1.5%–4% of all suicides and 5% of all homicides in the United States occur in the context of murder-suicide (Jacobs et al. 1999; Nock and Marzuk 1999). Homicide-suicide rates have been reported to range from 0.2 to 0.5 per 100,000 persons (Malphurs and Cohen 2002). The majority of homicide-suicides are spousal/consortial (70.5%), followed by infanticidal/pedicidal (10.5%) (Malphurs and Cohen 2002). Overall, 93%–97% of perpetrators of murder-suicide are male. Over 85% of all victims are female (Felthous et al. 2001; Nock and Marzuk 1999). The most frequent subtype of murder-suicide, killing the spouse at the
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same time as committing suicide, is mainly a male behavior pattern (Brockington 2001). Men are responsible for 90% of this type of incident, which is usually committed with a firearm and occurs in the context of a chaotic and abusive relationship (Felthous et al. 2001; Malphurs and Cohen 2002; Nock and Marzuk 1999). In contrast, the gender differential in spousal murder is less pronounced: 57% of simple spousal homicides are committed by men and 47% by women. Women who kill their husbands are much less likely to commit suicide afterward. From 19% to 26% of male spouse murderers commit suicide, compared with only 0%–3% of females. Most wifeperpetrated homicides are preceded by a history of violence by the husband; the murderous act is often unintentional or in self-defense. Men who kill their female partners, on the other hand, often do so in response to the women’s attempt to leave an abusive relationship (Nock and Marzuk 1999). Filicide-suicide, the second most common type of murder-suicide, also demonstrates gendered patterns. These incidents account for only about 6%–10% of all murder-suicide incidents. At least half of all pedicides (murder of a child ages 1–16) and infanticides (children under the age of 1 year) are perpetrated by a parent, most often the mother. In the United States, 16%–29% of mothers and 40%–60% of fathers commit suicide after murdering their own children over 1 year of age. This percentage falls to 2.3% of mothers and 10.5% of fathers when one considers only infanticide-suicides. A mother tends to kill only her children and herself. In contrast, a father who kills his children is more likely to kill his entire family, including his spouse (Malphurs and Cohen 2002; Nock and Marzuk 1999). In addition, mothers with severe postpartum depression and psychotic disorders commit a significant percentage of reported infanticides. Among mothers who commit infanticide, one study found, 62% commit suicide (Attia et al. 1999; Brockington 1996). In one of the studies of suicide during pregnancy and the postpartum period reviewed in the previous section, 5% of the suicides also committed infanticide (Appleby 1996). One author has estimated that two-thirds of mothers who kill their children attempt suicide. These women are generally motivated from the wish to spare the children from some external impending harm or from enduring the pain of being motherless after the mother commits suicide (Brockington 1996). These findings provide a chilling reminder that even a powerful protective factor can give way to fatal consequences in the context of severe psychiatric disorder, the most significant risk factor for suicide.
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Assisted Suicide Assisted suicide cases demonstrate a puzzling gendered pattern. The majority of cases of assisted suicide or euthanasia, whether practiced legally or illegally, for which information about ethnicity is available involve white women. Women represent half of the assisted suicide cases in Oregon and the Northern Territory of Australia and 70% of the Michigan Kevorkian cases (Canetto 2001). Of Kevorkian’s first 8 clients, all were women. Of his first 15 clients, 12 were women (Maris et al. 2000). In the Netherlands, women constitute about one-third of assisted suicides but more than half of the voluntary euthanasia cases. Women represent half (in the Netherlands and Australia) to two-thirds (in the United States) of nonvoluntary euthanasia cases. In the United States, dependence due to incapacity, loss of control of body functions and its consequent loss of autonomy, and altruistic concerns about being a burden appear to influence decisions for assisted suicide (Canetto 2001). The high rates of women involved in assisted suicide, given their low suicide rates, raise questions about gender influences in this controversial practice.
Conclusion Suicide is a complex behavior, and many factors besides gender play a role in determining the outcome of any set of circumstances resulting in a suicide attempt in any individual. Sociodemographic, psychiatric, biological, familial, and situational risk factors are not mutually exclusive. They can and do co-occur, and it is their comorbidity that may carry the greatest risk for suicide (Moscicki 1995; Simon 2004). In addition, all discussions of gender recognize that there is no generic female, just as there is no generic male. Factors such as race, religion, and culture will result in as many differences among women and men as there may be similarities. Moreover, some of the protective factors associated with female gender will apply to some men and will also not apply to some women. Nevertheless, protective factors specific to women (and ethnic and age groups) require further elucidation. One of the challenges for suicide research is to explain the gender paradox of high rates of depression and suicide attempts and low rates of suicide in women, and lower rates of depression and suicide attempts and high rates of suicide in men. Investigations from this perspective can provide opportunities to further our understanding of suicidal behavior. Mental health issues relevant to both women and men that would most readily emerge through the study of women and ethnic minorities have been over-
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looked (Canetto 2001). Insights developed through such research may well result in therapeutic interventions that could be utilized to reduce the suicide rates of high-risk populations as well as those of individuals in low-risk populations who may develop risk factors that increase their suicide potential.
❏ Key Points ■
Women demonstrate more depressive illness and suicide attempts than do men. Despite the association of these two major risk factors with suicide completion, women have lower suicide mortality rates.
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Protective factors related to gender decrease the risk of suicide mortality in women. These include the role of relationships in women’s psychological development and mental health and women’s sense of responsibility to others based on an ethic of caring and avoiding harm to others.
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Further elucidation of these and other as yet unknown genderrelated protective factors can be utilized to assist high-risk populations and individuals by suggesting therapeutic interventions that may reduce their risk of suicide.
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Studies that examine suicide risk factors in white male populations yield results that do not necessarily apply to female or nonwhite male groups. Relatively few studies examining suicide in nonwhite male groups exist.
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Generalization of results of male-focused research leads to the reinforcement and perpetuation of gender stereotypes in psychiatry.
References Alston MH, Anderson SE: Suicidal behavior in African-American women, in Women and Suicidal Behavior. Edited by Canetto SS, Lester D. New York, Springer, 1995, pp 133–143 American Association of Suicidology: Suicide Statistics Archive 1996–2002. Washington, DC, American Association of Suicidology, 2004. Available at: http://mypage.iusb.edu/~jmcintos/datayrarchives.htm. Accessed October 2, 2004. Appleby L: Suicidal behavior in childbearing women. Int Rev Psychiatry 8:107– 115, 1996 Appleby L, Mortensen PB, Faragher EB: Suicide and other causes of mortality after post-partum psychiatric admission. Br J Psychiatry 173:209–211,1998 Arana GW, Hyman S: Biological contributions to suicide, in Suicide: Understanding and Responding. Harvard Medical School Perspectives. Edited by Jacobs D, Brown HN. Madison, CT, International Universities Press, 1989, pp 73–86
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Attia E, Downey J, Oberman M: Postpartum psychoses, in Postpartum Mood Disorders. Edited by Miller LJ. Washington, DC, American Psychiatric Press, Inc., 1999, pp 99–117 Blehar MC, Norquist G: Mental health policy and women, in Women’s Mental Health: A Comprehensive Textbook. Edited by Kornstein SG, Clayton AH. New York, Guilford, 2002, pp 613–627 Blumenthal SJ: An overview and synopsis of risk factors, assessment, and treatment of suicidal patients over the life cycle, in Suicide Over the Life Cycle: Risk Factors, Assessment and Treatment of Suicidal Patients. Edited by Blumenthal SJ , Kupfer DJ. Washington, DC, American Psychiatric Press, 1990, pp 685–733 Bowman MA, Allen DI: Stress and Women Physicians. New York, SpringerVerlag, 1985 Brady KT, Randall CL: Gender differences in substance use disorders. Psychiatr Clin North Am 22:241–252, 1999 Brent DA: Firearms and suicide. Ann NY Acad Sci 932:225–240, 2001 Brockington IF: Motherhood and Mental Health. Oxford, England, Oxford University Press, 1996 Brockington IF: Suicide in women. Int Clin Psychopharmacol 16(suppl):S7–S19, 2001 Canetto SS: Elderly women and suicidal behavior, in Women and Suicidal Behavior. Edited by Canetto SS, Lester DL. New York, Springer, 1995, pp 215–233 Canetto SS: Older adult women: issues, resources, and challenges, in Handbook of the Psychology of Women and Gender. Edited by Unger RK. New York, Wiley, 2001, pp 183–197 Canetto SS, Lester D: Women and suicidal behavior: issues and dilemmas, in Women and Suicidal Behavior. Edited by Canetto SS, Lester D. New York, Springer, 1995, pp 3–7 Canterbury RJ: Alcohol and other substance use, in Women’s Mental Health: A Comprehensive Textbook. Edited by Kornstein SG, Clayton AH. New York, Guilford, 2002, pp 222–243 Carroll-Ghosh T, Victor BS, Bourgeois JA: Suicide, in The American Psychiatric Publishing Textbook of Clinical Psychiatry, 4th Edition. Edited by Hales RE, Yudofsky SC. Washington, DC, American Psychiatric Publishing, 2003, pp 1457–1483 Chrisler JC: Gendered bodies and physical health, in Handbook of the Psychology of Women and Gender. Edited by Unger RK. New York, Wiley, 2001, pp 201–214 Conner KR, Zhong YY: State firearm laws and rates of suicide in men and women. Am J Prev Med 25:320–324, 2003 Cooper J, Kapur N, Webb R, et al: Suicide after deliberate self-harm: a 4-year cohort study. Am J Psychiatry 162:297–303, 2005 Dubovsky SL, Davies R, Dubovsky AN: Mood disorders, in The American Psychiatric Publishing Textbook of Clinical Psychiatry. Edited by Hales RE, Yudofsky SC. Washington, DC, American Psychiatric Publishing, 2003, pp 439–542 Durkheim E: Suicide: A Study in Sociology (1897). Translated by Spaulding JA, Simpson G. London, England, Routledge and Kegan Paul, 1952 Felthous AR, Hempel AG, Heredia A, et al: Combined homicide-suicide in Galveston County. J Forensic Sci 46:586–592, 2001
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Finkelhor D: The international epidemiology of child sexual abuse. Child Abuse Negl 19:409–417, 1994 Frank E, Dingle AD: Self-reported depression and suicide attempts among U.S. women physicians. Am J Psychiatry 156:1887–1894, 1999 Garlow SJ: Age, gender and ethnicity differences in patterns of cocaine and ethanol use preceding suicide. Am J Psychiatry 159:615–619, 2002 Garlow SJ, Purselle D, Heninger M: Ethnic differences in patterns of suicide across the life cycle. Am J Psychiatry 162:319–323, 2005 Gilligan C: In a Different Voice: Psychological Theory and Women’s Development, 2nd Edition. Cambridge, MA, Harvard University Press, 1993 Good GE, Sherrod NB: The psychology of men and masculinity: research status and future directions, in Handbook of the Psychology of Women and Gender. Edited by Unger RK. New York, Wiley, 2001, pp 201–214 Gunderson JG, Ridolfi ME: Borderline personality disorder: suicidality and selfmutilation. Ann NY Acad Sci 932:61–73, 2001 Hensley PL, Nurnberg HG: Personality disorders, in Women’s Mental Health: A Comprehensive Textbook. Edited by Kornstein SG, Clayton AH. New York, Guilford, 2002, pp 323–343 Jacobs DG, Brewer M, Klein-Benheim M: Suicide assessment: an overview and recommended protocol, in The Harvard Medical School Guide to Suicide Assessment and Intervention. Edited by Jacobs DG. San Francisco, CA, JosseyBass, 1999, pp 3–39 Jordan JV (ed): Women’s Growth in Diversity: More Writings From the Stone Center. New York, Guilford, 1997 Jordan JV, Kaplan AG, Miller JB, et al (eds): Women’s Growth in Connection: Writings From the Stone Center. New York, Guilford, 1991 Kaplan AG, Klein RB: Women and suicide, in Suicide: Understanding and Responding. Harvard Medical School Perspectives. Edited by Jacobs D, Brown HN. Madison, CT, International Universities Press, 1989, pp 257–282 Kaplan MS, Adamek ME, Geling O, et al: Firearm suicide among older women in the U.S. Soc Sci Med 44:1427–1430, 1997 Kessler RC, Nelson CB, McGonagle KA, et al: The epidemiology of co-occurring addictive and mental disorders: implications for prevention and service utilization. Am J Orthopsychiatry 66:17–31, 1996 Kornstein SG, Wojcik BA: Depression, in Women’s Mental Health: A Comprehensive Textbook. Edited by Kornstein SG, Clayton AH. New York, Guilford, 2002, pp 147–165 Kposowa AJ: Marital status and suicide in the National Longitudinal Mortality Study. J Epidemiol Community Health 54:254–261, 2000 Kung HC, Pearson JL, Liu X: Risk factors for male and female suicide decedents ages 15–64 in the United States: results from the 1993 National Mortality Followback Survey. Soc Psychiatry Psychiatr Epidemiol 38:419–426, 2003 Kushner HI: Women and suicidal behavior: epidemiology, gender, lethality in historical perspective, in Women and Suicidal Behavior. Edited by Canetto SS, Lester D. New York, Springer, 1995, pp 11–34 Lester D: Do male and female suicides jump from different heights. Percept Mot Skills 96:798, 2003 Luoma JB, Martin CE, Pearson JL: Contact with mental health and primary care prior to suicide: a review of the evidence. Am J Psychiatry 159:909–916, 2002
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Malphurs JE, Cohen D: A newspaper surveillance study of homicide-suicide in the United States. Am J Forensic Med Pathol 23:142–148, 2002 Mann JJ, Arango V: The neurobiology of suicidal behavior, in The Harvard Medical School Guide to Suicide Assessment and Intervention. Edited by Jacobs DG. San Francisco, CA, Jossey-Bass, 1999, pp 98–114 Maris RW, Berman AL, Silverman MM: Comprehensive Textbook of Suicidology. New York, Guilford, 2000 Martin G, Bergen HA, Richardson AS, et al: Sexual abuse and suicidality: gender differences in a large community sample of adolescents. Child Abuse Negl 28:491–503, 2004 McLaughlin JK, Lipworth L, Tarone RE: Suicide among women with cosmetic breast implants: a review of epidemiologic evidence. J Long Term Eff Med Implants 13:445–450, 2003 Molnar BE, Berkman LF, Buka SL: Psychopathology, childhood sexual abuse and other childhood adversities: relative links to subsequent suicidal behavior in the US. Psychol Med 31:965–977, 2001 Miller JB: Toward a New Psychology of Women, 2nd Edition. Boston, MA, Beacon Press, 1987 Moller-Leimkuhler AM: The gender gap in suicide and premature death, or why are men so vulnerable? Eur Arch Psychiatry Clin Neurosci 253:1–8, 2003 Moscicki EK: Epidemiology of suicide. Int Psychogeriatr 7:137–148, 1995 Moscicki EK: Epidemiology of suicide, in The Harvard Medical School Guide to Suicide Assessment and Intervention. Edited by Jacobs DG. San Francisco, CA, Jossey-Bass, 1999, pp 40–51 National Institute of Mental Health: Suicide Facts. Bethesda, MD, National Institute of Mental Health, 2003. Available at: http://www.nimh.nih.gov/ suicideprevention/suifact.cfm. Accessed Nov 11, 2004. Nock MK, Marzuk PM: Murder-suicide: phenomenology and clinical implications, in The Harvard Medical School Guide to Suicide Assessment and Intervention. Edited by Jacobs DG. San Francisco, CA, Jossey-Bass, 1999, pp 188–209 Nonacs R, Cohen LS: Assessment and treatment of depression during pregnancy: an update. Psychiatr Clin North Am 26:547–562, 2003 Oates M: Suicide: the leading cause of maternal death. Br J Psychiatry 183:279– 281, 2003 Perry JC: Personality disorders, suicide and self-destructive behavior, in The Harvard Medical School Guide to Suicide Assessment and Intervention. Edited by Jacobs DG. San Francisco, CA, Jossey-Bass, 1999, pp 157–169 Phillips KA, Yen S, Gunderson JG: Personality disorders, in The American Psychiatric Publishing Textbook of Clinical Psychiatry. Edited by Hales RE, Yudofsky SC. Washington, DC, American Psychiatric Publishing, 2003, pp 803–832 Qin P, Nordentoft M: Suicide risk in relation to psychiatric hospitalization. Arch Gen Psychiatry 62:427–432, 2005 Regier DA, Boyd JH, Burke JD Jr, et al: One-month prevalence of mental disorders in the United States: based on five Epidemiologic Catchment Area sites. Arch Gen Psychiatry 45:977–86, 1988 Regier DA, Farmer ME, Rae DS, et al: Comorbidity of mental disorders with alcohol and other drug abuse: results from the Epidemiologic Catchment Area (ECA) study. JAMA 264:2511–2518, 1990
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Romero MP, Wintemute GJ: The epidemiology of firearm suicide in the United States. J Urban Health 79:39–48, 2002 Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment. Am J Psychiatry 161:2295–2301, 2004 Simon RI: Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management. Washington, DC, American Psychiatric Publishing, 2004 Skogman K, Alsen M, Ojehagen A: Sex differences in risk factors for suicide after attempted suicide: a follow-up study of 1052 suicide attempters. Soc Psychiatry Psychiatr Epidemiol 39:113–120, 2004 Slaby AE: Outpatient management of suicidal patients, in Risk Management with Suicidal Patients. Edited by Bongar B, Berman AL, Maris RW, et al. New York, Guilford, 1998 Sloan DME, Kornstein SG: Gender differences in depression and response to antidepressant treatment. Psychiatr Clin North Am 26:581–594, 2003 Stack S: Work and the economy, in Comprehensive Textbook of Suicidology. Edited by Maris RW, Berman AL, Silverman MM. New York, Guilford, 2000, pp 193–221 Steffens DC, Blazer DG: Suicide in the elderly, in The Harvard Medical School Guide to Suicide Assessment and Intervention. Edited by Jacobs DG. San Francisco, CA, Jossey-Bass, 1999, pp 443–462 Stephens BJ: The pseudocidal female: a cautionary tale, in Women and Suicidal Behavior. Edited by Canetto SS, Lester D. New York, Springer, 1995, pp 85–108 Stillion JM: Through a glass darkly: women and attitudes toward suicidal behavior, in Women and Suicidal Behavior. Edited by Canetto SS, Lester D. New York, Springer, 1995, pp 71–84 Turner LA, Kramer MS, Liu S: Cause-specific mortality during and after pregnancy and the definition of maternal death: Maternal Mortality and Morbidity Study Group of the Canadian Perinatal Surveillance System. Chronic Dis Can 23:31–36, 2002 Walinder J, Rutz W: Male depression and suicide. Int Clin Psychopharmacol 16(suppl):S21–S24, 2001 Webster Rudmin F, Ferrada-Noli M, Skolbekken JA: Questions of culture, age and gender in the epidemiology of suicide. Scand J Psychol 44:373–338, 2003 Weiss RD, Hufford MR: Substance abuse and suicide, in The Harvard Medical School Guide to Suicide Assessment and Intervention. Edited by Jacobs DG. San Francisco, CA, Jossey-Bass, 1999, pp 300–310 Willis LA, Coombs DW, Drentea P, et al: Uncovering the mystery: factors of African American suicide. Suicide Life Threat Behav 33:412–429, 2003 Wintemute GJ, Parham CA, Beaumont JJ, et al: Mortality among recent purchasers of handguns. N Engl J Med 341:1583–1589, 1999 Yang B, Lester D: Suicidal behavior and employment, in Women and Suicidal Behavior. Edited by Canetto SS, Lester D. New York, Springer, 1995, pp 97– 108 Young MA, Fogg LF, Scheftner WA, et al: Interactions of risk factors predict suicide. Am J Psychiatry 151:434–435, 1994 Zahl DL, Hawton K: Repetition of deliberate self-harm and subsequent suicide risk: long-term follow-up study of 11,583 patients. Br J Psychiatry 185:70– 75, 2004
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Social, Cultural, and Demographic Factors in Suicide Leslie Horton, M.D., Ph.D.
More than 1 million people died worldwide by suicide in the year 2000. Although most individuals who commit suicide have a major mental illness (especially depression and/or drug or alcohol abuse), suicide is more likely to occur, even in those with a mental illness, during periods of social, economic, family, and individual crisis. Although suicide is clearly multifactorial in cause, loss is a recurrent theme in events leading up to suicide: loss of a loved one, loss of employment, loss of “face,” loss of social support/social integration, and, ultimately, loss of a reason to live. Suicide is an emotionally heightened event, symbolically rich and driven by powerful motivations, anxieties, and fantasies. Although suicide is ultimately a most personal and individual act, it is also, paradoxically, a public event, a tear in the social fabric, and as such it sheds light on tensions within the family and society. Durkheim’s (1897/1966) influential study Suicide: A Study in Sociology was an attempt to show that suicide was a result of determinable social influences. In his comparison of suicide rates in urban and rural populations, different countries and different religious groups, he concluded that suicide was more prevalent where social ties were deteriorating. For Durkheim, the eroding of community ties was profoundly destruc-
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tive for the individual. Contemporary research has bolstered this claim (Duberstein et al. 2004). Suicide cannot be understood by any single perspective or approach. It cannot be clinically understood or prevented without careful individual psychological study of the particular person’s suffering. Yet suicide is not just an epiphenomenon of depression, because most depressed individuals do not become suicidal, and suicide can occur as depression lifts. Not everyone who commits suicide is mentally ill. There is socially expected and religiously sanctioned suicidal action. For example, suicide is culturally elaborated in Japan, where a variety of terms are used to describe it, including “suicide following the master’s death,” “sacrificial suicide,” “suicide for indignation,” “suicide for expiating mistakes,” and “suicide for remonstration” (Tseng 2001, p. 393). Suicide can result from shame or loss of face. Suicide after bankruptcy is a socially acceptable act in Japan, because it is believed to spare the family from generations of shame. In many societies, personality is “sociocentric” rather than “egocentric.” In sociocentric societies, identity comes from membership in a group, usually the extended family. Individual needs are often subordinated to those of the group, causing painful tensions. Yet social obligations are highly valued and can create a deep sense of personal wellbeing and safety. In these cultures, sadness or emotional pain that emerges from social stress or interpersonal conflict is usually not seen as a psychiatric problem. Yet hidden tensions may erupt into open conflict in rigid social and family structures. Negotiation of this conflict may be seriously restricted, and suicide may be the final outcome of a power struggle. Egocentric societies, on the other hand, have their identity centered in the individual self; personal freedom is valued, whereas dependency is not. The “rugged individual” is highly valued in the United States, but the flip side is that the playing field is not always equal. There is unequal access to resources and a greater gap between the wealthy and the poor in the United States than in many other modern industrialized societies. When these stressors are combined with isolation and free access to guns, suicide may be more likely. Culture can shape the nature of a stressor and sanction the appropriate response, up to and including suicide. Individual emotional structures act in tension with social organization and cultural values. Therefore, understanding suicide requires recognizing that although suicide is an individual act, it is shaped by sociocultural context and influenced by sociocultural factors.
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Cultural Case Study: Suicide in the Western Pacific Island of Tikopia In 1961, British social anthropologist R. Firth published an account of suicidal behaviors among the Tikopia, a small-scale communal society in the most easterly region of the Solomon Islands, considered culturally part of Western Polynesia (Firth 1961). Tikopia is a small volcanic island, about 6 square miles in size. Traditionally, if a young man or woman was particularly offended or hurt, they acted upon this hurt by swimming out to sea. Suicide was locally viewed as an aggressive revenge on the community. Yet there was also a role for “suicidal gestures.” An islander remarked to the anthropologist: “A woman who is reproved or scolded desires to die, yet desires to live. Her thought is that she will go to swim, but be taken up in a canoe by men who will seek her out to find her. A woman desiring death swims to seawards; she acts to go and die. But a woman who desires life swims inside the reef” (Firth 1961, p. 12; discussed in Littlewood 2002, pp. 41–42). For the survivor of a “swim to sea” suicide, there was the possibility of payoff, of improved status, and the chance to revisit and potentially resolve the original conflict. For an adolescent girl in conflict with her family over their authority and control, her reintegration back into the community would de-escalate and stabilize the situation. However, sympathy for the Tikopian swimmer is fleeting; it fades with repetition. Those who “swim to sea” can swim once too often.
Demographics The overall suicide rate in the United States fell between 1990 and 2002. The reasons for this decline are unknown, although more aggressive treatment of depression may be a factor, especially for youth. The numbers are still unacceptably high, however, with approximately 30,000 deaths annually attributed to suicide compared with approximately 20,000 deaths attributed to homicide. Epidemiological studies apply to broad groups of people among which there are many individual differences. It is helpful, however, to recognize patterns, such as those related to the ethnic distribution of individuals who complete suicide and the ages at which the risk is highest (Table 5–1). Before turning to suicide rates of individual ethnic groups in the United States, however, it is important to note that large-scale grouping of diverse ethnic groups into “Asian/Pacific Islanders,” “Hispanic or Latino” or “Native American/Alaskan Native” obscures intracultural variation in important social, cultural, and economic variables and dis-
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TABLE 5–1.
Textbook of Suicide Assessment and Management Suicide injury deaths and rates per 100,000 Number of deaths
Population
Crude rate
Age-adjusted ratea
White Black American Indian/ Alaskan Native Asian/Pacific Islander
28,731 1,939 324
234,468,792 37,675,660 3,070,782
12.25 5.15 10.55
11.99 5.34 10.20
661
12,758,767
5.18
5.34
Total
31,655
287,974,001
10.99
—
Race
Note. Data represent both sexes and all ages. Reports for all ages include those of unknown age. aStandard population is 2,000, all races, both sexes. Source. Centers for Disease Control and Prevention 2005.
counts historical factors that shape differing subgroup responses to cultural stressors. Class differences are also often overlooked in reporting on different ethnicities. The sociocultural specifics for different ethnic groups are discussed further in later sections of this chapter. With these caveats in mind, we now map out some of the variations in suicide rates across different ethnic groups, between genders, and over the life span. Suicide is the third leading cause of death among 15- to 19-year-olds, at a rate of 7.4 deaths per 100,000 in 2002 (Centers for Disease Control and Prevention 2005). It is also the third leading cause of death in 20- to 24-year-olds, at a rate of 12.3 deaths per 100,000 in 2002. The high rates of youth suicide have been attributed to the increase in alcohol and substance abuse (Garlow 2002), the breakdown in extended family and intergenerational support, and the increased availability of firearms, especially for young urban African American males (Joe and Kaplan 2002). In a study of completed suicide in Fulton County, Georgia, 50% of the white teens who completed suicide had used alcohol and/or cocaine prior to their death, compared with only 13.3% of the African American teens (Garlow 2002). The majority of deaths were violent, 62.6% by firearms. Alcohol intoxication at the time of suicide, in males, increases the likelihood that a gun will be used. The decreased inhibition from alcohol along with the increased impulsivity of youth makes alcohol abuse a particularly important risk factor in this age group. Methods of suicide fluctuate over time, with suffocation the most common method in the 10- to 14-year-old age group and firearms the most common method among 15- to 19-year-olds, but the trend is toward in-
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creasing use of suffocation versus firearms as the method for suicide. Although the number of suicides declined for white males ages 15–24 between 2000 and 2002, suicides by suffocation increased and suicides by firearm decreased. For black/African American males between 15 and 24 years of age, the suicides by both suffocation and firearms decreased (Centers for Disease Control and Prevention 2005). In the general population, however, the rate of firearm suicide in 2002 (5.9/100,000) significantly exceeded the rate of suffocation suicide (2.2/100,000) and poisoning suicide (1.9/100,000). Rates of youth suicide are particularly high among certain Native American and Alaskan Native communities. In 2002, the suicide rate for Native American males between 15 and 24 years of age was 27.9/100,000, a decline from 49.1 in 1990. Native American females between 15 and 24 years of age also have the highest suicide rates among similar-age females from all ethnic groups, 7.4/100,000. Native Alaskan males between 14 and 19 years of age were found to have extremely high rates, at 120/ 100,000 (Gessner 1997). One small Southwestern American Indian tribe had 23 completed suicides and 22 serious attempts within a 3-year period between 1990 and 1993; 21 of these individuals were younger than 35 years and 5 were younger than 18 years (Wissow et al. 2001). Non-Hispanic white males ages 15–24 years had the second highest rate (19.3/100,000), which represented a decline from 24.4/100,000 in 1990. In contrast, nonHispanic white females between 15 and 24 years of age in 2002 had suicide rates of 3.4/100,000, relatively unchanged from 2000. Black/African American male youth, historically at low risk for suicide, are narrowing the gap with their white peers. Black/African American males ages 15–24 years had a rate of 11.3 suicides per 100,000 in 2002, a decline from 15.1 in 1990. Black/African American females in this age group had the lowest rates compared with other similar-age ethnic groups, 1.7/100,000. Hispanic youth are the fastest-growing sector of the United States population, composing 48% of the total Hispanic population. Hispanic or Latino males between 15 and 24 years of age have a suicide rate of 10.6/100,000, a decline from 14.7 in 1990. Hispanic or Latino females of similar age have suicide rates of 2.1/100,000. Asian/Pacific Islander males ages 15–24 years had the lowest rates at 8.7/100,000, a decline from 13.5 in 1990. Asian/Pacific Islander females between 15 and 24 years of age had rates of suicide similar to those of white females in this age group, 3.3/100,000. Thus, for youth in 2002, Native American males and females have the highest rates, followed by white males and white females, with Asian/Pacific Islander females close behind. The lowest rates are for Asian/Pacific Islander males and Black/African American females.
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Life span rates of suicide vary across ethnic groups and genders. For white males, the rates continue to rise throughout the life span, with the highest rate, at 35.1/100,000, after age 65. In contrast, the rate for white females rises in the 45–64 age group, to 8.0/100,000, but then drops in the 65 and older group to 4.5/100,000. For African American males, there are two peaks. The first is the rising rates between ages 15 and 24 (11.3/100,000) and ages 25 and 44 (15.1/100,000), with a decline in middle age; the second rise occurs among older adult males age 65 and older. The rates are particularly significant for the 85 and older cohort, in which 13.8/100,000 is the second highest of the life span. The rates for African American women, while remaining low, peak in the 25- to 44year-old age group (2.4/100,000) but then reach their lowest levels in the 65 and older cohort (1.1/100,000). For Hispanic and Latino males, the rates rise throughout the life span, with the highest rates of suicide in the 65 and older cohort at 17.5/100,000. For Hispanic and Latino females, rates are highest in the 45- to 64-year age group at 2.5/100,000 and then decline to their lowest levels in the 65 and older group at 1.9/ 100,000. A striking finding is the high suicide rates for Asian/Pacific Islander females, whose rates for the 65 and older cohort increased significantly between 2000 and 2002, from 5.2 to 6.8/100,000. There is a steady rise in suicide rates for Asian/Pacific Islander females throughout the life cycle, a pattern found only within this group of women in contrast to all other ethnicities, in which female rates drop after 65 years of age. Asian/ Pacific males also show a steady rise in suicide rates over the life span, with a rate of suicide of 14.4/100,000 in the 65 and older cohort. For Native American males and females, suicide rates increase throughout middle age. For males ages 25–44 years, the rate is 27.9/ 100,000, which is higher than that for white males, and between ages 45 and 64, the rate is 26.8/100,000, which is slightly lower than that for white males. For Native American females, the risk is insignificant after 45 years of age, and for Native American males, it is insignificant after age 65. Native American males are the only male ethnic group in the United States whose suicide rates do not increase in the later stages of life.
International Perspectives on Suicide Internationally, suicide ranks high on the list of leading causes of disability in the world (Table 5–2). We examine in more detail the contemporary problem of suicide in four societies: Russia, China, posttransition Hong Kong, and rural America.
Social, Cultural, and Demographic Factors in Suicide TABLE 5–2.
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Leading causes of disability in the world among persons ages 15–44 years
Type of disability Unipolar major depression Tuberculosis Road traffic accidents Alcohol use Self-inflicted injuries (suicide) Bipolar illness War Violence Schizophrenia Iron deficiency anemia
Cost in disability, in adjusted life-years 42,972 19,673 19,625 14,848 14,645 13,189 13,134 12,955 12,542 12,511
Source. Murray CJ, Lopez AD: The Global Burden of Disease. Boston, MA, Harvard University Press, 1996.
Russia Russia has consistently had one of the highest suicide rates in the world (Figure 5–1). Pridemore and Spivak (2003) explored the significance of the pattern of rise and fall in Russia’s suicide rate. They noted that Russia is experiencing a unique transition politically, socially, and economically. Changes in the labor market, alcohol use, and the increasing inequality and stress from the sudden collapse of the paternalist Soviet system have taken their toll. During the mid-1980s there was a 40% decline in the suicide rate over a 2-year period that corresponded with the anti-alcohol campaign instituted by President Gorbachev; prices were increased, production was cut, and there was an overall decrease in alcohol consumption. As the campaign was phased out, suicide rates began to rise. A dramatic increase in suicide rates occurred in the 1990s, corresponding to the collapse of the Soviet Union. Working-age men in Russia have the highest rates of suicide, especially those in their 40s and 50s. Russian regions with the highest suicide rates also tend to have the highest rates of poverty, alcohol consumption, and single-parent families. This analysis by Pridemore and Spivak highlights the critical importance of social structure and historical changes in the fluctuation of suicide rates.
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80 70 60
Rate
50 40 30 20 10 0 Total Male Female
1980 34.6 59.2 13.6
1985 31.2 52.9 12.3
1990 26.5 43.9 11.1
1995 41.5 72.9 13.7
2000 39.4 70.6 11.9
2002 38.7 69.3 11.9
Year
FIGURE 5–1. 1980–2002. Source.
Suicide rates, per 100,000, by gender: Russian Federation,
World Health Organization 2004.
China China is the exception to the worldwide pattern of male suicides exceeding female suicides. It is unique in having the lowest suicide gender ratio in the world. Rural suicides account for 93% of completed suicides in China (Philips et al. 1999). The elderly in particular have difficulty getting their needs met, especially given the one-child policy. There are not enough young people to care for the aging population. Most notably in the rural areas, there is great hardship, especially for the sick or disabled. Chinese children are raised to place more value on their honor and reputation, and those of their families, than on their own life (Ji et al. 2001). This is not meant to imply that suicide is not taken seriously, for it is. It may be considered “rational suicide,” for it is often seen as the ultimate means to exact revenge, an opportunity for those lacking a sense of power to express their profound sense of having been wronged. Individuals who commit suicide become more powerful in death than they were in life. Many believe that the restless spirit of the person who commits suicide will return to haunt the household. Recent research has focused on the large number of suicides among rural young women (Pearson et al. 2002). The authors profiled the typical suicide as involving a young woman who impulsively harms herself by using highly lethal pesticides and fertilizers that are readily available in the household. Although some of these women are de-
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pressed or mentally ill, most are not. Instead, they experience intense family conflict, often with in-laws who exert rigid control, especially while the young women’s husbands are away from home working in urban areas. Suicide in China reflects the cultural values of honor and reputation, the plight of the aged, and the particular stressors of young women in power struggles within their families.
Posttransition Hong Kong The suicide rate in Hong Kong hit historic highs with the transition from British rule in 1997. Chan et al. (2005) undertook a unique analysis of this finding by investigating macro-level economic and social changes and linking them to the emergence of a new method of suicide in Hong Kong, charcoal-burning suicide. Burning charcoal in a barbeque grill within a small sealed apartment quickly generates a lethal level of carbon monoxide. The authors noted that the suicide rate rose from 13.3/100,000 in 1998 to 16.4/100,000 in 2003, a surge that was particularly evident among middle-aged, middle-income individuals without preexisting mental conditions who became heavily over-indebted during the “irrational exuberance” of the decade-long economic boom preceding the handover to China. During this period, the property market rose by over 600% and the stock market by 400%. Using a mix of qualitative and quantitative methods, the study authors showed that a segment of the population, spurred by an unrealistic and inflated sense of wealth, heavily overspent by shopping impulsively, gambling recklessly, and investing in speculative markets. Even when the recession hit in late 1997, many were reluctant to change their spending practices and refinanced their credit card and personal loans. Debts snowballed with interest rates of 30%, and many applied for additional credit cards to cover their growing debt. Soon, the overlending and overindebtedness bubble burst. Mountains of debt were unable to be cleared. At the same time, many in the media began inappropriate and extensive reporting on what was then a new method of suicide, charcoal burning. It is significant that this reporting did not adhere to the guidelines recommended by the World Health Organization (2004) with regard to suicide. One informant in the study stated, “I read a lot about charcoal-burning suicides in the newspapers. I thought it would not be painful. If I took hypnotics and drank alcohol at the same time, it’s like going to sleep” (Chan et al. 2005, p. 71). The media inadvertently presented charcoal burning as an easy and painless way out of overwhelming debt. This innovative study points to the urgent problem of overindebtedness in many parts of the world.
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It also highlights the role of the media in inadvertently popularizing a new method of suicide. This suicide phenomenon in Hong Kong poignantly illustrates the role of socioeconomic and political factors in influencing suicide rates.
Rural America Suicide rates in the United States are highest in the rural areas of the country, especially those in the Rocky Mountain states. Although suicide rates in general have remained the same or fallen, the rates for rural men have increased (Singh and Siahpush 2002). The problems associated with suicide in rural areas tap into an array of cultural, social, and economic issues. In his study of the family farm in America, Hanson (1996) described the male farmer, in particular, as placing a high value on self-reliance and independence, the “rugged individualist.” At the same time, he argued, there is a distrust of government, authoritarianism, and innovation. These cultural values and the need to maintain and to manage the responsibilities on the farm make mental health services, even if they were available, less likely to be utilized. Economic downturns associated with drought or abnormal weather patterns make financial problems a significant stressor, and economic shifts sending younger members of the community away increase the social isolation of those who remain. Add to this the ready availability of firearms, and the risk of suicide mounts. Most of those who die by suicide in rural areas do so with a firearm. Contrary to popular expectation, the risk of being shot to death in a rural area is as great as the risk of being shot to death in an urban area; the difference is that in urban areas the death is homicide, not suicide (Branas et al. 2004). In studying intentional injuries between 1989 and 1999, Branas et al. (2004) found that firearm suicides in the most rural communities were similar in number to the firearm homicides in the most urban ones. The rural American culture’s combination of valuing the rugged individualist, personal freedom, and self-reliance in the potential context of isolation, depression, alcohol, and guns places this population at increased risk for suicide.
Ethnicity and Suicide in America African Americans Suicide among African Americans, like that among Native Americans, is predominately a young adult phenomenon (ages 25–34). It is the third leading cause of death for African American youths (ages 15–24) after
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homicides and fatal accidents. A second rise in suicide risk is noted for elderly black men over the age of 65. In studying suicide among African Americans and whites in Atlanta, Garlow et al. (2005) found that although African Americans killed themselves at a much lower rate than whites, they did so at a significantly earlier age. Young African American men caught in the cycle of drug abuse, criminal activity, and self-devaluation may view an early death as inevitable or as an alternative to the wearying struggle that life has become (Poussaint and Alexander 2000). The particularities of self-devaluation and hopelessness that may result in suicidal behavior among young African American men have their roots, as Poussaint and Alexander (2000) have argued, in the particularities of American history. Proximal and distal risk factors for suicide in African American men are addressed in the work of Joe and Kaplan (2001). They described distal risk factors such as being exposed to violence (which is high in many parts of the African American environment) and living in areas of high economic and occupational inequality between whites and African Americans as particularly noteworthy. African American men who attempted suicide were more likely than African American women who attempted suicide to have been psychotic, intoxicated, and schizophrenic. One provocative finding was that higher suicide rates were also correlated with education, wealth, and fertility but not with unemployment. Proximal factors included substance abuse and presence of a firearm, in particular the combination of cocaine abuse and the presence of a firearm. One key finding in African American suicide is the remarkably low rates of suicide among black women (Nisbet 1996). Gibbs (1997) attributed this to the protective factors of religion, including the role of religion in the civil rights movement, women’s central involvement in the church, and strong values for endurance in the face of adversity. Gibbs notes that the belief that suicide is submission and rarely justified is common, something that “whites, not blacks, do.” This belief also makes the stigma associated with suicide exceptionally high among blacks. Women-dominated kinship networks are believed to be protective, providing flexible roles, resource sharing, and social support. Black women express negative emotional states such as hopelessness and depression and attempt suicide as frequently as white women but complete suicide less often. More research needs to be done to further understand this important finding. Both black men and black women are less likely than white men and white women to pursue professional counseling in the face of depression or other mental illnesses, despite the fact that African Americans had higher levels of lifetime or current mental disorders than whites in
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the Epidemiologic Catchment Area study of the 1980s (Regier et al. 1984). The majority of African Americans surveyed about attitudes and beliefs about depression (National Mental Health Association 2000) think depression is a “personal weakness,” and only one-third identified depression as a “health problem” for which they would be willing to take medications (in contrast to 69% of the general population). Twothirds believed that prayer and faith alone would successfully treat depression some or almost all of the time. Sensitivity to language is important for diagnosing major depression in some African American patients. Describing having “the blues” or “the aching misery” or as “being down” may indicate a severe depression (Poussaint and Alexander 2000, p. 16). There is need for more research into the role of perceived discrimination, the realities of racism, and the feelings of alienation from the dominant culture that may contribute to the risk of suicide in African Americans, particularly the young (see Castle et al. 2004).
Hispanic Americans and Latinos Research on suicide among Hispanics is limited and rarely differentiates between suicide rates of Central American and other Hispanics. Only recently has attention been paid to suicide among Central American immigrants (Hovey 2000). Census data have not distinguished between different Hispanic groups, and many individuals of Hispanic origin are undocumented workers who are not represented in census data or epidemiological studies. Large-scale groupings of diverse ethnic groups obscures intracultural variation in important social and economic categories and ignores historical and political differences in the countries of origin and in their immigration experience. In the 2003 nationwide survey of high school students (Youth Risk Behavior Surveillance—United States 2004), Hispanic students, particularly females, were significantly more likely to have reported suicidal ideation and suicide attempts than their white or black non-Hispanic fellow students (Grunbaum et al. 2004). Latino youths living in the United States are at significantly higher risk of suicidal behavior than comparable peers in their country of origin. Hovey and King (1997) described a sample of immigrant and second-generation Latino American adolescents in five southwestern states: 25% had reported critical levels of depression and suicidal ideation that were correlated positively with acculturative stress. The authors found the best predictors of depression and suicidal ideation were perceived family dysfunction, negative expectations for the future, and acculturative stress. Suicide rates of im-
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migrants tend to mirror the rates in the country of origin, with trends converging toward the host country over time (Kliewer and Ward 1988). For immigrants relative to native-born Americans between 1979 and 1989, foreign-born men were 52% less likely to die by suicide than native-born men (Singh and Siahpush 2001), but the differential narrowed with the older age cohorts. Data for immigrant women were not statistically significant because of the small number of deaths. This large epidemiological study focused on immigrants in general, not on specific ethnic groups. Lifetime rates of suicidal ideation, age and gender adjusted, for those Mexican Americans born in Mexico were significantly lower (4.5%) than for Mexican Americans born in the United States (13%) or for nonLatino whites (19.2%) (Sorenson and Golding 1988). Suicide attempt rates were lowest among Mexican Americans born in Mexico (1.6%) and higher among both Mexican Americans born in the United States (4.8%) and non-Latino whites (4.4%). In a comparison of suicide rates in five southwestern states, the suicide rate for Latinos (86% of whom were Mexican American) was lower than that for whites (9.0/100,000 versus 19.2/100,00), whereas the adolescent rates for Latinos approached that for whites (9.0 compared with 11.9) (Smith et al. 1985). The acculturative stress model, as originally formulated by Berry and Kim (1988) and Williams and Berry (1991), posits that cultural and psychological variables serve to mediate acculturative stress. These variables cover issues related to both pre- and postimmigration status such as support from within the new community, immediate and extended family support, work-status changes since immigration, employment, preimmigration mental health, knowledge of the new language and culture, motives for the move, attitudes toward acculturation, expectations for the future, and degree of tolerance and acceptance within the larger community. Hovey and King (1997) extended Berry’s model to look more specifically at possible consequences of increased levels of acculturative stress, such as depression and suicidality. In Hovey’s (2000) research on acculturative stress, depression, and suicidal ideation among Central American immigrants, immigrants experiencing heightened levels of acculturative stress also reported elevated levels of depression and suicidal ideation. The strongest predictors of suicidal ideation were depression, low religiosity, and lack of social support. These findings highlight the clinical importance of assessing the stress related to acculturation, including the reasons for immigration, the migration experience itself, and the experience of life within the new community. As part of the psychiatric evaluation of an immigrant from Mexico or Central America, the clinician needs to inquire as to the na-
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ture of the individual’s social support, perceived religiosity, past and current socioeconomic and work status, and expectations for the future. When suicide rates are compared with rates of depression in five ethnic groups in the United States (whites, blacks, Mexican Americans, Cuban Americans, and Puerto Ricans), the rates of depression were significantly higher among Puerto Ricans (6.9%) and significantly lower for Mexican Americans (2.8%) when compared with whites (3.6%) and blacks (3.5%) (Oquendo et al. 2001). Depression rates for women were consistently about twice that of men across all ethnicities. Yet both Mexican American and Puerto Rican men were better protected against suicide relative to the 1-year prevalence of major depression than were the other ethnic groups. Mexican American and Puerto Rican women had the lowest relative suicide rates as well. The authors found that those groups with lower than expected suicide rates given the depression rates included Mexican Americans and Puerto Ricans of both genders and Cuban American women. Although black women had lower suicide rates than would be expected based on their rates of depression, the suicide rates of black men were almost as high as those for white men, proportional to their depression rates—a finding that was unexpected. The authors of this study highlighted the need for identification of those factors that are protective against suicide in both Mexican American and Puerto Rican groups, groups that have marked similarities and differences, in order to develop better suicide prevention efforts.
Asian Americans Diverse countries serve as points of origin in Asia for immigrants to the United States, countries with diverse ethnic backgrounds, languages, and cultures such as China, Japan, Vietnam, Korea, the Philippines, India, Southeast Asia, Pakistan, Sri Lanka, and Samoa. Some groups, like the Japanese, have lived in the United States for generations; others, like the Chinese, include both recent and nineteenth-century immigrants whereas the Vietnamese have arrived in large numbers only since the Vietnam War. These individuals bring with them attitudes toward coping and suicide from their home country, evidence of the role of culture in influencing the circumstances of suicidal behavior (Lester 1994). In Japan, for example, suicide is permissible, or even appropriate in some specific contexts. Whereas most Americans would not kill themselves as a result of bankruptcy, in Japan bankruptcy is so disgraceful, shaming the family for generations, that an individual may choose to end his or her life to resolve the debt. Ritual suicide has been
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an honorable solution to certain social dilemmas. In contrast, Chinese societies have not generally codified suicide as socially acceptable. Suicide rates are lower in Hong Kong and Taiwan than in Japan. Asian/Pacific Islander females have an increased risk of suicide as they age, unlike females in other ethnic groups. In a study of completed suicides in the city of San Francisco, Shiang et al. (1997) found that Asian women over the age of 85 had the highest overall rates of suicide, higher than both white and Asian men and white women. Asians predominately used hanging to complete suicide, in contrast to the use of guns by whites. In China, hanging traditionally implied great anger and resentment toward one’s family or significant others. Someone who died by hanging would return to haunt the living as a ghost, and therefore death by hanging was seen as an act of revenge (Shiang et al. 1997). The suicide of an elderly Chinese American, especially of a widowed female, was often attributed to failure of younger family members to provide social support for their elderly parent. For most Asian Americans, the family unit is central to identity. Children are socialized into awareness that their individual actions reflect on the entire family, including extended family members (Lee 1996). Although this may impede a family’s willingness to seek treatment for a troubled relative, the strong sense of family as a support and obligation protects against suicide as well. Transition to the individualistic, communication-oriented United States society is a major and stressful change for many families (Committee on Cultural Psychiatry 1989, p. 60). Thus, the suicide rates of Asians in America are of particular concern for the elderly, especially women. Yet Asian Americans themselves are a highly diverse group with varying degrees of acculturation and acculturative stress. The group most at risk appears to be the traditionalists who live in tight-knit groups resistant to acculturative processes. They appear to function relatively well until their elderly years, when the culture clash between the values of the larger society and the Confucian tradition of strong family identity results in alienation of the elderly, who often commit suicide in the manner of their home country (Committee on Cultural Psychiatry 1989, p. 67).
Native Americans Native Americans (a category that includes American Indians and Alaskan Natives) have particularly high suicide rates, especially for adolescent and young men. Suicide remains a significant cause of Native American mortality for men until middle age, when their suicide rates begin to match that of males in the general population. Suicide becomes
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a relatively uncommon cause of death for Native American women after the age of 45 and for men after the age of 65. Native Americans and Alaskan Natives are a very heterogeneous population, with different tribal identities, varying degrees of urbanization, and different levels of tribal organization that contain diverse approaches to historical and cultural integration. Rates among Alaskan Native youth between the ages of 14 and 19, for example, approached 120/100,000 in one study (Gessner 1997), whereas white Alaskan males and Native Alaskan females both had rates around 31/100,000. Theories to explain these high rates tend to rely on family disintegration and social disruption as key factors. The role of alcohol use is often mentioned as well (Klausner and Foulks 1982), especially with regard to the rapid social and cultural changes that were brought about by intensive energy development projects in the Arctic. Groups that had historically been in contact with traders, missionaries, and government officials tended to be more prepared for the stressors of contact. The traditional use of dissociative trance states (particularly among the Inuit), which had long provided an outlet for emotional relief, was increasingly replaced by alcohol intoxication as a way to escape feelings of depression and hopelessness. Drinking has contributed to the disintegration of family life in many groups, leading to child neglect and abuse, intergenerational conflict, and community violence. Most research on suicide among American Indians focuses on reservation Indians, although 60% of Indians live in urban or nontribal areas (Freedenthal and Stiffman 2004). In their research comparing reservation and urban Indians, Freedenthal and Stiffman (2004) found that one-fifth of urban youth, in contrast to one-third of reservation youth, reported lifetime suicidal ideation. The urban youth had lower rates of substance use disorders and conduct disorders. The two groups had similar suicide attempts (14% versus 18%). This study calls attention to the need to increase research on urban Indians, to assess what might be their unique stressors, and to identify what protective mechanisms might distinguish them from their reservation counterparts in terms of suicidal ideation but not attempts. The influence of acculturation on Native American suicide was addressed by research on suicide rates in three groups of Native Americans in New Mexico: the Apache, Navajo, and Pueblo (Van Winkle and May 1986). The group with the highest suicide rate, the Apache (43.3/ 100,000), had the highest degree of acculturation and the lowest degree of social integration. Their reservations were small, surrounded by white communities with which they had had intense contact, with many living in mixed communities. Individualism had been a highly valued
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characteristic and remained so, but the raiding parties that had formerly provided social integration had been abandoned. Religion, in general, remained unimportant. Thus, Van Winkle and May (1986) argued that the lack of integrating forces in their culture and their high acculturation contributed to the high suicide rate. In contrast, the group with the lowest levels of suicide, the Navajo (12.0/100,000), were organized into bands with a strong matrilineal clan influence and had moderate social integration but low acculturation because they had been the most geographically isolated of the three groups. Of note, the Pueblo subgroup with the most acculturation had a higher suicide rate than the most traditional subgroup. Loss of essential values of the traditional culture without replacement by an active and fulfilling bicultural engagement in American society is a risk factor for alienation, identity confusion, depression, alcohol abuse, and suicide. On the contrary, commitment to tribal cultural spirituality (traditions that derive from pre-European contact) is associated with a reduced prevalence of suicide (Garroutte et al. 2003). In the report Suicide and Ethnicity in the United States prepared by the Committee on Cultural Psychiatry in 1989, the authors discussed the process of identity development and modes of adaptation to acculturative stress. They argued that a negative resolution of the developmental demands for identity and cultural integration can result in “role diffusion” (using Erikson’s developmental model) combined with cultural marginalization. They hypothesized that this combination is associated with the greatest risk for suicide. The youth at highest risk are the ones whose identification with their cultural heritage is intensely ambivalent and mostly negative (Committee on Cultural Psychiatry 1989, p. 103). They feel disconnected from both their own and the majority culture, lack a sense of security and acceptance within their family or community, and are often the focal point of intense intergenerational conflict related to their lifestyle, values, and relationships. They rarely have a supportive peer group or are part of a cross-generational network. Unemployment or underemployment erodes self-esteem and selfconfidence and increases the incidence of alcohol and substance abuse. This pattern is most evident among Native American and Alaskan communities but can also be generalized to include African American, Mexican American, and Latino youth. In summary, despite the wide variations in geography, culture contact, historical circumstances, and emotional experiences, most of those who commit suicide within this population are young people, especially males, who experience intense family discord, social disintegration, and cultural conflict (Committee on Cultural Psychiatry 1989, p. 50).
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Suicide and Religion Some cultures have socially expected and religiously codified suicidal action. Eastern religions, Hinduism in particular, permit suicide on religious grounds. The Hindu practice of suttee in India is an example. Suttee is an obligatory self-killing in which a widow cremates herself on her husband’s funeral pyre. The belief holds that the widow will join her husband to be blessed in paradise and in their subsequent rebirth. Although outlawed in India, the practice continues in rural areas. It is governed by rules and is a socially codified suicidal act, undertaken by the widow either voluntarily or, if necessary, by force. Hindu belief also condones suicide for incurable diseases or great misfortune. Suicide by starvation has also been an acceptable religious practice in Indian culture. Mahatma Gandhi developed the use of the hunger strike as a political weapon in his struggle against British rule in India. In contrast, cultures with strong religious beliefs, as in Islam, that the body is sacred and not to be damaged intentionally are less likely to have suicides. The rise of suicide as a political weapon among Islamic militants is contrary to this belief. Among cultures in which death by suicide is a traditionally accepted way of dealing with distress, suicide is more likely to occur. In religions that deemphasize the boundaries between the living and the dead, suicide is seen as less onerous. EchoHawk (1997) described how grief is somewhat tempered by a strong belief in the continued “presence” of loved ones. She quoted the famous Indian leader Chief Seattle on his belief in an afterlife: “For the dead are not powerless. Dead, did I say? There is no death. Only a change of worlds” (EchoHawk 1997, p. 86). Involvement in religion may provide social support and networks that reduce the risk of suicide. The belief system itself and the practice of spiritual techniques may act as a coping mechanism and provide a source of hope and purpose. It is by supplying a few core lifesaving beliefs that religious commitment appears to protect against suicide (Stack 1983). In a study of religious affiliation among depressed inpatients, Dervic et al. (2004) found that those inpatients who were religiously unaffiliated had significantly more lifetime suicide attempts and more first-degree relatives who had committed suicide than those who were religiously affiliated. They also had fewer perceived reasons for living and fewer moral objections to suicide. High lifetime aggression levels and weaker feelings of responsibility to family were significantly associated with suicide attempts. The authors argued for the use of therapeutic interventions aimed at reducing aggressive behaviors and for supporting those religious beliefs that patients find useful in
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coping with stress, beliefs that in themselves may also reduce anger and prevent suicide (Dervic et al. 2004, p. 2307). Gibbs (1997) discussed the importance of religious leaders as one protective factor in the low rates of suicide among African American women, in their role of engendering hope and belief in the promise of a better life in the hereafter. She also emphasized the role of religious leaders as civil rights leaders, lending hope for changes in life on earth. Religious involvement may also help to buffer acculturative stress, which is associated with depression and suicidal ideation (Hovey 2000). Infrequent church attendance and low levels of perceived influence of religion were related to high levels of suicidal ideation in immigrants from Central America (Hovey 2000). Research on the role of religion in reducing suicide points to the role of the individual’s perceived influence of religion on their life. Maris (1981) compared suicide rates among Catholics and Protestants in Chicago between 1966 and 1968. Scores on church attendance, perception of religiosity, and influence of religion were negatively associated with suicidal ideation. After sex, marital status, and socioeconomic status were controlled for, the perceived influence of religion was the most significant predictor of suicidal ideation. Research has focused on the religious networks themselves as enhancing social support and promoting networking. Areas that serve as historical religious hubs tend to have lower suicide rates for their members (Pescosolido 1990). Jewish persons, for example, living in New England have much lower suicide rates than those living in the South. When Muslims immigrate to Western countries, their suicide rate rises. Turks in Berlin have a higher suicide rate than Turks in Turkey but significantly lower rates than native Germans in Berlin. In conclusion, research stresses the importance and value of a strong spiritual orientation in preventing suicide. It behooves psychiatrists, no matter the presence or absence of a personal spiritual orientation, to support their patient’s spirituality as a protection against suicide.
Suicide and Occupation Certain occupations have been associated with higher rates of suicide, but detailed explanations of suicide risk have been undertaken only for a few, such as dentists, doctors, and police officers. However, these studies lack reliability because they overlook confounding demographic variables such as age, sex, race, socioeconomic class, and marital status (Stack 2001), variables that affect suicide rates in their own right. Stack (2001) looked at the relationship between suicide and 32 occupations. Of the 32, only 8 remained after basic demographic correlates of suicide
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(e.g., gender, age, race, and marital status) were controlled for. Dentists were 5.43 times more likely to die from suicide than the rest of the working-age population, whereas doctors were 2.31 times as likely. Controlling for effects of gender brought two female-dominated occupations into the group at highest risk: nurses with 1.58 times the risk, and social workers with 1.52 times the risk. The other four occupations associated with suicide, after demographics were controlled for, were mathematicians/scientists, lawyers, professors, and artists. Police officers were found not to be at higher risk. One major pattern in the findings was that health-related professions were at high risk for suicide. The greater access to lethal drugs may provide an increased opportunity for suicide in the health care professions. Occupational stress may also come from being largely client dependent—that is, being dependent on clients for income (Stack 2001). This holds for doctors, dentists, lawyers, social workers, and artists. Other occupational stresses may elevate the risk for scientists and mathematicians. These findings also could be due to some other correlate of suicide such as psychiatric morbidity. Physicians, and especially women physicians, are at a higher risk for suicide than the general population. In a consensus statement on depression and suicide in physicians published in JAMA, the authors argued that the culture of medicine places a low priority on physician mental health and places barriers to seeking help (Center et al. 2003). They noted that there may be discrimination in licensing, professional advancement, and hospital privileges. The consensus statement reviews the literature on women and suicide, noting that women physicians commit suicide at the same rate as men physicians but tend to attempt suicide less than do women nationally. Lethal overdose is the most common method, perhaps reflecting greater pharmacological knowledge along with access to drugs. Certain stressors, then, may be particular to certain occupations or types of occupations. Social isolation, for example, can contribute to risk of suicide. Sheepherders in Washington State had the highest suicide rate out of all 22 occupations studied (Wasserman 1992). Infrequent role sets may create additional work stress. Female laborers, for example, have higher suicide rates than male laborers (Stack 1995). However, data are inconsistent. Although women in traditional occupations have lower suicide rates than women in nontraditional occupations, women in moderately nontraditional occupations had the highest suicide rates (Stack 1987). Psychiatric problems may also predate employment in a specific occupation. Artists, for example, have a higher level of psychiatric mor-
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bidity than the general population and have a suicide risk 2.25 times higher. Highly educated people with depressive disorders also have higher suicide rates. Such individuals may tend to select psychiatry (Wasserman 1992), but the literature suggesting that certain specialties, such as psychiatry or anesthesiology, are at higher risk has significant methodological limitations. To determine whether it is the occupation itself that pushes someone to suicide or something associated with the occupation such as psychiatric morbidity, more research needs to be done to sort out occupational stressors from nonoccupational stressors (Wasserman 1992).
Suicide in Gay, Lesbian, Bisexual, and Transgender Individuals Research on suicide among gays and lesbians is particularly complex because of many factors, including an individual’s choice not to disclose his or her sexual orientation to researchers. There are problems in obtaining baseline prevalence rates; problems in reliability of postmortem reports of sexual orientation from family, friends, and physicians (especially among adolescents); small sample sizes because of the low prevalence of both suicide and homosexuality; and difficulties in achieving random sampling. The relationship between sexual behavior and sexual identity is also complex, because an individual may engage in same-sex behavior but not self-identify as gay or lesbian. Many recent studies using diverse research methodologies with a variety of sample populations of gay, lesbian, bisexual, and transgender (GLBT) youth have consistently found GLBT people to be at higher risk of suicide attempts than matched heterosexual comparison groups (Bagley and Tremblay 1997; DuRant et al. 1998; Faulkner and Cranston 1998; Fergusson et al. 1999; Garofalo et al. 1999; Herrell et al. 1999; Remafedi et al. 1998). The ratio of female-to-male reported suicide attempts is reversed with lesbian and gay youth: more males than females reported a suicide attempt (Remafedi et al. 1998). Risk factors that lead to suicide, such as psychiatric and substance use disorders, are shared by both GLBT youth and heterosexual youth. Other risk factors are unique to being gay, lesbian, or bisexual and include disclosure of sexual orientation to friends and family, homophobia, harassment, and gender nonconformity. Two important research studies were published in the Archives of General Psychiatry in October 1999. In one study using the co-twin control method (Herrell et al. 1999), a sample of 103 middle-aged male twin
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pairs was identified in which one of the twins from each pair reported having a male sexual partner after age 18, whereas the other did not. After adjustment for substance abuse and depressive symptoms other than suicidality, men with same-gender sexual orientation had more than a 4-fold increase in suicidal ideation and a more than 6.5-fold increase in suicide attempts. Using a co-twin method with reduced selection bias and controlling for substance abuse and depression, this study demonstrates a significantly increased lifetime prevalence of suicidal symptoms in male twins with a history of same-gender partners as opposed to their co-twin who had no same-gender partners. Analysis of longitudinal data gathered on a New Zealand birth cohort found 20 out of 1,007 persons who self-identified as gay, lesbian, or bisexual and 8 who reported having a same-sex partner since the age of 16 (Fergusson et al. 1999). This group of 28 were found to have elevated rates of suicidal ideation and suicide attempts along with increased rates of depression, anxiety, conduct disorder, and nicotine dependence. Although a small sample size combining males and females at an age (21) when only a portion of the gay/lesbian/bisexual individuals in the sample would so self-identify, the study shows that young people who disclose same-gender sexual behavior are clearly at increased risk of psychiatric disorders and suicidal behaviors. Lifetime prevalence of suicide symptoms and affective disorders among men with same-sex partners was examined in the third National Health and Nutrition Examination Survey (Cochran and Mays 2000). As with the two previously mentioned studies, this study provided an opportunity to assess prevalence rates for suicide symptoms in the absence of help-seeking behavior or gay-identified activities. A sample of 3,648 men between ages 17 and 39 were assessed, of which 78 (2.2%) reported any male sex partner in their lifetime. Men with same-sex partners were more than five times as likely to have attempted suicide. Small sample sizes limit these studies, but an elevated risk for suicide attempts among some cohorts of GLBT individuals is clear, particularly among youth. Aggressive treatment of psychiatric and substance use disorders, open and nonjudgmental support, and promotion of healthy psychosocial adjustment help to decrease the risk for suicide in GLBT youth as well as adults.
Suicide in Individuals With HIV/AIDS Despite the fact that more people with HIV/AIDS are living longer with newer treatments, the complicated stressors associated with the illness continue to overwhelm many individuals. People with HIV/AIDS of-
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ten have other comorbid factors such as substance abuse and other psychiatric diagnoses, while stigma, social isolation, and lack of support independently increase the risk of suicide as well. The direct effect of HIV on the brain also may manifest as cognitive deficits, memory loss, personality changes, depression, and psychosis. Any of these symptoms can increase the risk of suicide as well. Exposing oneself to HIV may also be an indirect attempt at suicide. Although there is a common assumption that people with AIDS are at high risk of suicide, the data are conflicting, with risk ranging from 66 times that of the general population (Marzuk et al. 1988) to twice that of the general population in more recent research (Marzuk et al. 1998). Marzuk et al. (1988) followed up on their earlier research by examining HIV seroprevalence among deaths by suicide in New York between 1991 and 1993. Of the 1,511 deaths by suicide in which the decedent had been screened for HIV, 7 were inconclusive and 133 were seropositive, for a rate of 0.088. Thus, almost 9% of those who committed suicide in New York during the early 1990s were HIV positive. Compared with HIVnegative decedents, HIV-positive decedents were more likely to be male, ages 25–54, and non-Hispanic black or Hispanic. They were almost twice as likely to use poisoning and one-third less likely to use firearms. Although the exact rate of seropositivity in New York during the early 1990s is unknown, the authors argued that after demographic adjustment, individuals with HIV have, at most, a twofold higher risk of suicide compared with the general New York City population. They noted the likelihood that many HIV-positive individuals had other risk factors for suicide such as substance abuse. Limited data have been published on suicide among women with HIV. Simoni et al. (1998) reported a survey of 230 seropositive women from New York City, median age 39.3, with 83% Latinas or African Americans and 44% high school graduates. The median time since diagnosis with HIV was 4.3 years, with 24% of the women diagnosed with AIDS. Drug use was rampant, with 66% reporting heavy crack or intravenous drug use in the past and 19% using within the past month. Rates of attempted suicide prior to diagnosis of HIV were 26%, with 19% attempting suicide since the diagnosis. Of those who attempted suicide after the diagnosis, 58% had also attempted suicide before receiving the diagnosis. Women who had attempted suicide after the diagnosis, compared with those who did not, were more likely to be younger, HIV symptomatic, depressed, lonely, and lacking social support. Lifetime and current drug use were not significantly correlated with attempted suicide after diagnosis. Latina women were more likely than others (26% vs. 13%) to have attempted suicide after their HIV diagnosis. Al-
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though uncontrolled, this study suggests the high risk of suicide attempts among seropositive women, a risk that is undoubtedly influenced by other factors. Kalichman et al. (2000) investigated the rates of suicidal ideation and suicide intention in 113 middle-aged and older men and women with HIV or AIDS in Milwaukee and New York City. They examined the relationship between suicidal ideation, self-reported emotional distress, well-being, and social support. Suicidal ideation was present during the previous week in 29 individuals (26% of the sample), but only two indicated that they would like to kill themselves, and none indicated that they would kill themselves if they had a chance. Suicidal ideation was most common in white gay men who were currently experiencing symptoms related to HIV (36%) versus those who were asymptomatic (17%). Those who were contemplating suicide were more likely to use escape and avoidance strategies and reported less social support from friends and family, even though they were more likely to have disclosed their HIV status to others. With the exception of physical functioning and coping strategies, there were no significant differences between those who contemplated suicide and those who did not after controlling for symptoms of depression. As the demographics of HIV continue to change, with increasing rates among women and in the developing world, research will need to evolve to address the needs of diverse groups of individuals. Treatment options making HIV/AIDS less of a life-threatening illness and more of a chronic one will also shift the nature of the illness burden itself, with implications for psychiatric disorders as well as suicide.
Suicide and Unemployment and Socioeconomic Change Unemployment has long been associated with increased rates of suicide. In 1897, Durkheim argued that employment protected an individual against suicide because of increased integration of the individual into society (Durkheim 1897/1966). Unemployment can affect the family of the unemployed along with the unemployed individual. It can lower the socioeconomic level of the family and produce marital and family strain along with a lowered standard of living. It can reduce the self-esteem of the unemployed person, increase anxiety, and enhance feelings of hopelessness as well as increase alcohol and drug use. A 1984 review by Platt of the research conducted between 1920 and 1980 on unemployment and suicide showed three out of four research methodolo-
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gies confirming the unemployment/suicide link (Platt 1984). Of the four types of studies, individual and aggregate cross-sectional studies and individual and aggregate longitudinal studies, only aggregate cross-sectional studies had weaker findings. Larger units of aggregation may pose problems for support of the unemployment/suicide hypothesis because of lack of homogeneity of the population. Where smaller units of aggregation were used in cross-sectional studies, a link was found between unemployment and suicide (Breault 1988). Individuallevel cross-sectional studies compare the suicide rate of the unemployed with that of the employed at one point in time. Platt (1984) reviewed data showing that the suicide rate for the unemployed in London was 73.4/ 100,000, whereas the suicide rate for the general population at the same point in time was 14.1/100,000. A recent study used U.S. National Longitudinal Mortality Study data to assess whether unemployed individuals were at greater risk for suicide than the unemployed (Kposowa 2001). The results confirmed the link between suicide and unemployment. At 2-year follow-up, men were two to three times as likely to have committed suicide. Living alone, being divorced, and having lower socioeconomic status increased the suicide risk. At or beyond 4 years of follow-up, however, there was no statistical association between unemployment and suicide for men. For women, the relationship between suicide and unemployment was even stronger and more long lasting. Unemployed women had much higher risk of suicide at each year of follow-up than employed women. After 2 and 5 years of follow-up, women who lived alone were two to four times as likely to commit suicide. Unemployed women continued to show an elevated risk at 9 years of follow-up, being three times as likely to commit suicide as employed women. As with men, younger unemployed women were more at risk than unemployed women older than 45 years. The number of women who died by suicide was small, but the results remain significant and powerful. Although in the past men were considered most at risk for suicide after becoming unemployed, we now know that women are at an even greater risk and for a longer period of time. Areas with socioeconomic deprivation also have larger numbers of unemployed people. In a study of geographical variations in the incidence of suicide attempts and suicide, Hawton et al. (2001) studied different wards, or communities, within Oxford, England. Wards with the highest socioeconomic deprivation rates were associated with the highest number of suicide attempts. These patients, both males and females, were more likely to be unemployed, to be living alone, and to be having problems with housing. There was a strong association found between
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suicide rates and socioeconomic deprivation; this was true for males but not for females. Men living in less deprived areas who had financial problems were even more likely to attempt suicide. This finding suggests that the dissonance between one’s own financial status and that of the neighborhood may increase the risk for attempting suicide. Unemployment and financial problems can affect suicide in other ways as well. Alcohol consumption and marital conflict rise with financial difficulties. This in turn can also increase risk of suicide. Large-scale economic changes have also been linked with suicide. Research on the business cycle and suicide has relied primarily on unemployment rates as an indicator of the business cycle. Other indicators include growth rates of the gross domestic product, the Ayres Index of industrial activity, change in the stock market index, and new dwelling construction rates (Stack 2000). Findings have consistently shown, especially for males, that the greater the prosperity, the lower the suicide rate, and conversely, the greater the trend toward recession, the greater the suicide rate. Studies using the Ayres Index of industrial activity and monthly suicide trends suggest that large swings in industrial production are needed to influence suicide, such as during the 1930s (Wasserman 1983, p. 717). In a longitudinal study of English and Welsh census data, between 1983 and 1992, unemployment was associated with a doubling of the suicide rate (Lewis and Sloggett 1998). Political context also influences suicide, as shown by the fact that suicide rates decline during times of war (Lester 1993). However, political systems can, through violence or social movements, increase suicide. In parts of the former Soviet Union where sociopolitical oppression was high (i.e., Baltic States), suicide rates were higher than other regions with less oppression (Varnik and Wasserman 1992).
Conclusion Culture plays a role in the shaping of risks that protect against or promote suicide. It can also affect the type of stressors prevalent in a particular group and shape the nature of the socially acceptable or unacceptable responses to those stressors, including suicide. Knowledge and sensitivity to common risk factors and contributors to suicide in different cultural and ethnic groups are important in addressing suicide risk and in formulating treatment. Cultural differences in beliefs about suicide and death vary, and knowledge of these differences will enable the clinician to more sensitively and accurately assess the patient’s mental state and risk for suicide. Social factors, including unemployment, poverty, and discrimination, also play a role in the frequency of suicide. In-
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creased psychiatric awareness needs to be focused on these difficult and painful social problems, and research needs to be undertaken on how they affect the emotional and psychiatric well-being of patients. In so doing we will also increase the clinician’s awareness of the interplay between psyche, society, and suicidal behaviors. Although the rate of suicide in the United States has diminished in recent years, the loss of life continues to be staggering in its breadth and in those particularly deep pockets of individual and family grief and loss.
❏ Key Points ■
Cultural stressors influence suicide. While there are patterns of suicide unique to each ethnic group, there are intracultural variations in important social, cultural, and economic variables, as well as historical factors, that shape differing subgroup responses to cultural stressors.
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For some groups, suicide may be considered a traditionally accepted way of dealing with shame, distress, and/or physical illness. In other cultures, suicide may be considered a disgraceful and private matter that should be denied.
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Knowledge of and sensitivity to common contributors to suicide in different ethnic and cultural groups, as well as differences in beliefs about death and views of suicide, are important when making clinical estimates of suicide risk and implementing plans to address suicide risk.
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For immigrant groups in general, suicide rates tend to mirror the country of origin and converge toward the rate of the host country over time. Acculturative stresses for immigrant groups and for Native American and Alaskan Natives appear to contribute to suicide.
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The high rates of youth suicide have been attributed to the increase in alcohol and substance abuse, the breakdown in the extended family and intergenerational support, and the increased availability of firearms. Rates of suicide are particularly high among youth and young adults in certain Native American and Alaskan Native communities. African American youth are narrowing the gap with their white peers. Hispanic students, particularly girls, were significantly more likely to report suicidal ideation and suicide attempts than their white or black non-Hispanic fellow students.
■
A striking finding is the high suicide rates for Asian/Pacific Islander women whose rates for the 65 and older cohort increased significantly between 2000 and 2002. There is a steady rise in suicide rates
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throughout the life cycle, with the highest rates after 65 years of age, a pattern unlike that for women in other ethnic groups. ■
Suicide rates in the United States are highest in the rural areas of the country, especially those in the Rocky Mountain states. Although suicide rates in general have remained the same or fallen, the rates for rural men have increased.
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Groups with lower-than-expected suicide rates (given the rates of depression) include Mexican American and Puerto Ricans of both genders and Cuban American women. African American women have the lowest suicide rates.
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Research stresses the importance and value of a strong spiritual orientation in preventing suicide.
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The health-related professions have a heightened risk for suicide.
References Bagley C, Tremblay P: Suicidal behavior in homosexual and bisexual males. Crisis 18:24–34, 1997 Berry J, Kim U: Acculturation and mental health, in Health and Cross-Cultural Psychology: Towards Application. Edited by Dasen P, Berry J, Sartorius N. London, Sage, 1988, pp 207–236 Branas C, Nance M, Elliott M, et al: Urban-rural shifts in intentional firearm death: different causes, same results. Am J Public Health 94:1750–1755, 2004 Breault KD: Beyond the quick and dirty: reply to Girard. Am J Sociol 93:1479– 1486, 1988 Castle K, Duberstein P, Meldrum S, et al: Risk factors for suicide in blacks and whites: an analysis of data from the 1993 National Mortality Followback Survey (see comment). Am J Psychiatry 151:395–397, 2004 Center C, Davis M, Detre T, et al: Confronting depression and suicide in physicians: a consensus statement. JAMA 289:3161–3166, 2003 Centers for Disease Control and Prevention: Web-based Injury Statistics Query and Reporting System (WISQARS) Injury Mortality Reports, 1999–2002. Atlanta, GA, National Center for Injury Prevention and Control, 2005. Available at: http://www.cdc.gov/ncipc/wisqars. Accessed December 5, 2005. Chan K, Yip P, Au J, et al: Charcoal-burning suicide in post-transition Hong Kong. Br J Psychiatry 186:67–73, 2005 Cochran S, Mays V: Lifetime prevalence of suicide symptoms and affective disorders among men reporting same-sex sexual partners: results from NHANES III. Am J Public Health 90:573–578, 2000 Committee on Cultural Psychiatry: Suicide and Ethnicity in the United States. New York, Brunner/Mazel, 1989 Dervic K, Oquendo M, Grunebaum M, et al: Religious affiliation and suicide attempt. Am J Psychiatry 161:2303–2308, 2004 DuRant R, Kruwchuck D, Sinal S: Victimization, use of violence, and drug use at school among male adolescents who engage in same-sex sexual behavior. J Pediatr 133:113–118, 1998
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Duberstein P, Conwell Y, Conner K, et al: Poor social integration and suicide: fact or artifact? A case-control study. Psychol Med 34:1331–1337, 2004 Durkheim E: Suicide: A Study in Sociology (1897). New York, Free Press, 1966 EchoHawk M: Suicide: the scourge of Native American people. Suicide Life Threat Behav 27:60–67, 1997 Faulkner AH, Cranston K: Correlates of same-sex behavior in a random sample of Massachusetts high school students. Am J Public Health 88:262–266, 1998 Fergusson D, Horwood L, Beautrais A: Is sexual orientation related to mental health problems and suicidality in young people? Arch Gen Psychiatry 56: 876–880, 1999 Firth R: Suicide and risk taking in Tikopia society. Psychiatry 2:1–17, 1961 Freedenthal S, Stiffman A: Suicidal behavior in urban American Indian adolescents: a comparison with reservation youth in a southwestern state. Suicide Life Threat Behav 34:160–171, 2004 Garlow S: Age, gender, and ethnicity differences in patterns of cocaine and ethanol use preceding suicide. Am J Psychiatry 159:615–619, 2002 Garlow S, Pursell D, Heninger M: Ethnic differences in patterns of suicide across the life cycle. Am J Psychiatry 162:319–323, 2005 Garofalo R, Wolf R, Wissow L, et al: Sexual orientation and risk of suicide attempts among a representative sample of youths. Arch Pediatr Adolesc Med 153:487–493, 1999 Garroutte E, Goldbert J, Beals J, et al: Spirituality and attempted suicide among American Indians. Soc Sci Med 56:1571–1579, 2003 Gessner B: Temporal trends and geographic patterns of teen suicide in Alaska, 1979–1993. Suicide Life Threat Behav 27:264–273, 1997 Gibbs J: African-American suicide: a cultural paradox. Suicide Life Threat Behav 27:68–79, 1997 Grunbaum J, Kann L, Kinchen S, et al: Youth risk behavior surveillance, United States, 2003. MMWR Surveill Summ 53:1–96, 2004 Hanson V: Fields Without Dreams: Defending the Agrarian Idea. New York, Free Press, 1996 Hawton K, Harriss L, Hodder K, et al: The influence of the economic and social environment on deliberate self-harm and suicide: an ecological and person-based study. Psychol Med 31:827–836, 2001 Herrell R, Goldberg J, True W, et al: Sexual orientation and suicidality: a co-twin control study in adult men. Arch Gen Psychiatry 56:867–874, 1999 Hovey J: Acculturative stress, depression, and suicidal ideation among Central American immigrants. Suicide Life Threat Behav 30:125–139, 2000 Hovey J, King C: Suicidality among acculturating Mexican-Americans: current knowledge and directions for research. Suicide Life Threat Behav 27:92– 103, 1997 Ji J, Kleinman A, Becker A: Suicide in contemporary China: a review of China’s distinctive suicide demographics in the sociocultural context. Harv Rev Psychiatry 9:1–12, 2001 Joe S, Kaplan M: Suicide among African American men. Suicide Life Threat Behav 11:106–121, 2001 Joe S, Kaplan M: Firearm-related suicide among young African-American males. Psychiatr Serv 53:332–334, 2002
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Kalichman S, Heckman T, Kohman A, et al: Depression and thoughts of suicide among middle-aged and older persons living with HIV-AIDS. Psychiatr Serv 51:903–907, 2000 Klausner S, Foulks E: Eskimo Capitalists. Montclair, NJ, Allenheld, Osmun & Co, 1982 Kliewer E, Ward R: Convergence of immigrant suicide rates to those of the destination country. Am J Epidemiol 127:640–653, 1988 Kposowa A: Unemployment and suicide: a cohort analysis of social factors predicting suicide in the U.S. National Longitudinal Mortality Study. Psychol Med 31:127–138, 2001 Lee E: Asian American families: an overview, in Ethnicity and Family Therapy. Edited by McGoldrick M, Giordano J, Pearce J. New York, Guilford, 1996, pp 66–84 Lester D: The effect of war on suicide rates: a study of France from 1826 to 1913. Eur Arch Psychiatry Clin Neurosci 242:248–249, 1993 Lester D: Differences in the epidemiology of suicide in Asian Americans by nation of origin. Omega 29:89–93, 1994 Lewis G, Sloggett A: Suicide, deprivation, and unemployment: record linkage study. BMJ 317(7168):1283–1286, 1998 Littlewood R: Pathologies of the West: An Anthropology of Mental Illness in Europe and America. Ithaca, NY, Cornell University Press, 2002 Maris R: Pathways to Suicide: A Survey of Self-Destructive Behaviors. Baltimore, MD, Johns Hopkins University Press, 1981 Marzuk P, Tierney H, Tardiff K, et al: Increased risk of suicide in persons with AIDS. JAMA 259:1333–1337, 1988 Marzuk P, Tardiff K, Leon A, et al: HIV seroprevalence among suicide victims in New York City, 1991–1993. Am J Psychiatry 154:1720–1725, 1997 National Center for Health Statistics: Health, United States, 2004, With Chartbook on Trends in the Health of Americans. Hyattsville, MD, National Center for Health Statistics, 2004 Nisbet P: Protective factors for suicidal black females. Suicide Life Threat Behav 26:325–341, 1996 Oquendo M, Ellis S, Greenwald S, et al: Ethnic and sex differences in suicide rates relative to major depression in the United States. Am J Psychiatry 158: 1652–1658, 2001 Pearson V, Philips M, He F, et al: Attempted suicide among young rural women in the People’s Republic of China: possibilities for prevention. Suicide Life Threat Behav 32:359–369, 2002 Pescosolido B: The social context of religious integration and suicide: pursuing the network explanation. Sociological Quarterly 31:337–357, 1990 Philips M, Liu H, Zhang Y: Suicide and social change in China. Cult Med Society 23:25–50, 1999 Platt S: Unemployment and suicidal behavior: a review of the literature. Soc Sci Med 19:93–115, 1984 Poussaint A, Alexander A: Lay My Burden Down. Boston, MA, Beacon Press, 2000 Pridemore P, Spivak A: Patterns of suicide mortality in Russia. Suicide Life Threat Behav 33:132–150, 2003 Regier DA, Myers JK, Kramer M, et al: The NIMH Epidemiologic Catchment Area program: historical context, major objectives, and study population characteristics. Arch Gen Psychiatry 41(10):934–941, 1984
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Remafedi G, French S, Story M, et al: The relationship between suicide risk and sexual orientation: results of a population based study. Am J Public Health 88:57–60, 1998 Shiang J, Blinn R, Bongar B, et al: Suicide in San Francisco, CA: a comparison of Caucasian and Asian groups, 1987 to 1994. Suicide Life Threat Behav 27:80– 91, 1997 Simoni J, Nero D, Weinberg B: Suicide attempts among seropositive women in New York City. Am J Psychiatry 155:1631–1632, 1998 Singh G, Siahpush M: All-cause and cause-specific mortality of immigrants and native born in the United States. Am J Public Health 91:392–399, 2001 Singh G, Siahpush M: Increasing rural-urban gradients in U.S. suicide mortality, 1970–1997. Am J Public Health 92:1161–1167, 2002 Smith J, Mercy J, Warren C: Comparison of suicides among Anglos and Hispanics in five Southwestern states. Suicide Life Threat Behav 15:14–26, 1985 Sorenson S, Golding J: Prevalence of suicide attempts in a Mexican-American population: prevention implications of immigration and cultural issues. Suicide and Life Threat Behav 18:322–333, 1988 Stack S: The effect of religious commitment on suicide: a cross-national analysis. J Health Soc Behav 24:362–374, 1983 Stack S: The effect of female participation in the labor force on suicide: a time series analysis. Sociological Forum 2:257–277, 1987 Stack S: Gender and suicide risk among laborers. Arch Suicide Res 1:19–26, 1995 Stack S: The effect of marital integration on African American suicide. Suicide Life Threat Behav 26:404–413, 1996 Stack S: Suicide: a 15-year review of the sociological literature, Part I: cultural and economic factors. Suicide Life Threat Behav 30(2):145–162, 2000 Stack S: Occupation and suicide. Social Science Quarterly 82:389–396, 2001 Tseng W: Handbook of Cultural Psychiatry. San Diego, CA, Academic Press, 2001 Van Winkle N, May P: Native American suicide in New Mexico, 1957–1979: a comparative study. Human Organization 45(4):296–309, 1986 Varnick A, Wasserman D: Suicides in the former Soviet Republic. Acta Psychiatr Scand 86(1):76–78, 1992 Wasserman I: Political business cycles, presidential elections, and suicide and mortality patterns. American Sociological Review 48:711–720, 1983 Wasserman I: Economy, work, occupation and suicide, in Assessment and Prediction of Suicide. Edited by Marris R, Berman A, Maltsberger J, Yufit R. New York, Guilford, 1992, pp 520–539 Williams C, Berry J: Primary prevention of acculturation stress among refugees: application of psychological theory and practice. Am Psychol 46(6):632– 641, 1991 Wissow L, Walkup J, Barlow A, et al: Cluster and regional influences on suicide in a Southwestern American Indian tribe. Soc Sci Med 53:1115–1124, 2001 World Health Organization: Preventing Suicide: A Resource for Media Professionals. Guidelines for Media. Geneva, World Health Organization, 2000 World Health Organization: Suicide Rates. Geneva, World Health Organization, 2004. Available at: http://www.who.int/mental_health/media/en/ 352.pdf Accessed December 14, 2005. Youth Risk Behavioral Surveillance—United States, 2003. Morb Mortal Weekly Rep, May 21, Vol 53, No SS-2
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Suicide Prevention in Jails and Prisons Jeffrey L. Metzner, M.D. Lindsay M. Hayes, M.S.
L ocal jails, which are usually administered by city or county officials, are facilities that hold inmates beyond arraignment, generally for 48 hours but less than a year. Prisons are state-operated or federally operated correctional facilities in which persons convicted of major crimes or felonies serve sentences that are usually in excess of 1 year. Six states (Alaska, Connecticut, Delaware, Hawaii, Rhode Island, and Vermont) and the District of Columbia have combined jail and prison systems (Metzner 1997). Despite the clear legal status differences between pretrial detainees in jails and inmates in prisons, the term inmate is used throughout this chapter to refer to both. There were 2,078,570 persons incarcerated in prisons and jails combined within the United States at midyear 2003. Inmates in state prisons and the federal prison system accounted for two-thirds of the incarcerated population (1,380,776 inmates). These inmates were housed in about 1,670 different facilities. The other third (691,301) were held in over 3,300 local jails. About 0.2% (3,000) of the total state prison population and 0.99% (6,800) of the total adult jail population were under the age of 18. The total prison population included 100,102 women, which accounted for 7.2% of all prisoners nationwide, compared with 82,169 women in jail as of June 30, 2003 (11.9% of the total jail population; Harrison and Karberg 2004; Metzner 2002). 139
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Studies and clinical experience have consistently indicated that 8%– 19% of prison inmates have psychiatric disorders that result in significant functional disabilities, and another 15%–20% will require some form of psychiatric intervention during their incarceration (Ditton 1999; Metzner 1993; Morrissey et al. 1993). A very high prevalence rate of substance abuse and substance use disorders among male prisoners has been frequently reported (Beck et al. 1993). The finding of high base rates of mental disorders in prison populations, associated with significant addictive disorder comorbidity, was also noted in the National Institute of Mental Health Epidemiologic Catchment Area study (Regier et al. 1990).
Suicide in Jails and Prisons The National Center on Institutions and Alternatives (NCIA) reported that the aggregated suicide rate (107 per 100,000 jail inmates) in jails of all types and sizes (e.g., rural and urban county jails, city jails, and police department lockups) during 1986 was approximately nine times greater than that of the general population (Hayes 1989). Hayes (1995) provided a very useful literature review of prison suicide rates and described the NCIA national survey results pertinent to suicides in prisons during 1993. Based on a total prison population of 889,836 inmates, the national suicide rate for 1993 was reported to be 17.8 per 100,000 inmates. Suicide was the third leading cause of death in prisons between 1995 and 1999, following natural causes (other than AIDS) and AIDS. Natural causes other than AIDS barely led suicide as the leading cause of death in jails from July 1, 1998, to June 30, 1999. The Bureau of Justice Statistics reported that the rate of suicide among prison inmates during 1999 was 14 per 100,000 as compared with 55 per 100,000 among jail inmates (Maruschak 1999). Although controversy exists about the actual suicide rate in correctional facilities per 100,000 inmates related to methodological issues in calculating such a rate (Metzner 2002), there is no question that many suicides in jails and prisons are preventable. Research has revealed a consistent profile for jail suicide victims based on aggregated jail data: young, white, single, first-time nonviolent offenders, intoxicated, substance abuse history, hanging by bed clothing, isolated jail housing, and death within the first 24 hours of arrest (Hayes 1983, 1989). Research on suicides in urban jail facilities specifically provides somewhat different findings. Most victims of suicide in urban facilities had been arrested for violent offenses and were dead within 1–4 months
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of incarceration. Intoxication is normally not the salient factor in urban jails that it is in other types of jail facilities. Suicide victim characteristics such as age, race, sex, method, and instrument remain generally consistent in both urban and nonurban jails (Copeland 1989; DuRand et al. 1995; Frost and Hanzlick 1988; Marcus and Alcabes 1993). Findings by Hayes (1995) and Bonner (2000) relevant to common characteristics of prison suicide victims described in the literature are summarized in Table 6–1. These findings were consistent with a New York State Department of Correctional Services review of psychological autopsies of a sample of 40 cases of inmate suicide that took place between 1993 and 2001. These inmates had all received mental health services during their incarceration. Factors associated with suicide included substance abuse, history of prior suicide attempts, mental health treatment prior to incarceration, recent “bad news,” recent disciplinary action, and manifestation of agitation and/or anxiety. A total of 76 inmates committed suicide in the New York Department of Correctional Services facilities from 1993 to 1999. Significant demographic differences between the inmates committing suicide and the general prison population were reported. White inmates, inmates convicted for violent offenses, and inmates with schizophrenia were all overrepresented and African American inmates were underrepresented among the inmates committing suicide (Kovasznay et al. 2004). He et al. (2001) found a strong association between completed suicides and prior suicide attempts during confinement. They reviewed Texas prison suicides occurring over a 12-month period and found that more than 64% of inmates committing suicide had made at least one prior suicide attempt while in prison. In addition, almost two-thirds of victims had been diagnosed with a psychiatric disorder, with the most frequent being mood disorders (64%), personality disorders (56%), and psychotic disorders (44%).
TABLE 6–1.
Common characteristics of prison suicide victims
Presence of serious mental illness History of suicide attempts Older age Lengthy sentences Institutional problems involving protective custody and immigration status Segregated and isolated housing
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Patterson and Hughes (2000) reviewed health care records of all 32 inmates who committed suicide in the California Department of Corrections from October 1998 through December 1999. The average daily population for the department was about 160,000 inmates during that time frame. There had been 22 suicides during 1998, with an average daily population of 158,159, and 24 suicides during 1999 in a population of 160,970. Analysis of these cases suggested some notably persistent variables: • • • • • •
• • • • •
Single-cell housing (67%) Inmates incarcerated for sex offenses (40.6%) Method by hanging (81.2%) Past history of suicidal behavior (63%) Recent discharge from an infirmary setting (within 5 days of death; 13%) Inadequate assessment (canceled appointments, referrals not completed, past records not reviewed, unsupported diagnosis, inappropriate level of mental health care assignment; 62.5%) Lack of response to recent threat or gesture (25%) Recent imposition of the equivalent of a segregation housing placement (37.5%) Mental health caseload (72%) Race (African American, 18.75%; Asian, 3.0%; Caucasians, 43.75%; and Hispanics, 34.4%) Gender (male, 100%)
In addition to the previously referenced high-risk periods during which an inmate may become suicidal in a correctional facility, an American Psychiatric Association (APA) task force report emphasized that an inmate may become suicidal at any point during his or her incarceration (American Psychiatric Association 2000). There is also a strong association between suicide in correctional facilities and housing assignments. Specifically, an inmate placed in and unable to cope with administrative segregation or other similar specialized housing assignments (especially single-cell) may also be at increased risk of suicide. Such housing units usually involve an inmate being locked in a cell for 23 hours per day for significant periods of time (American Psychiatric Association 2000; Bonner 1992; Kovasznay et al. 2004; White et al. 2002).
Case Example 1 John Smith is a 21-year-old male who was arrested after randomly shooting at five persons in a large shopping mall and inflicting serious injuries. While in the county jail, he is initially placed on suicide precautions as a result of information obtained from the arresting officers that he appeared to be encouraging them to return gunfire in a “suicide by cop”
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attempt to end his life. During the subsequent 4 months of his incarceration, Mr. Smith is only intermittently compliant with psychotropic medications prescribed to him for treatment of a serious mental disorder associated with periodic auditory hallucinations. Mr. Smith is later involuntarily hospitalized on the psychiatric unit in the county jail due to increasing depression and suicidal thinking, which is voiced in the context of his almost certain conviction that would result in a life sentence. However, an administrative law judge overturns the petition for involuntary hospitalization, although the written opinion is vague relevant to the rationale for this opinion. The mental health staff are required to discharge Mr. Smith from the psychiatric ward immediately following this decision. However, they do not clearly convey to the custody staff their concern relevant to Mr. Smith’s suicide potential and perceive that the administrative law judge’s decision essentially prohibits them from further suicide prevention efforts related to Mr. Smith. Custody staff determine that Mr. Smith should be housed in a segregation unit for protective custody purposes because of the high-profile nature of his alleged crimes. He is subsequently single celled in such a unit. A psychiatrist meets with Mr. Smith 5 days after his discharge from the psychiatric ward. Mr. Smith continues to deny any suicidal thinking, as he did during the involuntary hospitalization hearing, or any need for further mental health intervention. The plan is to follow up with Mr. Smith at his request on an as-needed basis only. Three weeks later Mr. Smith is found hanging in his cell. Cardiopulmonary resuscitation (CPR) is unsuccessful.
This case demonstrates the need for effective communication between custody and mental health personnel in the context of suicide prevention efforts. The housing placement for Mr. Smith was not appropriate, nor was the lack of timely and consistent mental health followup. In addition, mental health staff demonstrated a negative attitude relevant to suicide prevention after the appropriate attempt to involuntarily hospitalize Mr. Smith. In the next two sections, we provide more detailed discussion relevant to these issues.
Suicide Prevention Programming Experience has shown that negative attitudes often impede meaningful suicide prevention efforts. Such attitudes are not simply errors in judgment that contributed to an inmate’s suicide or a reluctance to thoroughly investigate the death; they are a systemic state of mind that implies inmate suicides cannot be prevented. Examples include • “If someone really wants to kill themselves, there’s generally nothing you can do about it.”
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• “We didn’t consider him suicidal; he was simply being manipulative, and I guess it just went too far.” • “Suicide prevention is a medical problem...it’s a mental health problem ...it’s not our problem.” • “Statistically speaking, suicide in custody is a rare phenomenon, and rare phenomena are notoriously difficult to forecast due to their low base rate. We cannot predict suicide because social scientists are not fully aware of the causal variables involving suicide.” Comprehensive suicide prevention programming has been advocated nationally by organizations such as the American Correctional Association (ACA), APA, and National Commission on Correctional Health Care (NCCHC). These groups have promulgated national correctional standards that are adaptable to individual jail, prison, and juvenile facilities (American Correctional Association 2004; American Psychiatric Association 2000; National Commission on Correctional Health Care 2000a, 2000b). The APA and NCCHC standards provide the more instructive standards and guidelines that offer recommended ingredients for a suicide prevention program: identification, training, assessment, monitoring, housing, referral, communication, intervention, notification, reporting, review, and critical incident debriefing (American Psychiatric Association 2000; National Commission on Correctional Health Care 2003a, 2003b). Consistent with these national correctional standards, in the following sections we describe eight components of a comprehensive suicide prevention policy as listed in Table 6–2.
Staff Training The essential component to any suicide prevention program is properly trained correctional staff, who form the backbone of any jail or prison facility. Very few suicides are actually directly prevented by mental health, medical, or other professional staff because suicides are usually attempted in inmate housing units and often during late evening hours or on weekends when program staff are not present. Suicides, therefore, must be prevented by correctional staff who have been trained in suicide prevention and have developed an intuitive sense about the inmates under their care. Correctional officers are often the only staff available 24 hours a day and form the primary line of defense in preventing suicides. All correctional staff, as well as medical and mental health personnel, should receive at least 8 hours of initial suicide prevention training
Suicide Prevention in Jails and Prisons TABLE 6–2.
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Components of a comprehensive suicide prevention policy
Staff training Intake screening and ongoing assessment Communication Housing Levels of supervision Intervention Reporting Follow-up and mortality review
followed by 2 hours of refresher training each year. Training should include why correctional environments are conducive to suicidal behavior, staff attitudes about suicide, potential predisposing factors to suicide, high-risk suicide periods, warning signs and symptoms, identification of suicide risk despite the denial of risk, liability issues, critical incident stress debriefing, recent suicides and/or serious suicide attempts within the facility/agency, and details of the facility/agency’s suicide prevention policy (Rowan and Hayes 1995). In addition, all staff who have routine contact with inmates should receive standard firstaid and CPR training. All staff should also be trained in the use of various emergency equipment located in each housing unit. In an effort to ensure an efficient emergency response to suicide attempts, mock drills should be incorporated into both initial and refresher training.
Intake Screening and Ongoing Assessment Screening and assessment of inmates when they enter a facility is critical to a correctional facility’s suicide prevention efforts. Although there is no single set of risk factors that mental health and medical communities agree can be used to predict suicide, there is little disagreement about the value of screening and assessment in preventing suicide (Cox and Morschauser 1997; Hughes 1995). Intake screening for all inmates and ongoing assessment of inmates at risk are critical because research consistently reports that two-thirds or more of all suicide victims communicate their intent sometime before death and that any individual with a history of one or more self-harm episodes is at a much greater risk for suicide than those without such episodes (Clark and HortonDeutsch 1992; Maris 1992). Screening for suicide risk may be contained within the medical screening form or as a separate form and should include inquiry regarding risk factors as summarized in Table 6–3. The
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Textbook of Suicide Assessment and Management Key points to inquire about in screening for suicide risk
Past suicidal ideation or attempts Current ideation Threat Plan Prior mental health treatment and hospitalization Recent significant loss (e.g., job, relationship, death of family member/ close other) History of suicidal behavior by family member/close other Suicide risk during prior confinement Belief of arresting/transporting officer(s) that inmate is currently at risk
process should also include referral procedures to mental health and/ or medical personnel for assessment. Following the intake process, if staff hear an inmate verbalize a desire or intent to commit suicide, observe an inmate engaging in any self-harm, or otherwise believe an inmate is at risk for self-harm or suicide, referral procedures should be implemented. Such procedures direct staff to take immediate steps to ensure that the inmate is continuously observed until appropriate medical, mental health, and supervisory assistance is obtained. Finally, given the strong association between inmate suicide and special management (e.g., disciplinary and/or administrative segregation) housing unit placement (Bonner 2000; Kovasznay et al. 2004; White et al. 2002), any inmate assigned to such a special housing unit should receive a written assessment for suicide risk by mental health staff upon admission.
Communication Certain behavioral signs exhibited by the inmate may be indicative of suicidal behavior and, if detected and communicated to others, may prevent a suicide. There are essentially three levels of communication in preventing inmate suicides: 1) communication between the arresting or transporting officer and correctional staff; 2) communication between and among facility staff, including medical and mental health personnel; and 3) communication between facility staff and the suicidal inmate. In many ways, suicide prevention begins at the point of arrest. What an individual says and how they behave during arrest, transportation to the jail, and at booking are crucial in detecting suicidal behavior. The scene of arrest is often the most volatile and emotional time. Arresting
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officers should pay close attention to the arrestee during this time; thoughts of suicide or suicidal behavior may be occasioned by the anxiety or hopelessness of the situation, and previous behavior can be confirmed by onlookers such as family and friends. Any pertinent information regarding the arrestee’s well-being must be communicated to correctional staff by the arresting or transporting officer. Effective management of suicidal inmates in the facility is based on communication among correctional officers and other professional staff. Because inmates can become suicidal at any point during incarceration, correctional officers must maintain awareness, share information, and make appropriate referrals to mental health and medical staff. Facility staff must use various communication skills with the suicidal inmate, including active listening, physically staying with the inmate if they suspect immediate danger, and maintaining contact through conversation, eye contact, and body language. Correctional staff should trust their own judgment and observation of risk behavior and avoid being misled by others (including mental health staff) into ignoring signs of suicidal behavior. The communication breakdown between correctional, medical, and mental health personnel is a common factor found in the reviews of many inmate suicides (Anno 1985; Appelbaum et al. 1997; Hayes 1995). In both jail and prison systems, communication problems are often caused by lack of respect, personality conflicts, and other boundary issues. Simply stated, facilities that maintain a multidisciplinary approach generally avoid preventable suicides. As aptly stated by one clinician: The key to an effective team approach in suicide prevention and crisis intervention is found in throwing off the cloaks of territoriality and embracing a mutual respect for the detention officer’s and mental health clinician’s professional abilities, responsibilities and limitations. All of us, regardless of professional affiliation, need to make a dedicated commitment to come forward and acknowledge that suicide prevention and related mental health services are only effective when delivered by professionals acting in unison with each other. Just as the security officer alone can not ensure the safety and security of the jail facility, neither can the mental health clinician alone ensure the safety and emotional well-being of the individual inmate. (Severson 1993)
Housing In determining the most appropriate housing location for a suicidal inmate, correctional officials (with concurrence from medical or mental health staff) often tend to physically isolate and sometimes restrain the individual. These responses might be more convenient for all staff, but
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they are detrimental to the inmate because the use of isolation escalates the inmate’s sense of alienation and further removes the individual from proper staff supervision. To every extent possible, suicidal inmates should be housed in the general population, mental health unit, or medical infirmary, located close to staff. Furthermore, removal of an inmate’s clothing (excluding belts and shoelaces) and the use of physical restraints (e.g., restraint chairs or boards, leather straps, straitjackets) should be avoided whenever possible and used only as a last resort when the inmate is physically engaging in self-destructive behavior. Handcuffs should rarely be used to restrain a suicidal inmate. Housing assignments should be based on the ability to maximize staff interaction with the inmate, avoiding assignments that heighten the depersonalizing aspects of incarceration. All cells designated to house suicidal inmates should be suicideresistant, free of all obvious protrusions, and provide full visibility (Atlas 1989; Hayes 2003). These cells should contain tamper-proof light fixtures and ceiling air vents that are protrusion-free. Each cell door should contain a heavy-gauge Lexan (or equivalent grade) glass panel that is large enough to allow staff a full and unobstructed view of the cell interior. Cells housing suicidal inmates should not contain any electrical switches or outlets, bunks with open bottoms, towel racks on desks and sinks, radiator vents, or any other object that provides an easy anchoring device for hanging. Finally, each housing unit in the facility should contain various emergency equipment, including a first-aid kit, pocket mask or face shield, Ambu-bag, and rescue tool (to quickly cut through fibrous material). Correctional staff should ensure that such equipment is in working order on a daily basis.
Levels of Supervision The promptness of response to suicide attempts in correctional facilities is often driven by the level of supervision afforded the inmate. Brain damage from strangulation caused by a suicide attempt can occur within 4 minutes and death often within 5–6 minutes (American Heart Association 1992). Standard correctional practice requires that “special management inmates,” including those housed in administrative segregation, disciplinary detention, and protective custody, be observed at intervals not exceeding every 30 minutes, with mentally ill inmates observed more frequently (American Correctional Association 2003, 2004). Inmates held in medical restraints and “therapeutic seclusion” should be observed at intervals of not more than 15 minutes (National Commission on Correctional Health Care 2003a, 2003b).
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Consistent with national correctional standards and practices, two levels of supervision are generally recommended for suicidal inmates: close observation and constant observation. Close observation is reserved for the inmate who is not actively suicidal but expresses suicidal ideation (e.g., expressing a wish to die without a specific threat or plan) or has a recent prior history of self-destructive behavior. In addition, an inmate who denies suicidal ideation or does not threaten suicide but demonstrates other concerning behavior (through actions, current circumstances, or recent history) indicating the potential for self-injury should be placed under close observation. Staff should observe such an inmate at staggered intervals of not more than 15 minutes (e.g., 5, 10, 7 minutes, etc.). Constant observation is reserved for the inmate who is actively suicidal, either threatening or engaging in suicidal behavior. Staff should observe such an inmate on a continuous, uninterrupted basis. Other aids (e.g., closed-circuit television, inmate companions or watchers) can be used as a supplement to, but never as a substitute for, these observation levels. Finally, mental health staff should assess and interact with (not just observe) suicidal inmates on a daily basis.
Intervention The degree and promptness of staff intervention often determine whether the victim will survive a suicide attempt. National correctional standards and practices generally acknowledge that facility policy regarding intervention should contain three primary components (National Commission on Correctional Health Care 2003a, 2003b). First, all staff who come in contact with inmates should be trained in standard firstaid procedures and CPR. Second, any staff member who discovers an inmate engaging in self-harm should immediately survey the scene to assess the severity of the emergency, alert other staff to call for medical personnel if necessary, and begin standard first aid and/or CPR as necessary. Third, staff should never presume that the inmate is dead but rather should initiate and continue appropriate lifesaving measures until relieved by arriving medical personnel. In addition, medical personnel should ensure, on a daily basis, that all facility emergency response equipment is in working order.
Reporting In the event of a suicide attempt or suicide, all appropriate correctional officials should be notified through the chain of command. Following the incident, the victim’s family should be immediately notified as well
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as appropriate outside authorities. All staff who came in contact with the victim prior to the incident should be required to submit a statement that includes their full knowledge of the inmate and incident.
Follow-up and Mortality Review An inmate suicide is extremely stressful for staff, who may feel angry, guilty, and even ostracized by fellow personnel and administration officials. After a suicide, reasonable guilt is sometimes displayed by the officer who wonders, “What if I had made my cell check earlier?” When suicide or a suicidal crisis occurs, staff affected by such a traumatic event should receive appropriate assistance. One form of assistance is critical incident stress debriefing (CISD). A CISD team, made up of professionals trained in crisis intervention and traumatic stress awareness (e.g., police officers, paramedics, firefighters, clergy, and mental health personnel), provides affected staff an opportunity to process their feelings about the incident, develop an understanding of critical stress symptoms, and develop ways of dealing with those symptoms (Meehan 1997; Mitchell and Everly 1996). For maximum effectiveness, the CISD process or other appropriate support services should occur within 24–72 hours of the critical incident. Every completed suicide, as well as each suicide attempt of high lethality (e.g., an attempt requiring hospitalization), should be examined through a mortality review process. If resources permit, clinical review through a psychological autopsy is also recommended (Aufderheide 2000; Sanchez 1999). Ideally, the mortality review should be coordinated by an outside agency to ensure impartiality. The review, separate and apart from other formal investigations that may be required to determine the cause of death, should include information as summarized in Table 6–4. TABLE 6–4.
Mortality review
Critically review the circumstances surrounding the incident. Critically review jail procedures relevant to the incident. Make a synopsis of all relevant training received by involved staff. Review pertinent medical and mental health services/reports involving the victim. Consider possible precipitating factors leading to the suicide. Make recommendations, if any, for change in policy, training, physical plant, medical or mental health services, and operational procedures.
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Case Example 2 George Baxter enters the reception center at the state department of corrections to serve a 4-year sentence for aggravated robbery. He has a history of mental illness and is taking psychotropic medication for depression. During the intake screening process at the reception center, Mr. Baxter’s behavior and responses to questions from the nurse are cause for concern. It is his first prison experience, and the 18-year-old appears anxious, expresses helplessness, and is crying during the interview. He has heard stories of violence and intimidation in the state prison system while awaiting transfer from the county jail. Mr. Baxter has had at least three serious prior suicide attempts, and the transporting officer informs the intake nurse that Mr. Baxter was on suicide precautions at the county jail following a hanging attempt a few days earlier. He also has a family history of suicide; his brother had committed suicide 6 years earlier, and his mother is currently being treated for depression after a recent drug overdose. Following the initial screening process, Mr. Baxter is placed on constant observation in the mental health unit and referred to mental health staff for further assessment of his suicide risk. Mr. Baxter is seen by the reception center psychiatrist the following morning. He denies any suicidal ideation and states, “I’m not suicidal. This is all a big mistake.” The psychiatrist determines that the constant observation status is “inappropriate,” and Mr. Baxter is released from suicide precautions and rehoused in the general population. He is seen by a nurse later that afternoon and appears tearful and scared. He denies any suicidal ideation and requests a cellmate. The nurse tells Mr. Baxter that she will forward his request to the shift supervisor. A few hours later, and approximately 10 hours after his release from suicide precautions, Mr. Baxter is found hanging in his prison cell.
A mortality review was subsequently conducted on George Baxter’s suicide. The review found that there was uncertainty as to whether the psychiatrist had reviewed Mr. Baxter’s medical file, which contained the intake medical screening form, as well as uncertainty as to whether the transporting officer’s observation and the county jail records regarding his suicidal behavior were effectively communicated to reception center intake staff. Recommendations offered during the mortality review included the stipulation that inmates placed on constant observation will remain on that status for a minimum of 72 hours and then will be stepped down to close observation until stable. Inmates assigned to the mental health unit will not be discharged until their case is reviewed during the weekly treatment team meeting. In addition, a sending agency discharge summary form should be created and completed by the sending agency (e.g., county jail) and/or transporting personnel prior to arrival at the reception center that documents any immediate concerns about a newly arrived inmate.
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Conclusion Undoubtedly, it is easier for officials to know that someone is having suicidal thoughts when that person says that he is having suicidal thoughts. However, having an inmate in custody creates a duty of care that must include enough attention to mental health concerns that inmates with obvious symptoms receive medical attention. Prison officials had numerous opportunities to meet their responsibilities to help [this inmate], but no one did. One cannot avoid responsibility by putting one’s head in the sand. (Jutzi-Johnson v. United States 2001)
The growth in the field of correctional mental health services has raised awareness concerning the problem of inmate suicide in correctional facilities, resulting in the development of effective suicide prevention programs becoming a standard of practice within this area of practice (Cox and Morschauser 1997; Freeman and Alaimo 2001; Goss et al. 2002; Hayes 1996; National Commission on Correctional Health Care 1999; Ruiz v. Estelle 1980; White and Schimmel 1995). New York experienced a significant drop in the number of jail suicides after the implementation of a statewide comprehensive prevention program (Cox and Morschauser 1997). From 1990 through 1998, the suicide rate in the Cook County (Illinois) jail system, the third largest pretrial detention system in the country, was reduced to a level of fewer than 2 suicides per 100,000 admissions (Freeman and Alaimo 2001). Texas saw a 50% decrease in the number of county jail suicides as well as almost a sixfold decrease in the rate of these suicides from 1986 through 1996, much of it attributable to increased staff training and a state requirement for jails to maintain suicide prevention policies (Hayes 1996). One researcher reported no suicides during a 7-year time period in a large county jail after the development of suicide prevention policies based on the following principles: screening; psychological support; close observation; removal of dangerous items; clear and consistent procedures; and diagnosis, treatment, and transfer of suicidal inmates to the hospital as necessary (Felthous 1994). In conclusion, although lacking the ability to accurately predict if and when an inmate will commit suicide, facility officials and their correctional, medical, and mental health personnel can identify, assess, and treat potentially suicidal behavior. Although not all inmate suicides are preventable, many are, and a systemic reduction of these deaths will not
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be attainable until we rid ourselves of negative attitudes and implement comprehensive suicide prevention programming in our correctional facilities.
❏ Key Points ■
Inmate suicide is a serious public health problem throughout the country.
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Although there are similarities between jail and prison suicide, there are also distinct differences.
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Negative attitudes impede meaningful suicide prevention efforts.
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Communication breakdown between correctional, medical, and mental health personnel is a common factor found in the reviews of many inmate suicides.
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Suicide rates in jails and prisons are decreasing, and correctional systems that implement and maintain comprehensive suicide prevention programs have effectively reduced the incidence of inmate suicides.
References American Correctional Association: Standards for Adult Correctional Institutions Facilities, 4th Edition, Lanham, MD, American Correctional Association, 2003 American Correctional Association: Performance-Based Standards for Adult Local Detention Facilities, 4th Edition. Lanham, MD, American Correctional Association, 2004 American Heart Association, Emergency Cardiac Care Committee and Subcommittees: Guidelines for cardiopulmonary resuscitation and emergency cardiac care. JAMA 268:2172–2183, 1992 American Psychiatric Association: Psychiatric Services in Jails and Prisons, 2nd Edition. Washington, DC, American Psychiatric Association, 2000 Anno B: Patterns of suicide in the Texas Department of Corrections, 1980–1985. J Prison Jail Health 5:82–93, 1985 Appelbaum K, Dvoskin J, Geller J, et al: Report on the Psychiatric Management of John Salvi in Massachusetts Department of Corrections Facilities: 1995– 1996. Worcester, University of Massachusetts Medical Center, 1997 Atlas R: Reducing the opportunity for inmate suicide: a design guide. Psychiatr Q 60:161–171, 1989 Aufderheide D: Conducting the psychological autopsy in correctional settings. Journal of Correctional Health Care 7:5–36, 2000 Beck A, Gilliard D, Greenfeld L, et al: Survey of State Prison Inmates, 1991. Bureau of Justice Statistics NCJ 136949. Washington, DC, U.S. Department of Justice, 1993, pp 1–41
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Bonner R: Isolation, seclusion, and psychological vulnerability as risk factors for suicide behind bars, in Assessment and Prediction of Suicide. Edited by Maris R, Berman A, Maltsberger J, et al. New York, Guilford, 1992, pp 398–419 Bonner R: Correctional suicide prevention in the year 2000 and beyond. Suicide Life Threat Behav 30:370–376, 2000 Clark D, Horton-Deutsch S: Assessment in absentia: the value of the psychological autopsy method for studying antecedents of suicide and predicting future suicides, in Assessment and Prediction of Suicide. Edited by Maris R, Berman A, Maltsberger J, et al. New York, Guilford, 1992, pp 144–182 Copeland AR: Fatal suicidal hangings among prisoners in jail. Med Sci Law 29:341–345, 1989 Cox J, Morschauser P: A solution to the problem of jail suicide. Crisis: The Journal of Crisis Intervention and Suicide Prevention 18:178–184, 1997 Ditton PM: Mental Health and Treatment of Inmates and Probationers. Bureau of Justice Statistics Special Report NCJ 174463. Washington, DC, U.S. Department of Justice, 1999, pp 1–12 DuRand CJ, Burtka GJ, Federman EJ, et al: A quarter century of suicide in a major urban jail: implications for community psychiatry. Am J Psychiatry 152: 1077–1080, 1995 Felthous A: Preventing jailhouse suicides. Bull Am Acad Psychiatry Law 22: 477–488, 1994 Freeman A, Alaimo C: Prevention of suicide in a large urban jail. Psychiatr Ann 31:447–452, 2001 Frost R, Hanzlick R: Deaths in custody: Atlanta city jail, and Fulton county jail, 1974–1985. Am J Forensic Med Pathol 9:207–211, 1988 Goss J, Peterson K, Smith L, et al: Characteristics of suicide attempts in a large urban jail system with an established suicide prevention program. Psychiatr Serv 53:574–579, 2002 Harrison PM, Karberg JC: Prison and jail inmates at midyear 2003. Bureau of Justice Statistics Bulletin NCJ 203947. Washington, DC, U.S. Department of Justice, 2004, pp 1–14. Available at: http://www.ojp.usdoj.gov/bjs/pub/ pdf/pjim03.pdf. Accessed December 3, 2004. Hayes LM: And Darkness Closes In…: A National Study of Jail Suicides. Crim Justice Behav 10:461–484, 1983 Hayes LM: National study of jail suicides: seven years later. Psychiatr Q 60:7– 29, 1989 Hayes LM: Prison suicide: an overview and guide to prevention. The Prison Journal 75:431–456, 1995 Hayes LM: Jail standards and suicide prevention: another look. Jail Suicide/ Mental Health Update 6:9–11, 1996 Hayes LM: Suicide prevention and protrusion-free design of correctional facilities. Jail Suicide/Mental Health Update 12:1–5, 2003 He XY, Felthous AR, Holzer CE, et al: Factors in prison suicide: one year of study in Texas. J Forensic Sci 46:896–901, 2001 Hughes D: Can the clinician predict suicide? Psychiatr Serv 46:449–451, 1995 Jutzi-Johnson v. United States 263 F.3rd 753 (7th Cir. 2001) Kovasznay B, Miraglia R, Beer R, et al: Reducing suicides in New York State facilities. Psychiatr Q 75:61–70, 2004 Marcus P, Alcabes P: Characteristics of suicides by inmates in an urban jail. Hosp Community Psychiatry 44:256–261, 1993
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Maris R: Overview of the study of suicide assessment and prediction, in Assessment and Prediction of Suicide. Edited by Maris R, Berman A, Maltsberger J, et al. New York, Guilford, 1992, pp 3–22 Maruschak LM: HIV in Prisons and Jails, 1999. Bureau of Justice Statistics Bulletin NCJ 187456. Washington, DC, U.S. Department of Justice, 2001, pp 1–12 Meehan B: Critical incident stress debriefing within the jail environment. Jail Suicide/Mental Health Update 7:1–5, 1997 Metzner JL: Guidelines for psychiatric services in prisons. Crim Behav Ment Health 3:252–267, 1993 Metzner JL: An introduction to correctional psychiatry, Part I. J Am Acad Psychiatry Law 25:375–381, 1997 Metzner JL: Class action litigation in correctional psychiatry. J Am Acad Psychiatry Law 30:19–29, 2002 Mitchell J, Everly G: Critical Incident Stress Debriefing: An Operations Manual for the Prevention of Traumatic Stress Among Emergency Services and Disaster Workers, 2nd Edition. Ellicott City, MD, Chevron Publishing, 1996 Morrissey JP, Swanson JW, Goldstrom I, et al: Overview of mental health services provided by state adult correctional facilities: United States, 1988. DHHS Publication No. (SMA) 93-1993. Washington, DC, Department of Health and Human Services, 1993, pp 1–13 National Commission on Correctional Health Care: Correctional Mental Health Care: Standards and Guidelines for Delivering Services. Chicago, IL, National Commission on Correctional Health Care, 1999 National Commission on Correctional Health Care: Standards for Health Services in Jails. Chicago, IL, National Commission on Correctional Health Care, 2003a National Commission on Correctional Health Care: Standards for Health Services in Prisons. Chicago, IL, National Commission on Correctional Health Care, 2003b Patterson P, Hughes K: Coleman suicide report, July 14, 2000. Submitted to United States District Court, Eastern District of California, Coleman et al. v. Davis et al., No. CIV S-90-0520 LKK JFM P, 2000 Regier DA, Farmer ME, Rae DS, et al: Comorbidity of mental disorders with alcohol and other drug abuse: results from the Epidemiologic Catchment Area (ECA) study. JAMA 264:2511–2518, 1990 Rowan JR, Hayes LM: Training Curriculum on Suicide Detection and Prevention in Jails and Lockups. Mansfield, MA, National Center on Institutions and Alternatives, 1995 Ruiz v. Estelle 503 F. Supp. 1265 (S.D. Texas 1980) Sanchez H: Inmate suicide and the psychological autopsy process. Jail Suicide/ Mental Health Update 8:3–9, 1999 Severson M: Security and mental health professionals: a (too) silent partnership? Jail Suicide Update 5:1–6, 1993 White TW, Schimmel DJ: Suicide prevention in federal prisons: a successful five-step program, in Prison Suicide: An Overview and Guide to Prevention. Edited by Hayes L. Washington, DC, National Institute of Corrections, U.S. Department of Justice, 1995, pp 46–57 White TW, Schimmel DJ, Frickey R: A comprehensive analysis of suicide in federal prisons: a fifteen-year review. Journal of Correctional Health Care 9: 321–343, 2002
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Cultural Competence in Suicide Risk Assessment Sheila Wendler, M.D. Daryl Matthews, M.D., Ph.D.
Culture is characterized by the way of life of a group of people, the configuration of the more or less stereotyped patterns of learned behavior which are handed down from one generation to the next through the means of language and imitation. Barnouw 1963
The word culture refers to the unique behavior patterns and lifestyle shared by a group of people that distinguish it from other groups. A culture is characterized by a set of views, beliefs, values, and attitudes. Culture shapes people’s behavior, but at the same time it is molded by the ideas and behavior of the members of the culture. Thus culture and people influence each other reciprocally and interactionally. The individual may be aware of these influences, or the influences may be operating at a subconscious level (Tseng 2001). 159
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Cultural competence is the ability to work successfully in a multicultural, multiethnic society. It does not consist of developing a large fund of knowledge about a particular culture or cultures. Rather, it involves being • Sensitive to the operation of culture in human behavior, including suicidal behavior. • Willing to get cultural consultation when necessary. • Empathic to the emotional issues posed by cultural factors. • Willing to view the clinician–patient interaction in a cultural context. • Willing to use cultural factors in developing treatment plans and approaches. Cultural variables do not operate alone but in a rich interaction with other variables: biological, psychological, and social. Terminology in this area is confusing as well, as terms have gone in and out of fashion and as varying lay meanings are applied to them. Race usually refers to a biological group that may or may not coincide with a culture system shared by the group. Although it may be possible to define races by biological factors (Tseng and Streltzer 1997), ethnic groups are generally a social phenomenon. The term ethnicity refers to social groups that distinguish themselves from other groups by a common history, normative system, and group identity. Culture refers to behavior patterns and value systems of a social group, whereas ethnicity refers to a group of people sharing a common culture (Tseng and Streltzer 1997). Suicide is a complex phenomenon, greatly influenced by social, psychological, and cultural factors. Yet studies that investigate whether what are usually considered risk factors for suicide differ by these variables and that adjust for confounding variables are rare (Kung et al. 1998). Culture affects suicide rates or risk of suicide both directly and indirectly through interactions with variables of other types. Just as it has been learned that there are psychological factors that enhance risk (e.g., hopelessness), so there are cultural factors enhancing risk (e.g., lack of acculturation). However, rarely does cultural research relate to an altogether relevant clinical population, and rarely are more than two cultures compared; when they are, it is often on measures vastly different from similar studies of other cultural groups. Because of the international character of some of this research, there exists much nonstandardization of definitions, methods, and instruments. There is marked international variation in suicidal behavior, some of which is based on cultural factors. Variations also in part reflect culturally based international differences in the reporting of suicide. This in turn impedes the understanding of cultural factors in suicidal behavior. Neg-
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ative cultural attitudes about suicide may lead to the suppression of information about suicidal behaviors. Rates of attempted suicides are more seriously underestimated than suicide rates. This is because suicides generally require medical-legal attention, so figures are closer to reality, whereas figures for attempted suicide depend on the extent to which the individual is referred for medical attention. In societies in which suicide is highly stigmatized, such as India, where, until recently, suicidal behavior was regarded as “a punishable legal offense” (Latha et al. 1996), suicide attempts tend to be concealed by the community (Tseng 2001). Because empirical evidence showing the differential effects of the various risk factors across cultures, races, or ethnicities is generally not available, the detection of cultural influences in suicide assessment depends on cultural sensitivity and cultural empathy. There are no algorithms permitting the inclusion of culture in suicide risk assessment. The literature reveals a few cross-cultural consistencies about suicidal behavior. For example, it appears generally true across cultures that women attempt suicide more often but that men are more likely to be successful. Men tend to use more violent methods. Additionally, suicide is associated with mental illness across a great range of international studies. Mental illness—particularly mood disorders—appears to be the most common risk factor cross-culturally. The comorbidity of a major mental illness and a personality disorder and/or an addictive disorder increases the suicide risk among the younger population. Otherwise, suicide appears to be strongly culturally shaped. In 1989 the World Health Statistics Annual (World Health Organization 1989) documented suicide rates ranging from 6 per 1 million women in Malta to 581 per 1 million men in Hungary. This wide range in suicide rates indicates that significant cultural and other social factors are at work. Many cultural differences in suicide rates operate through intervening variables. Key intervening variables between culture and suicide include the following: • Degree of acculturation • Differences in cultural attitudes toward suicide • Variations in the prevalence of risk factors such as unemployment, poverty, and alcohol and drug abuse • Differences in religious views of suicide • Differences in the lethality of the methods used for suicide in that culture • Genetic differences in susceptibility to depressive disorders • International differences in detecting and reporting suicide • Issues in the therapeutic alliance between individuals of different cultures
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Immigration and Acculturation Much of our information on culture and suicide comes from research conducted on indigenous national population groups—for example, on Poles in Poland and Brazilians in São Paulo. The relevance of risk factors of migrant Poles or Brazilians or their descendant groups is altogether unclear. National information should merely sensitize the clinician to the presence of a potential cultural issue. Suicide rates generally are found to change within the same ethnic groups after they migrate to other cultures. For example, the suicidal behaviors of Japanese who migrate to Hawaii changed in frequency and method after three or four generations compared with those of Japanese nationals in Japan (Tseng et al. 1992). Immigration and adjustment to a new society are stressful life events. Suicide rates are frequently higher among immigrants compared with the native born. Poles, Russians, French, Germans, and South Africans who immigrated to Britain showed higher rates compared with British-born people and those born in their respective country of origin (Johansson et al. 1997). Anthropologists have identified acculturation as an important sociocultural factor related to mental health among natives or immigrants in multicultural societies (Liu and Cheng 1998; Mavreas and Bebbington 1990; Neff and Hoppe 1992; Rogler et al. 1991). The concept of acculturation was originally developed to describe the sociocultural changes that occurred in precontact societies when they came in contact with Western cultures (Linton 1940; Redfield et al. 1936). Sociocultural changes in this situation are more or less one-sided, with the less developed societies being assimilated into the more developed societies. Some studies show that less assimilation into the dominant culture increases the risk for suicide. Natives who are less assimilated into the dominant society may be less prepared to handle the stress of an imposed new lifestyle and are at greater risk for suicide (Lee et al. 2002). Lee et al. (2002) found that less assimilation into the host Chinese society was associated with an increased risk for suicide among native Taiwanese, particularly in males. A similar observation was reported with depression as an outcome among Greek Cypriot immigrants in the United Kingdom (Mavreas and Bebbington 1990). Analogously, researchers have generally found high suicide rates among aboriginal groups compared with their nonnative counterparts. Groups studied include Maori populations in New Zealand (Skegg et al. 1995), native Australians (Clayer and Czechowicz 1991), native Americans (Kettl and Bixler 1991), and native Canadians (Malchy et al. 1997). Several authors have proposed that social disruption due to rapid social,
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economic, and cultural changes is responsible for high suicide rates among native groups in Australia, Alaska, and Canada (Clayer and Czechowicz 1991; Kettl and Bixler 1991; Malchy et al. 1997). The concept of anomie proposed by Durkheim in 1897 to describe the phenomena of a lack of social norms due to weakened social and cultural affiliation has been postulated to be one of the important contributors to the high suicide rates among natives in Alaska, Australia, and Manitoba (Clayer and Czechowicz 1991; Durkheim 1897/1951; Kettl and Bixler 1991; Malchy et al. 1997; Thorslund 1990). Canadian aboriginal youth have one of the highest suicide rates in the world. Youths ages 10 to 29 years living on reservations have a five to six times higher probability of dying from suicide than their peers in the general population (Kirmayer et al. 1994). Two types of hypothesis have been proposed to explain the effect of acculturation on suicide. One focuses on the cultural confusion experienced by immigrants; the other focuses on the socially disadvantaged position of immigrants at greater risk for mental disorders (Lee et al. 2002). Somewhat paradoxically, increasing assimilation into the larger culture may also increase vulnerability to suicide. Assimilation may remove the protection formerly afforded by membership in the minority subculture (Seiden 1981; Shaffer et al. 1994), increase social disruption and concomitant feelings of normlessness (Davenport and Davenport 1987; Earls et al. 1990; Trovato 1986), and result in a state of marginality in which the individual feels isolated because he or she is unaccepted by either group (Range et al. 1997). This sense of isolation may result from inability to acquire the skills (including language skills), values, and traditions of either culture. This applies to many native youth who may not have had a deep education in their tradition yet are cut off from mainstream society by poverty, isolation, and educational barriers. J. W. Barry noted that among native youth in northern Ontario, suicide “is related to the situation of being caught between two cultures, and being unable to find satisfaction in either” (quoted in Kirmayer 1994 , p. 30). This may be true of many cultural groups in the United States and Canada with high suicide rates. There may be an “inverted U” relationship between traditionalism and suicide in which both very traditional and highly assimilated individuals or communities are protected from suicide, whereas those in the intermediate state experience greater conflict and confusion about identity, resulting in increased risk for suicide (Berry 1985; Group for the Advancement of Psychiatry 1989).
Therapeutic Alliance One of the major challenges of developing cultural competence is improving one’s skill in establishing and maintaining a therapeutic alli-
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ance with individuals from backgrounds greatly dissimilar to one’s own. As Tseng and Streltzer (2004) pointed out, the sphere of interpersonal relations is closely governed by cultural norms, and the clinician–patient relationship is powerfully regulated in this way. The quality of therapeutic alliance is a major factor in assessing and responding to suicidality (Simon 2004). In a culturally competent suicide risk assessment, the clinician takes into account both difficulties that may arise in the development of an effective therapeutic alliance and those that may prevent an adequate assessment of its nature and strength. Barriers to effective therapeutic communication between cultures relevant to suicide risk assessment include • Western views of therapy as a collaborative effort versus Eastern views of the therapist as a learned teacher (Bernstein 2001). • Male views, within paternalistic cultures, that revealing weakness to females is shameful. (This has been described in both Latin and Arabic cultures. See Comas-Diaz 1988; Javier and Yussef 1995; Mass and Al-Krenawi 1994.) • Cultural views that generally favor nondisclosure to therapists. (For example, an Arabic proverb teaches that “Complaining to anyone other than God is a disgrace” [Dwairy and Van Sickle 1996, p. 237], whereas many Asian cultures view patient disclosure as a betrayal of family secrets [Uba 1994].) • Cultural practices that favor a passive patient role, including avoiding questioning or confronting an authority figure. (These traits have largely been described in Asian cultural groups [Uba 1994; Wong and Piran 1995]. Eye contact may be avoided as a demonstration of respect rather than anger, withdrawal, or something else. Complaints about the treatment process or the therapist may be suppressed, and patients may avoid taking medications producing adverse effects rather than describing such effects to the health care provider.) Attitudes toward the communication of suicidal ideas vary across cultures. People in some cultures consider having suicidal ideas disgraceful and unsuitable for revelation to others, including general medical or mental health professionals. In contrast, people in other cultures may feel quite comfortable disclosing thoughts of suicide. Tseng (2001) noted, “In some societies, people have even learned that expressing suicidal ideas is a powerful way of getting professional attention and care, even if, in reality, they are not seriously occupied with ‘depressive thoughts’” (p. 294).
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Religion Case Example 1 Father Sean is a 53-year-old Irish-American Catholic priest who as a teenager developed juvenile-onset diabetes mellitus (type 1 diabetes) and has had many medical sequelae. He spent many years as rector of a small parish in suburban Minneapolis. Because of declining recruitment into the priesthood, Father Sean was assigned additional pastoral duties in a neighboring parish. As the months passed, Father Sean became increasingly depressed. His sister encouraged him to obtain counseling through his diocese, but Father Sean demurred and remained without care. When his sister noticed his weight loss and withdrawal, she became insistent that he get help, and he finally agreed to see a private psychiatrist for an evaluation visit. When the doctor asks Father Sean if he is considering suicide, the priest reacts strongly and says, “Absolutely not; it is a mortal sin. And it would destroy my sister if I were to kill myself.” The psychiatrist knows that aging males with serious medical problems are at serious risk of suicide, and she wonders how much of a protective effect his religious convictions provide.
Evidence for the protective effect of social factors against suicide includes the often-reported link between religion and lower suicide rates (Payne et al. 1991; Stack 1983). Since the initial publication of Durkheim’s Suicide in 1897, it has been claimed that religion affects the suicide rate, with higher rates found among Protestants as compared with Catholics and Jews. However, in a study of U.S. suicide rates, Stack and Lester (1991) found no effect for type of religious affiliation, but more frequent church attendance was associated with a lower rate of suicide. This effect of religiosity was independent of education, gender, age, and marital status. Similarly, a high proportion of individuals without religious affiliation in a community has been found to be associated with an increased risk of suicide (Hasselback et al. 1991). A study of Inuit youth found that regular church attendance was associated with less likelihood of suicide attempts (Malus et al. 1994). Quality of family life and religiosity are highly correlated (Stack 1992). The impact of religion on suicide rates may be understood not solely by the presence of specific beliefs about suicide, death, suffering, and the afterlife but also by the extent to which religious affiliations and practices organize social support networks (Pescosolido and Georgianna 1989). Religiosity may reduce the suicide rate through its effects on strengthening social ties through adherence to rules and customs; such support networks have a protective effect on suicide risk.
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Durkheim (1897/1951) believed that integration into collective society leads members to focus on the needs and goals of the group, diverting their attention from their own concerns, including suicidal thinking. Stack (1983, 1992) argued that religion provides protective power through members’ commitment to a few core lifesaving beliefs. Stack and others have provided empirical support for the religious commitment theory using church attendance, religious affiliation, and the number of religious books produced nationally as measures of commitment (Hasselback et al. 1991; Stack 1983, 1992). Stack (1992) noted, however, that familial integration may reinforce or coincide with church attendance and therefore is itself a potent predictor of suicide risk. The religiously unaffiliated tend to identify fewer reasons for living and have weaker moral objections to suicide (Stack 1992). Eastern religions, in which traditions of reincarnation and circularity are prominent, generally do not vigorously condemn suicide. The monotheistic religions of the West (Judaism, Christianity, and Islam) are essentially linear and function on the presumption of eternal redemption or damnation based on the actions of a single lifetime. Suicide has generally been seen as a moral crime in these societies (Kok and Tseng 1992).
Marital Status, Support, and Interpersonal and Economic Factors The prevalence of completed suicide, in most societies, is higher among men; an exception for this seems to be mainland China, where the suicide rate is considerably higher for females. Rates are particularly high among young females in rural areas where the role of women is less favorable than that of men due to their lower social status and the highly restrictive environment in which they live (Tseng 2001; Tseng and Streltzer 1997). Suicide in the general population in Western societies is more frequent among both men and women who are single, separated, divorced, or widowed compared with those who are married (Trovato 1991). Those who are married with children have still lower rates. There are some cross-cultural data as well: among native Canadians, an analysis of data covering four decades (1951–1981) supported the hypothesis that a change from single or widowed to married status reduced suicide risk for men significantly more than for women (Trovato 1991). In the case of a transition from divorced to married status, both sexes benefited equally in reducing suicide potential (Kirmayer et al. 1994). The quality of an individual’s social network is a strong predictor of the risk for suicide attempts (Grossi and Violato 1992; Hart and Williams 1987; Magne-Ingvar et al. 1992). Interpersonal conflicts (usually
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family or marital discord, breakup of a significant relationship, or loss of personal resources) are the most common precipitants of suicide attempts (Weissman 1974). Several Western studies confirm that the most common immediate precipitants of youth suicide are an acute romantic, academic, or vocational failure (Hawton 1986; Shaffer et al. 1988). Because personal loss is well known to be a factor in many suicides, a culturally competent suicide assessment will take into account that social groups may differ in what constitutes a sufficiently grave loss. Suicide often derives from family conflict in societies in which family relationships are highly valued and there is a strong emphasis on hierarchy within the family system, characteristics common to many Asian cultures. In a Filipino study, 79.3% of suicides were attributed to familyrelated stress (Ladrido-Ignacio and Gensaya 1992); similar findings have emerged for Chinese and Indian populations (Ganapathi and Rao 1966; Zhang 1996). In many Western societies, when faced with overwhelming financial debt, people are given the more or less socially acceptable opportunity to declare bankruptcy as a solution. Tseng (2001), however, points out that in other, highly interpersonally oriented cultures such as Japan, it is considered disgraceful to claim bankruptcy, an act shaming the family for many generations. In such cultures, financial catastrophe may be more likely to result in suicide. Poverty and debt as motivation for suicide are relatively rare in economically developed societies; however, financial difficulty as a motive for suicide is still relatively common in undeveloped or developing societies. Unemployment as a risk factor for suicide must be examined in the context of the economic history and values of specific cultures. In cultures in which unemployment is viewed by society as a “community problem” rather than an “individual problem,” unemployment is not as strongly related to suicide risk as it is in cultures in which unemployment is linked to the individual self-esteem (Kirmayer et al. 1994). Male–female relationship problems are common reasons for suicide in societies in which romance is highly valued, and the man–woman relationship is a predominant axis in interpersonal relations (Tseng 2001). A failure in such relationships is associated with suicide in Western cultures.
Youth and Old Age Regardless of place or time, there does not appear to be an exception to the observation that suicide attempts—and to a lesser extent completed suicides—tend to occur among the young (those between the
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ages of 20 and 30 years, with the peak from ages 20 to 24). There is substantial evidence that in the West, this trend is exaggerated for disadvantaged minority populations. For example, this is true of the Alaskan and Canadian aboriginal population (Kirmayer et al. 1994), among Native American groups in the United States (Group for the Advancement of Psychiatry 1989; Kettl and Bixler 1991), and among African American youth (Garlow et al. 2005). Although the suicide rate for African American adolescents is still lower than for white adolescents, this gap has narrowed (Gould and Kramer 2001; Greening and Stoppelbein 2002). Psychiatric disturbances, stressful life events, and poor parent–child relationships seem to account for a significant proportion of the variance in suicidal ideation and attempts among African American youth (Greening and Stoppelbein 2002; Harris and Molock 2000; Joe and Kaplan 2001; King et al. 1990; Summerville et al. 1996). Gutierrez et al. (2001) suggested that Hispanic youth should be targeted for suicide prevention efforts based on higher prevalence of suicidal ideation and other risk factors for suicidal behavior, such as substance abuse, acculturative stress, and lower socioeconomic status, and on the high rates of suicide they identified in their study. The high suicide rate among young men in Micronesia partially reflects their role confusion in a largely matriarchal society. With the change of the economy in Micronesia from agrarian to cash-based and the subsequent increase in unemployment, young male contributions to family subsistence declined, producing the loss of a major male societal task. As the population urbanized, young people’s access to extended family and a large social network began to suffer, and adolescent males found themselves in an increasingly unsupportive and unstructured environment (Tseng and Streltzer 1997). The progressive decline in suicide rates observed among the elderly in Anglo-Saxon countries since the 1970’s, particularly in the United States and among white males, may have come about through improved attitudes toward retirement, improved social services, improved psychiatric care, greater economic security, and greater sociopolitical activism for the elderly. In contrast, in most Latin countries as well as in some Asian nations (e.g., Hong Kong), social changes and the collapse of traditional family structures may have contributed to increases in suicide rates in older age. In Asia, for example, industrialization and Westernization have transformed traditional family life into nuclear family arrangements, which may produce in the elderly, once supported by the extended family, a state of social isolation (De Leo and Spathonis 2004).
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Because the use of religion and spirituality as coping strategies tends to increase with age (Koenig et al. 1998), this may be a protective factor for the elderly. In contrast to such attitudes, the data are clear that most older adults who commit suicide were in some form of psychological distress and that major depression is the specific form of psychopathology most often linked to elder suicide (Duberstein and Conwell 2000). In the older age groups, somatic illness and stressful life events are also common risk factors (Kung et al. 1998).
Ethnicity Among racial groups, whites commit suicide twice as frequently as African Americans, although sharp increases have been reported recently in the suicide rate among young African American men (Kung et al. 1998). In the multiethnic society of Hawaii, the rate of suicide varies considerably among different ethnic groups. This variation is reflected more sharply in the male population. In the years 1978–1982, the suicide rate per 100,000 population was relatively higher in the Hawaiian (29.2) and Korean American (24.4) groups and relatively lower among the Filipino Americans (8.7) and Chinese Americans (7.1), with whites (18.5) and Japanese Americans (11.7) in between (Tseng et al. 1992). These findings suggest greater differences than similarities among different ethnic-cultural groups, even though they shared the same geographical and social environment over a period of time (Tseng 2001). Interactions between a minority group and the larger society of which it is a part also influence suicidality, often in complex ways. For instance, African American young adults may be more suicidal than older individuals because they encounter intense discrimination at a time when they have not yet developed coping skills that enabled their elders to survive (Seiden 1981). In considering suicide rates among various ethnic groups, attention should be paid to not only differences between individual ethnic groups but also differences between ethnic subgroups. For instance, American Indians have an exceptionally high suicide rate. However, members of the Apache tribe have much higher rates than members of the Navajo and Pueblo tribes (Earls et al. 1990; Young 1991). Variations among tribes in the cultural acceptability of self-destructive behavior may explain some of the intertribal differences in suicide rates (Range et al. 1997; Young 1991). The presence or absence of support networks in the community available to various ethnic groups also affects suicide rates; ethnic groups may differ, for example, in having viable social roles for the elderly. The elevated suicide rate in one study of elderly Chinese Americans may
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have been due to the social isolation among that cohort. In contrast, Native and African American groups may provide more satisfactory social roles for the elderly (Seiden 1981). The suicide rate among young Indian women is much higher than among older women (Banerjee et al. 1990). This finding has been explained by the relatively lower status of young women in traditional Hindu Indian culture and difficulties associated with the cultural practice of arranged marriage to a man of the parents’ choice (Maniam 1988).
Cultural Attitudes Toward Suicide Native American cultures have no strong sanctions against suicide, and some have actually favored altruistic suicidal acts (Davenport and Davenport 1987). Altruistic suicide is characterized by insufficient individualism, and its primary attributes are duty, moral obligations, and self-sacrifice for a higher cause, as illustrated in the Japanese kamikaze missions during World War II (Maris 2000). Another example of altruistic suicide is presented in the case example that follows.
Case Example 2 Ernenek is an elderly Yuit Eskimo who lives in Seattle with his wife, Umiak; his adult son, Papik, and his wife; and a 6-month old grandson Amuzian. Papik is a computer programmer who was educated in the United States. As his parents aged, Papik arranged to bring them to his home. Ernenek’s age and his years of hard outdoor work in the Arctic environment have taken their toll; Ernenek has no teeth, has difficulty walking and seeing, and is unable to work or even to help the family with any household work. Amuzian developed health problems, and Papik had to take time off work to help care for him. As a result, the family developed financial difficulties. Ernenek considers himself useless and is particularly unhappy that he could not even help care for his grandson. To spare the family the cost and effort of caring for him as well as Amuzian, he asks Umiak and Papik to shoot him. An intense emotional discussion ensued; in Yuit culture this request is not unreasonable, but Papik refuses, in part because he has adopted mainstream U.S. societal views about suicide. The family agrees to go to the emergency department and discuss the situation with the psychiatrist there before taking any action.
In this culture, suicide is a social process; deciding to die and carrying out the necessary actions are done as a group, usually including the relatives and friends of the individual contemplating suicide. In this nomadic hunting and gathering society, to become old, sick, and dependent might place the well-being and even survival of the family at risk.
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It is a common practice in this society for the individual contemplating suicide to request help from a family member in carrying out the plan. This request traditionally must be denied initially. However, if the request is repeated at least three times, it must be honored by the family. Suicide, when carried out in consideration of the welfare of the family and others in the group, is considered by the Yuit to be an act of respect, courage, and wisdom (Maris 2000). Hispanic Americans often have strong anti-suicide attitudes deriving from the Roman Catholic Church, although this prohibition may not apply to some Hispanics (e.g., young Puerto Rican men) (Queralt 1993). Similarly, women from groups with strong religious prohibitions against suicide (e.g., Islamic cultures) have lower suicide rates than women from groups that have no strong prohibitions, such as Buddhists and Confucianists (Kok 1988). In Pakistan, suicidal behavior is socioculturally considered to be gravely wrong. In contrast, some Asian suicides are often considered to be altruistic. In Japan, people believe that if a person is willing to take his own life, he should be excused from any prior misbehavior or debt. Most European countries formally decriminalized suicide in the eighteenth and nineteenth centuries, although it remained a crime in England and Wales until 1961 and in Ireland until 1993 (Jamison 1999), and it continues to be recognized as a crime in several U.S. jurisdictions (Simon et al. 2005). Given the complexity of the risk factors involved in suicide and the increasingly multicultural nature of American society, identifying and clarifying the factors associated with suicide among cultural groups while adjusting for confounding factors could provide a valuable focus for further research (Kung et al. 1998).
❏ Key Points1 ■
Develop general cultural competence in psychiatric evaluation.
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Become familiar with any special traditional suicidal behaviors that may exist in a cultural group.
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Explore the meaning of suicide from the patient’s cultural point of view. Is it an act of sacrifice, a social statement, or an attempt to end personal suffering? It is important to avoid the projection of
1 These key points for the culturally competent management of the suicidal patient are adapted from the work of Wen-Shing Tseng, M.D., of the University of Hawaii, who has spent 30 years instilling cultural competence in his students and residents.
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one’s own value system onto the patient and to recognize that a seemingly trivial stressor, such as an argument with a parent, can have culturally magnified consequences. ■
Be aware of the cultural context of help-seeking behavior and the varying expectations of the patient toward the clinician. Some people will behave deferentially, others look to the evaluator for advice and guidance, and still others will need a safe place to express emotions. Avoid the assumption that the patient wants what the clinician would want in similar circumstances.
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Distinguish between suicidal behavior that is culturally sanctioned and that which is pathological. Treatable illness is strongly associated with suicide in all cultures, and even in societies that are tolerant of suicide, there will always be individuals who, if prevented from killing themselves, will eventually be grateful for the intervention.
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Kok LP, Tseng W-S (eds): Suicidal Behavior in the Asia-Pacific Region. Singapore, Singapore University, 1992, pp 112–126 Kung HC, Liu X, Juon HS: Risk factors for suicide in Caucasians and in AfricanAmericans: a matched case-control study. Soc Psychiatry Psychiatr Epidemiol 33:155–161, 1998 Ladrido-Ignacio L, Gensaya JP: Suicidal behavior in Manila, Philippines, in Suicidal Behavior in the Asia-Pacific Region. Edited by Kok LP, Tseng WS. Singapore, Singapore University, 1992, pp 112–126 Latha KS, Bhat SM, D’Souza P: Suicide attempters in a general hospital unit in India: their socio-demographic and clinical profile—emphasis on crosscultural aspects. Acta Psychiatr Scand 94:26–30, 1996 Lee CS, Chang JC, Cheng ATA: Acculturation and suicide: a case-control, psychological autopsy study. Psychol Med 32:133–1441, 2002 Linton R: Acculturation in Seven American Indian Tribes. New York, AppletonCentury Company, 1940 Liu SI, Cheng ATA: Alcohol use disorders among the Yami aborigines in Taiwan: an inter-ethnic comparison. Br J Psychiatry 172:168–174, 1998 Magne-Ingvar U, Ojehagen A, Transkman-Bendz L: The social network of people who attempt suicide. Acta Psychiatr Scand 86:153–158, 1992 Malchy B, Enns MW, Yang TK, Cox BJ: Suicide among Manitoba’s aboriginal people, 1988 to 1994. CMAJ 156:1133–1138, 1997 Malus M, Kirmayer LJ, Boothroyd L: Risk factors of suicide among Inuit youth: a community survey. Culture and Mental Health Research Unit Report No 3. Montreal, Quebec, Canada, Institute of Community and Family Psychiatry, Sir Mortimer B. Davis–Jewish General Hospital, 1994 Maniam T: Suicide and parasuicide in a hill resort in Malaysia. Br J Psychiatry 153:222–225, 1988 Maris RW: Comprehensible Text Book of Suicidology. New York, Guilford, 2000, pp 170–191 Mass M, Al-Krenawi A: When a man encounters a woman, Satan is also present: clinical relationships in Bedouin society. Am J Orthopsychiatry 64:357–367, 1994 Mavreas V, Bebbington P: Acculturation and psychiatric disorder: a study of Greek Cypriot immigrants. Psychol Med 20:941–951, 1990 Neff JA, Hoppe SK: Acculturation and drinking patterns among US Anglos, Blacks and Mexican Americans. Alcohol Alcohol 27:293–308, 1992 Payne IR, Bergin AE, Bielema KA, et al: Review of religion and mental health: prevention and enhancement of psychosocial functioning. Prev Hum Serv 9:11–40, 1991 Pescosolido B, Georgianna S: Durkheim, suicide and religion: toward a network theory of suicide. Am Sociol Rev 54:33–48, 1989 Queralt M: Risk factors associated with completed suicide in Latino adolescents. Adolescence 28:831–850, 1993 Range LM, MacIntyre DI, Rutherford D, et al: Suicide in special populations and circumstances: a review. Aggress Violent Behav 2:53–63, 1997 Redfield R, Linton R, Herskovits MJ: Memorandum for the study of acculturation. Am Anthropol 38:149–152, 1936
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Rogler LH, Cortes DE, Malgady RG: Acculturation and mental health status among Hispanics: convergence and new directions for research. Am Psychol 46:585–597, 1991 Seiden RH: Mellowing with age: factors influencing the nonwhite suicide rate. Int J Aging Hum Dev 13:265–284, 1981 Shaffer D, Garland A, Gould M, et al: Preventing teenage suicide: a critical review. J Am Acad Child Adolesc Psychiatry 27:675–687, 1988 Shaffer D, Gould M, Hicks RC: Worsening suicide rate in black teenagers. Am J Psychiatry 151:1810–1812, 1994 Simon RI: Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management. Washington, DC, American Psychiatric Publishing, 2004 Simon RI, Levenson JL, Shuman DW: On sound and unsound mind: the role of suicide in tort and insurance litigation. J Am Acad Psychiatry Law 33:176– 182, 2005 Skegg K, Cox B, Broughton J: Suicide among New Zealand Maori: is history repeating itself? Acta Psychiatr Scand 92:453–459, 1995 Stack S: The effects of religious commitment on suicide: a cross-national analysis. J Health Soc Behav 24:362–374, 1983 Stack S: Marriage, family, religion and suicide, in Assessment and Prediction of Suicide. Edited by Marris RW, Berman AL, Maltsberger JT, et al. New York, Guilford, 1992, pp 540–552 Stack S, Lester D: The effect of religion on suicide. Soc Psychiatry Psychiatr Epidemiol 26:168–170, 1991 Summerville MB, Kaslow NJ, Doepke KJ: Psychopathology and cognitive and family functioning in suicidal African American adolescents. Current Direction in Psychological Science 5:7–11, 1996 Thorslund J: Inuit suicides in Greenland. Arctic Med Res 49:25–33, 1990 Trovato F: Interprovincial migration and suicide in Canada, 1971–1978. Int J Soc Psychiatry 32:14–21, 1986 Trovato F: Sex, marital status and suicide in Canada: 1951–1981. Sociological Perspectives 34:427–445 , 1991 Tseng W-S: Handbook of Cultural Psychiatry. San Diego, CA, Academic Press, 2001 Tseng W-S, Streltzer J (eds): Culture and Psychopathology. New York, Brunner/Mazel, 1997 Tseng W-S, Streltzer J (eds): Cultural Competence in Clinical Psychiatry. Washington, DC, American Psychiatric Publishing, 2004 Tseng W-S, Hsu J, Omori A, et al: Suicidal behavior in Hawaii, in Suicidal Behavior in the Asia-Pacific Region. Edited by Kok LP, Tseng W-S. Singapore, Singapore University, 1992, pp 238–248 Tseng W-S, Ebata K, Kim KI, et al: Mental health in Asia: social improvement and challenges. Int J Soc Psychiatry 4:8–23, 2001 Uba L: Asian Americans: Personality Patterns, Identity and Mental Health. New York, Guilford, 1994 Weissman MM: The epidemiology of suicide attempts 1960 to 1971. Arch Gen Psychiatry 30:737–746, 1974
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Wong OC, Piran N: Western biases and assumptions as impediments in counseling traditional Chinese clients. Canadian Journal of Counseling 29:107– 119, 1995 World Health Organization: World Health Statistic Annual 1989. Geneva, World Health Organization, 1989 Young TJ: Suicide and homicide among Native American: anomie or social learning? Psychol Rep 68:1137–1138, 1991 Zhang J: Suicide in Beijing, China, 1992–1993. Suicide Life Threat Behav 26:175– 180, 1996
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Psychological Testing in Suicide Risk Management Glenn R. Sullivan, Ph.D. Bruce Bongar, Ph.D., ABPP, FAPM
The ultimate challenge and responsibility of suicide risk assessment is the elimination of false negatives—that is, the misclassification of suicidal people as non-suicidal. This process is fraught with both personal and professional anxiety on the part of the mental health professional. The use of psychological testing is a common approach to managing this anxiety. In this chapter, we review some of the most commonly used psychological tests, suicide scales, and risk estimators and offer suggestions regarding their role in suicide risk assessment. Most clinicians rely primarily on the clinical interview and certain valued questions and observations to assess suicide risk. Traditional psychological tests such as the Minnesota Multiphasic Personality Inventory–2 (MMPI-2; Greene 2000), Rorschach Inkblot Test (Exner 2003), Beck Depression Inventory (BDI; Beck et al. 1996), and Thematic Apperception Test (TAT; Murray 1943) are used by less than half of psychologists, psychiatrists, and clinical social workers who evaluate suicidal adults and adolescents (Jobes et al. 1990). Suicide assessment instruments such as the Beck Hopelessness Scale (BHS; Beck and Steer 1988) and the Beck Suicide Intent Scale (SIS; Beck et al. 1974) are considered by practitioners to be somewhat more useful in the evaluation of suicide risk than traditional psychological tests, but only a minority of practitioners routinely use them (Jobes et al. 1990). 177
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Suicide is too complex a behavior to be adequately captured by a single sign or score (Eyman and Eyman 1991). Assessment of a patient’s risk for suicide should never be based solely of the results of psychological testing. A complete evaluation of risk factors, such as the patient’s psychiatric diagnosis, previous suicide attempts, substance abuse, family history of suicide, social isolation, physical illness, and availability of lethal means (especially firearms), should be considered in conjunction with psychological assessment results (Maris et al. 1992). Demographic risk factors, including gender, age, race/ethnicity, and religious beliefs, must also be considered when assessing a patient’s suicide potential. Since Pokorny published his work on suicide prediction in 1983, it has become increasingly clear that the critical issue for clinicians and researchers is not the prediction of suicide but rather the assessment of suicide risk (Pokorny 1983). For a variety of reasons, the low base rates of completed suicide in both clinical and general populations make it statistically impossible to develop a test or scale that can accurately predict whether a given individual will commit suicide over the long term. Despite this difficulty, the ability to predict suicide is perceived by the courts and public to be a prime competency of mental health practitioners and perhaps their most salient duty. Within that context, psychological tests and scales can be employed effectively to assist in the identification of individuals at increased risk for self-harm.
Minnesota Multiphasic Personality Inventory–2 The MMPI-2 is the most widely used instrument for assessing psychopathology in clinical practice (Greene 2000). Inconsistent findings among retrospective comparisons of suicide attempters and nonattempting comparison groups have led some researchers to conclude that despite considerable research effort, no item, scale, or profile configuration on the original MMPI consistently differentiated suicidal and nonsuicidal patients. Initial hopes that the restandardized MMPI-2 would provide more valid indicators of suicidality have yet to be realized. Nevertheless, when used properly, the MMPI-2 can be an important tool in the assessment of suicide risk, if not the prediction of actual completed or attempted suicide. The 567-item MMPI-2 represents a significant time investment for both administration (90% of patients complete the test in 90 minutes or less) and interpretation (which should be performed by a qualified psychologist). However, this method can provide important data about a patient’s subjective experience that might not be collected in a standard clinical interview. Psychological tests such as the MMPI-2 should be
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viewed as providing the clinician with hypotheses that can be verified with other methods (Osborne 1985). These other methods could include other psychological tests, suicide scales and risk estimators, and a comprehensive clinical interview and history (Hendren 1990).
Clinical Scales The MMPI-2 (and the earlier version of the test, the MMPI) is composed of 10 basic clinical scales that measure a broad band of psychopathology. The two highest elevations on these clinical scales determine a patient’s MMPI-2 code type. Elevations in scores on scale 2 (Depression) of the MMPI were frequently associated with a preoccupation with death and suicide (Dahlstrom et al. 1972). Clopton (1974) noted that “the one standard MMPI scale found most frequently to differentiate suicidal and nonsuicidal groups is scale 2” (p. 129). Agreeing with that assertion, Meyer (1993) stated that the prototypical pattern for suicidal individuals is the 2–7/7–2 code type (Depression and Psychasthenia). People with this code type are described as anxious, tense, and depressed. Suicidal ideation and attempts are “fairly likely” among persons with the 2–7/7–2 code type (Greene 2000). Meyer (1993) pointed out that the likelihood of suicidal ideation resulting in an attempt increases as scores on scales 4 (Psychopathic Deviancy), 8 (Schizophrenia), and 9 (Hypomania) rise. The increased elevations on these scales reflect greater impulsivity and/or resentment (scale 4), heightened alienation from self and others (scale 8), and increased energy to carry out a suicide attempt (scale 9). Based on data from Greene’s (2000) manual, Table 8–1 presents suicide risk information for 36 MMPI-2 code types.
Content Scales and Critical Items With the release of the MMPI-2, practitioners now have available the Koss-Butcher Critical Item Set–Revised, listing 22 items that are related specifically to depressed suicidal ideation. However, Butcher (1989) noted that these critical items are not “designed to operate as scales. They are used to highlight item content that might be particularly significant in the individual’s case. As sources of clinical hypotheses, the critical items might be used to key the clinician into problem areas or concerns the patient may have” (p. 17). (For additional information on the specifics of these critical items, see Butcher 1989; Butcher et al. 1989.) Six items on the MMPI-2 (items 150, 303, 506, 520, 524, and 530) directly inquire about suicidal ideation or behavior (Table 8–2). Sepaher et
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Textbook of Suicide Assessment and Management Suicide risk information for 36 MMPI–2 code types
Code type
Suicide risk information
Spike 1
There is a slight possibility of suicidal ideation that should be evaluated. Suicidal ideation should be evaluated carefully. Although suicidal ideation is quite unusual, the possibility of suicidal ideation should be evaluated carefully. Patient may have suicidal ideation that should be evaluated carefully. Suicidal ideation should be monitored carefully. Patient may have suicidal ideation that should be evaluated carefully. There is a slight possibility of suicidal ideation. Patient is unlikely to abuse substances or have suicidal ideation. There is a slight possibility of suicidal ideation that should be evaluated. There is some possibility of suicidal ideation that needs to be evaluated. Patient may have suicidal ideation that needs to be monitored carefully because of potential for substance abuse. Suicidal ideation is likely and should be evaluated carefully. Suicidal thoughts and attempts are fairly likely and should be evaluated carefully. Sleep medications should be prescribed cautiously, if at all, because of the potential for suicide. Suicidal ideation is very likely, and suicide potential should be evaluated very carefully and monitored regularly. Patient is likely to have suicidal ideation that should be reviewed carefully because of proneness to engage in risky behaviors, impulsivity, and substance abuse. Suicidal ideation is possible and should be monitored.
1–2/2–1 1–3/3–1
1–6/6–1 1–7/7–1 1–8/8–1a 1–9/9–1 1–0/0–1 Spike 2 2–3/3–2 2–4/4–2b
2–6/6–2b 2–7/7–2c
2–8/8–2a
2–9/9–2
2–0/0–2
Risk rating * ** *
** *** ** * * * ** ***
**** *****
*****
*****
***
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Suicide risk information for 36 MMPI–2 code types (continued)
Code type
Suicide risk information
Spike 3
Patient is unlikely to abuse substances or to report suicidal ideation. Patient is likely to have suicidal ideation that should be evaluated carefully. Use of sleep medications needs to be monitored, particularly if patient has suicidal ideation. Patient is likely to have suicidal ideation that should be evaluated carefully. Patient is likely to have suicidal ideation. Patient’s sense of futility and hopelessness increases the probability of suicidal behavior. Suicidal ideation is possible and needs to be evaluated carefully. Patient is apathetic and hopeless, which increases the possibility of acting out toward either self or others if provoked. Suicidal ideation should be evaluated carefully. Patient is likely to have a history of suicidal behavior, so suicidal ideation should be evaluated carefully. Patient’s isolation, hopelessness, and proneness to act out impulsively toward self or others increase the potential for suicide. Suicidal behavior is likely and should be evaluated carefully because of impulsive risk-taking behavior and propensity to abuse substances. Patient should be evaluated carefully for suicidal ideation; patient is hopeless and sees little likelihood of change in circumstances. Patient is likely to have suicidal ideation that should be evaluated. The possibility of suicidal ideation should be evaluated. Suicidal ideation should be monitored carefully.
3–6/6–3
3–7/7–3 3–8/8–3a
4–6/6–4
4–7/7–4 4–8/8–4a
4–9/9–4
4–0/0–4
5–6/6–5 5–8/8–5 6–7/7–6
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Risk rating * ****
**** *****
*****
** *****
*****
****
**** ** ***
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TABLE 8–1.
Textbook of Suicide Assessment and Management Suicide risk information for 36 MMPI–2 code types (continued)
Code type
Suicide risk information
6–8/8–6a
Patient is likely to have suicidal ideation. Patient feels hopeless and is generally apathetic, so potential for suicide should be monitored carefully. Suicidal ideation should be monitored carefully because of patient’s impulsive tendencies. Patient is unlikely to have suicidal ideation or to abuse substances. Patient is likely to have suicidal ideation that should be monitored carefully. Suicidal ideation should be monitored carefully because of impulsivity and potential for substance abuse. Suicidal ideation is very likely and should be monitored carefully. There is a slight possibility of suicidal ideation. Suicidal ideation is likely and should be monitored carefully because of patient’s impulsivity and potential for substance abuse.
6–9/9–6
Spike 7 7–8/8–7a 7–9/9–7
7–0/0–7 Spike 8 8–9/9–8
Risk rating *****
****
* **** *****
***** * *****
Note. MMPI=Minnesota Multiphasic Personality Inventory. a More than 20% of men and women with this code type endorsed both item 506 (“I have recently considered killing myself”) and item 520 (“Lately I have thought a lot about killing myself”) (Sepaher et al. 1999). b More than 20% of women with this code type endorsed both item 506 (“I have recently considered killing myself”) and item 520 (“Lately I have thought a lot about killing myself”) (Sepaher et al. 1999). c More than 20% of men with this code type endorsed both item 506 (“I have recently considered killing myself”) and item 520 (“Lately I have thought a lot about killing myself”) (Sepaher et al. 1999). Source. Derived from Greene 2000.
al. (1999) found endorsement base rates of approximately 20% and more for two of the most direct MMPI-2 suicide items (506 and 520) among nine different well-defined MMPI-2 code types. They referred to these items as the “I mean business” items because both items directly inquire about current suicidal intent. In their study, none of the patients who verbally endorsed the interview question “Are you currently suicidal?” failed to endorse item 506, and only 1% of those patients failed to endorse item 520.
Psychological Tests and Scales TABLE 8–2. 150. 303. 506. 520. 524. 530. Source.
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Minnesota Multiphasic Personality Inventory–2 suicide items
Sometimes I feel as if I must injure myself or someone else. Most of the time I wish I were dead. I have recently considered killing myself. Lately I have thought a lot about killing myself. No one knows it, but I have tried to kill myself. Sometimes I cut or injure myself on purpose without knowing why. Butcher et al. 1989.
Kaplan et al. (1994) found that many patients tend to disclose more information regarding recent suicidal ideation on self-report forms than they do in clinical face-to-face interviews. Glassmire et al. (2001) found that psychotherapy outpatients who failed to endorse suicidal ideation or behaviors during direct clinical inquiry often endorsed suiciderelated items on the MMPI-2. This suggests that certain MMPI-2 items have greater sensitivity for the detection of suicide potential than even direct verbal inquiry. These findings have important risk management implications because they suggest that clinicians should always look at the six MMPI-2 suicide items, particularly items 506 and 520, even when clients do not report depressed mood, current suicidal ideation, or past suicidal behavior. The MMPI-2’s five-item DEP4 (Suicidal Ideation) content component scale is regarded by many clinicians as highly useful when assessing suicide risk. However, there is a need for empirical studies of the association between this MMPI-2 scale and actual patient suicidal behaviors. The DEP4 scale is thought to assess “a pessimism about the future that is so dire as to support a wish to die and thoughts of suicide” (Greene 2000, p. 190). In addition to three of the six MMPI-2 suicide content items (303, 506, and 520), the DEP4 scale contains item 454 (“The future seems hopeless to me”) and item 546 (“My thoughts these days turn more and more to death and the life hereafter”). We strongly caution clinicians to remember that a raw score of zero on DEP4, or a negative finding on any other suicide scale or indicator, does not indicate the absence of suicide risk. For some patients, refusal to acknowledge suicidal ideation or intent on psychological testing may represent a strong determination to die. The results of a survey of specialists who use the MMPI-2 to assess suicide risk revealed that among the Validity scales, high F (a measure of distress) and high L (a potential sign of overcontrol or denial) scores were both considered important variables to examine (Glassmire et al.
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1999). However, K scores were rated as important to examine as to whether they were high (suggestive of overcontrol or denial) or low (indicating poor coping resources). The clinical scales most frequently cited by these experts as important in evaluating suicide risk were Scale 2 (Depression), followed by 4 (Psychopathic Deviancy), and finally 8 (Schizophrenia). Extreme elevation of any clinical scale or the elevation of multiple scales also warrants careful review. The MMPI-2 content scales most often cited by experts were DEP (Depression), followed by ANG (Anger) and MAC-R (MacAndrews Alcoholism). The Content Component scale DEP4 (Suicidal Ideation) was also cited by these experts as useful.
Rorschach Inkblot Test Historically, the Rorschach technique was the most commonly used method for estimating the risk of suicide, although it has been supplanted by more sophisticated psychometric instruments such as the MMPI-2 and various suicide lethality scales. The Rorschach may still be a potent tool for assessing suicide risk, if it is used correctly. Among the recent additions to the Rorschach Comprehensive System (Exner 2003) is the inclusion of a Suicide Constellation (S-CON) among the Rorschach special indices. The S-CON consists of 12 variables and highlights certain features that are common in the Rorschach protocols of individuals who completed suicide within 60 days of the test administration. A total of 101 individual protocols now compose the S-CON data set, an increase from the original 59 individuals whose protocols were first used to develop the index in the 1970s. Exner (2000) stated that proper interpretation of the Rorschach protocol of any person age 15 or older must begin with the scoring and review of the S-CON index. The endorsement of 8 of the 12 variables of the S-CON can serve as a red flag to warn a psychologist that commonalities exist between the patient being tested and the 101 suicide completers. Exner (2000) cautioned strongly that a score of less than 8 does not ensure that an individual will not attempt or complete suicide. In fact, the suicide sample was found to contain approximately 20%–25% falsenegative records. Hence, an endorsement of 7 S-CON variables should prompt the clinician to carefully rescore the protocol and to attend to the possibility of self-destructive preoccupation. Many of the items in the original adult S-CON contained variables that were developmentally normal for children and adolescents. To date, efforts to develop a child/ adolescent version of S-CON have been disappointing.
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A discussion of the conceptual foundations of the Rorschach variables that are indicative of potential suicide risk is beyond the scope of this chapter (for detailed review, see Exner 2003; Eyman and Eyman 1991; Meyer 1993). Whenever overt (e.g., “It looks like a man hanging from a bridge”) or covert (e.g., “A broken-down wreck of something”) suicidal content is provided during the administration of a Rorschach test, it should be taken seriously as a possible indication of self-destructive intent. In these cases, it should be assumed that the patient has used the Rorschach administration to communicate suicidal intent or feelings (Neuringer 1974). At this point, it is appropriate to comment on the production of false positives when using psychological testing in the assessment of suicide risk. Historically, much concern has been expressed regarding the importance of minimizing the number of false-positive identifications— that is, the percentage of nonsuicidal patients misclassified as suicidal. In our opinion, it is possible for this concern to be overstated. Realistically, the negative consequences for a patient who completes a psychological test or screen in a manner similar to that of patients who report suicidal thoughts or intent are limited. It is highly unlikely that an unjustified involuntary hospitalization or inappropriate psychopharmacological intervention would result solely from a score on a suicide risk scale. If done frankly and within the context of the clinician’s concern for the patient’s safety, the communication of positive test findings should not damage the therapeutic alliance. A conservative stance on the matter of false positives acknowledges that the purpose of testing is the assessment of risk, not the prediction of suicide, and that all patients who seek the services of mental health professionals are, in varying degrees, at elevated risk for suicide.
Other Measures There continues to be enormous interest in the development of suicide risk scales and estimators. Contemporary efforts at scale construction began in 1963 when the Los Angeles Suicide Prevention Center developed a special scale for assessing callers to their center (Farberow et al. 1968). The Los Angeles Suicide Prevention Center Scale focuses on demographic and clinical characteristics of patients. Although this scale has been widely used by suicide prevention and crisis centers, such instruments remain primarily useful “as research tools rather than aids for front-line clinicians” (Motto 1989, p. 249). Motto (1989) noted that methodological and practical problems have plagued the development of scales of suicide risk
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to the point of discouraging even devoted and experienced workers in the field of suicide prevention. …These obstacles have been small samples, limited data, a low base rate, nongeneralizabilty of critical stressors, the individual uniqueness of suicidal persons, unknown and uncontrollable variables that contribute to outcome, ambiguity of outcome (e.g., “suicidal behavior”), and problems of demonstrating reliability and especially validity. (p. 249)
Nevertheless, an abundance of suicide assessment measures are available to clinicians. None of these, however (with the possible exception of the BDI), has attained common and widespread use. One probable explanation for the lack of impact of such scales, collectively or individually, is that in their development, “little attention was paid to providing clinicians with a simple brief procedure that could be quickly translated into a clear indication of suicide risk” (Motto 1989, p. 250). However, there have recently been many attempts to construct clinically useful screening instruments for use by the clinician. One recent review included more than 35 suicide assessments (Rogers and Oney 2005). The following examples are meant to be representative of this approach to the assessment of suicide rather than an exhaustive listing of all available instruments.
Beck Depression Inventory and Beck Hopelessness Scale The revised Beck Depression Inventory (BDI-II; Beck et al. 1996) consists of 21 items designed to assess the severity of depression in adolescents and adults. Each item is rated on a three-point scale, so total scores can range from 0 (no reported symptoms of depression) to 63 (extreme symptom endorsement). Scores from 0 to 13 indicate minimal depression; 14–19, mild depression; 20–28, moderate depression; and 29–63, severe depression. The BDI-II is a clear and concise instrument that enables patients to self-report depressive symptoms in less than 10 minutes. The BDI-II supplants the original BDI, which over the past 25 years had become one of the most widely accepted and used instruments for assessing depression. In addition to the overall level of depression, it is important to attend to specific item content, particularly those items that reflect suicidal ideation. Beck et al. (1985) emphasized the importance of the BDI’s Pessimism item (item 2) in the prediction of eventual suicide. The possible mediating effect of hopelessness on suicidality contributed to the development of the BHS, a set of 20 true-or-false items that measure three major aspects of hopelessness: feelings about the future, loss of motivation, and expectations. Beck et al. (1985) reported that BHS scores of 9 or more were predictive of eventual suicide in 10 out of 11 depressed suicide ideators who were followed for
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5–10 years after discharge from the hospital. In a subsequent study of outpatients (Beck et al. 1990), a BHS cutoff score of 9 or above identified 16 of the 17 eventual suicides (94.2%). The high-risk group identified by this cutoff score was 11 times more likely to commit suicide than the rest of the outpatients. These findings strongly suggest that hopelessness is a superior predictor of suicidal intention rather than depression. Beck and Steer (1988) provided a vivid case example that demonstrates the complexities involved in using the BHS and BDI as predictors of suicide during therapy. At the time of his evaluation, the patient presented with severe depression and hopelessness but denied suicidal ideation. Over the course of three subsequent sessions, the tests were readministered; his BHS score held steady (at 20) but his BDI score dropped from 45 on intake to 35 and then rose only to 37 by the third session. The case of this patient, who killed himself 3 days prior to the next scheduled appointment, demonstrates that “in the presence of a high BHS and dropping BDI, a psychotherapist should be alert to the possibility of a suicide attempt” (Beck and Steer 1988, p. 22). Direct verbal inquiry about specific responses to BHS items is recommended, because clinical exploration of these responses may allow the patient to acknowledge suicidal intent, erode pervasive hopelessness, and foster therapeutic collaboration (Beck and Steer 1988). Young et al. (1996) reported that stable levels of hopelessness over time could be more predictive of suicide attempts in patients with remitted depression than a high level of current hopelessness at any one point in time.
Scale for Suicide Ideation and Suicide Intent Scale Beck and colleagues also developed two important scales for the measurement of suicidal ideation and intent: Scale for Suicide Ideation (SSI; Beck et al. 1979) and Suicide Intent Scale (SIS; Beck et al. 1974). The SSI is a 21-item rating scale that a trained clinician can use to measure the intensity of a patient’s current suicidal ideation. Each item presents three options graded on a three-point scale ranging from 0 (low suicidal intensity) to 2 (high suicidal intensity). The first 5 items are for screening purposes; if any suicidal ideation is evidenced on the screening items, then the subsequent 14 items are administered. Two additional items document the incidence and frequency of past suicide attempts. The ratings for the first 19 items are summed to yield a total score ranging from 0 to 38. Factor analysis has revealed three factors measured by the SSI: 1) active suicidal desire (e.g., attitudes toward living or dying); 2) suicide preparation (e.g., acquisition of lethal means, writing of a suicide note); and 3) passive suicidal desire (e.g., concealment of plans, avoidance of help) (Reinecke and Franklin-Scott 2005). Patients who scored 3 or higher on the
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SSI have been found to be seven times more likely to kill themselves than those who scored less than 3 (Brown et al. 2000). Rather than employing cutoff scores, however, it is recommended that any positive response to an SSI item should be immediately followed by thorough clinical inquiry. The SSI is not intended to replace the clinical interview; it is intended to provide clinicians with a rapid and reliable instrument for multimethod assessment of suicide ideation. The SIS is designed for use with extremely high-risk patients—that is, those who have recently made a suicide attempt or suicidal gesture. The 15 items that compose the SIS are administered as a structured clinical interview. The SIS assesses the patient’s pre-attempt communications, the perceived likelihood of being discovered during the suicide attempt, and attitudes toward living and dying, among other factors. In terms of what is measured, the SIS is very similar to the 10-item Risk-Rescue Rating Scale (Weissman and Worden 1972). Both scales focus on the patient’s suicidal intent as defined by high risk of death combined with low probability of rescue. The SSI and SIS further the cause of augmenting the clinical interview with clinical assessment protocols to assess suicidal ideation and intent more systematically.
Thematic Apperception Test After a review of the literature on the Thematic Apperception Test as a diagnostic instrument for the assessment of suicide risk, McEvoy (1974) concluded that the literature on the use of the Thematic Apperception Test as an estimator of suicide risk is clearly disappointing. He noted that “the literature is sparse and not easily compared for purposes of generalizations. Perhaps the only general conclusion is that the test has not proved to be useful for this purpose” (p. 102). As with other projective personality tests, the investment of time and skill required for the proper administration and interpretation of the test cannot be justified if the purpose of assessment is solely to gauge suicide risk potential.
Firestone Assessment for Self-Destructive Thoughts The conceptual foundation for the Firestone Assessment for SelfDestructive Thoughts (FAST; Firestone and Seiden 1990) is that suicide and self-destructive behavior are influenced by an inner “voice” (e.g., a negative thought process). The voice process represents a pattern of thoughts, attitudes, and beliefs that are antithetical to the self and hostile toward others. The voice ranges along a continuum of intensity, from self-defeating (e.g., “You’re stupid,” “You don’t deserve good things
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to happen to you”) to self-annihilating (e.g., “People would be better off without you,” “It’s the only way to end the pain”). The FAST is an 84-item self-report questionnaire that is designed to be used as a screening instrument. It can also be used to track changes in self-destructive thinking over time. The patient reports the frequency of negative thoughts on a five-point Likert-type scale (0 = “never”; 4 = “almost always”). (A Likert-type scale is a rating scale designed to measure user attitudes or reactions by quantifying subjective information.) The FAST helps clinicians identify the self-destructive thoughts that drive a patient’s self-destructive behaviors and facilitates directed interventions toward those areas (Firestone and Seiden 1990). Knowledge of where a patient’s score falls on the continuum can also assist clinicians in identifying patients who are at increased risk for suicide.
Linehan Reasons for Living Inventory The Linehan Reasons for Living Inventory (LRFL; Linehan et al. 1983) assesses the strength of an individual’s commitment not to die. The 48-item self-report measure takes about 10 minutes to administer; a 72-item version is also available. Internal consistency is high, and test-retest reliability over 3 weeks is moderately high. The LRFL has been noted to be sensitive to reductions in depression, hopelessness, and suicidal ideation in female patients receiving treatment for borderline personality disorder (Linehan et al. 1991). Conceptually, the basis for the LRFL is that the lack of positive reasons to live is as strong a contributor to suicide as the wish to die. Patients are asked to rate a series of reasons for NOT killing themselves, using a six-point Likert-type scale (1 = “not at all important”; 6 = “extremely important”). Subscales include Responsibility to Family (e.g., “My family depends on me and needs me”), Fear of Suicide (e.g., “I am afraid of the unknown”), and Moral Objections (e.g., “I believe only God has the right to end life”). The LRFL is a useful method of monitoring chronic suicidality in high-risk patients and measuring the effectiveness of suicide-focused treatment interventions.
Suicide Probability Scale The Suicide Probability Scale (SPS; Cull and Gill 1982) is a brief self-report measure designed to assist in the assessment of suicide risk in both adults and adolescents. This questionnaire asks patients to rate 36 items that address current suicide ideation, hopelessness, negative self-evaluation, and hostility. Respondents rate each item on a four-point Likert scale (1 = “none or a little of the time”; 4 = “most or all of the time”). The SPS can be com-
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pleted in about 10 minutes. A distinguishing feature of this instrument is the production of a suicide probability score that can be adjusted to reflect the base rates of suicidality in various clinical populations. However, there is a paucity of research on the predictive validity of the SPS. The authors of the SPS cautioned potential users of the instrument: “The SPS is intended solely as a screening instrument. It should not be used in isolation. Instead other methods such as clinical interview by trained psychiatric professionals should be used to supplement, corroborate, and investigate test results” (Cull and Gill 1982, p. 4). This instrument has a number of limitations, some of which are shared by many suicide measures: 1. The intent of the scale is not particularly disguised, making it particularly susceptible to exaggerated self-report of symptoms. 2. It assesses an individual’s reported feelings and behaviors only at one point in time and does not distinguish between remote and immediate history. Further research is needed to replicate findings with a wider range of representative samples and to assess the incremental validity of the SPS “in predicting suicidal behaviors beyond what could be predicted on the basis of commonly available patient demographic and clinical characteristics alone” (Cull and Gill 1982, p. 61).
Risk Estimator for Suicide Motto et al. (1985) developed an empirical suicide risk scale for adults hospitalized due to a depressive or suicidal state. Their study of 2,753 suicidal patients prospectively examined 101 psychosocial variables. After a 2-year follow-up, 136 (4.94%) of the participants had committed suicide. The authors used rigorous statistical analysis, including a validation procedure, to identify 15 variables as significant predictors of suicidal outcome. Their findings were translated into a paper-andpencil scale that gives an estimated risk of suicide within 2 years. Motto (1989) noted that instruments such as these could provide a valuable supplement to clinical judgment as well as the kind of quantitative expression of suicide risk that represents to many clinicians an opportunity to fine-tune their clinical judgment. However, Clark et al. (1987) undertook a field test of Motto et al.’s (1985) Risk Estimator for Suicide that “raised questions” about the instrument, although without invalidating the scale. They selected a subset of psychiatric patients with major or chronic affective disorders that
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corresponded to Motto’s sample. The subjects in the sample exhibited distinctly lower suicide rates over a 2-year follow-up (2.4%) than the sample reported by Motto (4.9%). The study by Clark et al. (1987) highlights the critical need to understand the limitations of all such scales, particularly the likelihood that suicide scales derived by multivariate analysis of a large number of clinical, psychosocial, and demographic variables may tend to be arbitrary and sample specific. Our impression is that empirically derived scales based on a single cross-sectional assessment are always difficult to validate. Repeated assessments over time on a broad array of clinical features may be necessary to develop an adequate and replicable prediction system. (p. 926)
Clark et al. (1987) recommended the use of serial assessments that monitor changing clinical symptoms and life stressors and consider the patient’s long-standing character structure.
Suicide Assessment Battery Yufit (1988) proposed that the assessment of suicidal behavior is best conducted through the use of a Suicide Assessment Team. Such a team would comprise a multidisciplinary staff of psychologists, social workers, nurses, and psychology graduate students specially trained in the use of a focused screening interview format and other assessment techniques for the identification and evaluation of suicide potential. (We further suggest the inclusion of psychiatrists on this team whenever possible.) The Suicide Assessment Team is intended to serve as consultants to inpatient psychiatric treatment teams and to conduct three levels of suicide assessment: a focused interview (Level I), specialized rating scales (Level II), and an extended psychological assessment (Level III) including the interviews and ratings described earlier as well as special psychological assessment techniques, termed the Suicide Assessment Battery. Comprehensive Suicide Assessment Teams are rarely used today and may be economically infeasible in the best of circumstances. Proposed Level II rating scales include the BDI, the Risk-Rescue Rating scale, and the Los Angeles Suicide Prevention Center Assessment of Suicide Potential. Some of the 13 recommended components of the Suicide Assessment Battery include the Suicide Assessment Checklist, Coping Abilities Questionnaire, Time Questionnaire, Sentence Completion, Draw-a-Person in the Rain Test, Thematic Apperception Test, Rorschach Inkblot Test, Experience Inventory, Autobiography, and Erikson Questionnaire.
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Yufit (1988) concluded, [E]ven in a psychiatric hospital setting, where psychiatric sophistication may be considered deep, there is a need for more comprehensive evaluation procedures of the complex behavior of suicide. At this stage of development, these techniques are not necessarily conclusive, nor are they often objective, but they very often do serve as important guidelines to assist in the identification and the assessment of the components of suicide potential. They should supplement clinical judgment, not substitute for it. (p. 33)
In short, instruments such as those included in the Suicide Assessment Battery may allow clinicians to supplement their own clinical judgment with a systematized approach to collecting assessment information.
Clinical Inquiry Motto (1989) noted that the most straightforward way to determine the probability of suicide is to ask the patient directly. This approach should emphasize matter-of-factness, clarity, and freedom from implied criticism. A typical sequence might be to ask the following questions: 1. Do you ever have periods of feeling sad or depressed about how your life is going? 2. How long do such periods last? How frequent are they? How bad do they get? Does the depression produce crying or interfere with daily activities, sleep, concentration, sex drive, or appetite? 3. Do you ever feel hopeless, discouraged, or self-critical? Do these feelings ever get so intense that life doesn’t seem worthwhile? 4. How often do thoughts of suicide come to mind? How persistent are such thoughts? How strong have they been? Does it require much effort to resist them? Have you had any impulses to carry them out? 5. Have you made any plans to end your life? How would you go about doing it? Have you taken any initial steps, such as hoarding medications or buying a gun? 6. Are there any firearms in your home? If you wanted to, how quickly could you get hold of a gun? Where would you get it? Are you satisfied that this situation is safe for you? If not, how can it be made safer? 7. Can you manage these feelings if they come back? If you can’t, is there a support system for you to turn to in helping to manage these feelings? What is your plan for getting through the next down period? Whom should you tell when you have these feelings?
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Motto (1989) pointed out that the above brief inquiry, when carried out in an empathic and understanding way, will provide the clinician with a preliminary estimate of risk. The approach rests on the premise that “going directly to the heart of the issue is a practical and effective clinical tool, and patients and collaterals will usually provide valid information if an attitude of caring concern is communicated to them” (p. 247). As always, however, the clinician should remember that the absence of reported suicidal thoughts or behaviors does not rule out the presence of suicide risk.
❏ Key Points ■
Use routine psychological testing and suicide scales because ■
Suicidal ideation and elevated suicide risk are often present in patients whose initial presentation may not trigger a suicide inquiry.
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Patients often disclose more information regarding suicidal thoughts and behaviors on self-report measures than during clinical interviews.
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Tests and scales contribute to a multimethod assessment that challenges the biases and blind spots of clinical judgment.
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Conduct a thorough psychodiagnostic evaluation for all patients. Accurate psychiatric diagnosis is perhaps the most important signal to alert clinicians to suicidal behavior over the life cycle. All patients must undergo thorough psychodiagnostic evaluation and receive a DSM diagnosis. Psychological testing can inform this process.
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Treat the identified psychiatric disorder. Use psychological testing and/or suicide scales such as the FAST (Firestone Assessment for Self-Destructive Thoughts) to identify areas of concern and treatment goals.
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Obtain complete patient histories, interview collaterals, and obtain relevant medical or mental health records. The use of self-report measures can provide a time-efficient and systematic means of collecting informative data.
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Document suicide risk assessment, even in cases when the risk is deemed minimal. The importance of thorough documentation cannot be overstated. Suicide risk assessment is a clinical procedure that should always be carefully documented in a timely manner. Psychological tests, when administered, should be properly scored and interpreted and added to the patient’s chart.
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■
Use reliable and valid suicide risk assessment instruments to supplement clinical judgment. Obtain consultation from qualified practitioners who are trained in the appropriate use of these instruments.
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Review the patient’s responses on any test or scale that has been administered, preferably before the patient leaves the clinician’s office. It is negligent, for example, to obtain a Rorschach protocol and not score the Suicide Constellation (S-CON).
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Investigate red flag items (e.g., the Minnesota Multiphasic Personality Inventory–2 [MMPI-2] suicide items) thoroughly, and document the ensuing follow-up inquiry.
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Review omitted items on suicide measures individually with the patient, and explore the reasons for the omissions.
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Perform clinical inquiries regarding suicide throughout the course of treatment. Instruments such as the revised Beck Depression Inventory (BDI-II) or Linehan Reasons for Living Inventory (LRFL) can be used not only at intake but also as a means of measuring patient progress at various time intervals.
References Beck AT, Steer RA: Manual for the Beck Hopelessness Scale. San Antonio, TX, The Psychological Corporation, 1988 Beck AT, Schuyler D, Herman I: Development of suicidal intent scales, in The Prediction of Suicide. Edited by Beck AT, Resnik HLP, Lettieri DJ. Bowie, MD, Charles Press, 1974, pp 45–56 Beck AT, Kovacs M, Weissman A: Assessment of suicidal intention: the scale for suicide ideation. J Consult Clin Psychol 47:343–352, 1979 Beck AT, Steer RA, Kovacs M, et al: Hopelessness and eventual suicide: A 10year prospective study of patients hospitalized with suicidal ideation. Am J Psychiatry 142:559–563, 1985 Beck AT, Brown G, Berchick RJ, et al: Relationship between hopelessness and ultimate suicide: a replication with psychiatric outpatients. Am J Psychiatry 147:190–195, 1990 Beck AT, Brown G, Steer RA: Beck Depression Inventory II Manual. San Antonio, TX, The Psychological Corporation, 1996 Brown GK, Beck AT, Steer RA, et al: Risk factors for suicide in psychiatric outpatients: a 20-year prospective study. J Consult Clin Psychol 68:371–377, 2000 Butcher JN: The Minnesota Report: Adult Clinical System MMPI-2. Minneapolis, MN, University of Minnesota Press, 1989 Butcher JN, Dahlstrom WG, Graham JR, et al: MMPI-2: Manual for Administration and Scoring. Minneapolis, University of Minnesota Press, 1989 Clark DC, Young MA, Scheftner WA, et al: A field test of Motto’s risk estimator for suicide. Am J Psychiatry 144:923–926, 1987
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Clopton JR: Suicidal risk via the Minnesota Multiphasic Personality Inventory (MMPI), in Psychological Assessment of Suicide Risk. Edited by Neuringer C. Springfield, IL, Charles C Thomas, 1974, pp 118–133 Cull JG, Gill WS: Suicide Probability Scale Manual. Los Angeles, CA, Western Psychological Services, 1982 Dahlstrom WG, Welsh GS, Dahlstrom LE: An MMPI Handbook, Vol I. Minneapolis, MN, University of Minnesota Press, 1972 Exner JE: A Primer for Rorschach Interpretation. Asheville, NC, Rorschach Workshops, 2000 Exner JE: The Rorschach: A Comprehensive System, Vol I: Basic Foundations, 4th Edition. New York, Wiley, 2003 Eyman JR, Eyman SK: Personality assessment in suicide prediction. Suicide Life Threat Behav 21:37–55, 1991 Farberow NL, Helig S, Litman R: Techniques in Crisis Intervention: A Training Manual. Los Angeles, CA, Suicide Prevention Center, 1968 Firestone RW, Seiden RH: Suicide and the continuum of self-destructive behavior. J Am Coll Health 38:207–213, 1990 Glassmire DM, Stolberg RA, Ricci CM, et al: The utility of MMPI-2 suicide items for assessing suicide history. Paper presented at the 34th Annual Symposium on Recent Developments in the Use of the MMPI-2/MMPI-A Workshop and Symposia. Huntington Beach, CA, April 1999 Glassmire DM, Stolberg RA, Greene RL, et al: The utility of MMPI-2 suicide items for assessing suicidal potential: development of a suicidal potential scale. Assessment 8:281–290, 2001 Greene RL: The MMPI-2: An Interpretive Manual. Boston, MA, Allyn & Bacon, 2000 Hendren RL: Assessment and interviewing strategies for suicidal patients over the life cycle, in Suicide Over the Life Cycle: Risk Factors, Assessment, and Treatment of Suicidal Patients. Edited by Blumenthal SJ, Kupfer DJ. Washington, DC, American Psychiatric Press, 1990, pp 235–252 Jobes DA, Eyman JR, Yufit RI: Suicide risk assessment survey. Paper presented at the annual conference of the American Association of Suicidology, New Orleans, LA, April 1990 Kaplan ML, Asnis GM, Sanderson WC, et al: Suicide assessment: Clinical interview vs self-report. J Clin Psychol 50:294–298, 1994 Linehan MM, Goodstein JL, Nielsen SL, et al: Reasons for staying alive when you are thinking of killing yourself: The Reasons for Living Inventory. J Consult Clin Psychol 51:276–286, 1983 Linehan MM, Armstrong HE, Suarez A, et al: Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry 48:1060– 1064, 1991 Maris RW, Berman AL, Maltsberger JT, et al (eds): Assessment and Prediction of Suicide. New York, Guilford, 1992 McEvoy TL: Suicidal risk via the Thematic Apperception Test, in Psychological Assessment of Suicide Risk. Edited by Neuringer C. Springfield, IL, Charles C Thomas, 1974, pp 3–17 Meyer RG: The Clinician’s Handbook: Integrated Diagnostics, Assessment, and Intervention in Adult and Adolescent Psychopathology, 3rd Edition. Boston, MA, Allyn & Bacon, 1993
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Motto JA: Problems in suicide risk assessment, in Suicide: Understanding and Responding: Harvard Medical School Perspectives on Suicide. Edited by Jacobs DG, Brown HN. Madison, CT, International Universities Press, 1989, pp 129–142 Motto JA, Heilbron DC, Juster RP: Development of a clinical instrument to estimate suicide risk. Am J Psychiatry 142:680–686, 1985 Murray HA: Thematic Apperception Test Manual. Cambridge, MA, Harvard University Press, 1943 Neuringer C: Rorschach inkblot test assessment of suicidal risk, in Psychological Assessment of Suicide Risk. Edited by Neuringer C. Springfield, IL, Charles C Thomas, 1974, pp 74–94 Osborne D: The MMPI in psychiatric practice. Psychiatr Ann 15:542–545, 1985 Pokorny AD: Prediction of suicide in psychiatric patients: report of a prospective study. Arch Gen Psychiatry 40:249–257, 1983 Reinecke MA, Franklin-Scott RL: Assessment of suicide: Beck’s scales for assessing mood and suicidality, in Assessment, Treatment, and Prevention of Suicidal Behavior. Edited by Yufit RI, Lester D. New York, Wiley, 2005, pp 29–61 Rogers JR, Oney KM: Clinical use of suicide assessment scales: enhancing reliability and validity through the therapeutic relationship, in Assessment, Treatment, and Prevention of Suicidal Behavior. Edited by Yufit RI, Lester D. New York, Wiley, 2005, pp 7–27 Sepaher I, Bongar B, Greene RL: Codetype base rates for the “I mean business” suicide items on the MMPI-2. J Clin Psychol 55:1167–1173, 1999 Weissman AD, Worden JW: Risk-rescue in suicide assessment. Arch Gen Psychiatry 26:553–560, 1972 Young MA, Fogg LF, Scheftner W, et al: Stable trait components of hopelessness: baseline and sensitivity to depression. J Abnorm Psychol 105:155–165, 1996 Yufit RI: Manual of Procedures: Assessing Suicide Potential: Suicide Assessment Team. Unpublished manual, 1988
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Psychopharmacological Treatment and Electroconvulsive Therapy H. Florence Kim, M.D. Lauren B. Marangell, M.D. Stuart C. Yudofsky, M.D.
Suicide and suicidal behavior can be devastating emotionally to affected individuals and their families. As detailed in previous chapters of this book, suicide is also an enormous public health problem. Suicide was the eleventh most common cause of death in 2002 (Kochanek and Smith 2004), with an incidence of attempts in 0.7% of the general U.S. population and suicidal ideation in 5.6% of the population in a 12-month period (Crosby et al. 1999). The annual incidence of completed suicide is 0.0107%, or 10.7 suicides for every 100,000 persons per year (Crosby et al. 1999). The risk of suicide and suicidal behaviors increases dramatically in psychiatric populations. For mood disorders, including unipolar major depression and bipolar disorder, the lifetime suicide risk is 15–20 times greater than the risk in the general U.S. population (Harris and Barraclough 1997). For primary psychotic disorders, the risk of suicide is estimated to be 8.5 times higher for schizophrenic patients than for the general U.S. population (Harris and Barraclough 1997). The most signif199
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icant risk factor for suicide is the presence of a psychiatric disorder, and 93% of those who completed suicide met criteria for at least one psychiatric diagnosis at postmortem psychological autopsy (Henriksson et al. 1993). Mood disorders specifically, including unipolar major depression and bipolar disorder, are the diagnoses most often found in completed suicide (Henriksson et al. 1993). Thus, it is of utmost importance that suicidal individuals receive treatment for underlying psychiatric disorders. In fact, two studies have shown that most individuals who complete suicide were not taking antidepressants immediately prior to death. In a Swedish study of 3,400 of 4,000 suicides for which forensic data in 1990–1991 were available, antidepressants were detected via toxicological screen in less than 16% (542 of 3,400 cases; Isacsson et al. 1994b). A smaller U.S. study showed that only 19 (8%) of 247 suicide completers between 1981 and 1983 in the San Diego area had tricyclic or tetracyclic antidepressants as detected by postmortem toxicology (Isacsson et al. 1994a). Of 97 subjects who met the criteria for major depression, bipolar depression, or atypical depression by postmortem research analysis, in the 90 days preceding suicide, only 52 (54%) had seen a physician, 33 (34%) had been diagnosed with depression, and 20 (21%) had been prescribed tricyclic or tetracyclic antidepressants. Finally, 9 of these 97 subjects (9%) had antidepressants present by postmortem toxicology (Isacsson et al. 1994a). Thus, it appears that at least in the case of depression, most individuals were not taking antidepressants immediately prior to their completed suicide, thus inferring possible undertreatment or insufficient treatment for underlying psychiatric disorders (Licinio and Wong 2005). Management of suicide and suicidal behaviors is complex and multidisciplinary and includes aggressive pharmacotherapy in conjunction with a strong psychotherapeutic alliance with the affected individual. As illustrated in preceding chapters, a thorough clinical assessment, early detection of risk factors and suicidal ideation, aggressive reduction of reversible risk factors and methods of suicide, careful consideration of hospitalization, and a strong therapeutic alliance with concomitant interpersonal and/or cognitive-behavioral therapy go hand-in-hand with careful but aggressive pharmacological and/or electroconvulsive therapy (ECT) treatment. Medications to treat symptoms such as psychic pain and anxiety and turmoil, panic attacks, agitation, impulsiveness, aggression, and feelings of hopelessness can be extremely helpful in managing the patient with suicidal tendencies. Long-term pharmacological treatment is associated with a decreased suicide rate. A Swiss long-term follow-up study of almost 400 patients hospitalized for affective disorders showed that long-term medication
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treatment (longer than 6 months’ duration) with psychotropic medications including antidepressants, lithium, and neuroleptics was associated with significantly lower suicide rates compared with those patients who were not treated with psychotropic medications over the 22-year follow-up period (Angst et al. 2002). However, in the acute phases of treatment with antidepressants, suicidal thoughts and behaviors may increase. This is of particular concern in children and adolescents, as articulated in recent warnings from the U.S. Food and Drug Administration and the European Committee for Medicinal Products for Human Use. These risk assessments were based on 24 placebo-controlled clinical trials among children and adolescents treated with antidepressants that, in aggregate, demonstrated a risk of suicidal thinking or behavior in 4% of participants treated with antidepressants compared with 2% of participants given placebo. There were no completed suicides, and all trials were less than 4 months in duration. These warnings apply to all antidepressant medications. Although data from adult placebo-controlled trials have not been evaluated in the same systematic manner, a recent study by Jick et al. (2004) does suggest that caution is warranted in the first few weeks of treatment. These investigators evaluated 555 cases of first-time nonfatal suicidal behavior or ideation (ages 10–69) and reported that the relative risk of suicidal behavior was four times greater for patients within 1–9 days of starting an antidepressant compared with patients who had started taking an antidepressant more than 90 days before developing nonfatal suicidal behavior (Jick et al. 2004). However, given the long-term benefit of antidepressants, these warnings are not intended to prevent the use of these medicines but rather underscore the need for close monitoring in the early phases of treatment.
Case Examples The following two cases illustrate the importance of treatment with pharmacotherapy and ECT as well as the complexity underlying treatment of these psychiatric disorders of which suicidality is a symptom. Evidence for clinical efficacy of psychotropic medications and ECT in prevention of suicide and suicidal behaviors is presented after the cases, although clinical trial data are rather disparate and often limited.
Case Example 1 Mr. A is a 64-year-old certified public accountant (CPA) who lost his job 2 years prior to psychiatric hospitalization. He had worked in the business office of a multinational company for 36 years and was told that his
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position was eliminated because of “a consolidation in the central office.” Mr. A believed that the real reason that he was fired was because of his seniority and the cost savings associated with replacing him with a far younger accountant. For about 1 year he tried in vain to find another position and ultimately reluctantly decided to retire. For most of Mr. A’s adult life, his passion had been his work, and consequently he had few hobbies or recreational interests. Upon retiring, he spent most of his time around the house and was bored. For the first time in his life, he began to drink scotch during the daytime hours and drank even more heavily at dinner and before bedtime. He rarely left home, became argumentative with his wife, lost his appetite and stopped eating regular meals, and could only fall asleep if he were intoxicated. Without trying to diet, Mr. A lost 35 pounds in a period of 8 months. He became preoccupied with his former boss from work. He confided to his wife that his boss “always had it in for me, had me fired, and won’t be happy until I’m dead.” His wife was alarmed when Mr. A told her that he found “evidence” that his former boss had placed listening devices around the house “in order to monitor my habits.” He became fearful that his food was being poisoned by this man. Although his wife encouraged him to see a psychiatrist, Mr. A staunchly refused: “I am not crazy, so there is no need for me to see some headshrinker.” Finally, his wife arranged to have their family physician evaluate her husband at home. This physician diagnosed Mr. A to have major depression and prescribed paroxetine, 20 mg/day. Over the next 3 weeks, Mr. A became increasingly more agitated and confused. He began to talk to himself, and it appeared to his wife that he was having conversations with people who were not in the house. She called the family physician, who told her to be patient and to be sure that her husband took the medication because it “might take two or three more weeks before it becomes effective.” Mr. A was now remaining in his room most of the time, staying in his bed, refusing to eat or drink—except the scotch, into which his wife would empty the capsule of paroxetine. Five weeks after the medication was initiated, Mrs. A heard a gunshot in her husband’s bedroom and found him lying motionless in bed in a pool of blood. She called 911 and the emergency medical services (EMS) arrived within several minutes. Mr. A was stabilized by the EMS team and general hospital emergency department physicians and staff and required 7 hours of surgery to repair the damage of the gunshot wound to his chest. Fortunately, the .22-caliber bullet missed his heart and vital blood vessels. Six days later he was transferred from the surgical service of the general hospital to the inpatient psychiatric service. At the time of his admission to the psychiatry service, Mr. A was not speaking, not interacting with family or staff, and not accepting food or medication. Although he did not demonstrate waxy flexibility, he barely moved and seemed to be in a catatonic state. With the cooperation and approval of Mrs. A, the psychiatric service successfully petitioned the local court for permission to treat their patient with intramuscular haloperidol, but his mental status did not change. Although Mr. A was on
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intravenous fluids and received nasogastric feedings, his psychiatric condition did not improve over the next 2 weeks. The psychiatric team returned to court to seek permission to administer a course of 7–10 ECT treatments, and this request was granted by the judge. Following his second treatment, Mr. A began to speak with family and staff, to walk about the psychiatry unit, and to feed himself. He acknowledged having felt so frightened, sad, and desperate that he had tried to kill himself at home by shooting himself in the chest. He stated, “At this point, I just don’t know what got into me. I felt I was in great danger, I was hearing the voice of my former boss talking to me and threatening me, and I felt hopeless. I guess I really lost it.” Following the course of 7 ECT treatments, Mr. A denied feeling hopeless, suicidal, or even sad. He willingly and productively participated in psychotherapy and group treatments. He was discharged with twice-weekly psychiatric follow-up and family counseling once a week with a social worker.
Mr. A exhibited many biopsychosocial risk factors for suicide: • • • • • •
Being a Caucasian male over 60 years old Having recently been fired from his job Not accepting or adapting to retirement Abusing alcohol Suffering from major depression with psychotic features Refusing psychiatric treatment
Although the family practitioner correctly diagnosed major depression and prescribed an antidepressant, he failed to recognize the concomitant psychotic symptoms and alcohol abuse or to take into account their significance with regard to treatment. People with depression accompanied by psychosis have increased risk of suicide, and they do not respond nearly as well to antidepressants as do people with depression without psychosis. Alcohol abuse may have occurred as the result of depression and/or may have affected his brain in ways that intensified Mr. A’s depression. Treatment with antidepressants, without the concomitant alcohol abuse first being diagnosed and treated, was destined to fail. Psychiatric hospitalization was indicated at the time of Mr. A’s initial evaluation by the family practitioner in order to monitor him closely as medications were initiated and to facilitate the safe withdrawal from alcohol. In addition, an antipsychotic medication should have been initiated along with the antidepressant, because this approach is virtually always required in patients with both depression and psychosis. Monitoring severely depressed patients closely and regularly for suicidal ideation and intent is imperative during the early phases of
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antidepressant treatment. After his suicide attempt and surgical treatment, Mr. A became catatonic. ECT is highly effective in treating major depression, psychosis, and catatonia and does so more rapidly and reliably than medication treatment. Given Mr. A’s deteriorating mental status and physical state during his hospitalization, ECT was clearly indicated at that point in his care. Following his ECT and his resulting euthymia, the psychiatric team considered prescribing a course of antidepressants. Because this was Mr. A’s first episode of depression, because he had stopped abusing alcohol, because he was being compliant in regular psychotherapeutic follow-up, because psychosocial interventions (including exercise and structured socialization) were initiated, and because of concern of eliciting further psychotic symptoms and other side effects, the psychiatric team chose to follow the patient closely without initiating antidepressant medications.
Case Example 2 Ms. E was a 26-year-old employee of a commercial airline company when she entered treatment with a social worker for “anxiety and failures in all my important relationships.” Her father, who had mood swings, irritability, and chronic alcoholism, abandoned the family when Ms. E was 5 years old, and her mother remarried 2 years later to a man who had two teenage sons from a previous marriage. Ms. E’s stepfather was critical and stern, and her mother, who chronically complained of back pain and fatigue, was often bedridden and unable or unavailable to care for Ms. E throughout her childhood. From the time Ms. E was 8 years old until she left home at age 17, she was recurrently abused sexually by both of her stepbrothers. Ms. E entered treatment with the social worker after the breakup of a 2-year relationship with a co-worker. Her therapist initially diagnosed her as having “grief reaction, moderate depression, and intermittent anxiety.” The thrust of treatment involved insight-oriented psychotherapy intended to help Ms. E connect her low self-esteem and dysfunctional behavioral patterns with the traumatic events of her childhood. During the first year of twice-weekly psychotherapy, Ms. E became increasingly dependent on her psychotherapist for support and guidance in her personal life. Approximately once a month Ms. E experienced what she termed as “the worst anxiety of my life.” During those episodes, she became terrified that she was going to have a heart attack and die, had racing of her heart, experienced tingling about her face and in the fingers of both hands, and felt as though she had “separated from my body.” Because she feared having another attack when she would be alone and could not get help, Ms. E began restricting her activities, eventually limiting them to work and her therapy sessions. When the psychotherapist left for a planned holiday, Ms. E cut her left wrist deeply with a razor blade. Several hours later, she went of her own accord to a
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general hospital emergency department “to be sewn up.” She was referred by the surgeon to the emergency department psychiatrist following the closure of her wound. She told the psychiatrist, “When I cut myself, I fully intended to kill myself, but I changed my mind several hours later. Now I feel fine and have no plans to hurt myself.” The psychiatrist also learned that this was not Ms. E’s first suicide attempt: she had taken overdoses of over-the-counter sedatives on at least three occasions during adolescence and in her early twenties. All suicide attempts were made at times when Ms. E believed that she was being abandoned by important people in her life. Ms. E also revealed that, on occasion, she would cut the trunk of her body with razor blades and disclosed that “cutting makes me feel real and sometimes reduces my anxiety.” Ms. E also told the psychiatrist of her “anxiety episodes” and how she had limited her activities as a consequence thereof. The psychiatrist made the diagnoses of panic disorder with agoraphobia and borderline personality disorder. The psychiatrist made the following recommendations to the patient and her psychotherapist: 1. Begin the antidepressant sertraline, 50 mg/day, to treat panic disorder and agoraphobia. 2. Transfer Ms. E’s outpatient care to a senior social worker with special expertise in treating patients with borderline personality disorder. The patient and her psychotherapist accepted this recommendation. On this regimen, Ms. E did not experience the recurrence of panic attacks or suicidal behavior. In addition, she became progressively less withdrawn, confident in social situations, and engaged in a fulfilling relationship that ultimately led to marriage.
Two important principles are illustrated in this case. The first principle is “Diagnosis comes before effective treatment.” Although Ms. E’s first psychotherapist recognized that his client had anxiety, he failed to make the correct diagnoses of borderline personality disorder and panic disorder with agoraphobia. His treatment was not sufficiently attentive to the establishment of appropriate boundaries with his client, who believed that the supportive and involved therapist could replace intimacies in her personal life. Ms. E regressed and became dangerously dependent on her therapist to meet all her life’s needs. The vacation of the therapist enraged the patient, who believed that she was being “led on to feel that he cared for me more than he really did.” Additionally, Ms. E’s dependencies on her therapist were intensified by her social withdrawal related to her undiagnosed and untreated panic disorder with agoraphobia. The use of sertraline not only treated Ms. E’s panic attacks but also reduced her anxiety in general and the extreme level of her emotional responses to such stressors as perceived rejection.
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A second principle of care illustrated by the case of Ms. E is that experienced and knowledgeable psychotherapists are required to treat people with severe personality disorders. Working with a psychotherapist experienced in the treatment of people with borderline personality disorder enabled Ms. E to derive the benefit of understanding the implications of her childhood trauma without becoming overly dependent on her therapist, psychologically regressed, and socially withdrawn. Under this therapeutic regimen Ms. E’s suicidal or self mutilating behavior has not recurred. For those readers who would like a detailed presentation of how such psychotherapeutic treatment is conceptualized and implemented in combination with psychiatric medications, please refer to Chapter 6 in the book Fatal Flaws (Yudofsky 2005).
Pharmacological Treatment Antidepressants Antidepressant medications such as selective serotonin reuptake inhibitors (SSRIs), combination selective serotonin and norepinephrine reuptake inhibitors (SSRI/SNRIs), tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs) are proven first- and second-line treatments for mood and anxiety disorders. It has been assumed that because they treat the affective and anxiety disorders often underlying suicidal behavior, these medications should inferentially treat the suicidal behaviors and thoughts that are symptoms of these disorders. In a longterm follow-up study of 400 patients with affective disorders treated for at least 6 months with multiple medications, including antidepressants, Angst and colleagues (2002) found a reduction in suicide rates in the medication group compared with those patients with affective disorders who were not treated with medications. Unfortunately, the study did not examine antidepressants alone; hence no definitive conclusions could be made concerning their possible benefits in reducing suicidal behavior. Clinical data are lacking as to antidepressants’ proven efficacy in the reduction of suicide or suicidal behaviors in the short and long term, partly because available data are derived from studies whose primary focus is on the treatment of affective disorders or secondary meta-analyses, as few studies exist that examine suicidal behaviors as their primary endpoint (Muller-Oerlinghausen and Berghofer 1999; Tondo et al. 2001). A recent meta-analysis by Khan et al. (2003) of controlled clinical trials for antidepressant treatment in depression from the FDA database showed no significant differences in rates of suicide for patients treated with SSRIs, non-SSRI antidepressants, and placebo.
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On the other hand, a few meta-analyses of single SSRI agents have reported a decrease in suicidal ideation in treated patients. A meta-analysis of controlled trials with fluoxetine demonstrated reduced suicidal ideation, although no significant difference in suicide attempts was found in patients given fluoxetine versus patients given placebo (Beasley et al. 1991). Meta-analyses of short-term controlled clinical trials with paroxetine showed significant decreases in suicidal ideation and completed suicides in paroxetine-treated patients compared to placebo or active control arms (Montgomery et al. 1995). A meta-analysis of fluvoxamine treatment trials found a significant improvement in suicidal ideation in patients given fluvoxamine compared with those given placebo (Letizia et al. 1996). Long-term prospective studies of antidepressant medications’ effects on suicide and suicidal behaviors do not exist (Baldessarini 2001). Furthermore, data about suicide risk with antidepressant treatment are largely for patients with major depressive disorder, with little data available about antidepressant use and suicide risk and behaviors in other psychiatric disorders, such as anxiety disorders and primary psychotic disorders. Some information about the effect on suicidal behaviors is available from clinical trials of SSRI antidepressant use in personality disorders. In a double-blind, placebo-controlled study, personality disorder patients with a history of recurrent suicide attempts and without a history of major depression or bipolar disorder who were treated with paroxetine showed a significant decrease in suicide attempts over a 1-year follow-up period compared with those receiving placebo (Verkes et al. 1998). This study substantiates data from smaller open-label trials of fluoxetine in patients with personality disorder who are at high risk for suicide. Because of several case reports that suggest SSRI antidepressants may be associated with increased risk of impulsivity, aggression, and suicidal behaviors (Mann and Kapur 1991; Teicher et al. 1990), several researchers have undertaken retrospective analyses to determine whether treatment with SSRIs may in fact increase suicide and suicidal behaviors. However, none of these retrospective analyses has shown that suicidal behavior and suicide rates increase with SSRI treatment (Khan et al. 2003; Tollefson et al. 1994). Even though there is inconclusive evidence for improvement in suicide rates and suicidal behaviors with antidepressant treatment, antidepressants are still effective treatments for the affective disorders often underlying suicidal behaviors and have established benefit in the acute short and long term for patients with affective disorders. Close monitoring by the clinician and patient education are critical to ensuring the safety of the suicidal patient treated with antidepres-
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sants. Upon initiation of treatment with antidepressants, the clinician must closely monitor patients for symptoms of increased anxiety, restlessness, agitation, sleep disturbance, and the precipitation of mixed states or psychotic episodes. Furthermore, the patient should be educated about the delay in symptom relief, because the effects of antidepressants may not manifest until weeks after initiation of treatment. Patients should also be closely monitored and educated about a possible increase in suicidal impulses in the initial phases of recovery when they have more energy to act on these impulses. Fortunately, overdose risk is lessened with the SSRIs and newer antidepressants. TCAs and MAOIs can be lethal in overdose and thus should be prescribed in limited quantities to patients at high risk for suicide (Baldessarini 2001). However, because they may be efficacious in depressed individuals whose illness has been resistant to the newer antidepressants, the risks associated with acute overdose should not preclude the use of TCAs and MAOIs. Table 9–1 lists adverse effects associated with overdose of antidepressant and other psychotropic medications.
Mood Stabilizers Lithium Much better data exist for lithium’s effect on suicide and suicidal behaviors. Long-term maintenance trials with lithium have established its significant reduction of suicide and suicide attempts in individuals with affective disorders (Baldessarini et al. 2003; Tondo et al. 2003). Recent meta-analyses of long-term lithium maintenance treatment in patients with affective disorders showed a highly significant decrease in completed suicides and suicide attempts of up to 14-fold in patients treated with lithium compared with their time off lithium (Schou 1998; Tondo et al. 2003). In another larger meta-analysis of 33 studies of patients with bipolar disorder, major depression, or schizoaffective disorder, completed suicide rates decreased by more than 80% and suicide attempts decreased by more than 90% with lithium treatment compared with suicide risk during time patients were untreated with lithium. The risk of all suicidal acts for lithium-treated patients was reduced to 0.21 suicidal acts per 100 person-years from 3.10 suicidal acts per 100 personyears for those patients who did not receive lithium. A similar suicide risk reduction was seen across all psychiatric disorders represented in the meta-analysis (Baldessarini et al. 2003). A few controlled, prospective clinical trials do exist involving lithium compared with other treatments’ effects on suicidal behaviors that generally point to lithium’s protective effect on suicide risk (Thies-
Adverse effects associated with overdose by class of medication
Class
Citalopram/escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline
Serotonin syndrome can occur with any drug with serotonergic action (SSRIs, MAOIs, TCAs, and other nonpsychotropic medications). Symptoms typically include restlessness, hyperreflexia, muscle twitches, tremor, and autonomic dysfunction. More severe intoxication can progress to seizures and coma. Death can occur rarely with overdosage.
Serotonin-norepinephrine reuptake inhibitors (SNRIs)
Venlafaxine, duloxetine
Same as for SSRIs.
Dopamine-norepinephrine reuptake inhibitors Serotonin modulators Norepinephrine-serotonin modulators
Bupropion
Same as for SSRIs.
Nefazodone, trazodone Mirtazapine
Same as for SSRIs. Same as for SSRIs.
Tricyclic/tetracyclic antidepressants (TCAs)
Imipramine, amitriptyline, doxepin, clomipramine, desipramine, nortriptyline, amoxapine
Severe intoxication occurs at doses of imipramine above 1 g. Deaths have been reported with doses of imipramine of 2 g or more. Acute overdose can result in delirium, hypotension, cardiac arrhythmias, and seizures, followed by rapid development of coma and depressed respiration. Anticholinergic delirium is a medical emergency requiring full supportive care.
Antidepressants Selective serotonin reuptake inhibitors (SSRIs)
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TABLE 9–1.
Adverse effects associated with overdose by class of medication (continued)
Antidepressants (continued) Monoamine oxidase inhibitors (MAOIs)
Medication
Effects of overdose
Mood stabilizers Lithium
Antiepileptics
Valproate
Symptoms consist of tremor, ataxia, vomiting, diarrhea, seizures, cardiac arrhythmias, and hypotension and may progress to coma and death. Neurotoxic side effects may be irreversible. Supportive treatment is recommended. Dialysis is recommended for serum lithium concentrations greater than 4.0 mEq/L for acute overdoses and greater than 1.5 mEq/L in chronic overdoses. Toxicity results in sedation, confusion, hyperreflexia/hyporeflexia, seizures, respiratory suppression, and supraventricular tachycardia and may progress to coma. Treatment consists of gastric lavage, cardiac monitoring, respiratory support, and treatment of seizures.
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Phenelzine, tranylcypromine, Toxic reactions from overdose of an MAOI may occur in a matter of hours moclobemide despite the long delay in onset of a therapeutic response. Effects of overdose include agitation, hallucinations, hyperreflexia, hyperpyrexia, and convulsions. Both hypotension and hypertension also occur. Treatment of such intoxication is problematic, but conservative treatment is often successful. Hypertensive crisis can occur with concomitant ingestion of foods with high tyramine content, resulting in headache, hypertension, and possible intracerebral hemorrhage.
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TABLE 9–1.
Adverse effects associated with overdose by class of medication (continued)
Class
Medication
Effects of overdose
Mood stabilizers (continued) Antiepileptics (continued)
Carbamazepine
Symptoms of toxicity include nausea and vomiting, urinary retention, myoclonus, hyperreflexia, nystagmus, cardiac conduction problems, seizures, and coma. Treatment consists of induction of vomiting, gastric lavage, cardiac monitoring, and supportive care. Toxicity may result in ataxia, nystagmus, altered mental status, intraventricular conduction delay, seizures, and coma. Overdose can result in death. Isolated cases of overdose up to 24 g have occurred; recovery in all with symptomatic treatment.
Lamotrigine
Oxcarbazepine Antipsychotic agents First-generation/Typicals
Chlorpromazine, thioridazine, pimozide, trifluoperazine, fluphenazine, perphenazine, thiothixene, loxapine, haloperidol
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Death is rare in overdose if supportive care is given and there is no concomitant ingestion of other central nervous system (CNS) drugs or alcohol. Fatalities have occurred due to respiratory compromise related to dystonia and neuroleptic malignant syndrome (NMS). NMS is more likely to occur with high-potency neuroleptics and consists of autonomic instability, tremor, catatonia, fluctuating mental status, creatine kinase elevation, and myoglobinemia.
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TABLE 9–1.
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Adverse effects associated with overdose by class of medication (continued) Medication
Anxiolytics Benzodiazepines
Buspirone
Toxicity results in CNS depression, hypotension, tachycardia. Seizures occur most commonly with clozapine overdose. Anticholinergic side effects are most common with clozapine and olanzapine. QT prolongation can occur. Significant extrapyramidal symptoms are less likely than with typical antipsychotics but can occur and are dose related. NMS can occur with atypical antipsychotic overdose. Deaths occur infrequently with overdose, related to cardiovascular complications, although fatalities can occur from pulmonary, endocrine, gastrointestinal, and neurological complications. Treat with supportive measures and cardiac monitoring. Dangerous in overdose because of synergistic effects with other CNS depressants and alcohol. Treat with respiratory support and benzodiazepine antagonist flumazenil. Symptoms of overdose include dizziness, vomiting, sedation. No reported deaths with overdose.
Source. Information in this table comes from Baldessarini 2001; Baldessarini and Tarazi 2001; Marangell et al. 2003; and drug manufacturer prescribing information.
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Antipsychotic agents (continued) Second-generation/Atypicals Clozapine, aripiprazole, olanzapine, quetiapine, risperidone, ziprasidone
Effects of overdose
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Flechtner et al. 1996; Tondo and Baldessarini 2000). One large noncontrolled retrospective study of completed and attempted suicides in patients with bipolar disorder over a mean follow-up period of 2.9 years compared suicidal behaviors for three groups (treatment with lithium, valproate, and carbamazepine). Lithium-treated patients had a significantly lower rate of suicide attempts and completed suicides compared with those taking valproate. Comparisons with carbamazepine were not possible due to the relatively low number of patients being treated with carbamazepine (Goodwin et al. 2003). Lithium treatment does not completely negate the effects of psychiatric disorder on suicidality. The suicide rate during lithium treatment, although lower than the untreated suicide risk, is still much higher than the suicide rate of the general population (0.0107%; Tondo and Baldessarini 2000). Furthermore, lithium data as they relate to suicide risk are largely limited to bipolar disorder patients. However, a few small studies of lithium treatment for major depression have found a significant decrease in suicidal acts (to almost 0% compared with 1.33% per year in non-lithium-treated patients; Baldessarini et al. 2003). The pathophysiological mechanism by which lithium decreases suicide risk is unknown. It is possible that lithium reduces the impulsivity, aggression, or anger that may precipitate a suicide attempt. Or lithium may exert general mood-stabilizing qualities that decrease severity of depression or mixed dysphoric states. It is also possible that patients benefit from the close medical and laboratory monitoring associated with lithium treatment (Tondo and Baldessarini 2000). Lithium in overdose can have significant toxicity; thus the prudent clinician should consider prescribing conservative quantities of this medication to suicidal patients. This potential toxicity should not prevent lithium treatment of suicidal patients, especially given lithium’s association with suicide risk reduction. When weighing the risks and benefits of first-line treatments for a bipolar disorder patient with significant suicide risk factors, lithium’s association with suicide risk reduction should certainly be considered.
Antiepileptic Mood Stabilizers Valproate and carbamazepine are also first-line treatments for the prophylaxis and acute episodes of bipolar disorder. However, studies of the effects of mood stabilizers other than lithium are few in number, with even fewer controlled prospective studies of these medications’ effects on suicidal behavior. In a retrospective chart review, completed suicides and suicide attempts were measured while patients were treated
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with lithium and then while taking either valproate or carbamazepine. For the 140 patients with bipolar disorder, no significant difference was observed in suicide attempt rate between lithium and either valproate or carbamazepine (2.94 attempts/100 patient-years for lithium vs. 3.75 attempts/100 patient-years for valproate/carbamazepine; Yerevenian et al. 2003). However, the study by Goodwin et al. (2003) found significantly higher risk of suicide attempts and completed suicides in patients treated with valproate compared with those treated with lithium. Comparisons with carbamazepine were not possible due to the small sample treated with carbamazepine included in this study. The results of this study are limited by nonrandomization of treatment groups, and it is unclear whether illness severity may have influenced practitioners’ choice of medication (i.e., less acutely suicidal and less severely ill patients may have been put on lithium rather than antiepileptic mood stabilizers). Data regarding the effects of newer antiepileptics such as lamotrigine and oxcarbazepine on suicidal behaviors are not yet available. At this time, it is unclear whether antiepileptic mood stabilizers modify suicidal behaviors.
Antipsychotics Second-generation or atypical antipsychotic medications include aripiprazole, clozapine, olanzapine, quetiapine, risperidone, and ziprasidone and are first-line treatments for primary psychotic disorders as well as for bipolar mania. They are generally preferred for clinical use over traditional, first-generation antipsychotic agents because of their favorable side-effect profile with fewer extrapyramidal symptoms and improved cognition (Meltzer and McGurk 1999). First-generation antipsychotics, although quite effective for treatment of acute psychosis, agitation, and aggression, are clearly understudied with respect to their effect on suicidal behaviors. Second-generation antipsychotic agents are somewhat better studied and in fact have become very helpful in the treatment of suicidal patients with psychotic disorders due to their effects of calming anxiety as well as curbing impulsivity, agitation, and mania. The most data on risk reduction of suicidal behaviors exist for the atypical antipsychotic clozapine, the only FDA-approved treatment for the reduction of suicide risk, although this indication is limited to patients with schizophrenia. Its use is limited and is generally prescribed when primary psychosis does not respond to the other antipsychotic agents available because of possible hematologic complications. Yet strong evidence exists in schizophrenia and schizoaffective disorders
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for an association between clozapine use and decreased rates of suicidal behaviors (Reid et al. 1998; Walker et al. 1997). Data from the Texas Department of Mental Health and Mental Retardation as well as the Clozapine National Registry show the annual suicide rate was decreased by 75%–80% for clozapine-treated patients with schizophrenia and schizoaffective disorder (Reid et al. 1998). Additionally, in a long-term study of 88 patients with chronic schizophrenia or schizoaffective disorder receiving clozapine monotherapy, the annual number of suicide attempts decreased 12-fold in the 6-month to 7-year follow-up period compared with the 2 years prior to clozapine treatment (Meltzer and Okayli 1995). Furthermore, patients reported improvement in depression and hopelessness symptoms. A recent randomized, controlled open-label study compared the effects on suicidal behavior of clozapine with a new atypical antipsychotic, olanzapine. Schizophrenia and schizoaffective patients considered at high risk for suicide based on previous suicide attempts in the 3 years prior to enrollment or current suicidal ideation were enrolled in the International Suicide Prevention Trial (InterSePT) and treated with either open-label clozapine or olanzapine. Although this study was not specifically powered to study the reduction in suicide deaths as an endpoint, the study nonetheless showed that clozapine-treated patients experienced a significant reduction in the rate of all suicidal events. Clozapine-treated patients had significantly lower rate of suicide attempts compared with olanzapine-treated patients, although there was no statistical difference in completed suicide rate. In fact, the rate of suicide attempts for the olanzapine-treated patients was half that prior to enrollment. Thus, olanzapine is also associated with a decreased risk of suicidal behaviors, although not perhaps as great as that for clozapine (Meltzer et al. 2003). Thus, clozapine appears to have preventive effects on suicidal behavior in schizophrenia and schizoaffective disorder, more so than other antipsychotics, both typical and atypical agents. However, clozapine’s effect on suicidal behavior in other psychiatric disorders is not available. Clearly, it is useful for suicidal patients with schizophrenia and schizoaffective disorder (Meltzer et al. 2003). When assessing whether a patient should be treated with clozapine, the clinician must weigh the potential antisuicide effects as well as the other benefits of treatment with clozapine against potential adverse effects including fatal agranulocytosis, cardiomyopathy, and myocarditis. Olanzapine also appears to have preventive effects on suicidal behavior, although not as great as those for clozapine. Few other studies exist about olanzapine and the other atypical antipsychotics’ effects on
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suicidal behaviors in primary psychotic disorders and for other psychiatric disorders. One study of note followed 339 patients with schizophrenia, schizoaffective disorder, and schizophreniform disorder treated with short-term olanzapine or risperidone. Secondary analysis of the suicide attempt rates found that patients given olanzapine had significantly lower rates of suicide attempts than those treated with risperidone during the 28-week follow-up period (Tran et al. 1997). No known studies examining the effects on suicidal behavior exist for the other atypical antipsychotics ziprasidone, quetiapine, or aripiprazole.
Anxiolytics Psychic anxiety, panic, agitation, and insomnia are commonly associated with suicide risk in depression (Fawcett et al. 1990). Thus it would be expected that anxiolytic medications such as benzodiazepines, antidepressants, low-dose atypical antipsychotics, and mood stabilizers may have a calming and beneficial effect on suicidal patients. However, limited clinical trial data do not support this assumption for either short-term or long-term treatment with anxiolytic medications. A recent meta-analysis of controlled clinical trials of anxiety disorder treatments found no difference in rates of suicidal behaviors between patients treated with anxiolytic medications and those given placebo (Khan et al. 2002). Very few studies exist on the effects of anxiolytics on suicidal behavior. It would seem clinically prudent to continue to directly target anxiety symptoms such as intrapsychic distress, anxiety, agitation, and insomnia in order to limit suicide risk, especially given earlier reports that benzodiazepine removal may be associated with increased risk of suicidal behavior (Gaertner et al. 2002; Joughin et al. 1991). Thus short-term benzodiazepine treatment for the acute treatment of anxiety symptoms can be helpful, with longer-acting agents preferable to shorter-acting agents to prevent rebound anxiety. Gradual discontinuation through dose titration is recommended, accompanied by vigilant monitoring for increasing suicidality, agitation, anxiety, or depression. Patients treated with benzodiazepines should also be monitored for disinhibition, increased aggressive behaviors and impulsivity (Cowdry and Gardner 1988), and interaction with other prescribed drugs, illicit drugs, and alcohol.
Electroconvulsive Therapy ECT is an established therapeutic modality for severe major depression with or without psychotic features as well as for the treatment of manic
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or mixed episodes of bipolar disorder and acute episodes of schizoaffective disorder or schizophrenia. It can be extremely useful for acutely suicidal patients due to its rapid antidepressant response and associated rapid reduction in short-term suicidal ideation (Ciapparelli et al. 2001; Kellner et al. 2005; Prudic and Sackeim 1999; Rich et al. 1986). The few studies that assess the short-term effects of ECT on suicidality (suicidal ideation or intent) all show rapid, significant improvement in suicide ratings with ECT (Ciapparelli et al. 2001; Kellner et al. 2005; Prudic and Sackeim 1999; Rich et al. 1986). However, no studies exist of ECT effects on suicide attempts or completed suicides or of the long-term effects of ECT. Based on the limited data available for the short-term effects of ECT, ECT can be helpful for severe major depressive episodes accompanied by suicidal behavior, especially when a delay in treatment response would be life-threatening, such as for patients who are overtly psychotic, catatonic, or refusing to eat. ECT may also be helpful for pregnant patients who are suicidal and whose illness is resistant to medications or who are unable to tolerate medications. Because of the lack of data regarding the long-term effects of ECT on suicidality, it is recommended that after acute treatment with ECT, maintenance treatment should continue with psychotropic medication or further ECT.
Conclusion Treatment of suicide and suicidal behaviors is complex, requiring aggressive pharmacotherapy in conjunction with a strong psychotherapeutic alliance with the affected individual. Although variable data exist as to their short-term and long-term efficacy in decreasing rates of suicide and suicidal behaviors, psychotropic medications and/or ECT to treat symptoms such as psychic pain and anxiety and turmoil, panic attacks, agitation, impulsiveness, aggression, and feelings of hopelessness can be extremely helpful in managing the patient with suicidal tendencies. Aggressive pharmacological and/or ECT treatments used in conjunction with early identification and reduction of risk factors for suicide, thorough clinical assessment and diagnosis, close monitoring by the treatment team, careful consideration of hospitalization, and a strong therapeutic alliance are all essential components of successful management of the suicidal patient.
❏ Key Points ■
Treatment of suicide and suicidal behaviors is complex and multidisciplinary and includes aggressive pharmacotherapy in conjunction with a strong psychotherapeutic alliance with the affected individual.
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Medications to treat symptoms such as psychic pain and anxiety and turmoil, panic attacks, agitation, impulsiveness, aggression, and feelings of hopelessness can be extremely helpful in managing the patient with suicidal tendencies.
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Good short-term and long-term data are lacking regarding the clinical effectiveness of psychiatric medications and ECT on suicidal behaviors, largely because data on suicidal behaviors are obtained through secondary analyses of treatment efficacy studies and metaanalyses. Despite this, lithium and the atypical antipsychotic agent clozapine appear to exert a positive effect on suicidal behaviors. Promising data are accruing for the newer atypical antipsychotic agents’ effects on decreasing suicidal behaviors.
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Even though there is inconclusive evidence for improvement in suicide rates and suicidal behaviors with antidepressant treatment, antidepressants are still effective treatments for the affective disorders often underlying suicidal behaviors and have established benefit in the acute short and long term for patients with affective disorders.
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Close monitoring by the clinician and patient education, especially during initiation of therapy with an antidepressant medication, are critical to ensuring the safety of the suicidal patient treated with antidepressants.
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Although data are limited as to the effects of ECT on suicide rates, ECT can be helpful for severe major depressive episodes accompanied by suicidal behavior, especially when a delay in treatment response would be life-threatening, such as for patients who are overtly psychotic, catatonic, or refusing to eat.
References Angst F, Stassen HH, Clayton PJ, et al: Mortality of patients with mood disorders: follow-up over 34–38 years. J Affect Disord 68:167–181, 2002 Baldessarini RJ: Drugs and the treatment of psychiatric disorders: antidepressant and antianxiety agents, in Goodman and Gilman’s The Pharmacological Basis of Therapeutics, 10th Edition. Edited by Goodman LS, Hardman JG, Limbird LE, et al. New York, McGraw-Hill, 2001, pp 447–484 Baldessarini RJ, Tarazi FI: Drugs and the treatment of psychiatric disorders: psychoses and mania, in Goodman and Gilman’s The Pharmacological Basis of Therapeutics, 10th Edition. Edited by Goodman LS, Hardman JG, Limbird LE, et al. New York, McGraw-Hill, 2001, pp 485–520 Baldessarini RJ, Tondo L, Hennen J: Lithium treatment and suicide risk in major affective disorders: update and new findings. J Clin Psychiatry 64(suppl): 44–52, 2003
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Beasley CM, Dornseif BE, Bosomworth JC, et al: Fluoxetine and suicide: a metaanalysis of controlled trials of treatment for depression. BMJ 303:685–692, 1991 Ciapparelli A, Dell’Osso L, Tundo A, et al: Electroconvulsive therapy in medication-nonresponsive patients with mixed mania and bipolar depression. J Clin Psychiatry 62:552–555, 2001 Cowdry RW, Gardner DL: Pharmacotherapy of borderline personality disorder: alprazolam, carbamazepine, trifluoperazine, and tranylcypromine. Arch Gen Psychiatry 45:111–119, 1988 Crosby AE, Cheltenham MP, Sacks JJ: Incidence of suicidal ideation and behavior in the United States. Suicide Life Threat Behav 29:131-140, 1999 Fawcett J, Scheftner WA, Fogg L, et al: Time-related predictors of suicide in major affective disorder. Am J Psychiatry 147:1189–1194, 1990 Gaertner I, Gilot C, Heidrich P, et al: A case control study on psychopharmacotherapy before suicide committed by 61 psychiatric inpatients. Pharmacopsychiatry 35:37–43, 2002 Goodwin F, Fireman B, Simon G, et al: Suicide risk in bipolar disorder during treatment with lithium, divalproex, and carbamazepine. JAMA 290:1467– 1473, 2003 Harris EC, Barraclough B: Suicide as an outcome for mental disorders: a metaanalysis. Br J Psychiatry 170:205–228, 1997 Henriksson MM, Aro HM, Marttunen MJ, et al: Mental disorders and comorbidity in suicide. Am J Psychiatry 150:935–940, 1993 Isacsson G, Bergman U, Rich CL: Antidepressants, depression, and suicide: an analysis of the San Diego study. J Affect Disord 32:277–286, 1994a Isacsson G, Holmgren P, Wasserman D, et al: Use of antidepressants among people committing suicide in Sweden. BMJ 308:506–509, 1994b Jick JH, Kaye JA, Jick SS: Antidepressants and the risk of suicidal behaviors. JAMA 292:338–343, 2004 Joughin N, Tata P, Collins M, et al: Inpatient withdrawal from long-term benzodiazepine use. Br J Addict 86:449–455, 1991 Kellner CH, Fink M, Knapp R, et al: Relief of expressed suicidal intent by ECT: a consortium for research in ECT study. Am J Psychiatry 162:977–982, 2005 Khan A, Leventhal RM, Khan S, et al: Suicide risk in patients with anxiety disorders: a meta-analysis of the FDA database. J Affect Disord 68:183–190, 2002 Khan A, Khan S, Kolts R: Suicide rates in clinical trials of SSRIs, other antidepressants, and placebo: analysis of FDA reports. Am J Psychiatry 160:790– 792, 2003 Kochanek KD, Smith BL: Deaths: Preliminary data for 2002. Natl Vital Stat Rep 52:1–48, 2004 Letizia C, Kapik B, Flanders WD: Suicidal risk during controlled clinical investigations of fluvoxamine. J Clin Psychiatry 57:415–421, 1996 Licinio J, Wong ML: Depression, antidepressants and suicidality: a critical appraisal. Nat Rev Drug Discov 4:165–172, 2005 Mann JJ, Kapur S: The emergence of suicidal ideation and behavior during antidepressant pharmacotherapy. Arch Gen Psychiatry 48:1027–1033, 1991 Marangell LB, Silver JM, Goff DC, Yudofsky SC: Psychopharmacology and electroconvulsive therapy, in The American Psychiatric Publishing Textbook of Clinical Psychiatry, 4th Edition. Edited by Hales RE, Yudofsky SC. Washington, DC, American Psychiatric Publishing, 2003, pp 1047–1149
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Meltzer HY, Okayli G: Reduction of suicidality during clozapine treatment of neuroleptic-resistant schizophrenia: impact on risk-benefit assessment. Am J Psychiatry 152:183–190, 1995 Meltzer HY, McGurk SR: The effects of clozapine, risperidone, and olanzapine on cognitive function in schizophrenia. Schizophr Bull 25:233–255, 1999 Meltzer H, Alphs L, Green A, et al: Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT). Arch Gen Psychiatry 60:82–91, 2003 Montgomery SA, Dunner DL, Dunbar GC: Reduction of suicidal thoughts with paroxetine in comparison with reference antidepressants and placebo. Eur Neuropsychopharmacol 5:5–13, 1995 Muller-Oerlinghausen B, Berghofer A: Antidepressants and suicidal risk. J Clin Psychiatry 60(suppl):94–99, 1999 Prudic J, Sackeim HA: Electroconvulsive therapy and suicide risk. J Clin Psychiatry 60(suppl):104–110, 1999 Reid WH, Mason M, Hogan T: Suicide prevention effects associated with clozapine therapy in schizophrenia and schizoaffective disorder. Psychiatr Serv 49:1029–1033, 1998 Rich CL, Spiker DG, Jewell SW, et al: Response of energy and suicidal ideation to ECT. J Clin Psychiatry 47:31–32, 1986 Schou M: The effect of prophylactic lithium treatment on mortality and suicidal behavior: a review for clinicians. J Affect Disord 50:253–259, 1998 Teicher MH, Glod C, Cole JO: Emergence of intense suicidal preoccupation during fluoxetine treatment. Am J Psychiatry 147:207–210, 1990 Thies-Flechtner K, Muller-Oerlinghausen B, Seibert W, et al: Effect of prophylactic treatment on suicide risk in patients with major affective disorder. Pharmacopsychiatry 29:103–107, 1996 Tollefson GD, Rampey AH, Beasley CM, et al: Absence of a relationship between adverse events and suicidality during pharmacotherapy for depression. J Clin Psychopharmacol 14:163–169, 1994 Tondo L, Baldessarini RJ: Reduced suicide risk during lithium maintenance treatment. J Clin Psychiatry 61(suppl):97–104, 2000 Tondo L, Ghiani C, Albert M: Pharmacologic interventions in suicide prevention. J Clin Psychiatry 62(suppl):51–55, 2001 Tondo L, Isacsson G, Baldessarini RJ: Suicidal behavior in bipolar disorder: risk and prevention. CNS Drugs 17:491–511, 2003 Tran PV, Hamilton SH, Kuntz AJ, et al: Double-blind comparison of olanzapine versus risperidone in the treatment of schizophrenia and other psychotic disorders. J Clin Psychiatry 17:407–418, 1997 Verkes RJ, van der Mast RC, Hengeveld MW, et al: Reduction by paroxetine of suicidal behavior in patients with repeated suicide attempts but not major depression. Am J Psychiatry 155:543–547, 1998 Walker AM, Lanza LL, Arellano F, et al: Mortality in current and former users of clozapine. Epidemiology 8:671–677, 1997 Yerevenian BI, Koek RJ, Mintz J: Lithium, anticonvulsants and suicidal behavior in bipolar disorder. J Affect Disord 73:223–228, 2003 Yudofsky SC: Fatal Flaws: Navigating Destructive Relationships With People With Disorders of Personality and Character. Washington, DC, American Psychiatric Publishing, 2005
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Psychodynamic Treatment Glen O. Gabbard, M.D. Sara E. Allison, M.D.
Treatment of the suicidal patient may be likened to negotiating the perils of a minefield—with each step, one is terrifyingly aware of the potential lethality underfoot. Because most, if not all, psychiatrists will eventually find themselves attempting to guide a patient through this terrain fraught with risk and uncertainty, a psychodynamically informed road map may be helpful to both strengthen the clinician’s footing and identify hazards on the path to recovery. Psychodynamic treatment of the suicidal patient refers not only to psychotherapy but to a broader approach to treatment in general. This conceptual model is used by the clinician to determine the most appropriate interventions designed to alter the patient’s fundamental wish to die. The patient-specific psychodynamic treatment strategy is largely derived from the clinician’s exploration of the patient’s internal world, including unconscious conflicts, deficits and distortions of intrapsychic structures, and internal object relations (Gabbard 2005). This understanding must, of course, be integrated with contemporary findings from the neurosciences and psychopharmacology. Psychodynamic psychiatry, as a whole, is shaped by a number of theoretical models, including ego psychology, with its central notion of unconscious conflict; object relations theory; self psychology; and attachment theory. From the outset of each therapeutic relationship, the psychiatrist undertakes a dynamic assessment of the patient’s needs and uses the findings to construct a coherent conceptual framework 221
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from which all future interventions are prescribed. The dynamic psychiatrist employs a wide range of treatment modalities, including pharmacotherapy, risk factor assessment and modification, mobilization of social support, and psychotherapy. Regardless of whether the patient’s plan of care includes dynamic psychotherapy, the treatment is, by definition, dynamically informed. A set of time-honored principles guides the dynamic psychiatrist’s approach to the treatment of the suicidal patient. These ideological cornerstones include the belief that suicidality may have unconscious meanings, that the past repeats itself in the present, that unconscious motivations may lead to patient resistance, that transference to the clinician may have a major impact on the treatment, and that countertransference responses of the treater to the patient must be taken into account to avoid potential errors.
Literature Review Efficacy Although there is a good deal of research on the efficacy of dynamic psychotherapy in the treatment of depression (Leichsenring et al. 2004), there is very little elucidation of the direct effect this form of therapy may have on suicidality in major depression. Guthrie et al. (2001, 2003) randomly assigned 119 patients who presented to the emergency department following deliberate self-poisoning to receive either brief psychodynamic interpersonal therapy or treatment as usual (outpatient follow-up with a general practitioner). Those patients who received the therapy demonstrated a significantly greater reduction in suicidal ideation at 6-month follow-up compared with control subjects. They also were less likely to report repeat attempts at self-harm. In contrast to the relative lack of empirical evidence demonstrating the efficacy of dynamic psychotherapy in the treatment of suicidality in major depression, data have shown this modality’s promise in the care of those with borderline personality disorder (BPD). Research involving the treatment of BPD using a randomized controlled trial of psychodynamically based partial hospitalization (in which dynamic individual therapy and group therapy were the foundation of the program) demonstrated dramatic reductions in suicidality (Bateman and Fonagy 2001, 2003). Although 95% of the sample of 38 borderline patients had attempted suicide in the 6 months prior to the beginning of the study, only 5.3% had made attempts in the 6 months after treatment at the investigators’ 18-month follow-up.
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Psychodynamic Themes Further studies have sought to delineate the psychodynamic themes relevant to suicidal patients. Kaslow et al. (1998) compared 52 inpatients following a suicide attempt with 47 inpatients with no history of suicidal behavior. Their results highlighted the importance of recent losses in the context of a history of childhood loss, a pattern found to be significantly more common in the population of suicide attempters. More impaired object relations were also demonstrated within the suicidal group as compared with the control group. Preexisting psychological variables may increase the likelihood of acting on suicidal thoughts. Through the use of projective psychological testing, researchers (Smith 1983; Smith and Eyman 1988) have studied and identified four patterns of ego functioning and internal object relations paradigms that differentiate individuals who made serious attempts from those who merely made gestures to control significant others. The serious attempters exhibited 1) an inability to give up infantile wishes for nurturance, associated with conflict about being openly dependent; 2) a sober but ambivalent view toward death; 3) excessively high selfexpectations; and 4) overcontrol of affect, particularly aggression. Although this pattern applies more to men than to women (Smith and Eyman 1988), an inhibitory attitude toward aggression distinguishes serious female attempters from those who make mild gestures. These test findings imply that the preexisting psychological structures that favor suicide are more consistent across individual patients than are the various motivations behind a particular suicidal act. Empirical studies (Beevers and Miller 2004; Blatt et al. 1995; Hamilton and Schweitzer 2000) have consistently linked high levels of perfectionism with suicidal ideation. In fact, one study (Beevers and Miller 2004) demonstrated the impact of perfectionism to be both independent of and equal in significance to hopelessness, a factor commonly regarded as the best cognitive predictor of suicidal ideation (Weishaar 1996). Moreover, high levels of perfectionism were discovered to have a negative impact on all four brief treatment strategies for depression (cognitive-behavioral therapy, interpersonal therapy, imipramine, and placebo) investigated in the National Institute of Mental Health Collaborative Study (Blatt et al. 1995). Psychodynamic clinicians have developed a substantial literature that provides useful exploration of the varying meanings of the wish to die as well as the formidable obstacles that may be encountered as one attempts to treat the suicidal patient. Operating under the assumption that the ego could kill itself only by treating itself as an object, Freud (1917/1963) pos-
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tulated that suicide results from displaced murderous impulses—destructive wishes toward an internalized object that are instead directed against the self. However, recent studies have not supported this theory (Kaslow et al. 1998); specifically, a sample of 99 suicide attempters did not acknowledge more self-directed or externally targeted anger as compared with control subjects. After the development of the structural model (Freud 1923/1961), Freud redefined suicide as the victimization of the ego by a sadistic superego. Karl Menninger’s (1933) conceptualization was a bit more complex, with a view of the suicidal act as consisting of at least three wishes—the wish to kill, the wish to be killed, and the wish to die. Object relations theorists have noted the recurrent theme of a struggle between a sadistic, persecuting internal object, dubbed the “hidden executioner” (Asch 1980), and a tormented victim who may grow to believe that the only method of escape is through the act of suicide. In other cases, aggression plays less of a role and the patient’s motivation is instead fulfillment of a reunion wish (Fenichel 1945)—that is, a fantasy involving the joyous and magical rejoining with a lost loved one or a narcissistic union with a loving superego figure. When an individual’s selfesteem and self-integrity depend on attachment to a lost object, suicide may seem to be the only way to restore self-cohesion. The pursuit of perfectionism or an idealized view of the self, held to rigidly despite repeated disappointments, may also lead to the belief that suicide is the only way out (Gabbard 2005).
Countertransference Pitfalls Psychodynamic clinicians (Gabbard and Wilkinson 1994; Maltsberger and Buie 1974) have also stressed the countertransference pitfalls associated with treatment of suicidal patients, particularly those with significant Axis II pathology. Hate, rescue fantasies, and narcissistic vulnerability are among the most prominent responses. There is little doubt that intensive psychotherapy of suicidal patients stirs sadistic and murderous wishes in the therapist, a reaction noted to be the flip side of the fervent wish to rescue the patient (Chessick 1977). When the therapist assumes the role of savior or omnipotent rescuer who will go to all forms of self-sacrifice to save the patient, countertransference hate and resentment are often the unfortunate by-products. This may take the form of aversion, leading the therapist to abandon the patient in subtle ways (forgetting appointments, withdrawing emotionally), or malice, filling the therapist with impulses to respond to the patient in overtly hostile or sarcastic ways. Therapists may fear that a patient’s suicide will make them look bad to their colleagues, and this recognition of the
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patient’s power over them may breed resentment. In addition, borderline patients often realize that the therapist’s narcissism is on the line when a patient is contemplating suicide. They may exploit this vulnerability by enjoying the sadistic power they wield over the therapist. The most useful principle of managing these countertransference pitfalls is prevention. By refusing to take the role of the patient’s rescuer, the therapist can avoid the resentment and hatred often accompanying that role. Monitoring one’s responses and the defensive postures assumed to deal with such hateful feelings are also essential measures in managing countertransference.
Treatment Steps Navigation of the perilous landscape of psychodynamic treatment of the suicidal patient is best embarked upon in a series of deliberate, carefully placed steps (see Table 10–1). First and foremost, a solid therapeutic alliance between the patient and clinician must be established to ensure honest communication of any suicidal threat. Second, differentiating between the fantasy of suicide as a means of escape and the intent to carry out the act of suicide is of the utmost importance and may be useful in determining whether the psychodynamic treatment will be conducted on an outpatient basis or within the safe confines of the inpatient psychiatric unit. Third, the clinician and patient must have a frank discussion about the limits of treatment. It should be made clear to patients that the therapist cannot stop them from committing suicide. Moreover, there must be a clear differentiation between the therapist’s responsibilities and the patient’s responsibilities within the context of the therapeutic alliance. Fourth, the therapist must investigate precipitating events that may have triggered the patient’s suicidality. These stressors may provide hints about the relevant dynamic themes that inform the meaning of the suicide. Exploring the patient’s fantasy about the specific interpersonal impact of suicide may also be productive. In the chronically suicidal patient, a baseline level must be established so that a descent into an acute risk state can be detected. Finally, as treatment progresses, the therapist must carefully monitor both transference and countertransference.
Case Example 1: Acute Suicidality Ms. A, a 34-year-old single female with no previous history of suicide attempts, was in psychotherapy twice a week for long-standing difficulties in romantic relationships. She came to a session one day in considerable distress. She said that the man she was dating had told her on
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TABLE 10–1. Steps in the psychodynamic treatment of the suicidal patient Establish a therapeutic alliance. Differentiate between the fantasy and the act of suicide. Discuss the limits of treatment. Investigate precipitating events. Explore fantasies of the interpersonal impact of suicide. Establish level of suicidality present at baseline. Monitor transference and countertransference. their second date that he was not ready to commit to a relationship so soon after his recent divorce. She said he had been very considerate to her and had behaved “like a gentleman.” She found herself deeply wounded by his wish to end their budding relationship. She even said that she no longer wanted to date. She said she felt hopeless about ever finding the right man. She looked at Dr. B, her therapist, and asked poignantly, “Do you think any man is ever going to want me?” Her therapist sputtered a bit, knowing that he was on potentially perilous ground, and tried his best to respond in a helpful way: “Well, it’s a hard question for me to answer with any certainty, but I definitely don’t think it’s hopeless like you do. You’ve had some very positive relationships.” Ms. A replied, “Yeah, but they never go anywhere.” Dr. B then said, attempting to reassure Ms. A, “But most relationships don’t result in marriage. It doesn’t mean that there aren’t positive things about them.” A pause ensued, and Ms. A then told her therapist, with some hesitation: “When I was lying awake last night, I kept thinking about committing suicide. I couldn’t get it out of my mind.” Dr. B was taken aback by this revelation. Unable to suppress his surprise, he expressed his frank amazement (somewhat unempathetically): “I don’t understand. You’ve known this man for a few weeks and been on two dates with him. Is he worth committing suicide over?” Ms. A responded: “I know it makes no sense. I can’t understand why I’m reacting this intensely.” Her therapist asked what it was about him that made the loss so unbearable. Ms. A thought for a moment and said, “He just seemed like a great catch. He was caring, thoughtful, and financially well off. He’s worldly, too. He’s been everywhere, has a kind of class about him, and he’s older and wiser than most of the men I’ve dated.” The therapist knew that Ms. A had lost her father when she was 10, leading him to formulate in his mind the possibility that the current loss reawakened the pain and longing from the childhood loss. He posed a tentative interpretive understanding in the form of a simple observation: “Old enough to be your father.” Ms. A hesitated: “Yeah, but he’s different than my father—at least the way I remember him.”
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“Yes, of course he’s not exactly like your dad. But sometimes one loss reawakens feelings about an earlier loss,” Dr. B responded. Ms. A responded with reflectiveness this time. She noted, “There must be something like that going on. It just doesn’t make sense that I’d feel this much pain over the end of our relationship. I didn’t even know him that well.” The therapy then continued to explore the meaning of the precipitating event: the linkage—previously unconscious, now more conscious—between the much older romantic partner and Ms. A’s father. Recognizing that the patient’s hopelessness and suicidality were serious, Dr. B engaged the patient in further discussion in order to establish her potential threat to self. Although Ms. A admitted to fantasizing about suicide, she denied any specific plan or intent to carry out the act. Dr. B felt that outpatient care with frequent follow-up was most appropriate and, after discussion with the patient, recommended Ms. A begin an antidepressant medication.
This case of acute suicidality in a woman who never considered suicide before supports the findings of Kaslow et al. (1998) that one may be at high risk if a recent loss is superimposed on a history of childhood loss. The therapist explored the meaning of the triggering event and helped the patient to understand how a previous loss was amplifying the impact of the current loss.
Case Example 2: Chronic Suicidality in Borderline Personality Disorder Ms. G was a 23-year-old patient with borderline personality disorder who was admitted to a psychiatric inpatient unit after the latest in an extensive history of suicide attempts, this time by overdose. She was then referred to Dr. H for psychotherapy. She met with Dr. H while still hospitalized. Dr. H asked Ms. G if she wanted to work on the reasons for her chronic suicidality. Ms. G said that she really did not want to work on it. She just wanted to die. Dr. H asked her why she was intent on dying. Ms. G told her that it was impossible for her to live up to her parents’ expectations. She went on to say that her parents, both academics, had raised her to follow in their footsteps. Throughout her childhood, they had gone over homework assignments with her, corrected her grammar on her English papers, and helped her memorize material for her exams. She said she knew they loved her, but she could not measure up to what they thought she should be. She contrasted herself to her brother, who was a Ph.D. candidate at a prestigious university. She had graduated from college with a reasonably good grade point average but was denied admission to the highly competitive program to which she had applied. Hence she had started graduate school in comparative literature at what she regarded as a “mediocre university.” She explained that her chronic level of suicidality had become worse when she had received a B on her first essay in a graduate course in an area of great interest to her.
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Dr. H made a simple observation: “A B is a pretty decent grade.” Ms. G replied, “No it isn’t. In grad school you really have to get A’s or you’ll never get a job.” Dr. H argued a bit with her and noted, “But it’s only your first paper. Most professors grade a little lower at first and expect improvement in the course of the semester.” “My professor hates me. There is no way she will ever give me an A. My parents would be so upset if they knew I was getting B’s,” Ms. G insisted. Dr. H began to note the combination of intense perfectionism and the borderline tendency to see “bad objects” everywhere. She asked, “Do you think your parents hate you, too?” Ms. G thought for a moment and said, “Well, I know they think I’m a failure and a brat for giving up and trying to kill myself. I hate them for what they’ve done to me.” Dr. H observed quietly, “Well, suicide is one way to get back at them.” She then went on, “They must be terribly worried about you right now.” Ms. G’s face became twisted with scorn: “They could care less. I think they’d be glad if I died because I’m such a pain in the ass for them.” Dr. H asked, “Is it possible that they might think differently than you imagine they do?” Ms. G was puzzled: “What do you mean?” Dr. H replied, “Well, you said earlier that you knew they loved you when they tried to help you with your homework as a child. I’m sure that no matter how much of a pain in the ass you have been recently, they still have feelings of love for you.” Ms. G said, “How do you know that?” “I don’t know for sure, but in my experience, parents rarely stop loving their kids. Has it occurred to you that they might be devastated if you killed yourself and might never get over it?” Dr. H continued to stress this approach of helping the patient see that her parents’ reaction to her suicide might be quite different than what she may have imagined. Ultimately, with the help of meetings with her parents and the social worker on the inpatient unit, she realized that she had misread her parents’ attitude toward her. She told Dr. H, “I realize now that if I killed myself, I wouldn’t be eliminating my pain. I’d simply be passing it on to them.” Dr. H also helped her realize that she had internalized her parents’ expectations so that now her perfectionism reflected her own internal expectations of what she should do. Her parents made it clear to her that they would love her “even if she was a ditchdigger.” After helping her own her perfectionism and her need to berate herself for never achieving her excessively high self-expectations, the therapy then focused on the need to mourn this tormenting and idealized view of herself and settle for more reasonable goals. Ms. G gradually began to accept that she could be a worthwhile person despite having flaws. At the same time she could see that she could achieve excellence in her writing while still being less than perfect.
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The case of Ms. G illustrates a number of key principles in the psychodynamic treatment of suicidal patients. First, one must differentiate acute suicidality from the chronic baseline of suicide risk in patients with borderline personality disorder. Second, as with many borderline patients, Ms. G’s ability to mentalize was impaired (Bateman and Fonagy 2004a, 2004b). Mentalization refers to the capacity to understand that one’s own and others’ thinking is representational in nature and that one’s own and others’ behavior is motivated by internal states, such as thoughts and feelings (Fonagy 1998). Ms. G demonstrated impairment in this function because she found it difficult to imagine how the mind of her parents might be different from her own mind. Dr. H worked in therapy to help her appreciate that the impact of her suicide on her parents would be much more devastating than she thought. Similarly, the therapist helped her see that one meaning of her wish to die was a way of seeking revenge against her parents. She could make them suffer and get back at them for driving her to perform at a level that met their expectations. Dr. H also helped Ms. G see that her parents’ perfectionistic expectations were now internalized as her own. She had to take responsibility for them and recognize that they were so unreasonable that they led to feelings of hopelessness and a wish to die. She had to mourn her fantasized achievements to ultimately lead a more realistic existence. Although the first two cases are examples of how psychodynamic therapy can be useful in treating suicidal patients, the following case illustrates the value of applying psychodynamic thinking to a case in which treatment becomes seriously misguided.
Case 3: Countertransference and Boundary Violations Ms. X was a chronically suicidal female who came to treatment at the age of 32 with Dr. Y, an experienced female psychotherapist. Ms. X had seen three previous therapists but had “fired” all three of them for what she perceived as their failings, specifically, their inability to help her with her feelings of hopelessness and helplessness. She had struggled with romantic relationships and work for her entire adult life and had frequently felt like giving up and taking her own life. She had never actually attempted suicide, but she thought about it every day. In her first meeting with Dr. Y, Ms. X told her that she had been a victim of multiple episodes of childhood incest perpetrated by her father and had felt like a “whore” and a “slut” ever since. She thought of herself as “damaged goods” and worried that no man would want her. She also had intense anger at her mother for not protecting her from her father. Her parents were divorced, and she had not seen her father for years. She and her mother had an intensely conflictual relationship, so she often felt that she had no familial support. Her previous psychiatrist
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had diagnosed her as having dysthymia with major depressive episodes periodically superimposed, or “double depression.” Dr. Y suggested that they have twice-weekly therapy sessions and also started Ms. X on paroxetine. About 4 weeks into the treatment, Ms. X told her that she was not taking the medication. Dr. Y asked her why she had stopped it. Ms. X replied, “I’ve had every drug in the book for depression and not a single one has helped.” Dr. Y suggested that she try it anyway because she didn’t think therapy alone would be enough. Ms. X looked at Dr. Y with contempt and said, “You’re not listening to me. You’re treating me from a textbook instead of listening to what I need. Please hear what I’m saying. These drugs don’t work with me.” Dr. Y then backed off and agreed not to press the issue of medication. The therapy continued twice a week, but Ms. X continued to feel suicidal and hopeless. At the end of the sessions, when Dr. Y said, “We have to stop now,” Ms. X would seem terribly wounded, and she would often say that she was right in the middle of a story. Sometimes she would ask if she could finish. Dr. Y would reluctantly extend the hour even though she was then late for her next patient. As therapy continued, Dr. Y began to feel that her observations were not helping Ms. X, and she told her so. Ms. X gave her a piercing look and said, “Words don’t help me. I need to be loved. I wasn’t loved as a child, and I need someone to love me now to heal.” Dr. Y replied that therapy was all about understanding and she had to convey that understanding with words. Ms. X became intensely angry and told her therapist, “You’re not listening again. Words don’t help me. You’re just like my mother. You’re more interested in yourself than you are in me. What I really need is a hug.” Dr. Y felt pangs of guilt. She had wanted to provide a different parenting experience for Ms. X and didn’t want to be considered a “bad mother” in the same way that the real mother was regarded by Ms. X. She reluctantly agreed to hug Ms. X. Her patient thanked her and seemed to feel better. The patient still felt terrible, however, and she regularly asked Dr. Y for a hug. Pretty soon the hug was a regular occurrence in each session. Dr. Y felt guilty about it since she knew that hugs were not ordinarily part of psychotherapy. She also felt that she should not be extending the length of the sessions, but she feared that Ms. X would be deeply wounded if she tried to stop what she had started. She even worried that her patient would become more suicidal if she denied her the hugs; thus, she continued them. The hugs became more prolonged and more intense. On one occasion, Dr. Y actually feared that Ms. X wouldn’t let go so that the session could end. The patient frequently talked about horrific sexual episodes with her father where she felt trapped and unable to escape from him. She told her therapist that during the incestuous sexual relations with her father, she would often imagine how suicide was her only way out. She knew her mother would not rescue her, so suicide was her only option. Dr. Y felt a good deal of empathy for her dilemma, and she vowed to be a different kind of mother in her therapeutic role.
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Ms. X told Dr. Y that she wanted to call her “Mom.” With some hesitation, Dr. Y consented to this request, fearing that to turn her down would be devastating. She began to get calls from her patient nearly every night, usually around 10 or 11 P.M. Dr. Y felt she had to talk with her or she might kill herself. Dr. Y was feeling tormented at this point. She felt that her life was completely controlled by the patient and that she had no recourse but to continue the course she had begun. At one point Dr. Y contacted a consultant. She confided that she felt she was in the patient’s grip and that the patient would never let her go. To make matters worse, she had dramatically reduced the fee because the patient had been fired from a job, and Dr. Y felt that she was being paid a pittance to treat an extraordinarily difficult patient. The consultant told her that she must be furious about it. Dr. Y recognized that she had been burying her rage at the patient because she was intent on being a good mother to her, and she really felt she loved her patient at some level. The consultant pointed out that it is common to hate someone you love. Dr. Y felt freed up by the consultation and realized how much she had allowed herself to be utterly controlled by the patient. She told the patient that she was no longer able to continue under the circumstances and offered a referral to a trainee in a local clinic where, after an appropriate transitional period to end her work with Dr. Y, she could continue to receive low-fee care. Ms. X was furious and told her that she felt deeply betrayed. She stomped out of the office without saying good-bye. She later heard from the trainee at the clinic who took over the case that the patient was still coming to therapy and still had not attempted suicide.
Several lessons can be learned from this terribly misguided treatment. First, many patients who have experienced severe child abuse and neglect will approach psychotherapy with the expectation that they deserve to be compensated for their tragic past by extraordinarily special treatment on the part of the therapist (Davies and Frawley 1992). The ordinary professional boundaries of our work are felt as depriving and even sadistic. Therapists may feel coerced into desperate efforts to demonstrate that they are completely different from the abusive object from the past, an approach that has been termed “disidentification with the aggressor” (Gabbard 2003). One reason this strategy fails is that the patient is searching for a “bad enough object” (Rosen 1993; Gabbard 2000). In other words, such patients desperately need the therapist to take on characteristics of the abusive internal object that they carry within themselves, because abusive object relations are both predictable and familiar to these patients. If therapists do not allow themselves to be transformed into the bad object role, the patient will need to continue to escalate the demands until they finally provoke the therapist into exasperation. Dr. Y, much like her patient, began to lose the capacity to mentalize. Her own sense of reflective analytic space got lost in the flurry of concern about what action should be taken to prevent the suicide. This collapse of reflective space
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paralleled the patient’s failure to distinguish between impulsive actions and fantasy (Gabbard and Wilkinson 1994; Lewin and Schulz 1992). Suicidality and the act of suicide are not the same thing. It is noteworthy, in this regard, that Ms. X never attempted suicide despite thinking about it every day. The anxiety about keeping the patient alive may lead to a frantic effort to take away the suicidality, which may be a valuable source of escape for the patient. For this patient, it was the only way out of horrific incest. As Nietzsche (1886/1966) once noted, “The thought of suicide is a great source of comfort: with it a calm passage is to be made across many a bad night.” The case of Ms. X also illustrates the dangers of encouraging the patient to think of the therapist as a real parent who is always available. This implied promise fills the patient with false hopes that will ultimately be dashed and lead to further contemplation of suicide. The patient will also assign the responsibility for keeping herself alive to the therapist, one of the most lethal features of suicidal patients (Hendin 1982). When therapists place themselves in bondage to the patient, they soon find their omnipotent wishes to heal are thwarted. Furthermore, under this intense confinement, therapists may find themselves in the grips of countertransference hate and the powerful urge to enact these feelings. Whether in the more subtle form of aversion (forgetting appointments, withdrawing emotionally) or outright acts of malice (sarcastic or hostile responses), these behaviors communicate the therapist’s unconscious wish to abandon or even kill the patient, often serving only to heighten or acutely worsen the patient’s suicidality. The case also illustrates the problem with surrendering good judgment on such issues as the need for medication, the prohibition of hugging, and the charging of reasonable fees for care. Finally, Dr. Y wisely sought consultation before the pattern of boundary violations dragged her down the slippery slope to a point of more severe ethical transgressions. Consultation with a colleague on a regular basis should be a routine part of the treatment of chronically suicidal borderline patients. In addition, Dr. Y returned to her own psychotherapy in order to more fully explore her vulnerabilities. Personal therapy or analysis for clinicians who do intensive dynamic therapy of suicidal patients serves as a further protective measure, providing the therapist useful insight and perspective on the limits of the art.
❏ Key Points ■
Suicidality has meanings that vary from patient to patient. These meanings may be multiple and complicated; thus, they require careful exploration in the context of a strong therapeutic alliance.
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Suicidal patients create intense countertransference feelings, ranging from anxiety to despair to hatred and beyond, in those who treat them. These feelings can lead to boundary violations as well as lifethreatening errors if they are disavowed.
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Thoughtful reflection on the transference/countertransference developments in psychotherapy often reveals the major interpersonal themes relevant to the patient’s suicidality.
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Patients who are suicidal must be cautioned that no one can save them from suicide. They are ultimately responsible for their own safety while they are working in psychotherapy to find ways to live with pain.
References Asch SS: Suicide and the hidden executioner. Int Rev Psychoanal 7:51–60, 1980 Bateman AW, Fonagy P: Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 18-month follow-up. Am J Psychiatry 158:36–42, 2001 Bateman AW, Fonagy P: Health service utilization costs for borderline personality disorder patients treated with psychoanalytically oriented partial hospitalization versus general psychiatric care. Am J Psychiatry 160:169–171, 2003 Bateman AW, Fonagy P: Mentalization-based treatment of BPD. J Personal Disord 18:36–51, 2004a Bateman AW, Fonagy P: Psychotherapy for Borderline Personality Disorder: Mentalization-Based Treatment. Oxford, England, Oxford University Press, 2004b Beevers CG, Miller IW: Perfectionism, cognitive bias, and hopelessness as prospective predictors of suicidal ideation. Suicide Life Threat Behav 34:126– 137, 2004 Blatt SJ, Quinlan DM, Pilkonis PA, et al: Impact of perfectionism and the need for approval in the brief treatment of depression: the National Institute of Mental Health Treatment of Depression Collaborative Research Program revised. J Consult Clin Psychol 63:125–132, 1995 Chessick RD: Intensive Psychotherapy of the Borderline Patient. New York, Jason Aronson, 1977 Davies JM, Frawley MG: Dissociative processes and transference-countertransference paradigms in the psychoanalytically oriented treatment of adult survivors of childhood sexual abuse. Psychoanalytic Dialogues 2:5–36, 1992 Fenichel O: The Psychoanalytic Theory of Neurosis. New York, WW Norton, 1945 Fonagy P: An attachment theory approach to treatment of the difficult patient. Bull Menninger Clin 62:147–169, 1998 Freud S: The ego and the id (1923), in The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol 19. Translated and edited by Strachey J. London, England, Hogarth Press, 1961, pp 1–66 Freud S: Mourning and melancholia (1917), in The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol 14. Translated and edited by Strachey J. London, England, Hogarth, 1963, pp 237–260
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Gabbard GO: On gratitude and gratification. J Am Psychoanal Assoc 48:697– 716, 2000 Gabbard GO: Miscarriages of psychoanalytic treatment with suicidal patients. Int J Psychoanal 84:249–261, 2003 Gabbard GO: Psychodynamic Psychotherapy in Clinical Practice, 4th Edition. Washington, DC, American Psychiatric Publishing, 2005 Gabbard GO, Wilkinson SM: On victims, rescuers, and abusers, in Management of Countertransference With Borderline Patients. Washington, DC, American Psychiatric Press, 1994, pp 47–70 Guthrie E, Kapur N, Mackway-Jones K, et al: Randomised controlled trial of brief psychological intervention after deliberate poisoning. BMJ 323:135– 138, 2001 Guthrie E, Kapur N, Mackway-Jones K, et al: Predictors of outcome following brief psychodynamic-interpersonal therapy deliberate self-poisoning. Aust N Z J Psychiatry 37:532–536, 2003 Hamilton TK, Schweitzer RD: The cost of being perfect: perfectionism and suicide ideation in university students. Aust N Z J Psychiatry 34:829–835, 2000 Hendin H: Psychotherapy and suicide, in Suicide in America. New York, WW Norton, 1982, pp 160–174 Kaslow NJ, Reviere SL, Chance SE, et al: An empirical study of the psychodynamics of suicide. J Am Psychoanal Assoc 46:777–796, 1998 Leichsenring F, Rabung S, Leibing E: The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders: a meta-analysis. Arch Gen Psychiatry 61:1208–1216, 2004 Lewin RA, Schulz CG: Losing and Fusing: Borderline and Transitional Object and Self Relations. Northvale, NJ, Jason Aronson, 1992 Maltsberger JT, Buie DH: Countertransference hate in the treatment of suicidal patients. Arch Gen Psychiatry 30:625–633, 1974 Menninger KA: Psychoanalytic aspects of suicide. Int J Psychoanal 14:376–390, 1933 Nietzsche F: Beyond Good and Evil: Prelude to a Philosophy of the Future (1886). Translated by Kaufman W. New York, Random House, 1966 Rosen IR: Relational masochism: the search for a bad-enough object. Presented to the Topeka Psychoanalytic Society, Topeka, KS, January 1993 Smith K: Using a battery of tests to predict suicide in a long term hospital: a clinical analysis. Omega 13:261–275, 1983 Smith K, Eyman J: Ego structure and object differentiation in suicidal patients, in Primitive Mental States of the Rorschach. Edited by Lerner HD, Lerner PM. Madison, CT, International Universities Press, 1988, pp 175–202 Weishaar ME: Cognitive risk factors in suicide, in Frontiers of Cognitive Therapy. Edited by Salkovskis PM. New York, Guilford, 1996, pp 226–249
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Split Treatment Donald J. Meyer, M.D. Robert I. Simon, M.D.
Split treatment, also known as collaborative treatment, refers to outpatient mental health care that is contemporaneously provided by a psychiatrist and one or more mental health colleagues who typically are not physicians (Balon and Riba 2001; Meyer and Simon 1999a, 1999b). The psychiatrist, at a minimum, provides the patient’s pharmacotherapy. The nonprescribing therapist(s) may provide all or some of the remaining nonsomatic psychotherapeutic modalities to the patient. Most commonly both practitioners are independently licensed. Particularly with sick and unstable patients, the prescribing and nonprescribing clinicians must collaborate in the prospective gathering and sharing of clinical data and in clinical decision making. The greatest challenge in applying the split treatment paradigm to suicidal patients is the multiple barriers to the clinicians’ commitment and collaboration these patients require. Suicidal patients require clinician availability, continuity, and reassessment. Treaters who meet these clinical demands must overcome their own instincts to avoid individual exposure to clinical uncertainty, anxiety, helplessness, unreimbursed services, and potential professional liability.
Clinical and Financial Factors Encouraging Split Treatment Historically, split treatment has been fostered by both demographic and financial forces. The number of nonphysician therapists vastly outnumbers 235
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psychiatrists. There has been an ever-expanding range of psychopharmacological interventions to which patients in psychotherapy want access. Psychiatrists may be in short supply, particularly in rural areas and in publicly funded health care systems. Split treatment can expand the clinical reach of the individual prescribing psychiatrist to a larger number of patients. Some psychiatrists are more interested in somatic than verbal therapies. Split treatment facilitates their pursuit of that subspecialty interest. Although research findings about the cost of split treatment have been mixed, some third-party payers, believing the cost for split treatment could be lower than care provided by a psychiatrist alone, have also constructed their network of credentialed providers, their members’ access to that provider network, and provider reimbursement levels to foster split treatment (Dewan 2000; Goldman et al. 1998). While the paradigm of a psychiatrist providing medication backup to a single nonphysician therapist is still the most common form of split treatment, the paradigm has also been affected by the development of an ever-increasing number of specific types of psychotherapy that have been brought into the mainstream of mental health treatments. Currently, a patient’s psychotherapy, particularly of sicker patients, may include psychodynamic, cognitive-behavioral, dialectical behavioral, time-limited, and other psychotherapeutic components. As the range of therapeutic modalities expands, a single practitioner may not have all the relevant therapeutic skills. Fashioning a treatment with all the desired psychotherapeutic elements for a patient may then require the addition of greater numbers of mental health clinicians. Although multiple mental health providers can each represent multiple therapeutic modalities, this does not mean that the clinicians are a coordinated, collaborative therapeutic team. As mental health providers are added to provide specific elements to a patient’s treatment, there is the risk that clinicians may view their own role as defined by the specific therapeutic modality they are providing rather than by the clinician’s responsibility to the patient’s care as a whole. A psychiatrist who provides medication backup and a psychologist who is doing cognitivebehavioral therapy may each see their clinical job description as defined by that special therapeutic modality that they provide for the patient. Analogous to the medical patient whose care falls between the cracks of the patient’s medical specialists, so-called collaborative care can be in fact uncollaborative, with mental health subspecialists being increasingly myopic in their view of their overall clinical responsibility to and for the patient. Nowhere are those mistaken mental health clinician assumptions more potentially clinically disastrous than when treating patients who are at risk for suicide.
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Overview of Clinical Assessment in the Split Treatment of Suicidal Patients With the exception of mental retardation, all major mental illnesses, including the Axis II disorders, statistically increase an individual’s relative risk of suicide (American Psychiatric Association 2003). More seriously ill patients often require pharmacotherapy in addition to a verbal therapy. These patients may have multiple psychiatric disorders, treatment-resistant disorders, and an increased risk of suicide. By virtue of their therapeutic needs, often requiring pharmacological treatment in addition to verbal therapy, they are likely to compose most of the split treatment patient population. Patient demographics notwithstanding, mental illness does not lend itself to being parsed along lines drawn between different theories or modalities of treatment. Neither the nature of mental illness nor the stages of its treatment are easily separable into medical and nonmedical components (Meyer and Simon 1999a, 1999b). For both patient care and clinician risk management, the clinicians involved in split treatment need to evaluate not only the patient but also the clinical capacities of their split treatment colleagues and the interpersonal fit of respective professional relationships. The outcome of those three assessments should provide answers to several clinical questions: • What are this suicidal patient’s premonitory signs and symptoms of deterioration? • Are the patient and all treaters aware of how those signs and symptoms might present in the clinical setting in which each therapist will have access to the patient? • Has the patient and, if needed, a family member or significant other been enlisted in the process of what premonitory indicators to watch for and whom to inform? • How will routine and emergency information be shared within the team? Who will assume emergency responsibilities of clinician(s) in charge if the patient deteriorates? • How will others assist? • Has the patient been informed of and agreed to the plan? • Do all the clinicians and the patient involved appreciate the importance of the unrestricted flow of clinical information?
Patient Selection and Patient Risk Assessment Ideally, prescription of split treatment for a suicidal patient should be an eyes-open clinical choice made after consideration of the relative
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risks and benefits. Patients are routed to split treatment from a variety of pathways. Some patients, having been hospitalized for their suicidality, are then ready for discharge to a posthospitalization outpatient treatment plan. Clinicians then have a prospective choice whether to use split treatment with a suicidal patient. Other patients may have become suicidal during the course of a split treatment. These clinicians may not have had the opportunity to make a prospective choice for split treatment and need to reassess whether they are still agreeable to the same treatment paradigm now that the patient is suicidal. Although the ability to combine multiple treatment modalities may argue for split treatment, risk assessment of a suicidal patient may have special implications for or against split treatment. No single treatment modality, split treatment included, is right for everyone. Some patient personality traits represent a relative obstacle to split treatment for a suicidal patient. Are there personality risk factors in the patient’s presentation that will likely strain communication between treatment team members? Patients who have an unstable sense of self or who in past treatment relationships have had a history of reliance on splitting, projection, and projective identification may present very differently to different clinicians on the split treatment team. The patient’s intrinsic pathology may in fact be fostered by having two or more clinicians between whom the patient can present polarized, unintegrated elements of his or her inner life. Clinicians may find themselves correctly feeling they no longer have an informed overview of the patient and are unable to perform ongoing risk assessment of the patient’s risk for suicide. Worse still, they may feel undermined by the patient’s presentation of different psychological faces to different treaters. Clinicians may feel at odds about who this patient really is and may become adversarial with each other, fragmenting communication and collaboration. Some suicidal patients have a history of knowingly or unwittingly concealing important information from the treating clinician. This problem may be compounded with an increasing number of treaters whose teaming depends on an accurate flow of information. Schizoid or paranoid suicidal patients with few relational skills may be hard-pressed to relate to a team of mental health treaters. Dividing a patient’s limited capacity for disclosure between a number of different clinicians may worsen an already serious patient management problem by further diluting available clinical data. Suicidal patients whose affective illness or psychosis has a history of rapid deterioration will need frequent reassessments by the prescribing clinician. These frequent reassessments, although medically necessary, may in turn change the interpersonal dynamics and responsibilities
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within the clinical team. Frequent patient reassessments can also negate the attempt to distribute the prescriber’s time among a large number of patients.
Medications and the Suicidal Patient in Split Treatment Medications can treat but also exacerbate both affective and psychotic disorders and, in turn, a patient’s risk for suicide. Suicidal patients whose drug regimens have not yet been stabilized will require more oversight by the prescribing clinician. Patients who are prescribed multiple drugs from different classes of medications or who are receiving off-label prescriptions may also require more time from the prescribing clinician. Team members need to be aware of how medications may affect the patient’s risk for suicide and thus the team’s need to reassess the patient. Patients who are newly given benzodiazepines can become disinhibited. Antipsychotics and other medications can produce an akathisia that can wrongly be diagnosed as anxiety. The psychological dysphoria associated with some extrapyramidal symptoms can precipitate selfdestructive impulses and acts, including suicide. Changing antidepressants may require removing a partially effective antidepressant and thereby exposing the patient to a relapse of symptoms. New and raised dosages of antidepressants may precipitate a manic switch in susceptible patients. Any of these medication side effects can precipitate or exacerbate a patient’s risk for suicide. The prescriber can provide notice to the other team members of medication changes that can affect the patient’s clinical status. Non-prescribing team members, for their part, need to alert the prescriber should these side effects appear. Adherence with drug regimens can be an unrecognized factor in the failure or partial response of drug treatment regimens (Osterberg and Blaschke 2005). Suicidal patients who appear ambivalently involved in their nonpharmacological treatment may act out similar feelings by not taking their medication. Nonprescribing colleagues who themselves may have ambivalent attitudes toward pharmacotherapy may unwittingly encourage patient noncompliance with drug regimens or may make medication recommendations to the patient (Lee and Hills 2005). Patient noncompliance and collegial departures from clinical roles and responsibilities can create severe risks to the treatment of suicidal patients and must be clarified and addressed. Prescribers may face a variety of pressures from third-party payers to minimize the duration and frequency of patient visits and to maxi-
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mize the intended time span of each prescription refill. Many patients are encouraged by their insurer to seek 3-month refills of their medications. Suicidal patients need to be assessed and prescribed for according to their clinical needs. The prescriber bears the responsibility for that decision, regardless of the financial and benefit disincentives from a third-party payer (Wickline v. State 1987). The following vignette illustrates the ease with which a team’s mistaken presumption of the patient’s stability can be facilitated by a lack of communication about the potential side effects of medication and the patient’s subsequent change in clinical status. When many patients do well clinically, it is easy to forget how quickly another patient can deteriorate or be impulsive.
Case Example 1 A 33-year-old lesbian woman in individual and couples treatment was referred for medication consultation for symptoms of depression. She was diagnosed by the medicating psychiatrist with major depressive disorder and treated with a selective serotonin reuptake inhibitor. The therapist and psychiatrist, each in private practice, knew each other professionally from a common institutional affiliation, an affiliation that also attested to the professionals’ training, experience, and insurance. The patient was seen in follow-up 2 weeks later by the psychiatrist and appeared to be responding to treatment. The patient was scheduled for a medication backup visit in 2 months. Two weeks later the therapist noted that the patient’s mood was continuing to improve and that the patient seemed more able to assert herself in the couples setting. However, after another 2 weeks, the couples therapist informed the individual therapist that the patient seemed to have crossed the line from being assertive to being enraged and intolerant. She was “fed up and not going to be shortchanged.” The individual therapist noted the patient was reporting insomnia and presumed it to be secondary to the acrimony in the relationship. The patient called the psychiatrist for additional medication for the sleeplessness. Trazodone was phoned in without patient reassessment. In the subsequent 3 weeks, the patient’s dysphoric manic switch became full blown but remained undiagnosed. She precipitously had an affair that she then announced to her partner. Her partner threatened to leave. Soon after, the partner came home to find the patient had hung herself.
Several issues are highlighted by this case. The therapists had not been alerted by the prescriber of the risks of mania from treatment of depression. The patient’s sudden assertiveness, short temper, and sleeplessness were not diagnostically appreciated to be early symptoms of a manic switch.
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The patient’s medication appointment in 8 weeks might have been all right as long as the patient remained on a stable trajectory. However, the prescriber did not assess either on the phone or in person the significance of the patient’s new-onset insomnia and wrongly assumed it must be simply a reaction to the couple’s acrimony or a medication side effect. Because her medicating psychiatrist did not take that opportunity for reassessment and was not informed by the patient’s therapist of the patient’s hypomanic behavior, the patient went undiagnosed. She became more disinhibited, angry, and hypersexual. In a dysphoric state, she felt intense shame and guilt for her infidelity and for the loss of the relationship and committed suicide. The patient’s estate sued all three therapists for malpractice. The case was settled for a six-figure sum.
Psychiatrists’ Shared and Separate Responsibilities Thus far, the discussion of the ramifications for split treatment from the clinical assessment of the patient has routinely referred to “a team” as if it were an established clinical fact. Achieving that interdisciplinary clinical team may take considerable time and work and also requires the professional assessment of one’s colleagues, a process that is less familiar to most clinicians than the assessments they routinely perform with patients. Consequently, assessments of a colleague’s clinical capacity and of the shared and separate clinical responsibilities are often not undertaken. In considering the assessment of their professional colleagues in a split treatment, psychiatrists should be guided by the position of the American Psychiatric Association (1980) that collaborative treatment involves “a shared responsibility for the patient’s care in accordance with the qualifications and limitations of each therapist’s discipline and abilities” (p. 1490). Psychiatrists who treat suicidal patients in split treatment cannot delegate responsibility for assessment and management of the patients’ risk for suicide by insisting their role and responsibility is limited to psychopharmacology. It is not possible to responsibly initiate prescribing of psychoactive medications to a person with major mental illness in the absence of a comprehensive psychiatric assessment. It is unethical to prescribe medication for patients whom the prescribing clinician has not examined (American Psychiatric Association 2000). It is not possible to continue prescribing in the absence of continued understanding of and respond-
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ing to the patient’s psychology. All psychopharmacology requires psychotherapy, and the psychiatrist’s responsibility for both are legally and ethically unassignable (Gutheil 1982). Medication visits are sufficient to generate transference and also to be a repository of transference that the patient has split off from the primary psychotherapy. Both processes need to be identified and psychologically managed, even if not directly interpreted. Absent the psychopharmacologist’s continued psychological understanding of the patient, patients can be misdiagnosed, have poor medication adherence, and receive treatment below the accepted standard of care. The APA continues, “[I]t is incumbent upon psychiatrists to satisfy themselves as to the level of competence, level of training and, where required, the licensure of the therapist” (American Psychiatric Association 1980, p. 1491). The corollary of this position is that it is both poor practice and poor risk management to attempt collaborative treatment with self-proclaimed psychotherapists who are, in fact, unlicensed or lack training (Sederer et al. 1998). The standard of care requires each clinician to make an eyes-open choice of a colleague with whom to collaborate. In an era in which patients as consumers feel the legitimacy to want the specific treatment and treaters they want—whether traditional or not—psychiatrists continue to have a responsibility not to endorse or be a party to collaborative treatment with individuals, however well meaning, who are not appropriately trained and licensed mental health clinicians. An interesting wrinkle on the issue of licensure is split treatment by mental health trainees. Trainees are not independently licensed. Mental health trainees typically have dependent licensure to practice medicine as long as they are both supervised by a fully licensed clinician and practicing within a clinical facility that has been licensed by the state to have clinician trainees. The trainee must have an assigned supervisor who ultimately is responsible both for the supervisory decision of the scope of clinical authority granted the trainee and for the trainee’s clinical decisions themselves (Cohen v. State of New York 1976). Under the law, a trainee’s work is not held to a different standard of quality and competence than the work of a non-trainee (St. Germain v. Pfeifer 1994). It is the supervisor’s responsibility to ensure that the trainee’s treatment meets the legal standard of care for that trainee’s discipline. Legally, a psychiatric resident’s work must be as good as the average psychiatrist’s practice in similar circumstances (Meyer and Simon 2004). It is possible within a training institution that a split treatment team of clinicians may be composed of both staff and trainees or of trainees
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alone. Supervisors ultimately are the guarantors of the quality of care and may need to not only supervise the care of their individual supervisee but also ascertain the competence of the trainee with whom their supervisee is working in order to make the necessary supervisory judgments about split treatment. When the split treatment team is composed of both staff and trainee clinicians, trainees often feel that they lack the authority to question their staff member colleague even in the face of serious clinical missteps by the staff person. It may fall to the trainee’s supervisor to take up quality-ofcare issues on a staff-to-staff basis to achieve a dialogue that is not influenced by seniority. Direct supervisory involvement may also be required if the trainee split treatment team crosses between institutions or includes a private practitioner who is not affiliated with the institution. Increasing administrative conflicts may be reason enough that split treatment will not be a workable or appropriate choice for a suicidal patient. In contrast to split treatment with trainees who are dependently licensed to practice and must have supervision, independently licensed clinicians should clarify among themselves and with the patient that the clinicians are colleagues practicing under their own individual authority and that the split treatment relationship has not also established a supervisory relationship between the clinicians.
Assessment of Collegial Training, Competence, and Clinical Temperament Most clinicians are unaccustomed to making inquiry about colleagues’ training and experience. At worst, the questions may be perceived as intrusive or authoritarian, perceptions that can be a serious impediment to team building. In an effort to mitigate that response, inquiring clinicians can offer their own background information to the other clinician. The offer of one’s own information is a good-faith gesture that helps demonstrate a matter-of-fact, egalitarian attitude to the interprofessional disclosure. A clinician can also use this opportunity to volunteer information about emergency availability, after-hours and vacation coverage, and malpractice coverage. Having disclosed this information about one’s self, a clinician can reasonably make an inquiry of a colleague without sounding high-handed or disrespectful. Split treatment clinicians may or may not be familiar with each other’s clinical skills and judgment. Knowing that a colleague is trained and credentialed is a beginning to assessing a colleague’s clinical capacities, not the assessment itself. In the course of the discussion of a patient, clinicians should also assess whether their colleague is able to clearly
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describe the patient’s current status and provide a coherent history. In split treatment, much will depend on each clinician’s capacity to accurately narrate elements of the patient’s current status. An inability to accurately describe the patient may not be a problem when the therapist is working alone but can be an insurmountable hurdle to the communication and collaboration required by split treatment. Noticing what details a colleague chooses to report or omit about the patient is very informative about the clinician’s capacity for observation and for attribution of clinical meaning. In the subsequent discussion about the patient, clinicians will also reveal whether they are able to make and support a phenomenological diagnosis, formulate a psychodynamic understanding of the patient’s adaptational organization, and identify transference and countertransference as it may present in the treatment of this patient. Mental health colleagues who do not perform psychodynamic psychotherapy still need the ability to notice and manage transference and countertransference even if they have no plan to directly interpret the process to the patient. The way in which a colleague tells the story of the patient may also reflect on the clinician’s own clinical temperament. Suicidal patients require clinical commitment to the treatment even in the face of the patients’ being oppositional or uncollaborative. Patients who are contemplating suicide at times may regard clinicians as the enemy, the spoiler, or an uninvited intruder (Resnick 2002). Suicidal patients, in acting out a mixture of longing, anger, and guilt, may involve clinicians as a witness to their own deterioration as opposed to working with them as agents of change. A split treatment colleague who is effective in noticing and responding to the stresses of treating a suicidal patient can offer ballast and assistance to patient and colleague alike. A colleague who is pathologically certain, defensive, interminably vague, indecisive, or inappropriately hierarchical will militate, not mitigate, the problems of treatment.
Data, Communication, and Collaboration Whatever the benefits of having a team of providers performing the patient’s treatment, it will require administrative time to articulate a therapeutic strategy for the patient and to coordinate the implementation of that strategy over time. Administrative time in mental health care is largely unreimbursed although it is still a required ethical and clinical duty in split treatment, regardless of the financial disincentives. As treatment proceeds, clinicians in split treatment must not only incorporate new clinical data into their own treatment plan for the patient
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but also provide notice of clinically important developments to their split treatment colleagues. Often simply providing updated information by voice mail or e-mail to a colleague about a patient contact will suffice. The leaving of the voice message or e-mail can be included as part of the clinical visit with the patient present. It reinforces to the patient that there is a team of health care providers who require a flow of ongoing clinical information. Simple notice by voice mail or e-mail may not suffice for more important clinical changes and may require intercollegial discussion. A major loss, a disruption in a relationship, worsening depression, a change in the pharmacological regimen, and a change in the frequency of meetings all may have important implications for all the treating clinicians. No clinician treating a suicidal patient wants to be uninformed of important clinical developments. The prescribing clinician is especially vulnerable to being left out of the loop, a potentially disastrous position when treating suicidal patients. Some clinicians have chosen to use e-mail as a method of communicating with colleagues and with patients. Because of the informality associated with e-mail, clinicians may forget that a casually written note becomes a permanently archived clinical memo. E-mailed memos should be written with the knowledge that they have become an immutable part of the patient’s record. Although e-mail may be helpful in facilitating contact and scheduling appointments, using it for exchanges with patients as a method of clinical assessment is not recommended. Patients in emotional distress or in a regression cannot be expected to be effective authors in communicating the range and the subtleties of their emotional distress. Having reconciled themselves to providing unreimbursed administrative time for notice and collaboration with their split treatment colleagues, clinicians also need to appreciate that with the formation of a clinical team, even though their individual authority over treatment decisions has been diminished, their clinical responsibility for the patient has not. In a split treatment team, at a minimum there are two different clinicians, each having the authority to make clinical treatment decisions. Their responsibility for the patient, flowing from ethical, clinical, and legal standards, is also not diminished. Particularly in the event of a clinical emergency or a clinical bad outcome, prescribing therapists should not assume their responsibility will be less simply because they met with a patient infrequently during times of clinical stability. Apart from the financial and administrative barriers to ongoing collaboration, clinicians may also be inhibited from collaborative communication by anticipated shame or loss of stature that might result from revealing
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anxiety or clinical uncertainty about the patient (Meyer 2002). This can be particularly risky with patients who at baseline have a history or current risk for suicide. Prescribing therapists can best diminish this risk by conveying an interest in and tolerance of clinical uncertainty. Showing one’s own uncertainty can often facilitate colleagues’ feeling more comfortable doing likewise. Clinical and role conflicts between colleagues should not be sidelined in deference to the hope that a working alliance will develop later. True alliances are based on shared values, respect for differences, and a demonstrated capacity to work out rather than ignore conflicts. The following vignette illustrates some obstacles that can arise from a split treatment created by default rather than by choice.
Case Example 2 A resident presented the new case of a suicidal patient from her psychopharmacology clinic. The patient had been referred by the patient’s primary care physician who no longer wanted to prescribe both antidepressants and stimulants for this patient. The patient was a 34-year-old single woman who had reported symptoms of depression and anxiety beginning 3 years previously, when she and her boyfriend broke off their relationship. The patient had commenced treatment with a psychotherapist who specialized in eye movement desensitization and reprocessing (EMDR). However, the EMDR therapist had not felt the patient was ever sufficiently stable to begin that specialty treatment. The therapist thought the patient had been “traumatized” by a borderline mother and had a posttraumatic stress disorder variant. The EMDR therapist asked the patient’s primary care physician for a medication evaluation. The patient, who had symptoms of anxiety, depression, impaired attention, and rejection sensitivity, was ultimately prescribed both a selective serotonin reuptake inhibitor and Ritalin. Since the psychiatric resident had taken over doing the patient’s medication backup, the EMDR therapist had also, without consultation, enlisted an additional psychotherapist from a community mental health clinic who could be more available to the patient than the EMDR therapist was prepared to be. The resident reported that the patient would page her and report suicidal feelings and at the same time assure the resident that she would never “do anything.” The patient explained her paging the resident because the resident was the most accessible of the three mental health care clinicians. The patient was also irregularly attending her psychotherapy.
There is insufficient information to know whether it will be possible for this patient to be contained and treated in split treatment, but the information does justify the resident’s worry. The patient’s diagnosis is in doubt. The severity of her suicidal risk is unassessed. The appropriate-
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ness of the medication regimen is in question. Equally important, the “team” responsible for making these determinations is not in it together. The EMDR therapist is responding as though the patient is more than she can handle. The case involves clinicians from two institutions and a third who is a solo practitioner. The patient is attending treatment erratically and selecting the trainee as the clinician in charge of emergencies. Ironically, it is the most junior member of the team who is the most clinically concerned, and her concerns are appropriate. These clinicians, either through their own collaboration or through use of a consultant, need to agree on a working diagnosis, perform an adequate risk assessment, and then formulate a treatment plan. It is possible but not yet clear whether the patient has character traits (a tendency to split and act out) that will prove a contraindication for split treatment. If the clinicians go forward with split treatment, they need to parse the clinical tasks “in accordance with the qualifications and limitations of each therapist’s discipline and abilities.” The EMDR therapist cannot delegate her availability to another clinician. She may have to resign from the case. The resident may need additional supervisory support in the event that the appropriate clinical goals are not supported by the more senior clinicians.
Suicide Risk Assessment in Split Treatment Suicidal patients require ongoing risk assessment. Risk assessment is a prospective process, not a one-time event. “Risk assessment involves making a clinical judgment of the patient’s vulnerability at the time of examination and a prospective hypothesis about the patient’s level of function in the immediate and intermediate future....Risk management for these patients involves helping patients foster conscious awareness of high risk situations, of their unique premonitory signs of deterioration and of potential ameliorating and emotionally sustaining responses” (Meyer 2002, p. 58). Early in the treatment process, the clinicians on the split treatment team need to agree on what individual signs and symptoms will serve as indicators that a suicidal patient is at greater risk. Suicide risk assessment scales may help inform or operationalize this dialogue even though the instruments themselves are not predictive. The treaters can consider whether anyone in the patient’s social network should be included as a regular or emergency informant of the patient’s level of function and which member of the treatment team that individual would contact.
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Suicidal patients are almost always ambivalent about their wish to die at their own hand. To the extent possible, it is important that all members of the team be informed about the psychology of what makes suicide attractive to this patient and what makes suicide a less acceptable or unacceptable option. Team members should know what this patient’s reasons for living are, what in life is sustaining to them, and what events or relationships make it worth enduring their present suffering (Malone et al. 2000). For most suicidal patients who go on to act on their suicidal wishes, there is a window of time during which the balance of the patient’s ambivalence toward suicide has shifted but before a decision has been sealed. In split treatment, the team needs to know what areas of a patient’s life and psychological function typically provide the greatest counterweight against self-destructive wishes. Team members can each make some inquiry into these areas of strength during their visits with the patient. The team should also be alert to behaviors that suggest rehearsing or practicing a plan even though the patient does not endorse active or imminent intent. Writing notes that a patient might want to use someday, going to a place where a patient would commit suicide someday, and buying or moving an instrument (e.g., a special knife, a hose for a motor vehicle tailpipe) for suicide are all forms of rehearsal that will lower the barrier of unfamiliarity to a suicide plan and thereby increase future risk. In one author’s experience, the medication backup physician directed the patient to bring the actual hose she had bought to her next appointment with her therapist in order to talk about the associated suicidal feelings and thoughts. Having the actual object in the room diminished the patient’s denial about the increasing depth of her suicidality and offered an opportunity to intervene. Of particular concern with suicidal patients is the onset of psychological activators: anxiety, agitation, paranoia, internal shame, guilt, and public humiliation. Patients who have been stable yet chronically at risk can acutely have their existing defenses overwhelmed by these affects and feel psychologically energized to enlist action as a problematic way of relieving internal distress.
Leaving a Split Treatment Team No matter how rigorous the assessment of patients and colleagues, no matter how energetic the efforts at collaboration, clinicians may come to feel that the split treatment paradigm is no longer appropriate for this individual suicidal patient or with these colleagues. The anticipated
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clinical status of the patient may have become worse than initially hypothesized. Sometimes clinical or stylistic difficulties between clinicians have emerged and have been resistant to resolution. A therapist’s own life may have changed in a way that has diminished the clinician’s ongoing professional availability. Clinicians have a duty to end treatments that they no longer deem effective. Should a clinician choose to terminate with a patient, the patient needs to be provided with adequate notice and reasonable efforts to assist the patient in finding alternate medical care. Sometimes patients may decide that they no longer want to work with an individual member of the split treatment team. Clinicians should be alert to the possibility of patients splitting off some portion of a conflicted emotional response, a portion that needs to be put into dialogue within the treatment and not into action by rejecting one member of the split treatment team. Patients can also sometimes be the unwitting spokesperson for interprofessional conflicts within the treatment team, conflicts to which the patient has been privy but that have not been discussed by the clinicians on a collegial basis. In the final analysis, patients have the right to choose their clinicians, as long as the clinicians are also willing. However, clinicians in split treatment are not required to work with just anyone. Clinicians sometimes inappropriately surrender their own rights to choose their colleagues, their patients, and the setting in which they are willing to work. Their response often is a problematic surrender to the patient’s neediness.
❏ Key Points ■
Split treatment of suicidal patients can offer a multidimensional therapy by combining the skills of clinicians with differing expertise. In some health care systems and some geographic areas, split treatment may be the only practical way to provide patient access to psychopharmacological therapies.
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No single treatment paradigm is right for every patient. Patients’ biologically based diagnosis, their character defenses, the complexity of their pharmacological regimen, their history of impulsivity and suicidality, and their historic pattern of relating to health care providers are all important determinants of suicidal patients’ suitability for split treatment.
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Risk assessment and risk management of a suicidal patient in split treatment is a process to be performed repeatedly and collaboratively by a team of mental health clinicians sharing clinical data and clinical decision making.
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■
Clinicians need to assess themselves and each other for the availability, competence, and interpersonal fit required to work collaboratively, even in the face of financial and administrative disincentives for that required collaboration.
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Suicidal patients need to be assessed and prescribed for according to their clinical needs. The clinician, not the insurer, bears the responsibility for the decision.
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Mental health clinicians who are truly a team can provide each other with consultation and emotional ballast during the sometimes grueling process of treating suicidal patients.
References American Psychiatric Association: Guidelines for psychiatrists in consultative, supervisory, or collaborative relationships with nonmedical therapists. Am J Psychiatry 137:1489–1491, 1980 American Psychiatric Association: APA condemns Kaiser prescribing policy (press release). No 0012. Washington, DC, American Psychiatric Association, April 14, 2000 American Psychiatric Association: Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry 160(suppl):1– 60, 2003 Balon R, Riba MB: Improving the practice of split treatment. Psychiatr Ann 31: 594–596, 2001 Cohen v State of New York, 382 NYS 2nd 128 (1976) Dewan M: Are psychiatrists cost-effective? An analysis of integrated versus split treatment. Am J Psychiatry 157:305–306, 2000 Goldman W, McCulloch J, Cuffel B, et al: Outpatient utilization patterns of integrated and split psychotherapy and pharmacotherapy for depression. Psychiatr Serv 49:477–482, 1998 Gutheil TG: The psychology of psychopharmacology. Bull Menninger Clin 46: 321–330, 1982 Lee TS, Hills OF: Psychodynamic perspectives of collaborative treatment. J Psychiatr Pract 11:97–101, 2005 Malone KM, Oquendo MA, Haas GL, et al: Protective factors against suicidal acts in major depression: reasons for living. Am J Psychiatry 157:1084–1088, 2000 Meyer DJ: Split treatment and coordinated care with multiple mental health clinicians: clinical and risk management issues. Primary Psychiatry 9:56–60, 2002 Meyer DJ, Simon RI: Split treatment: clarity between psychiatrists and psychotherapists, Part I. Psychiatric Annals 29:241–245, 1999a Meyer DJ, Simon RI: Split treatment: clarity between psychiatrists and psychotherapists, Part II. Psychiatr Ann 29:327–332, 1999b Meyer DJ, Simon RI: Psychiatric malpractice and the standard of care, in The American Psychiatric Publishing Textbook of Forensic Psychiatry. Edited by Simon RI, Gold LH. Washington, DC, American Psychiatric Publishing, 2004, pp 185–203
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Osterberg L, Blaschke T: Adherence to medication. N Engl J Med 353:487–497, 2005 Resnick PJ: Recognizing that the suicidal patient views you as an adversary. Curr Psychiatry 1:8, 2002 Sederer LI, Ellison J, Keyes C: Guidelines for prescribing psychiatrists in consultative, collaborative and supervisory relationships. Psychiatr Serv 49:1197– 1202, 1998 St Germain v Pfeifer, 418 Mass 511–522 (1994) Wickline v State, 192 CalApp3d 1630, 239 Cal Rptr 810 (1987)
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Depressive Disorders Jan Fawcett, M.D.
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bout 60% of the approximately 30,000 deaths from suicide each year occur in people with major depression, and increased rates of prescriptions for selective serotonin reuptake inhibitors (SSRIs) and other new-generation non-SSRIs are associated with lower suicide rates both between and within countries over time (Gibbons et al. 2005). A meta-analysis and literature review has shown that suicide occurs in patients with major depression 20.4 times more frequently than in the general population, based on a comparison using standardized mortality ratios (SMRs) (Harris and Barraclough 1997). A study of trends in suicidal ideation, suicide, suicidal plans and gestures, and suicide attempts in the United States has shown that despite a dramatic increase in treatment between 1990–1992 and 2001–2003, there has been no significant decrease in suicidal thoughts and suicide plans, gestures, or attempts (Kessler et al. 2005). A study of completed suicides found that of the 75% of patients who had an affective disorder, 70% had received psychiatric care within 1 year of their suicide and 51% had received care within 1 month of their suicide (Robins 1981). A study in Finland showed that 75% of the individuals who committed suicide had a history of psychiatric treatment, and 45% were receiving active treatment at the time of death. Only 3% had received antidepressants in adequate dosages, 7% had received weekly psychotherapy, and 3% had received electroconvulsive therapy (Isometsa et al. 1994). We can conclude from these findings that major depression is the most common diagnosis in individuals who commit suicide; that suicide has shown signs of decreasing as the use of medication treatment has increased; that although the long255
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term risk is greater, suicide rates are not currently directly related to the frequency of attempts and gestures; and that although suicide seems to be reduced with modern medication treatment, patients who commit suicide still receive inadequate treatment, and suicide still occurs all too frequently in patients in active treatment.
Assessment of Suicide Risk Assessment of suicide risk in patients with depressive disorders is one of the most challenging and important tasks for the clinician to continually perfect. It has repeatedly been shown that suicide is not predictable in an individual patient (MacKinnon and Farberow 1976; Pokorny 1983, 1993); therefore, the purpose of a suicide assessment is to assign the patient to a risk group such as acute high risk, chronic high risk but moderate immediate risk, or low risk. A patient with acute high risk for suicide is at risk of suicide over a period of hours, days, weeks, or a few months and requires immediate treatment intervention to prevent suicide. A patient at chronic high risk for suicide is at risk for suicide over a period of years and requires treatment to reduce the chronic risk for suicide. The assessment process begins with the initial evaluation of the patient and assessment of his or her current clinical state as well as an initial review of patient and family history. A history of past suicidal thoughts, plans, and behavior or a family history of these can help establish the degree of long-term risk. Carefully asking the patient about these issues at his or her worst point in the past can elicit important information that may be pertinent to the patient’s current state.
Current Clinical State Patients will be most focused on their present state of discomfort, disability, or psychic pain. Although some more obsessional or narcissistic patients will want to give their history “from the beginning”—which could be at birth—it is important to get the patient to share his or her current clinical state and to describe their symptoms and personal situation (e.g., loss of relationship or job, financial reversal, recent or worsening medical illness, or loss of function). It is usually useful to the clinician as well as the patient to frame descriptions of current symptoms and their severity. For distracted and alexithymic patients, it sometimes is difficult to describe what they are feeling. It is important to understand not only the presence of symptoms such as psychic anxiety, panic attacks, poor sleep, anhedonia, and hopelessness but also the severity of each symptom as it is experienced by the patient now and in
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the recent past. Severity is estimated by the intensity and magnitude (e.g., interrupted, unrestful sleep as opposed to the inability to sleep at all) and the duration (does the patient have moments of hopelessness or is he or she in a state of total hopelessness all the time?) of the symptom. It is useful to agree on a list of four or five of the most prominent “target symptoms” with the patient, ordered from most to least severe or most to least painful to the patient. Overall it is important to assess how severe a state of psychic pain the patient is experiencing and how well the patient is able to tolerate this pain. If the patient feels in excruciating psychic anxiety with psychic pain and is totally hopeless about finding relief, suicide may seem the only solution to the patient regardless of whether they admit to suicidal ideation and plans. The presence of comorbid illnesses can increase the severity of suicide risk in patients. These include alcohol or substance abuse disorders, panic disorders, posttraumatic stress disorder, Axis II Cluster B disorders, and certain organic mental disorders (all of which can manifest increased impulsivity), as well as chronic physical pain disorders and certain medical disorders (Isometsa et al. 1994).
Chronic Versus Acute Suicide Risk Because patients with depressive disorders present with a wide range of symptoms and severities in a constantly changing environment of stresses and supports, their suicide risk may fluctuate over the course of illness from a chronic high-risk state of severity requiring long-term preventive treatment to an acute high-risk state requiring some form of immediate clinical intervention. Thus, assessment of acute suicide risk can be viewed as a process that must be repeated depending on the patient’s clinical situation. The suicide assessment process should lead to a decision as to whether the patient is at a chronic high risk of suicide, acute high risk of suicide, or no increased risk of suicide at this time.
Chronic High Suicide Risk Group Chronic high-risk status is indicated by a past history of attempts, high lethality of attempts, suicide plans, hospital admissions for suicidality, high suicidal tendencies, high sustained level of hopelessness, chronic physical pain, recent serious medical diagnosis, or the presence of comorbid conditions such as alcohol abuse, substance abuse, or Cluster B Axis II disorders (Beck and Lester 1976; Beck et al. 1985; Fishbain 1999; Harris and Barraclough 1997). A history of highly impulsive aggressive behavior toward self or others is also a chronic high-risk factor. Another risk factor is a family history of suicide (Brent and Mann 2005). Patients
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in this group have the potential to enter a high suicide risk category with a depressive recurrence or in the presence of a major life stress or loss (e.g., loss of a relationship or job, financial loss, onset of a serious or painful medical illness). If any of these conditions occur, a repeat suicide assessment should be conducted.
Acute High Suicide Risk Group If a patient meets criteria for acute high suicide risk, immediate intervention is necessary to reduce the risk. This may necessitate a psychiatric hospitalization. If hospitalization cannot be achieved or is refused and the patient cannot be involuntarily hospitalized, outpatient management is necessary. Prospective studies of suicides, one of which included a comparison group, have shown that factors associated with high acute suicide risk in patients with affective disorders include agitated state (may be a mixed dysphoric state in a bipolar I or bipolar II patient), severe psychic anxiety, panic attacks, and severe or global insomnia (patient is hardly able to sleep at all) (Fawcett et al. 1990). In addition, it was shown that the recent onset of moderate alcohol abuse (often as an attempt at self-treatment of severe anxiety, panic attacks, or insomnia) and severe anhedonia significantly differentiates short-term suicides from nonsuicides. (All clinical depressive states are associated with some decreased interest and pleasure; severe anhedonia would imply that the patient cannot be distracted from the depressed state by any positive experience; see Fawcett et al. 1990.) In the same study, prior suicide attempts (past or recent), severity of suicidal ideation, and severity of hopeless were significantly greater in the suicide group after only 1 year of follow-up. A subsequent study of patients presenting to an emergency department after a suicide attempt sufficiently severe to require hospitalization showed that 90% of these patients reported severe psychic anxiety within 1 month prior to their suicide attempt as well as a high rate of insomnia (Hall et al. 1999). A more recent study of the clinical records of 76 inpatient suicides found that 77% of these patients had a recorded statement denying suicidal intent in their chart as their last communication before their suicide, and 72% of these patients had episodes of severe anxiety or agitation recorded in their clinical record by staff within 7 days of their suicide in the hospital (Busch et al. 2003). These findings suggest 1) that the assessment of the severity of anxiety symptoms should be a standard component of a clinical assessment of acute suicide risk, and 2) that anxiety symptoms in depressed patients should be aggressively treated. Anxiety symptoms are common in major depressive illness. One study using the Schedule for Affective
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Disorders and Schizophrenia (SADS), which yields a severity rating for each symptom rather than a “present” or “absent” rating, found that 65% of patients diagnosed with major depression had at least moderate levels of anxiety (Fawcett and Kravitz 1983). Another study using the SADS combined anxiety symptom severity ratings and found that about 10% of the sample of 954 cases rated had combined anxiety symptom severity ratings at the most severe level (Clayton et al. 1991). It is therefore important to assess the severity of a patient’s anxiety, not only its presence, in order for the assessment to be relevant to the issue of acute or immediate suicide risk.
Severity of Anxiety It has been shown that anxiety is very common in patients with major affective disorders (Fawcett and Kravitz 1983). Presence or absence of a symptom, as is used in reaching a DSM-IV-TR (American Psychiatric Association 2000) diagnosis, is not enough to discriminate risk, although the association of severe anxiety with acute high suicide risk has led me to assiduously monitor the severity of and aggressively treat anxiety symptoms in depressed patients. It is therefore important to assess the severity of anxiety and to try to estimate the psychic pain the patient is experiencing. It is difficult to objectify such an assessment, and close agreement among different clinicians may be difficult to attain. Clinical psychiatry has always struggled with this problem. The solution is not to ignore the severity assessment because it is difficult to achieve an “objective” assessment but to continue to perfect one’s clinical assessment skills with respect to symptom severity. Assessment can be aided by using three criteria: 1) intensity of the symptom as described by the patient, 2) tolerability of the pain associated with the symptom as experienced by the patient, and 3) the amount of time every day the symptom occupies the patient and when it is present (e.g., during the night when unable to sleep, or all day, or both). Use of relatively simple SADS-C (SADS, Change Version) rating scales for symptoms such as psychic anxiety, panic attacks, and insomnia can be helpful in this regard (see Table 12–1). Patients with ratings of 5 (severe) or greater should be considered to be experiencing severe psychic anxiety (Endicott and Spitzer 1978). A useful way to look at severe anxiety symptoms is to consider them as measures of psychic pain. The concept of psychic pain has not been fully developed and should probably include abject hopelessness and the concept of “psychache” (Shneidman 1998), but anxiety itself would qualify as a dimension of psychic pain in which a depressed individual
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TABLE 12–1. Assessment of severity of psychic anxiety (Schedule for Affective Disorders and Schizophrenia—Change Version) 1. 2. 3. 4. 5. 6.
No anxiety Slight, occasionally feels somewhat anxious Mild, often feels somewhat anxious Moderate, anxious most of the time Severe, nearly all the time; ruminative, interferes with other thoughts Extreme, pervasive feelings of intense anxiety—feels intolerable
with little hope of relief may be willing to do anything, including ending life, to escape. The book Leviticus from the Hebrew Bible succinctly describes this state by listing the curses that will befall mankind for failure to follow God’s laws: “The sound of a driven leaf shall put them to flight. Fleeing as though from the sword, they shall fall though none pursues” (Lev. 26:36). This level of anxiety can be literally perceived by a depressed patient as constant, inescapable torture.
Suicidal Tendencies Patients who have manifested high suicidal tendencies in past episodes of depression should be carefully evaluated for a similar high-risk state in a current episode. A recent pilot study of 12 inpatient suicides showed that 7 of these patients had past strong suicidal tendencies from past worst episodes but were rated at moderate to low suicidal tendencies in the week prior to their suicide (Busch and Fawcett 2004). Past history may, in some cases, be a better acute predictor of risk than the patient’s presentation of their current state. Findings of high suicide intent at the worst point in a patient’s prior episode have been associated with completed suicide (Beck and Lester 1976). Many depressed patients can be classified into a low-risk group by the absence of chronic or acute high-risk factors. If patients fail to improve or the condition evolves into a treatment-resistant or refractory depression, or if they experience a major stressor or loss, their risk group status could change.
Timing of Suicide Assessments Suicide risk assessments should be done and documented at an initial evaluation early in treatment when the patient has not yet recovered; at times of clinical worsening, relapse, or recurrence of depressive symptoms; and at other known times of high risk such as shortly after dis-
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charge from a psychiatric hospitalization, where the risk is greater the shorter the time since discharge up to 1 year (Fawcett et al. 1990; Hoyer et al. 2004; Qin and Nordentoft 2005). Periods of great stress, including the loss of an important relationship, financial loss, job loss, recent medical diagnosis, onset or worsening of painful physical symptoms, and onset of alcohol or drug abuse, would also be times when repeat suicide assessments should be done and documented. Failure to respond to treatment over time should also result in repeat suicide assessments.
History of Illness and Suicidality at Worst Period Attention to the patient’s worst episodes can establish the patient’s suicidal tendencies, as outlined by the Suicidal Tendencies Scale of the SADS (Coryell and Young 2005). If a patient has a history of a mentally rehearsed suicide plan (as distinguished from frequent thoughts of suicide) or preparations for a potentially serious attempt, they have a significantly higher likelihood of completing suicide at some time in the future. The use of the Suicidal Tendencies Scale (see Table 12–2) has proved more robust in correlating with later suicide than a history of suicide attempts alone. It has also been shown (Bostwick and Pankratz 2000) that if a patient has a history of hospitalization for a suicidal attempt or suicidal ideation, they have an 8.8% lifetime risk of suicide, compared with a patient admitted for other reasons (4.4%) or a depressed outpatient (2.2%). The past history of attempts helps in about half of patients who commit suicide. Isometsa and Lonnqvist (1998), in their series of 1,397 suicides in Finland, showed that 56% died on their first suicide attempt. If the patient has a history of comorbid alcohol or substance abuse, Cluster B personality disorders, or severe anxiety disorders (e.g., panic disorder), he or she is at a higher long-term risk. A careful history of the patient’s past episodes of illness can provide the basis for a working relationship that both provides valuable clinical data and enhances the clinician’s ability to build an alliance with the patient. A useful transition can be the question of how difficult life was for the patient when the depression was at the worst it has ever been. If the patient tells of a past episode that was associated with suicide plans or suicidal behaviors, one can assume that a similar danger may exist if the present episode is described in terms of similar symptom severity.
Suicidal Ideation and Suicide Plan If the present episode is the first episode or the worst ever, the clinician can assess the patient’s current level of acute risk of suicide. As the patient de-
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TABLE 12–2. Suicidal Tendencies Scale (Schedule for Affective Disorders and Schizophrenia) 1. 2. 3. 4. 5. 6. 7.
No morbid thoughts Morbid thoughts, no suicide thoughts Occasional suicide thoughts, no plans Often thinks of suicide, has thought of method Has mentally rehearsed a plan; has made a gesture Has made preparations for a potentially serious attempt Suicide attempt with intent to die or that is potentially medically harmful
scribes the severity of symptoms associated with the present episode of depression, the clinician should inquire about feelings of hopelessness that are frequently associated with severe depression. Such a discussion is a good segue into an inquiry into the presence of suicidal ideation, a suicide plan, or recent suicide attempts. It is useful to recall that the classic studies of Robins (1981) found that although 69% of patients who committed suicide had communicated suicidal ideas or thoughts to spouses (50%) and coworkers (40%), less than 20% of the suicide group had communicated these thoughts to a physician or other helping person. This provides a strong basis for talking with and listening to significant others, if possible, as part of a suicide risk assessment. It is not uncommon for patients to make threats to significant others and later repudiate them when examined by a clinician. It is also important to recognize that several authors have found either that there was no relationship between suicidal ideation and subsequent suicide or that suicide was discussed in only 22% of last outpatient visits before suicide (Gladstone et al. 2001; Isometsa et al. 1995). A prospective study of 34 suicides found no relationship between severity of suicidal ideation and suicide as an outcome within 1 year of assessment (Fawcett et al. 1990). A study of 76 inpatient suicides found that 78% of inpatients denied suicidal ideation to staff prior to their suicide as their last communication recorded in the hospital chart (Busch et al. 2003). A denial of suicidal ideation and even a suicide “no-harm contract” are not in themselves deterrents to suicide (28% of patients making a verbal or written “no-harm contract” were inpatient suicides) and, although therapeutically useful at times, do not by themselves constitute a complete suicide assessment. The use of concepts from case-based interviewing, such as the “gentle assumption” that conveys to the patient that suicidal ideation is common in depression and asks how severe their ideation was at the most severe point in their depression, will often allow a patient to admit the presence of ideation and its severity by degrees in an assessment interview (Shea 2004).
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Research studies have suggested that the standard items of suicidal ideation, hopelessness, and prior or recent suicide attempts—while serving as indicators of chronic elevated risk for suicide—do not alone provide a strong basis for estimating the acute risk of suicide within the hours, days, or weeks following the assessment (Fawcett et al. 1990). This finding suggests that relying on these well-established risk factors alone may not be enough to indicate the need for immediate intervention to the clinician, although they may indicate the need for increased vigilance and more intensive treatment aimed at reducing long-term risk.
Case Example 1 A 33-year-old white woman with a history of alcohol and drug abuse and depression becomes agitated with her husband and storms out of their apartment shouting, “You’ll never see me alive again.” She drives her sport-utility vehicle down a major highway, calls her husband on her cell phone, screams “I’m not afraid to do it” repeatedly, and then drives her vehicle into a cement wall separating her lane from oncoming traffic. The vehicle careens off the cement wall and rolls, landing upright. The state trooper assigned to the scene finds the woman dazed, with several cuts and abrasions, but amazingly intact given the condition of the vehicle and the fact that the driver had not been wearing a seat belt. He drives her to the nearest hospital emergency department despite her protests and claims that it was “only an accident.” The patient is agitated and pacing in the presence of her husband while awaiting evaluation, but during the clinical assessment she denies depression or suicidal intent despite her repeated threats of suicide to her husband both before and after the crash of her vehicle. The patient’s husband is not interviewed by the emergency department staff. Because of her denials, she is released to a friend without anyone talking with her husband. Her car disabled, she rents a loaner car to drive home, to be followed by her friend, but instead drives ahead, losing her friend. She drives to her parents’ home, goes immediately to a shed on the property, and hangs herself within 6 hours of her discharge.
This case illustrates several points. The patient intended to conceal both the lethality of her attempt with her vehicle and her current high-risk state and therefore did not display her agitated state to the clinical evaluator and denied any suicidal intent. The patient’s spouse, who was aware of his wife’s high intent and current state of agitation, was not interviewed. The result was that the patient’s clinical state was not adequately understood and the denial of the patient’s high-intent suicide attempt was not recognized. Her denial of suicidality was accepted, and she was discharged only to hang herself within hours. If the significant other had been interviewed and the patient evaluated based on the available history, the decisions made and the outcome may have been quite different.
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Case Example 2 A 52-year-old woman presents to a hospital emergency department with a packed bag, saying “I’m here to be admitted for services.” When an attempt is made to examine the patient, she announces, “I’m not here for 20 questions; just admit me.” She has a history of a prior hospitalization about 6 months before and describes having taken a medication, but she stopped taking it 2 months ago. She denies suicidal thoughts and any psychotic symptoms but is in general uncooperative. While waiting for her examination in the emergency department, she calls one of her sisters, telling her that she is having intolerable pain in her brain caused by hair dye she used that is eating through her skull into her brain. She is agitated and screaming as she describes her state and tells her sister that she can no longer stand the pain and is going into the hospital. Because the patient denies symptoms of depression, psychosis, or suicidal thoughts, she is discharged with a referral for an outpatient clinic visit in 1 month. The emergency department staff never calls her sister to obtain further information and history. The next day, the sister, who assumed that her sibling would be admitted, finds her dead. She had hung herself in her garage at home.
This case illustrates several points. This patient presented in a somewhat bizarre manner, arriving with her suitcase and demanding a psychiatric admission but refusing to be interviewed or asked questions and denying symptoms of depression or suicidality. Her response that she wanted to be “admitted for services” in the presence of a denial of symptoms was not questioned, nor was the bizarre nature of the request (raising the possibility of a psychosis) pursued in her evaluation. Finally, although staff were presented with an uncooperative patient demanding hospitalization who, if asked, would have admitted she had a home to live in, no effort was made to contact a close relative. If such effort had been made, it would have been more clear that the patient was psychotic and having episodes of severe anxiety and agitation based on her delusional belief that her hair dye was eating into her brain and causing intolerable pain. This might have led to the understanding that this patient was in an acute highrisk state and requiring immediate intervention, in this case hospitalization. Her acute suicidal state could have been recognized and her suicide prevented with a therapeutic intervention.
Management of Patients at High Suicide Risk Acute High Suicide Risk In today’s practice, with limitations on our ability to admit patients and newer criteria for risk assessment, the clinician may come to the conclusion that a patient who refuses hospitalization and is not technically
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committable or cannot for reasons of insurance coverage access hospital care is at high acute risk. The clinician thus may be forced by these realities to manage a patient assessed at high acute risk as an outpatient. There are no double-blind random-assignment studies to guide us in our treatment of an acutely suicidal patient. If the patient can be hospitalized, either voluntarily or involuntarily by a concerned family member who has evidence of acute risk based on the patient’s behavior, it is our duty to effect hospitalization. If the patient is not committable and will not or cannot be admitted voluntarily, then we have to manage the patient with the resources available. If a concerned significant other or family member is available, we should contact them and express our concern that the patient is at high risk and under the best of conditions should be hospitalized. The concerned relative can be told that patients are less likely to commit suicide in the presence of others and if lethal means (e.g., firearms) are removed. Symptoms of anxiety or agitation should be treated aggressively with long-acting benzodiazepines (e.g., clonazepam) that may be less likely to be disinhibiting in their action and less likely to have anxiety rebound associated with their offset of action. The patient and any available significant other should be warned that the medication must be maintained on a regular basis until modified by the clinician. When there is a question of threat to life, confidentiality should not prevent the contacting of relatives or others to obtain information required for an accurate assessment of risk. Studies have shown that clonazepam will improve the anxiety, rapidity, and degree of antidepressant response over the first 4–8 weeks (Londborg et al. 2000). Sedating atypical antipsychotic medications such as quetiapine and olanzapine have been found to be helpful in rapidly reducing severe anxiety and agitation as well as improving severe insomnia (Calabrese et al. 2005). Use of these medications, along with available support from relatives and therapists, and close observation of the patient through frequent visits and phone contacts can help defuse acute suicide risk states by reducing agitation, severe psychic anxiety, impulsiveness, and severe insomnia.
Case Example 3 The patient, a 52-year-old female attorney, has been in psychoanalysis for 2 years for a narcissistic personality disorder. She is a very successful attorney who has a successful corporate law practice and is on the board of a company. She took the lead in making changes that saved the company from bankruptcy through her leadership of the company’s board of directors. Then a new chief executive officer (CEO) was recruited for the company by the board. The new CEO found that the patient had
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been receiving director’s fees while at the same time billing the company for legal services. She faces dismissal from the board and exposure to her law firm that threatens her career. The patient becomes acutely depressed, is unable to sleep, and has anxious ruminations about her imminent disgrace and ruined career. When seen by the clinician, she is found to be in a state of severe anxiety and agitation, with thoughts of crashing her car in such a way that it would appear accidental. It is strongly recommended that she be hospitalized. She informs the psychiatrist that hospitalization would draw attention to her disgrace, and she refuses the recommendation. When commitment is mentioned, she counters by saying that she knows judges who would have her out of a hospital in minutes on a habeas corpus writ (and the psychiatrist would lose any chance to be of help). It is decided to manage the patient at home over the weekend after talking with her husband, who seems very supportive of her. The patient is given nortriptyline in daily bedtime doses, with increases up to 100 mg, and clonazepam 1.0 mg four times a day. She and her husband are warned against her driving because of drug-related drowsiness. The clinician calls her daily over the weekend, and her husband is also consulted as to her status. When seen late on Monday, she is more calm and resigned to her situation and no longer appears to be anxious, agitated, or suicidal. By the following Friday her depression shows signs of improvement. By the following week she has reconstituted and is busy negotiating herself out of her “hopeless” situation. She returns to her psychoanalyst, who supervises her maintenance treatment with ongoing consultation and without further incident.
This patient was clearly in an acute high-risk state based on her symptoms of anxiety and complete hopelessness plus a specific suicide plan, which was viewed by the patient as an altruistic suicide plan. Because of the patient’s resistance to hospitalization and her ability to effectively resist any attempt at involuntary hospitalization, it was decided that the most realistic approach was to recruit her husband, who was concerned about her, for help in a plan to utilize high-dosage benzodiazepines to address her severe anxious/agitated state. The patient, supervised by her husband, was essentially “put to bed” for the weekend, which markedly reduced her symptoms and the likelihood that she would make a suicide attempt, and she was started on an antidepressant medication. This strategy reduced her acute risk over a weekend, and by early the next week the patient was noting a lifting of her depression in response to antidepressant medication. As her agitation and anxiety abated, the patient’s acute suicide risk decreased. Her depression responded to nortriptyline over the following 2 weeks. She was able to negotiate her situation and continue in her career and was monitored on her successful antidepressant therapy by her psychoanalyst.
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Protective Factors It is important to assess and utilize protective factors in managing a suicidal patient. In the cases discussed, the availability of a concerned other was very helpful in managing an acute suicide risk state in some instances and was not accessed in other instances. The existence of children under 18 is a protective factor if the patient is not experiencing a psychotic depression, but in the presence of a psychotic depression it is of less use and should not be counted on. It is important to identify and find ways to use the support of concerned significant others for a patient who is in an acute high suicide risk category. A patient who has had a spiritual interest or who has any feeling of being part of a greater meaning can be helped to use these interests toward recovery after they are helped past their acute suicide risk state. Religious beliefs and involvement can be rekindled to promote recovery once the acute highrisk state is under control but again should not be relied on to protect a patient in a high acute suicide risk state against suicide. A close relationship is an asset if the patient is in a state to feel the support and love, but often in an acute high-risk state, supportive and even loving relationships are of little help to the depressed, self-depreciating, hopeless, and severely anxious patient.
Maintaining Realistic Hope Patients who have reached an acute high suicide risk state vary in characteristics of course, but a clinician will see typical patterns that can be therapeutically addressed. Losing hope of improvement in the face of persistent psychic pain from severe anxiety and depression often leads a patient to conclude that the only solution is to end the suffering by suicide. Suicide notes often mention going to a better place where the pain of living will end. For this reason it is important to nurture realistic hope that the patient will achieve relief from his or her pain and suffering through treatment. Statements such as “There are many ways to approach this problem, but it is difficult to predict which will be helpful for you”; “We will try this approach and if it is not helpful in a few days, let me hear from you so we can try another approach”; “I will not give up in trying to help you, I know you are suffering”; or “We’ll keep trying until we have found the way that helps you, so don’t give up” recognize the reality of the patient’s situation and the realistic impossibility of predicting an individual’s medication response (usually the patient is doubtful anything will be helpful at this point anyway). At the same time, they let the patient know there are other treatment alternatives. This can provide continuing support to the patient to hold on un-
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til he or she feels some relief from the treatment. The clinician’s strong conviction that treatment can help if the right one for the patient is found, combined with a never-give-up attitude, can sustain a patient who is in pain and hopeless about recovery if close contact is maintained through the crisis. One patient who went through such a crisis said, “I was sure that either you were deluded or you really believed I could recover. So I decided to stay around just to find out.” Often, patients with treatment-refractory depression feel that all their treatment options have been used up without help and that there is nothing left to do. It is important to let them know that there are more treatment options to try. When a clinician feels hopeless about a patient’s situation, it is time for a second opinion or a transfer to another experienced clinician who treats patients with refractory depression. When the clinician becomes doubtful or loses hope that the patient can recover, the patient will sense this and his or her distress and hopelessness will be reinforced. Frequently a patient will misinterpret the clinician as saying that “nothing more can be done.”
Case Example 4 A 48-year-old white man is under treatment for bipolar I disorder with therapeutic dosages of lithium carbonate. He lost his career because of untreated mania and recently went through a divorce. His father had been a successful CEO of a company despite symptoms of mood swings and later committed suicide “unexpectedly” with a handgun while at “the height of his career.” After his job loss and divorce, the patient, who was a successful attorney, is reduced to living on public aid funds. He is very close to his three children ages 10, 15, and 17. The patient’s mood was stable until about 6 months after his divorce, when he begins missing his children and ruminating about the thought that he will not be able to send them to college, something he has always assumed he would be able to do. These ruminations about his financial plight increase to the point of interfering with his sleep. One morning he awakes with the thought that he is destitute and that there is no chance his children will have the opportunity to go to college because of his illness. He cannot stop these thoughts and becomes quite agitated. He decides his only way out is to take his life. He goes out to his garage and starts his car, but after a few minutes he leaves the garage and calls his psychiatrist. He is admitted to the hospital as an emergency; he is given venlafaxine, in an escalating dosage, as well as alprazolam 1–2 mg four times a day. His anxiety and agitation abate and his depression begins to improve in 5 days. He is discharged and continues to take venlafaxine 300 mg/day, alprazolam 1.0 mg three times a day, and lithium carbonate 1,200 mg/day. The patient does not have a recurrence. He pursues graduate studies in neurobiology and receives a scholarship for a Ph.D. program.
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This patient had achieved what appeared to be good control of his bipolar mood swings with the use of a regimen of lithium carbonate. Life circumstances overwhelmed the patient, and he went into a suicidal depression with features of guilt and severe ruminative anxiety. Fortunately, he called for help, and his acute high-risk suicidal state was addressed. He recovered from this depression and went on to a very high level of function. His relationship with his psychiatrist, built on hope and the possibility of overcoming setbacks, led him to call the psychiatrist in the midst of his high-risk suicidal state. This resulted in a timely, probably lifesaving, intervention that allowed the patient to proceed to develop a very high level of function with the purpose of helping others. In the cases discussed in this chapter, the patients’ drive toward suicide increased as they felt overwhelmed with anxiety and agitation. Hopelessness restricted their ability to see any way out of their suffering, and suicide became the only option they could see to escape their pain. Treating their agitation, anxiety, and sleeplessness rapidly decreased their agitation, anxiety, and severe insomnia, which was associated with a decrease in urgency toward suicide. Effective antidepressant treatment restored their capacity for hope and problem solving over the following several weeks. This chapter has addressed the assessment of suicide risk with the purpose of assigning a patient to a risk group rather than making an individual prediction of high risk for suicide, because attempts to do this have proved unsuccessful. Clinicians should decide whether a given patient is at high chronic risk but low acute risk or at high acute risk for suicide and in need of immediate intervention. From studies reviewed showing that severe anxiety/agitation and panic attacks in depressed patients are found more commonly in relatively immediate suicides, it appears that assessing the severity of anxiety in a patient would in many cases help identify patients at high acute risk for suicide. In cases in which severe anxiety/agitation or panic symptoms are established, aggressive, closely supervised treatment with benzodiazepines or atypical antipsychotic medications can reduce suicide risk by addressing severe anxiety/agitation, panic, and severe insomnia. This allows time for antidepressants to exert their effects on both anxiety and depression. One caveat is finding that at least short-acting benzodiazepines such as alprazolam may induce disinhibition and worsening of impulsive behavior in patients with comorbid borderline features. Longer-acting benzodiazepines such as clonazepam may be preferable, and in cases in which there is a history of abuse, atypical antipsychotic medications may be preferable. If the clinician weighs the risk of death from suicide
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against the risk of abuse of medications closely supervised over a limited period of several weeks to several months, it usually is apparent that acute treatment is the best choice for the patient’s well-being.
Chronic High Suicide Risk I estimate that at least 50% of patients in psychiatric practices and clinics will fall into a chronic high suicide risk group. Some of these patients are likely to become acutely suicidal and require therapeutic intervention. This is why it is so important to have useful criteria for acute high suicide risk. What is the evidence that any type of treatment will reduce suicide long term? First, there is evidence that short-term treatment with antidepressant medications alone will not reduce suicide risk, at least in randomized, double-blind, controlled U.S. Food and Drug Administration trials, even though there are studies showing that short-term treatment reduces suicidal ideation as measured by the Hamilton Rating Scale for Depression (Khan et al. 2003; Tollefson et al. 1993). Of course, double-blind, controlled studies are not conducted exactly the same way as good psychiatric practice. It is presumed that the patients enrolled in a study are not at high suicide risk unless they present with a worsening of symptoms. In clinical practice, we frequently observe patients with very positive responses to treatment who show a marked reduction in acute suicide risk factors. Yet we need to be alert to the patients who do not respond and who continue to manifest high acute suicide risk factors. One study showed that treatment maintained for at least 6 months with antidepressants combined with antipsychotic medications and lithium reduced suicide by 2.5 times in patients discharged from a hospital (and therefore at higher risk) over a 35- to 44-year follow-up period (F. Angst et al. 2002; J. Angst et al. 2005). Thirty-four studies of treatment with lithium carbonate have shown that patients who comply with this regimen have an 8-fold reduction in suicide and a 13-fold reduction in suicides and suicide attempts (Baldessarini et al. 2003). All but one of these studies are uncontrolled, retrospective analyses, and one is a prospective study. This study showed that patients taking prophylactic lithium had significantly fewer suicides and suicide attempts than a comparison group taking carbamazepine (Thies-Flectner 1996). A recent review of studies on the effect of lithium in reducing suicide in patients on maintenance treatment confirms that its use confers an 8-fold reduced rate of suicide compared with nonuse of lithium and concludes that the antisuicidal effect is not
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necessarily coupled to lithium’s episode-suppressing efficacy (MullerOerlinghausen et al. 2005). Another recent study from Denmark of 13,186 patients who purchased lithium found that the purchase of lithium only once was associated with a higher risk of suicide than those who did not purchase lithium, whereas the purchase of lithium at least twice was associated with a 0.44 reduced rate of suicide (Kessing et al. 2005). What is needed are prospective studies of lithium versus treatment as usual to prove that the antisuicidal effect is due to the pharmacological activity of lithium, and not to factors related to treatment compliance. The Angst studies quoted earlier show us that keeping a patient on effective treatment for at least 6 months has the effect of reducing suicide even in high-risk patients. The study by Khan et al. (2003) noted earlier showed that we cannot rely solely on antidepressant medications to prevent suicide over an 8-week period, because active medication did no better than placebo in preventing suicide over that period of time. There are now two studies showing that cognitive therapy reduces suicidal ideation, hopelessness, depression, and suicide attempts significantly better than treatment as usual (Brown et al. 2005). This strongly suggests that cognitive therapy may reduce long-term suicide risk in chronic high suicide risk patients. Preventing suicide is a very difficult goal accepted by psychiatry. First, suicide is impossible to predict in an individual patient, but it may be possible to predict as more common in patients assigned to a group by various clinical criteria or even certain biological measures in the future (Fawcett et al. 1990; Mann et al. 2005). Second, despite clinical conviction that patients can show significant improvement and reduction of suicidality with antidepressant treatment, there are no data showing that antidepressant medications used alone prevent suicide compared with placebo over 8 weeks of treatment. On the other hand, there is evidence that medication treatment (lithium, antidepressants, and antipsychotic medications in varying combinations) for at least 6 months will reduce suicide in formerly hospitalized patients compared with patients who have not received at least one 6-month period of sustained treatment and that sustained treatment will reduce overall mortality (F. Angst et al. 2002; J. Angst et al. 2005). These data suggest that we need to be particularly alert for signs of acute high suicide risk in the early phases of treatment and make every effort to keep our chronic high-risk patients on sustained maintenance treatment. Obviously, not everyone who commits suicide will manifest presently known acute risk factors, and research is needed to expand the criteria for
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an acute high suicide risk state. It is my estimate that more than half of patients who commit suicide while in treatment could have their suicide risk detected in advance and could be treated successfully in the short term by assessing and addressing severe anxiety symptoms. Much more research is needed to develop clinical tools to help the clinician identify patients at acute risk so that preventive treatment can be initiated. Given the available data regarding detection of risk and prevention of suicide, why would anyone want to take on this task? Society in general holds the expectation that treatment should prevent suicide, as unrealistic as that expectation may be. Successful treatment certainly can reduce the risk of suicide, but in a free society we cannot force treatment or compliance with treatment on anyone. Failing to prevent suicide is one of the most common bases for lawsuits against psychiatrists. The fact is that preventing suicide is a primary goal of psychiatry. The battle against untimely death is a major goal of medicine. Dealing with suicide is the ultimate struggle: living a meaningful life versus dread and death. Reducing psychic pain and hopelessness is a life-giving goal. It is worth the struggle, but we need much more research to increase our effectiveness in both identifying and treating the suicidal patient.
❏ Key Points ■
Suicide occurs too frequently in patients who are under psychiatric care.
■
Suicide is not predictable in an individual patient, but a clinical suicide assessment can help identify a patient as being at acute high risk (the patient is at risk for suicide within hours, days, weeks, or a few months and immediate therapeutic intervention is needed), chronic high risk (the patient is at risk for suicide over a period of years and requires treatment to reduce the risk of suicide), or low risk.
■
Assessment of the patient’s current clinical state should include an estimate of the severity of symptoms of psychic anxiety, panic attacks, poor sleep, and anhedonia and an assessment of the patient’s level of psychic pain and capacity to tolerate this painful state.
■
Severe psychic anxiety, agitation, severe panic attacks, severe insomnia, and past suicidal tendencies (or high death intent of a prior attempt) when at their worst can suggest the presence of an acute high-risk state requiring an immediate therapeutic intervention to reduce the high-risk symptoms. A specific suicide plan and recent attempts also raise the issue of an acute suicide risk state.
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■
If the patient has a history of suicidal ideation, suicidal gestures, suicide plans, or suicide attempts and presents with comorbid alcohol or substance abuse, Axis II Cluster B disorders, or other forms of comorbidity, he or she should be considered at chronic high risk for suicide, and a treatment plan for reducing risk and preventing the occurrence of an acute high-risk state should be considered. Maintenance treatment with lithium, antipsychotic medications, and antidepressant medications has been shown to significantly reduce suicide in chronic high-risk patients. Cognitive therapy has demonstrated an ability to reduce suicide attempts and may reduce the long-term risk of suicide.
■
Because of the importance of severe anxiety symptoms occurring in a depressive disorder for acute high suicide risk, the severity of anxiety symptoms should be assessed as an integral part of a suicide assessment.
■
Although inquiring about suicidal ideation and a suicide plan is a standard part of a suicide assessment, it must be remembered that the denial of suicidal ideation or intent by itself is not sufficient evidence to conclude that a patient is not at acute risk. Rather, a careful assessment of the patient’s current clinical state, any available information from significant or concerned others, and past history of suicidal tendencies should be taken into account.
■
Patients assessed to be at high suicide risk usually have severe highrisk symptoms that can be rapidly modified by medication treatment, which if sustained and continually supervised may reduce the acute suicide risk while the depression is treated. Judicious use of benzodiazepines and atypical antipsychotic medications can be of great use.
■
Reduction of suicide in our patients is a difficult task, especially considering the clinician’s limited ability to predict behavior in an individual and limited ability to influence treatment compliance. We need more clinical or biological indicators of acute suicide risk to aid the clinician in this effort.
References American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000 Angst F, Stassen HH, Clayton PJ, et al: Mortality of patients with mood disorders: follow-up over 34–38 years. J Affect Disord 68:167–181, 2002
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Angst J, Angst F, Gerber-Werder R, et al: Suicide in 406 mood-disorder patients with and without long term medication: a 40 to 44 years follow up. Arch Suicide Res 9:279–300, 2005 Baldessarini RJ, Tondo L, Hennen J: Lithiun treatment and suicide risk in major affective disorders: update and new findings. J Clin Psychiatry 64(suppl): 44–52, 2003 Beck AT, Lester D: Components of suicidal intent in completed and attempted suicides. J Psychol 92:35–38, 1976 Beck AT, Steer RA, Kovacs M, et al: Hopelessness and eventual suicide: a 10 year prospective study of patients hospitalized with suicidal ideation. Am J Psychiatry 142:559–563, 1985 Bostwick JM, Pankratz VS: Affective disorders and suicide risk: a reexamination. Am J Psychiatry 157:1925–1932, 2000 Brent DA, Mann JJ: Family genetic studies, suicide and suicidal behavior. Am J Med Genet C Semin Med Genet 133:13–24, 2005 Brown GK, Ten Have T, Henriques GR, et al: Cognitive therapy for the prevention of suicide attempts. JAMA 294:563–570, 2005 Busch KA, Fawcett J: A fine grained study of inpatients who commit suicide. Psychiatr Ann 34:5, 2004 Busch KA, Fawcett J, Jacobs DG: Clinical correlates of inpatient suicide. J Clin Psychiatry 64:14–19, 2003 Calabrese JR, Elhaj O, Gajwani P, et al: Clinical highlights in bipolar depression: focus on atypical antipsychotics. J Clin Psychiatry 66 (suppl 5):26–33, 2005 Clayton PJ, Grove WM, Coryell W, et al: Follow-up and family study of anxious depression. Am J Psychiatry 148:1512–1517, 1991 Coryell W, Young EA: Clinical predictors of suicide in primary major depressive disorder. J Clin Psychiatry 66:412–417, 2005 Endicott J, Spitzer RL: A diagnostic interview: the schedule for affective disorders and schizophrenia. Arch Gen Psychiatry 35:837–844, 1978 Fawcett J, Kravitz HM: Anxiety syndromes and their relationship to depressive illness. J Clin Psychiatry 44:8–11, 1983 Fawcett J, Scheftner WA, Fogg L, et al: Time-related predictors of suicide in major affective disorder. Am J Psychiatry 147:1189–1194, 1990 Fishbain DA: The association of chronic pain and suicide. Semin Clin Neuropsychiatry 4:221–227, 1999 Gibbons RD, Hur K, Bhaumik DK, et al: The relationship between antidepressant medication and the rate of suicide. Arch Gen Psychiatry 62:165–172, 2005 Gladstone GL, Mitchell PB, Parker G, et al: Indicators of suicide over 10 years in a specialist mood disorders unit sample. J Clin Psychiatry 62:945–951, 2001 Hall RC, Platt DE, Hall RC: Suicide risk assessment: a review of risk factors for suicide in 100 patients who made severe suicide attempts. Evaluation of suicide risk in a time of managed care. Psychosomatics 40:18–27, 1999 Harris EC, Barraclough B: Excess mortality of mental disorders: suicide as an outcome for mental disorders. Br J Psychiatry 170:205–228, 1997 Hoyer EH, Olesen AV, Mortensen PB: Suicide risk in patients hospitalised because of an affective disorder: a follow-up study, 1973–1993. J Affect Disord 78:209–217, 2004 Isometsa ET, Lonnqvist JK: Suicide attempts preceding completed suicide. Br J Psychiatry 173:531–535, 1998
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Isometsa ET, Henriksson MM, Aro HM, et al: Suicide in major depression. Am J Psychiatry 151:530–536, 1994 Isometsa ET, Heikkinen ME, Marttunen MJ, et al: The last appointment before suicide: is suicide intent communicated? Am J Psychiatry 152:919–922, 1995 Kessing LV, Sondergard L, Kvist K, et al: Suicide risk in patients treated with lithium. Arch Gen Psychiatry 62:860–866, 2005 Kessler RC, Berglund P, Borges G, et al: Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990–1992 to 2001–2003. JAMA 293:2487–2495, 2005 Khan A, Khan S, Kolts R, et al: Suicide rates in clinical trials of SSRIs, other antidepressants, and placebo: analysis of FDA reports. Am J Psychiatry 160: 790–792, 2003 Londborg PD, Smith WT, Glaudin V, et al: Short term cotherapy with clonazepam and fluoxetine: anxiety, sleep disturbance and core symptoms of depression. J Affect Disord 61:73–79, 2000 MacKinnon DR, Farberow NL: An assessment of the utility of suicide prediction. Suicide Life Threat Behav 6:86–91, 1976 Mann JJ, Currier D, Stanley B, et al: Can biological tests assist prediction of suicide in mood disorders? Int J Neuropsychopharmacol 21:1–10, 2005 Muller-Oerlinghausen B, Felber W, Berghofer A, et al: The impact of lithium long-term medication on suicidal behavior and mortality of bipolar patients. Arch Suicide Res 3:307–319, 2005 Pokorny AD: Prediction of suicide in psychiatric patients: report of a prospective study. Arch Gen Psychiatry 40:249–257, 1983 Pokorny AD: Suicide prediction revisited. Suicide Life Threat Behav 23:1–10, 1993 Qin P, Nordentoft M: Suicide risk in relation to psychiatric hospitalization: evidence based on longitudinal registers. Arch Gen Psychiatry 62:427–432, 2005 Robins E: The Final Months: A Study of the Lives of 134 Persons Who Committed Suicide. New York, Oxford University Press, 1981, pp 424–425 Shea SC: The delicate art of eliciting suicidal ideation. Psychiatr Ann 34:5, 2004 Shneidman ES: Perspectives on suicidology: further reflections on suicide and psychache. Suicide Life Threat Behav 28:245–250, 1998 Thies-Flechtner K, Muller-Oerlinghausen B, Seibert W, et al: Effect of prophylactic treatment on suicide risk in patients with major affective disorders: data from a randomized prospective trial. Pharmacopsychiatry 29:103–107, 1996 Tollefson GD, Fawcett J, Winokur G, et al: Evaluation of suicidality during pharmacologic treatment of mood and nonmood disorders. Ann Clin Psychiatry 5:209–224, 1993
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C
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Bipolar Disorder Ross J. Baldessarini, M.D. Maurizio Pompili, M.D. Leonardo Tondo, M.D.
Bipolar manic-depressive disorders are prevalent, often severe and disabling, major psychiatric illnesses found worldwide (Goodwin and Jamison, in press; Tondo and Baldessarini 2005; Tondo et al. 2003). Lifetime prevalence of type I bipolar disorder (with mania and often psychotic features) is at least 1%, and total prevalence of bipolar disorder syndromes recognized in DSM-IV-TR (American Psychiatric Association 2000) may be as high as 5% if bipolar II disorder (severe depression with hypomania) and cyclothymia (mild to moderate mood shifts) are included (Kessler et al. 2005b). Bipolar disorder presents elevated risks of premature mortality due to adverse outcomes of medical disorders,
Supported, in part, by a Stanley Medical Research Institute International Mood Disorders Center award and a National Alliance for Research on Schizophrenia and Affective Disorders (NARSAD) Investigator grant (to L.T.); a fellowship from the University of Rome (to M.P.); and a grant from the Bruce J. Anderson Foundation and the McLean Private Donors Psychopharmacology Research Fund (to R.J.B.). Some material reported previously (Tondo and Baldessarini 2005; Tondo et al. 2003) has been updated, revised, and expanded in this chapter. Dr. Baldessarini has consulting or research relationships with pharmaceutical corporations whose products are discussed in this chapter, including Eli Lilly, IFI SpA, Janssen, JDS, and Novartis; Drs. Pompili and Tondo have no such relationships.
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accidents, and complications of commonly comorbid substance use disorders. By far, however, the major source of early mortality is a very high risk of suicide (Angst et al. 1998; Tondo and Baldessarini 2005; Tondo et al. 2003). In this chapter, we summarize current knowledge of risks, predictive factors, and treatment considerations relevant to suicidal behaviors in patients with bipolar disorder, as a contribution to sound clinical management.
Suicide Risk in Bipolar Disorder Risks of completed and attempted suicide for the general population vary widely among countries and regions, in part owing to differences in methods of identifying and reporting such events. Reported rates probably err toward low estimates, particularly for suicide attempts. Recent international rates of completed suicide averaged 0.014 %± 0.007% per year (14/100,000 persons per year ± SD) in the general populations of developed countries (Tondo and Baldessarini 2005). Risks among persons diagnosed with major affective disorders, in general, are much greater, although many studies fail to differentiate subtypes of bipolar disorder (especially types I vs. II) or bipolar disorder from major depressive or other forms of recurrent mood disorders, or to define risks related to sex, age, or illness severity, which vary widely across these factors (Jacobs 1999; “Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors” 2003).
Suicide Rates in Patients With Bipolar Disorder In unusually comprehensive meta-analyses (Harris and Barraclough 1997) comparing suicide risks as standardized mortality ratios (SMRs; rate in a disorder:rate in general population) for a number of psychiatric and medical disorders was recently updated for bipolar disorder (Tondo and Baldessarini 2005; Tondo et al. 2003). Estimates of suicide risk among patients diagnosed with bipolar disorder (mostly type I) considered separately from other mood disorders and relative to the general population (average SMR=22) may be somewhat greater than those among patients with severe major depression that usually led to hospitalization at some time (SMR =20) or with polysubstance use disorders (SMR =19), and much greater than those for patients with moderately severe depression (SMR =9) or other psychiatric or medical disorders (Table 13–1). The pooled, weighted mean annual incidence of suicide in patients with bipolar disorder was 0.39%, or 390/100,000 (based on 28 studies involving 823 suicides among 21,484 patients with bipolar disorder at risk for an aver-
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age of 9.93 years) (Tondo and Baldessarini 2005; Tondo et al. 2003). Some studies did not provide adequate information about treatment status, but for those providing data for treated and untreated patients, we considered only subgroups without ongoing long-term treatment. The suicide rate of 390/100,000 per year is nearly 28 times higher than the rate in the general population. These findings indicate that risk of suicide in patients with bipolar disorder is very high, and possibly higher than for any other psychiatric or substance use disorder.
Sex Differences in Suicide Risk Long-term studies suggest that the proportion of deaths ascribed to suicide among patients with major affective disorder averages 15%–19% (Goodwin and Jamison, in press; Tondo and Baldessarini 2005), but projections from annual suicide risk estimates suggest that this proportion may exceed 20% of causes of death among those with bipolar disorder (Table 13–1). In the general population, risk of suicide is several times higher among men than women, especially among young Caucasian men (Jacobs 1999; “Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors” 2003). Among patients diagnosed with bipolar disorder, the risk of completed suicides appears to be more similar between the sexes, although the proportions vary widely among studies and range from <2:1 to as high as 4:1 (Goodwin and Jamison, in press; Tondo and Baldessarini 2005). Based on estimates of projected lifetime risks of suicide as a proportion of causes of death among patients with bipolar disorder, the male: female risk ratio was less than twofold (18.5±9.5 vs. 12.5±10.0; relative risk=1.85 [95% CI, 1.32–2.38]; P=0.023 [Clark and Goebel-Fabbri 1999]), compared with a male:female risk ratio of 3.24 (24.1:7.45) in the international general population (World Health Organization 2005).
Effects of Illness Severity Suicide risk also varies with severity of major affective illness, at least in nonbipolar depressive disorders. Notably, risk of suicide recognized as a cause of death among never-hospitalized patients with affective illnesses of moderate severity (mainly major depression or dysthymia) is substantially elevated (about 8%), but less than half of proportions found among patients with bipolar disorder or those with more severe unipolar depression (Table 13–1) (O’Leary et al. 2001; Tondo and Baldessarini 2005). Systematic comparisons of suicide risk among hospitalized versus less severely ill patients with bipolar disorder are not available.
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TABLE 13–1. Risk of suicide in specific disorders
Disorder
Relative risk, SMR
Bipolar disorders Severe depression Mixed substance abuse Severe anxiety disorders Moderate depression Schizophrenia Personality disorders Cancer General population
Suicide rate, %/year
Lifetime risk, %
28 21 20
0.39 0.29 0.28
23.4 17.4 16.8
11
0.15
9.0
0.13 0.12 0.10 0.03 0.014
7.8 7.2 6.0 1.8 0.8
9 9 7 2 1.0
Note. SMR=standardized mortality ratio to risk in the general population, adjusted for age and sex. Lifetime risk is based on annual suicide rate multiplied by 60 years of potential risk. Risk in types I and II bipolar disorder are similar, but the rate of completed suicides in men somewhat exceeds that in women diagnosed with bipolar disorder (by 1.85-fold), whereas the male:female risk ratio in the international general population averages 3.24 (World Health Organization 2005). Severe depression involves hospitalization; moderate depression is an estimate for outpatient major depression plus dysthymia. Anxiety disorders include panic disorder with agoraphobia and obsessive-compulsive disorder. Source. Data from Harris and Barraclough 1997; Tondo et al. 2003.
Lethality of Attempts Another important feature of suicidal behavior among patients with major affective disorders is the evidently high lethality of suicide attempts (presumably reflecting both intent and means), as indicated by the ratio of estimated rates of attempts to suicides. This ratio is much lower among those with bipolar disorder than in the general population. The general population ratio of suicide attempts to completed suicides varies with such factors as age, sex, ethnicity, comorbid conditions, and the accuracy of case identification, especially for suicide attempts of varied severity and potential lethality (Tondo and Baldessarini 2005). Given these caveats, rates of suicide attempts in the general population are estimated to be 0.14%–0.28% per year, compared with an average suicide rate of 0.014% per year, for a ratio of at least 10:1 and as high as 30:1 (Kessler et al. 2005a; Tondo and Baldessarini 2005). We recently reviewed 60 published studies of risks of suicide attempts among more than 70,000 persons with mood disorders that supported
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comparisons of bipolar disorder versus nonbipolar major depression or a mix of major mood disorders not otherwise separated (Table 13–2). The annualized risk of suicide attempts was approximately 0.86% per year among patients with bipolar disorder, suggesting that the great majority of such patients may make at least one attempt within several decades. This attempt risk was somewhat higher among those with bipolar disorder compared with those with depressive or unspecified mood disorders (Table 13–2). The ratio of this rate of attempts to the preceding rate of suicides in bipolar disorder subjects is only 2.2 (0.86%: 0.39% per year)—much lower than the ratio in the general population and consistent with the proposal that the lethality of suicide attempts among patients with bipolar disorder is high. Of note, the sex-specific risk of suicide attempts was not significantly greater among men with bipolar disorder but was slightly greater among women with nonbipolar or unspecified major mood disorders (Table 13–2); earlier findings had suggested higher rates of suicide attempts among women with bipolar disorder (Tondo and Baldessarini 2005). TABLE 13–2. Risk of suicide attempts in mood disorders Bipolar disorder
Major affective disorders
Cases with suicide attempts Total subjects at risk Attempt risk (%) Estimated exposure (years) Attempt rate, %/year (95% CI)
1,915 31,814 6.02 7.02 0.86 (0.56–1.15)
2,443 45,276 5.40 13.80 0.39 (0.20–0.58)
Risk ratio by sex (men/women)
1.38
0.84
Measure
Note. Analyses are based on a review of 60 reports reviewed by Pompili, Tondo, and Baldessarini (Baldessarini et al., in review): 29 studies were of bipolar disorder subjects, and 31 were of subjects diagnosed with either unipolar major depression or unspecified major affective disorders (and may include some bipolar disorder subjects); 15 studies provided data on sex-specific risks in men versus women. Data are subjects with suicide attempts, and total subjects at risk, and their ratio as a percentage attempt rate; estimated exposure time (years) is based on the subject number-weighted average across studies. The estimated suicide attempt rate (% of subjects per year) is the ratio of the attempt risk (% of subjects with attempts): years at risk, with 95% confidence interval (CI). The risk ratio by sex (men/women) is based on the average (unweighted) rate (%/year). Note that the relative risk of attempts/suicides in bipolar disorder subjects (0.86/0.39 = 2.21) is much lower than in the general population (approximately 20-fold higher risk of attempts), suggesting relatively high lethality among bipolar disorder patients.
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Other Suicide Risk Factors Age and Duration of Illness Suicide risk appears to be particularly high early in the course of bipolar disorder (Dilsaver et al. 1997; Goodwin and Jamison, in press; Ösby et al. 2001; Tondo et al. 1998). In some samples, nearly one-quarter of lifethreatening suicidal acts occurred within the first year of illness, and half took place within 5 years. Ominously, the average latency from onset of bipolar disorder illness to establishing sustained treatment is typically 5–10 years, indicating a need for redoubled efforts to diagnose and treat the condition earlier, including in juveniles, in whom bipolar disorder may often be unrecognized or misdiagnosed (Faedda et al. 1995, 2004; Tondo and Baldessarini 2005; Tondo et al. 1998).
Diagnostic and Clinical Subtypes Some comparisons have been reported concerning suicide risk in specific types of manic-depressive or major affective disorders. The risk of suicide associated with bipolar disorder probably is similar to that found in major depressive disorder that is sufficiently severe as to require psychiatric hospitalization at some time (Goodwin and Jamison, in press; Tondo and Baldessarini 2005; Tondo et al. 2003). Probably reflecting the wide range of illness severity among persons diagnosed with DSM-IV-TR major depressive disorders, studies differ in their findings concerning relative risk of suicide in bipolar disorder versus nonbipolar major depression. Several studies have found higher risks in bipolar disorder; others have found no difference or even higher risks in unipolar depression (Goodwin and Jamison, in press; Tondo and Baldessarini 2005; Tondo et al. 2003). In general, risk of suicide is very high in both bipolar and unipolar forms of major affective disorders and probably increases with greater illness severity. In the 1970s Dunner and Fieve (1974) introduced the concept of type II bipolar disorder, with more prominent depressive than hypomanic phases (and no mania), and noted the high risk of suicide associated with it. A recent review found a particularly high risk of suicide attempts associated with bipolar II disorder (61/253, or a 24.1% lifetime risk), an intermediate risk in bipolar I disorder (103/606, or a 17.0% lifetime risk), and the lowest risk in unipolar depression (143/1,214, or an 11.8% lifetime risk) (Rihmer and Pestality 1999). Depressive and dysphoric-irritable states in all types of bipolar disorder appear to be particularly associated with a high risk for suicide. In a large sample of outpatients with type I or II bipolar disorder who
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made serious suicide attempts or committed suicide, 73% of the suicidal acts were judged to be associated with depression, 16% with dysphoric– mixed manic-depressive states, 11% with mania, and none with hypomania, indicating that 89% of all suicidal acts were associated with ongoing depression or mixed dysphoric mood states (Tondo et al. 1998). Other studies of patients with bipolar disorder also found that 79%– 90% of suicides were associated with depressive or mixed dysphoric mood states (Arató et al. 1988; Dilsaver et al. 1997; Isometsa et al. 1994; Tondo et al. 1998), and previous severe depression was highly predictive of later suicidal behavior (Dilsaver et al. 1997; Tondo et al. 1998).
Demographics Risk factors for suicide in general, as well as in bipolar disorder, include Caucasian ethnicity and being unmarried (“Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors” 2003). Additional clinical predisposing factors that are particularly important in bipolar disorder include previous suicide attempts, current depression or dysphoric mixed states, previous severe depression, hopelessness, and substance or alcohol abuse or dependence (Dilsaver et al. 1997; Goodwin and Jamison, in press; Isometsa et al. 1994; Jacobs 1999; “Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors” 2003; Tondo et al. 1998). Impulsivity also is a relevant clinical factor in suicidal behavior and is a common trait among persons with bipolar disorder (Tondo and Baldessarini 2005). However, impulsivity has been tentatively associated primarily with suicide attempts of limited lethality rather than with completed suicide (BacaGarcia et al. 2001). It is not clear whether a relatively high rate of illness recurrence or presence of rapid cycling (more than four recurrences within a year) increases risk of suicide in mood disorders. There may also be a genetic predisposition to suicide, but the risk associated with such a predisposition has not been shown to be independent of the risk for bipolar disorder or depressive illness (Baldessarini and Hennen 2004).
Effects of Stressors Predisposing factors for suicide probably interact with precipitating stressors, but deaths, separations, and other major losses, scandals, or imprisonment may precipitate suicide even in the absence of a psychiatric disorder. Relevant stressful events identified as suicide risk factors include spousal death and divorce, interpersonal or occupational difficulties, separations and personal or economic losses, retirement, im-
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prisonment or social isolation, and limited access to support or clinical services (“Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors” 2003; Tondo et al., in press).
Assessment for Suicide Risk Effective clinical assessment of suicidal potential requires inquiry into suicidal thinking, the nature of the intent associated with such thoughts, and access to lethal means (Jacobs 1999; “Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors” 2003). Many physicians and even mental health professionals avoid discussing suicide directly and frankly with patients for fear of “provoking” suicidal behavior or, more likely, because of personal discomfort. Suicidal thoughts rarely are new to suicidal persons; many potential victims are willing to discuss their suicidal thoughts, and the topic needs to be investigated, especially when agitation, severe anxiety, anguish, or psychosis is present. As with any patient at risk for suicide, it is important to evaluate those with bipolar disorder longitudinally, and particularly during depressive phases of illness, for indications of suicidal intent such as making a specific plan or preparing notes, making a will, giving away possessions or pets, or putting business matters pertaining to survivors in order (Jacobs 1999; “Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors” 2003). Key elements in evaluating suicide risk, as recommended by Perlis and Stern (2000), include 1) assessing the intensity of suicidal ideation; 2) inquiring about details of suicide plans, access to lethal means, and the possibility of rescue; 3) identifying current or recent precipitants for suicidal thinking; 4) screening for the presence of major psychiatric illness, particularly depression; 5) reviewing past suicide attempts and plans; 6) screening for risk and protective factors; 7) evaluating interpersonal and other social supports; and 8) administering an adequate mental status examination. A determination of high acute suicide risk calls for family involvement and often requires immediate hospitalization, sometimes by legal commitment, especially if the potentially suicidal patient is not already in treatment or is unwilling to accept help.
Access to Care About 40% of persons with a range of psychiatric diagnoses who eventually committed suicide had contacted a mental health professional within several months of death (Pirkis and Burgess 1998). Most of those
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who committed suicide (75%–80%) had consulted a physician at least once within the year before death, 66% within 1 month, and 20% in the week before (Andersen et al. 2001; Miller and Druss 2001). Only 46% had seen a psychiatrist within the previous month and 36% in the week before death (Pirkis and Burgess 1998). Little is known about utilization of clinical services by suicidal bipolar disorder patients specifically. However, in one study 74% of (mainly type II) bipolar disorder patients who committed suicide were receiving some treatment at the time of death (Arató et al. 1988). Although surprisingly few studies have addressed the point, these preceding observations and clinical experiences strongly suggest that access to care and, very likely, the quality of care and of close follow-up may play a crucial role in suicide prevention (Tondo et al., in press).
Limitations of Risk Factor Analyses Interpretation of analyses of risk factors associated with suicide based on case finding only after a suicide is confounded by lack of knowledge of the proportion of potential suicides that may have been prevented by timely assessment and effective interventions and therefore is not included in the data considered. Reliance on routine screening of patients at risk for suicide for risk factors as considered earlier can be helpful but has uncertain power to predict specific risk and its timing in individual patients (“Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors” 2003). Such unpredictability may be particularly challenging in the assessment of patients with bipolar disorder, owing to effects of sometimes rapid shifts in mood (lability), reactivity to losses or other stressors, impulsivity, loss of behavioral control, and the disinhibiting effects of commonly abused central depressants including alcohol and sedatives.
Treatments Aimed at Limiting Suicide Risk in Patients With Bipolar Disorder Evidence that specific medical treatments, notably including use of psychotropic medicines, reduce suicide risk, particularly over the long term, is very limited and largely inconclusive (Tondo and Baldessarini 2005; Tondo et al. 2003). Moreover, even if some treatments are helpful in limiting suicide risk, use of specific psychiatric treatments in postmortem samples of suicides has been remarkably infrequent, often below 30% and sometimes as low as 3% of cases (Andersen et al. 2001; Miller and Druss 2001; Tondo and Baldessarini 2005; Tondo et al. 2003).
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Psychopharmacological Treatment Antidepressants Suicidal behavior is particularly strongly associated with acute depressive illness, and antidepressants have been proven effective, at least in the short-term treatment of acute, nonpsychotic major depression of moderate severity (Baldessarini 2005). It follows that antidepressant treatment is a highly plausible intervention to prevent suicide in depression associated with major depressive disorder and perhaps also in bipolar disorder. Risk of dying by overdoses of antidepressants has been reduced greatly since the introduction of serotonin reuptake inhibitors and other relatively safe modern antidepressants to replace the tricyclic and monoamine oxidase inhibitor antidepressants. On the other hand, other lethal means are readily available. The striking increases in international consumption of modern antidepressants since the 1980s have shown suggestive but inconsistent temporal associations with trends toward minor decreases in generalpopulation suicide rates in some regions, and particularly among young men (Gibbons et al. 2005; Grunebaum et al. 2004; Helgason et al. 2004; Isacsson 2000; Tondo et al. 2003). Interpretation of such “ecological” correlations is fundamentally limited by the lack of association of relevant variables at the level of individual persons. Despite widespread clinical use of effective antidepressants for more than 40 years and broad acceptance of better-tolerated and less toxic modern antidepressants, direct evidence obtained in individually treated patients that antidepressant treatment is associated with lowering of suicide risk remains inconclusive for major depression and strikingly deficient for bipolar depression (Angst et al. 1998; Baldessarini et al., in review; Khan et al. 2000; “Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors” 2003). To some extent the lack of demonstrated effectiveness of antidepressant treatment in reducing suicide risk may reflect low rates of closely supervised antidepressant treatment, particularly in young men, as well as inadequate dosing and duration of sustained treatment for many depressed patients (Baldessarini, in press). Alternatively, suicidal behavior surely requires more than depressed mood, and the relevant factors (possibly including elements of anger, aggression, and impulsivity) may be little benefited by antidepressant treatment (Baldessarini et al. 2005b). Moreover, in some vulnerable patients, mixed dysphoric-agitated states in bipolar disorder can be induced by antidepressant treatment; these may not be recognized as such clinically and thus not accurately
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differentiated from worsening depression. Such states, as well as other adverse behavioral responses to antidepressant treatment (such as insomnia, restlessness, irritability, agitation, mixed manic-depressive states), in patients with mood disorder may well increase the risk of aggressive-impulsive acts, perhaps including suicidal behavior, in some adults and children, and such responses may be particularly likely among bipolar disorder patients in depressive or mixed states (Baldessarini et al. 2005a, 2005b). The quantitative contribution of such potential energizing effects of antidepressant treatment to suicidal behaviors specifically remains uncertain (Baldessarini et al. 2005b; Pompili et al. 2005). Such associations of agitation and aggression with use of serotonergic antidepressants, particularly the serotonin reuptake inhibitors, are counterintuitive in view of substantial evidence indicating a deficiency of central serotonergic functioning in association with violent acts including suicide (Mann et al. 2001). More generally, the status of antidepressant treatment in the overall care of patients with bipolar disorder remains remarkably poorly studied in comparison with unipolar major depression (Baldessarini 2005), and some evidence suggests that the short- and long-term benefits may be quite limited, particularly in view of the risks of destabilizing effects of antidepressant treatment even with, and especially without, a moodstabilizing regimen, at least in patients with type I bipolar disorder (Ghaemi et al. 2004; Yatham 2005). Risks of increased agitation and aggression during antidepressant treatment are likely to emerge early and can be limited by close clinical supervision and removal of the antidepressant or by addition of a mood-stabilizing, antipsychotic, or sedative agent (Pompili et al. 2005).
Lithium Salts Based on present knowledge about pharmacological interventions and risks of suicide and suicide attempts, prophylactic treatment with lithium provides the strongest available evidence of reduced suicide risk and during any psychopharmacological treatment (Baldessarini et al. 2003, in press; Müller-Oerlinghausen 2001; Tondo et al. 2001). Studies reporting on the association of lithium treatment and suicide in bipolar disorder and other major affective disorders, including several prospective, randomized, and controlled trials, consistently have found lower rates of suicides and attempts during lithium maintenance treatment than without it (Baldessarini et al., in press). In our initial meta-analysis of 22 studies involving a total of 5,647 patients with bipolar disorder or other types of manic-depressive disor-
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ders (mainly recurrent major depression and some cases of schizoaffective disorders) and 33,473 patient-years of risk, long-term treatment with lithium, essentially as a monotherapy, was associated with a nearly 6-fold reduction of the crude average rate for completed suicide and a computed reduction of 8.85-fold, or 85%, based on multivariate modeling (Tondo et al. 2001). In one of these studies, initially involving 360 Sardinian type I and type II bipolar disorder patients evaluated before, during, and after discontinuation of maintenance lithium treatment (again as a monotherapy), we found that rates of suicide and lifethreatening attempts were reduced by 6.4-fold, or 83% (Tondo et al. 1998). Moreover, in that study, the risk of suicidal acts increased by 20-fold within several months after discontinuation of lithium maintenance treatment and later fell back to the same level encountered before initiation of lithium treatment. This early suicide risk was 2-fold higher after abrupt or rapid discontinuation of treatment (Tondo et al. 1998). A more recent, comprehensive meta-analysis of studies of lithium adds additional support to the impression that lithium has major beneficial effects against both suicides and suicide attempts and that these effects are found consistently across almost all trials reported over the past three decades, including trials involving randomization and doubleblind assessments (Baldessarini et al., in press). This larger analysis considered a total of 45 reports involving 53,472 patients with bipolar disorder or more broadly defined manic-depressive disorders (including unipolar recurrent major depressive and schizoaffective disorder) treated and evaluated for an average exposure of nearly 348,000 personyears with or without lithium. Risks for both completed suicide and suicide attempts were reduced by nearly fivefold, or 80% (Table 13–3). TABLE 13–3. Lithium treatment versus suicide risk Outcome Suicides Suicide attempts All suicidal acts
Studies
Risk ratio
95% CI
P
25 20 31
4.9 4.9 4.9
3.5–6.9 3.6–6.6 3.8–6.3
<0.001 <0.001 <0.001
Source. Adapted from a comprehensive meta-analysis reported elsewhere (Baldessarini et al., in press), based on 31 analyzable studies from a total of 45 reports involving 53,472 bipolar disorder patients treated and evaluated for an average of 6.5 years with or without lithium. Studies of other proposed antimanic or mood-stabilizing agents remain rare but include evidence of a lesser antisuicide effect with carbamazepine (Greil and Kleindienst 1999; Theis-Flechtner et al. 1996) or divalproex (Goodwin et al. 2003) than with lithium.
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Most of the studies analyzed are open to the hypothetical criticism that there may be selection bias if patients who accept a stable, long-term treatment regimen also have lower suicide risk than those who find the treatment intolerable or otherwise discontinue early. Some studies of lithium and suicide risk are based on comparisons of the same patients without versus during treatment or involve randomization to different treatments (Baldessarini et al., in press; Tondo et al. 2001). Even though the same persons are involved under two conditions of treatment or are assigned to treatments at random, those who accept, tolerate, and continue the treatment might differ from other randomly selected patients in subtle ways not readily identified by considering their morbid histories alone. On the other hand, it simply is not feasible to evaluate any long-term treatment without substantial acceptance, tolerance of, and adherence to the treatment being investigated. Therefore, we suggest that the available findings with lithium treatment, at a minimum, reflect substantial and consistent reductions in suicide risk among those who accept, tolerate, and adhere to long-term prophylactic treatment with lithium salts compared with alternative treatments or a placebo (Baldessarini et al., in press). The effectiveness of lithium treatment in preventing suicide in broadly defined manic-depressive syndromes is likely to operate through reduction of risk or severity of recurrences in depression or mixed dysphoricagitated states (Baldessarini et al., in press). However, some experts have suggested that lithium may have specific effects against suicide independent of its mood-stabilizing actions (Ahrens and Müller-Oerlinghausen 2001; Müller-Oerlinghausen 2001). Specific contributions of lithium treatment of particular interest may include reduction of impulsivity or aggressive and hostile behavior, possibly mediated through enhanced functioning of the central serotonin system that has been identified as an action of lithium (Tondo and Baldessarini 2005; Müller-Oerlinghausen 2001). Finally, additional support for relatively selective effects of lithium treatment has come from comparisons with alternative active treatments, such as use of anticonvulsant or antipsychotic agents (Baldessarini et al., in press), as are considered in the following subsections.
Anticonvulsants A growing number of anticonvulsants have demonstrated antimanic efficacy and are used empirically for possible long-term mood-stabilizing effects in patients with bipolar disorder. Most of these agents remain largely unexamined for possible beneficial effects on suicidal behavior. Specifically, potential antisuicidal effects of carbamazepine, lamotrigine, and valproic acid on suicidal behaviors are not established, but there is some
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evidence that these agents all may be less effective than lithium (Baldessarini et al., in press; Bowden et al. 2003; Calabrese et al. 2003; Dardennes et al. 1995; Denicoff et al. 1997; Goodwin et al. 2003; Greil and Kleindienst 1999; Thies-Flechtner et al. 1996). The evident superiority of lithium over other agents with antimanic or putative mood-stabilizing properties may reflect effects beneficial for suicidal behaviors that are specific to lithium, such as against impulsivity and aggressive tendencies. Alternatively, lithium may simply have superior mood-stabilizing properties, particularly against bipolar depression or mixed states (Baldessarini and Tarazi, in press; Tondo and Baldessarini 2005; Tondo et al. 2003). Potential beneficial effects of anticonvulsants against suicide risk in conditions other than bipolar disorder have not been investigated.
Antipsychotics A clinically and historically important finding is evidence of reduced risk of some suicidal behaviors in several studies of clozapine (Hennen and Baldessarini 2005; Modestin et al. 2005), including an important randomized trial comparing clozapine with olanzapine in patients with schizophrenia (Meltzer et al. 2003). Despite insufficient proof of reduction in mortality and limitation only to the treatment of patients with chronic psychotic disorders (schizophrenia or schizoaffective disorders), this drug is the first treatment of any kind to receive regulatory approval by the U.S. Food and Drug Administration (FDA) for the indication of reducing risk of suicidal behaviors—a precedent-setting development. Interestingly, like lithium prophylaxis but in contrast to standard clinical practice in the use of antidepressants, clozapine is employed with unusually close medical supervision and regular blood testing to minimize the risk of potentially lethal adverse effects. It is therefore noteworthy that levels of patient contact and follow-up with clozapine and olanzapine were closely matched in the pivotal randomized trial by Meltzer et al. (2003). This circumstance suggests specific pharmacodynamic and antisuicidal benefits of treatment with clozapine. Clozapine remains officially under “off-label” (not FDAapproved) status for all phases of bipolar disorder, but it is sometimes used empirically when other treatments prove to be unsatisfactory (Baldessarini and Tarazi 2005). A growing number of other modern antipsychotic agents, including amisulpride, aripiprazole, olanzapine, quetiapine, risperidone, and ziprasidone, are employed internationally for the treatment of bipolar disorder and schizoaffective disorders (Gardner et al. 2005). Most of these agents (with the exception of amisulpride) have FDA approval for the treatment of mania, and aripiprazole and olanzapine are approved also for
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long-term use in type I bipolar disorder. However, their potential for limiting risks of suicidal behavior in patients diagnosed with bipolar disorder or major depression remains unknown (Baldessarini and Tarazi 2005).
Electroconvulsive Therapy Electroconvulsive therapy (ECT) has a clinical reputation of being the most effective and rapid treatment for emerging or ongoing suicidality in severe depressive illness and has been considered a treatment of choice in emergency situations involving high suicide risk (Rose et al. 1985; Weiner 2000). Nevertheless, effectiveness of ECT for sustained suicide prevention has not been proved and requires further study, including in patients with bipolar disorder (“Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors” 2003).
Psychosocial Interventions Specific and comprehensive suicide prevention strategies are required for patients at increased risk for suicide and in bipolar disorder in particular. A growing number of public and professional educational programs have been developed to increase awareness of suicide risk and of the treatability of bipolar disorder and other psychiatric illnesses strongly associated with suicide with psychosocial as well as pharmacological methods (Tondo and Baldessarini 2005). Such approaches may be particularly helpful when complex psychiatric and substance use comorbidities are present, as is very common among patients with bipolar disorder (Krishnan 2005). Despite the widespread clinical application of such programs, there are remarkably few experimental studies of the effectiveness of psychosocial interventions aimed specifically at reducing either morbidity or mortality in bipolar disorder (Huxley et al. 2000). Several investigations of psychotherapeutic treatments and clinical management techniques, including some trials involving randomization and controls, have considered suicidal behavior as an outcome measure (Gray and Otto 2001). Psychotherapeutic techniques based on problem solving, rehearsal, and use of cognitive and behavioral methods may be effective in reducing suicide risk in various types of patients, particularly when applied in combination with appropriate pharmacotherapy, although there is little evidence of specific antisuicidal benefits of such methods among patients with bipolar disorder (Brown et al. 2005; Huxley et al. 2000; Tondo and Baldessarini 2005). An evidently widely employed clinical tactic involves “contracts for safety” between clinicians and patients who agree to report impending loss of control of suicidal impulses. This approach may seem plausible
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but has evidence of frequent failures and has not been tested in a scientifically adequate manner. Moreover, its effects with bipolar disorder patients, specifically, remain unknown (Egan 1997; “Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors” 2003). A recent review considered studies of suicide risk reduction in broad samples of psychiatric patients in association with psychosocial treatments and interventions, including intensive community services and rapid hospitalization as well as specific types of psychotherapy. The findings did not indicate significant reductions in suicidal behavior (Huxley et al. 2000). A possible reduction of suicide attempts was found in a very small number of methodologically variable studies involving cognitive-behavioral psychotherapy, mainly in patients with depression, but the technique has not specifically been tested for effects on suicide risk among patients with bipolar disorder (Huxley et al. 2000; Brown et al. 2005). Treatments currently employed for patients with bipolar disorder are summarized in Table 13–4.
Conclusion Bipolar manic-depressive disorders are prevalent, often severe and disabling, illnesses with greatly increased early mortality due to accidents and complications of comorbid substance use and medical illnesses, but particularly due to suicide. Suicide rates in bipolar disorder patients average 0.4% per year, at least 25 times higher than in the general population (0.014% per year). Suicidal acts often occur early in the illness, in association with severe depressive and dysphoric-agitated mixed phases, and following repeated, severe depressions. High lethality of suicide attempts is suggested by the much lower ratio of attempts to completed suicides among bipolar manic-depressive disorder patients (2:1) versus the general population (about 20:1). Consideration of risk factors helps to identify patients at increased risk for suicide, but ongoing clinical assessment is essential to limit risk. Widely employed short-term interventions to manage acute suicidality in bipolar disorder patients range from close clinical supervision and rapid hospitalization to electroconvulsive treatment. Remarkably, however, evidence of long-term effectiveness against mortality associated with bipolar disorder and other psychiatric disorders is rare. A notable exception is lithium prophylaxis, which is associated with compelling and consistent evidence of sustained reduction of risk of suicides and attempts and decreased ratio of suicides to attempts. Such
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TABLE 13–4. Treatments used in bipolar disorder: effects on suicide risk Treatment
Comments
Lithium salts
Strong, consistent evidence of reduced risk of both attempts and completed suicides in bipolar disorder and broadly defined manicdepressive illnesses
Anticonvulsants Carbamazepine
Divalproex
Lamotrigine
Others
Antipsychotics Aripiprazole
Chlorpromazine Clozapine
Olanzapine
Quetiapine Risperidone
Ziprasidone
Approved by the U.S. Food and Drug Administration (FDA) for mania; less effective than lithium long term and vs. suicide risk Highly antimanic; not FDA-approved for longterm bipolar disorder prophylaxis; less effective than lithium in suicide risk Ineffective and impractical for acute mania; FDA-approved for bipolar disorder prophylaxis but effective mainly for bipolar disorder depression; no evidence regarding suicide risk All remain FDA-unapproved for mania, bipolar disorder prophylaxis, and lack evidence concerning suicide risk (including gabapentin, levetiracetam, oxcarbazepine, topiramate, and zonisamide) FDA-approved for mania and bipolar disorder prophylaxis (with limited evidence); untested in suicide risk Only older neuroleptic FDA-approved for mania (only); untested in suicide risk Not FDA-approved for bipolar disorder; more effective than olanzapine in some measures of suicide risk in schizophrenia, with FDA approval First modern antipsychotic to be FDA-approved for mania and bipolar disorder prophylaxis; untested vs. suicide risk in bipolar disorder FDA-approved for mania; untested in suicide risk First modern antipsychotic to be FDA-approved for schizophrenia; also FDA-approved for mania; untested in suicide risk FDA-approved for mania, but can induce excitation; untested in suicide risk
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TABLE 13–4. Treatments used in bipolar disorder: effects on suicide risk (continued) Treatment
Comments
Antidepressants
Widely used empirically, although both shortand long-term efficacy and safety remain unproven for bipolar disorder depression, with no evidence of reduced suicide risk in any disorder; may, however, increase suicide risk in some patients with bipolar disorder (especially those with type I, including children); risk of inducing agitation/aggression is reduced by cotreatment with mood stabilizers and lower antidepressant dosages, but not necessarily by use of some widely used modern antidepressants (including serotonin reuptake inhibitors and bupropion)
Other treatments Electroconvulsive therapy Psychosocial methods
Probably effective in acute suicide risk, but no evidence of long-term benefit May contribute to better overall clinical outcome and improved adherence to medication, but effects on suicide risk remain minimally tested
Source. Based on evidence from Baldessarini 2005; Baldessarini and Tarazi 2005; Baldessarini et al. 2003, 2005a, 2005b, in review; Goodwin et al. 2003; Greil and Kleindienst 1999; and Krishnan 2005.
effects are not found, or remain untested, for emerging pharmacotherapeutic treatments for bipolar disorder, including anticonvulsants, second-generation antipsychotics, and modern antidepressants, or for psychosocial interventions. For now, treatment aimed at reducing suicide risk in patients with bipolar or other major affective disorders can be enhanced by applying current knowledge systematically, with close and sustained clinical supervision of patients who are well evaluated and well known to responsible clinicians.
❏ Key Points ■
Bipolar disorder is highly prevalent internationally, often severe, sometimes disabling, and potentially fatal.
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Bipolar disorder is associated with very high risks of suicide and relatively lethal attempts, especially early in the illness when sustained clinical interventions, and even the diagnosis, may not have been established.
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Suicide risk in bipolar disorder continues over many years, eventually accounting for at least 15% of causes of death.
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The epidemiology of suicide risk has been confounded by inconsistent separation of bipolar disorder from unipolar major depression or of type I from II bipolar disorder.
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Depressive and dysphoric-agitated mixed phases of bipolar disorder are especially life-threatening as well as challenging to diagnose and to treat effectively and safely.
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Bipolar disorder is associated with high rates of substance use, anxiety disorders, impulsivity, lack of insight, and poor treatment adherence—all adding to suicide risk and complicating treatment.
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Short-term interventions that are widely accepted empirically for managing acute suicidality include close clinical supervision, rapid hospitalization, and use of ECT.
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Other treatments, including specific mood-altering medications and widely accepted psychosocial therapies, have little evidence of sustained effectiveness in reducing long-term suicide risk in patients with bipolar disorder.
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Lithium maintenance treatment is a unique exception, with abundant research support for consistent, substantial, and sustained reduction of risk of suicide and reduction of both rates and lethality of attempts in bipolar disorder and possibly in other mood disorders.
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Anticonvulsants, modern antipsychotics, and less toxic modern antidepressants are widely employed in the treatment of bipolar disorder, but their potential ability to limit suicide risk either is unsupported by preliminary evidence or requires study.
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Long-term prophylactic effectiveness of available treatments for bipolar disorder, especially against depression, mixed states, sustained dysthymia, rapid cycling, comorbidity, demoralization, and dysfunction, in addition to mania and psychosis, largely remains to be demonstrated and compared critically over realistically prolonged observation times.
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Efforts to reduce suicide risk among patients with bipolar disorder can usefully include improved and earlier diagnosis and optimized and sustained clinical management based on knowledge that requires greater dissemination and more systematic application, as well as improved access to care and to clinicians skilled in the clinical management of patients with major, complex, life-threatening psychiatric illnesses.
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References Ahrens B, Müller-Oerlinghausen B: Does lithium exert an independent antisuicidal effect? Pharmacopsychiatry 34:132–136, 2001 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000 Andersen UA, Andersen M, Rosholm JU, et al: Psychopharmacological treatment and psychiatric morbidity in 390 cases of suicide with special focus on affective disorders. Acta Psychiatr Scand 104:458–465, 2001 Angst J, Sellaro R, Angst F: Long-term outcome and mortality of treated vs. untreated bipolar and depressed patients: a preliminary report. Int J Psychiatr Clin Practice 2:115–119, 1998 Arató M, Demeter E, Rihmer Z, et al: Retrospective psychiatric assessment of 200 suicides in Budapest. Acta Psychiatr Scand 77:454–456, 1988 Baca-Garcia E, Diaz-Sastre C, Basurte E, et al: Prospective study of the paradoxical relationship between impulsivity and lethality of suicide attempts. J Clin Psychiatry 62:560–564, 2001 Baldessarini RJ: Drugs therapy of depression and antianxiety disorders (Chapter 17), in Goodman and Gilman’s The Pharmacological Basis of Therapeutics, 11th Edition. Edited by Brunton LL, Lazo JS, Parker KL. New York, McGraw-Hill, 2005, pp 429–459 Baldessarini RJ, Hennen J: Genetics of suicide: an overview. Harv Rev Psychiatry 12:1–13, 2004 Baldessarini RJ, Tarazi FI: Pharmacotherapy of psychosis and mania (Chapter 18): antipsychotic and antimanic agents, in Goodman and Gilman’s The Pharmacological Basis of Therapeutics, 11th Edition. Edited by Brunton LL, Lazo JS, Parker KL. New York, McGraw-Hill, 2005, pp 461–500 Baldessarini RJ, Tondo L, Hennen J: Lithium treatment and suicide risk in major affective disorders: update and new findings. J Clin Psychiatry 64(suppl): 44–52, 2003 Baldessarini RJ, Faedda GL, Hennen J: Risk of mania with serotonin reuptake inhibitors versus tricyclic antidepressants in children, adolescents, and young adults. Arch Pediatr Adolesc Med 159:298–299, 2005a Baldessarini RJ, Pompili M, Tondo L, et al: Antidepressants and suicidal behavior: are we hurting or helping? Clin Neuropsychiatry 2:73–75, 2005b Baldessarini RJ, Tondo L, Hennen J, et al: Lithium treatment and suicide risk in major affective disorders: a meta-analysis. Bipolar Disord (in press) Baldessarini RJ, Hennen J, Pompili M, et al: Suicidal risk and antidepressant treatment: meta-analysis. Manuscript in review Bowden CL, Calabrese JR, Sachs G, et al: Placebo-controlled 18-month trial of lamotrigine and lithium maintenance treatment in recently manic or hypomanic patients with bipolar I disorder. Arch Gen Psychiatry 60:392–400, 2003 Brown GK, Ten Have T, Henrigues GR, et al: Cognitive therapy for the prevention of suicide attempts: randomized controlled trial. JAMA 294:563–570, 2005 Calabrese JR, Bowden CL, Sachs G, et al: Placebo-controlled 18-month trial of lamotrigine and lithium maintenance treatment in recently depressed patients with bipolar I disorder. J Clin Psychiatry 64:1013–1024, 2003
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Clark DC, Goebel-Fabbri AE: Lifetime risk of suicide in major affective disorders, in The Harvard Medical School Guide to Suicide Assessment and Intervention. Edited by Jacobs DG. San Francisco, CA, Jossey-Bass, 1999, pp 270–286 Dardennes R, Even C, Bange F, et al: Comparison of carbamazepine and lithium in the prophylaxis of bipolar disorder: a meta-analysis. Br J Psychiatry 166:378– 381, 1995 Denicoff KD, Smith-Jackson EE, Disney ER, et al: Comparative prophylactic efficacy of lithium, carbamazepine, and the combination in bipolar disorder. J Clin Psychiatry 58:470–478, 1997 Dilsaver SC, Chen Y-W, Swann AC, et al: Suicidality, panic disorder and psychosis in bipolar depression, depressive-mania and pure mania. Psychiatry Res 73: 47–56, 1997 Dunner DL, Fieve RR: Clinical factors in lithium carbonate prophylaxis failure. Arch Gen Psychiatry 30:229–233, 1974 Egan MP: Contracting for safety: concept analysis. Crisis 18:17–23, 1997 Faedda GL, Baldessarini RJ, Suppes T, et al: Pediatric-onset bipolar disorder: a neglected clinical and public health problem. Harv Rev Psychiatry 3:171–195, 1995 Faedda GL, Baldessarini RJ, Glovinsky IP, et al: Pediatric bipolar disorder: phenomenology and course of illness. Bipolar Disord 6:306–313, 2004 Gardner DM, Baldessarini RJ, Waraich P: Modern antipsychotic drugs: a critical overview. CMAJ 172:1703–1711, 2005 Ghaemi SN, Rosenquist KJ, Ko JY, et al: Antidepressant treatment in bipolar vs. unipolar depression. Am J Psychiatry 161:163–165, 2004 Gibbons RD, Hur K, Bhaumik DK, et al: Relationship between antidepressant medication use and rate of suicide. Arch Gen Psychiatry 62:165–172, 2005 Goodwin FK, Jamison KR: Manic-Depressive Illness, 2nd Edition. New York, Oxford University Press (in press) Goodwin FK, Fireman B, Simon GE, et al: Suicide risk in bipolar disorder during treatment with lithium and divalproex. JAMA 290:1467–1473, 2003 Gray SM, Otto MW: Psychosocial approaches to suicide prevention: applications to patients with bipolar disorder. J Clin Psychiatry 62(suppl):56–64, 2001 Greil W, Kleindienst N: The comparative prophylactic efficacy of lithium and carbamazepine in patients with bipolar I disorder. Int Clin Psychopharmacol 14:277–281, 1999 Grunebaum MF, Ellis SP, Li S, et al: Antidepressants and suicide risk in the United States, 1985–1999. J Clin Psychiatry 65:1456–1462, 2004 Harris EC, Barraclough B: Suicide as an outcome for mental disorders: a meta-analysis. Br J Psychiatry 170:205–208, 1997 Helgason T, Tomasson H, Zoega T: Antidepressants and public health in Iceland: time series analysis of national data. Br J Psychiatry 184:157–162, 2004 Hennen J, Baldessarini RK: Reduced suicidal risk during treatment with clozapine: a meta-analysis. Schizophr Res 73:139–145, 2005 Huxley NA, Parikh SV, Baldessarini RJ: Effectiveness of psychosocial treatments in bipolar disorder: state of the evidence. Harv Rev Psychiatry 8:126–140, 2000 Isacsson G: Suicide prevention: a medical breakthrough? Acta Psychiatr Scand 102:113–117, 2000 Isometsa ET, Henriksson MM, Aro HM, et al: Suicide in bipolar disorder in Finland. Am J Psychiatry 151:1020–1024, 1994
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Jacobs DG (ed): The Harvard Medical School Guide to Suicide Assessment and Intervention. San Francisco, CA, Jossey-Bass, 1999 Kessler RC, Berglund P, Borges G, et al: Treands in suicide ideation, plans, gestures, and attempts in the United States, 1990–1992 to 2001–2003. JAMA 293:2487–2495, 2005a Kessler RC, Chiu WT, Demler O, et al: Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62:617–627, 2005b Khan A, Warner HA, Brown WA: Symptom reduction and suicide risk in patients treated with placebo in antidepressant clinical trials: analysis of the FDA database. Arch Gen Psychiatry 57:311–317, 2000 Krishnan KR: Psychiatric and medical comorbidities of bipolar disorder. Psychosom Med 67:1–8, 2005 Mann JJ, Brent DA, Arango V: The neurobiology and genetics of suicide and attempted suicide: a focus on the serotonergic system. Neuropsychopharmacology 24:467–477, 2001 Meltzer HY, Alphs L, Green AI, et al: Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT). Arch Gen Psychiatry 60:82–91, 2003 Miller CL, Druss B: Suicide and access to care. Psychiatr Serv 52:1566–1567, 2001 Modestin J, Dal Plan D, Agarwalla P: Clozapine diminished suicidal behavior: retrospective evaluation of clinical records. J Clin Psychiatry 66:534–538, 2005 Müller-Oerlinghausen B: Arguments for the specificity of the antisuicidal effect of lithium. Eur Arch Psychiatry Clin Neurosci 251(suppl):72–75, 2001 O’Leary D, Paykel E, Todd C, et al: Suicide in primary affective disorders revisited: a systematic review by treatment era. J Clin Psychiatry 62:804–811, 2001 Ösby U, Brandt L, Correia N, et al: Excess mortality in bipolar and unipolar disorder in Sweden. Arch Gen Psychiatry 58:844–850, 2001 Perlis RH, Stern TA: Suicide, in Psychiatry Update and Board Preparation. Edited by Stern TA, Herman JB. New York, McGraw-Hill, 2000, pp 409–413 Pirkis J, Burgess P: Suicide and recency of health care contacts: systematic review. Br J Psychiatry 173:462–474, 1998 Pompili M, Tondo L, Baldessarini RJ: Suicidal risk emerging antidepressant treatment: recognition and intervention. Clin Neuropsychiatry 2:66–72, 2005 Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry 160 (11, suppl):1–60, 2003 Rihmer Z, Pestality P: Bipolar II disorder and suicidal behavior. Psychiatr Clin North Am 22:667–673, 1999 Rose RM, Burt RA, Clayton PJ: Consensus development conference statement: electroconvulsive therapy. JAMA 254:2103–2108, 1985 Thies-Flechtner K, Müller-Oerlinghausen B, Seibert W, et al: Effect of prophylactic treatment on suicide risk in patients with major affective disorders: data from a randomized prospective trial. Pharmacopsychiatry 29:103–107, 1996 Tondo L, Baldessarini RJ: Suicidal risk in bipolar disorder. Clin Neuropsychiatry 2:55–65, 2005
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Tondo L, Baldessarini RJ, Hennen J, et al: Lithium treatment and risk of suicidal behavior in bipolar disorder patients. J Clin Psychiatry 59:405–414, 1998 Tondo L, Hennen J, Baldessarini RJ: Reduced suicide risk with long-term lithium treatment in major affective illness: a meta-analysis. Acta Psychiatr Scand 104:163–172, 2001 Tondo L, Isacsson G, Baldessarini RJ: Suicide in bipolar disorder: risk and prevention. CNS Drugs 17:491–511, 2003 Tondo L, Albert M, Baldessarini RJ: Suicide rates in relation to health-care access in the United States. J Clin Psychiatry (in press) Weiner RD (ed): Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging. A Task Force Report of the American Psychiatric Association, 2nd Edition. Washington, DC, American Psychiatric Association, 2000 World Health Organization. Available at: http://www.who.int/mental_ health/prevention/suicide/countryreports/en/index.html. Accessed October 8, 2005. Yatham LN: Diagnosis and management of patients with bipolar II disorder. J Clin Psychiatry 66(suppl):13–17, 2005
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Schizophrenia Jong H. Yoon, M.D. Cameron S. Carter, M.D.
The management of suicidality in patients with schizophrenia represents a common but highly challenging problem for clinicians. The lifetime prevalence of completed suicides and suicide attempts in this patient group is much higher than in the general population, with a generally accepted range of 5%–10% for completed suicides and 25%–50% for suicide attempts (Palmer et al. 2005). The basics of the proper assessment and management of the suicidal patient with schizophrenia share many features with the treatment of suicidality in other patient populations. For example, factors such as previous attempts, comorbid depression or substance abuse, and male gender confer higher suicide risk in individuals with schizophrenia, mirroring important risk factors in the general population. However, the unique constellation of symptoms in schizophrenia and their sequelae present special challenges in the implementation of assessment and treatment strategies. Some clinical features of schizophrenia also offer specific factors that may be especially helpful in assessing risk and guiding treatment. Our goal in this chapter is to highlight these disease-specific assessment and treatment strategies through the use of two representative case studies, which are augmented by a limited review of empirical studies focusing on schizophrenia and suicide. It must be emphasized that despite progress in identifying predictive factors of suicide in schizophrenia, we are still far from identifying any risk factor that has a high degree of sensitivity or specificity. Thus, the proper detection and 301
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management of suicidality in this patient population require the same commonsense approach required by other specialties that deal with rare but lethal conditions—namely, a high index of suspicion and an aggressive approach to instituting the appropriate evaluation and treatment modalities.
Case Example 1: Elevated Suicide Risk in a Newly Diagnosed Patient With Schizophrenia CM came from a solidly middle- to upper-middle-class family without any history of major mental illness. His birth, childhood development, and adolescence were unremarkable, with no evidence of cognitive, behavioral, or emotional abnormalities. CM was a talented, bright young male with a record of academic as well as extracurricular achievements in high school that gained him entry into an exclusive undergraduate school. During his freshman year, he was social, was well liked by peers and teachers, and enjoyed a large circle of friends. He had the capacity for intimacy in that he became romantically involved with a couple of women in high school and college. In short, CM appeared to be a typical high-achieving young adult with a very bright future at the start of college and no warning signs of impending severe mental illness. During his sophomore year in college, CM began to exhibit what his friends considered to be manifestations of mild depression characterized by social withdrawal, blunting of affect, sluggishness, and poor personal hygiene. He also became overly concerned about his popularity and how others viewed him. He began to experience nonspecific cognitive problems such as the inability to concentrate and a tendency for vagueness in his speech. Consequently, he began to receive uncharacteristically poor grades and was barely able to complete his courses that semester. While at home during winter break, at the urging of his parents, he began seeing a psychiatrist, who diagnosed him with major depression and treated him with antidepressants. On his return to college for the spring semester, his friends did not notice any significant improvement in his condition. As the semester wore on, CM became more reclusive and erratic. He limited his social contacts to a few select peers. In public, he often appeared upset, anxious, and fearful. To his closest confidants, he started to express concerns that people were making fun of him or talking about him behind his back. Soon, his friends could not convince CM that he was being sensitive or just imagining that people were doing this. His grades were failing, and he feared being placed on academic probation. Scholastic failure was an entirely new situation for him and caused him significant anxiety. His increasing preoccupation about being singled out for ridicule by his peers and his worsening academic situation caused him to stay up late at night worrying. His dormitory mates noted that he could be heard talking to himself in his room. CM’s concerns about others’ treatment of him started to affect his behavior in public. On a few occasions, he abruptly interrupted a conversation between strangers to ac-
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cuse them of talking about him. In one of these confrontations, he threatened to kill one of the students. It was at this point that CM was taken by the university’s security officers for an evaluation by a counselor at the university. CM was deemed to present an imminent risk of harm to others, and he was placed on a 72-hour psychiatric hold and admitted to the local psychiatric hospital for further evaluation. During the evaluation in the hospital, CM reports to the inpatient psychiatric attending physician his firm conviction that other students have been singling him out for persecution in a variety of ways, including plotting to get him expelled from school. He also relates that he is hearing voices of a man who frequently makes derogatory comments about him. He is reluctant to tell anyone about the voices because he has all along realized that these voices are not real and their presence may signal that he has a major mental illness. After a couple of days in the hospital, CM begins to express some doubts about the veracity of his prior claims. CM initially refuses all psychiatric medications except anxiolytics. However, after meeting with his parents, the patient reluctantly agrees to a trial of haloperidol. Within 1 week of hospitalization, CM notes decreased auditory hallucinations and less concern about being persecuted by classmates. CM is discharged to his parents, and he takes a leave of absence from school. CM remains compliant with medications for a brief period after discharge. However, as his symptoms improve, CM believes that he no longer requires them, and he stops all of his psychiatric medications despite his parents’ admonishments. He attempts to take on various jobs in his neighborhood, but for one reason or another he is not able to keep them for any length of time. CM communicates with his college friends by phone or mail, but otherwise he does not socialize much and spends most of his time in his room. When asked about any of his symptoms, he categorically denies them, but his parents got the distinct feeling that he is not being truthful. CM’s condition remains in this quasi-stable state for the remainder of his time with his parents. CM is feeling well enough to return to college the following fall semester. However, it becomes very apparent soon after start of classes that CM cannot manage. He begins exhibiting overt signs of paranoia and internal preoccupation. He takes another leave of absence and returns home to his parents. This time, CM’s parents are able to convince him of the need to continue to take psychiatric medications, and he begins regular visits to his psychiatrist. He reluctantly continues to take neuroleptics but complains about many side effects, including sedation, weight gain, and restlessness. After returning home, his parents notice that he becomes even more reclusive and less talkative. He also appears to be sleeping more than usual. Then, one morning, when CM does not respond to repeated requests for him to come to breakfast, his parents go to CM’s room, where they find him lying dead in his bed. They find an empty bottle of tricyclic antidepressants in his room.
The case of CM highlights several important issues in the assessment and management of the suicidal patient with schizophrenia. First, patients with the diagnosis of schizophrenia represent a high-risk group
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with a substantially higher rate of suicide compared with the general population. The lifetime prevalence of suicide has generally been taken to be 5%–10% (Palmer et al. 2005). Second, the timing of his suicide in relation to the onset of his illness is very pertinent. Within the context of overall higher lifetime prevalence of suicide, studies have clearly documented that the period after initial diagnosis of schizophrenia represents an especially vulnerable period. Palmer et al. (2005) showed in a metaanalysis that the risk of suicide among cohorts of first-episode schizophrenics is nearly three times the rate of a chronic cohort. Other studies have also documented the greatest risk within the few years of illness (Black and Winokur 1988; Kua et al. 2003). This increased suicide rate early in the course of illness likely represents the despair experienced by these individuals in anticipating future years filled with disability and downward drift in socioeconomic status associated with this condition. In the case of CM, he came from a privileged background with a history of academic and social achievement and high expectations for his future. It is noteworthy that the suicide occurred after he acknowledged having a major mental illness, inferred by his willingness to voluntarily accept treatment. For individuals like CM, the transition in his expectations for himself in terms of level of functioning before and after the onset of schizophrenia most likely proved to be too difficult to manage. This is consistent with the results of a recent large, multicenter study that demonstrated a relationship between a patient’s insight into his or her illness and higher risk of committing suicide (Bourgeois et al. 2004). Interestingly, the authors of this and another related study (Kim et al. 2003) further suggested that the positive correlation between increased insight and suicide may be mediated by depression and sense of hopelessness. These results highlight the important role the clinician can play in allaying some of the fears that may be fueling a patient’s sense of hopelessness about the future. In the course of educating the patient and family about the likelihood that this illness will most likely result in significant disability, the clinician may find that some of the fears may be based on commonly held misconceptions about schizophrenia. The patient with new-onset schizophrenia and family members may not be aware that this illness can have a highly variable course (Davidson and McGlashan 1997) and that there are now many medications that can significantly ameliorate many of the symptoms. Additionally, they may not be aware that early treatment of psychosis can have a significant impact on short- and long-term level of functioning (Bottlender et al. 2000, 2003). Second, the importance of comorbid depression in individuals with chronic schizophrenia or what has often been described as “postpsychotic”
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depression as a risk factor for suicide cannot be overemphasized, particularly around the initial episodes of illness. As with other medical conditions, the presence of comorbid depression increases substantially the risk of suicide. Consequently, the appearance of depressive symptoms should be seen as a red flag to prompt the clinician to directly assess this risk. The assessment of depression in schizophrenia does, however, present some unique issues. Core features of the illness can render the usual signs and symptoms of depression difficult to detect. Affective blunting and other negative symptoms of schizophrenia can mimic, and therefore mask, the symptoms of depression. People with schizophrenia can appear affectively blunted and unreactive, uninterested in activity or avoiding social situations. The masking of symptoms of depression can be further exacerbated by the side effects of neuroleptics, especially the typical neuroleptics with their ability to induce parkinsonian symptoms. For these reasons, clinicians should rely on additional strategies to assess depression in schizophrenia. Studies conducted by Kring and colleagues (Earnst and Kring 1999; Kring et al. 1993) suggest one potential method to conduct a thorough assessment for the presence of depression in a patient with schizophrenia. Contrary to the commonly held view that people with schizophrenia do not experience the same degree of emotional reactivity to rewarding stimuli, Kring’s studies have shown that these patients are in fact capable of experiencing the same degree of enjoyment while engaged in pleasurable activity. These studies do, however, document a deficit in the anticipation of enjoyment in the future. Consequently, the usual questions that the clinician may use to screen for depression by assessing anticipatory anhedonia— for example, “Do you look forward to going to the movies?”—may not be as effective as questions that probe in-the-moment experience of pleasure, such as “Yesterday, when you went to see the movie, did you enjoy it?” Consistent with the idea that the outward observable signs of emotion may not be a good indicator of the patient’s internal state, a study conducted by Cohen et al. (1990) found that a patient’s subjective sense of emotional distress, and not the clinician’s observation of distress, was significantly predictive of suicide risk. Another effective strategy to assess the presence of depression may be to gather collateral observational information from the patient’s family, case manager, or others who are in a position to directly observe the patient’s ability to engage in and enjoy activities. Once depression is suspected, the psychiatrist should aggressively treat it. If the patient appears to be depressed as a consequence of having insight into his or her illness, supportive psychotherapy and psychoeducation, both for the patient and his or her family support system, are indicated.
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Finally, emerging evidence from the neurobiology of the brain’s reward system may provide guidance in effectively treating psychosis while minimizing the patient’s chances of becoming depressed. The neural circuitry of reward, the ventral tegmental area–nucleus accumbens circuit, is dependent on dopamine and signaling through the dopamine D2 receptor subtype to convey pleasurable experiences (Di Chiara et al. 2004). Consequently, typical neuroleptics with high D2 antagonism, such as haloperidol, at high dosages may block the function of the reward circuitry in patients. A recent study found that the degree of D2 antagonism by typical neuroleptics is highly positively correlated with the presence of depressive symptoms in patients with schizophrenia (Bressan et al. 2002). Additionally, there may be a therapeutic window of optimal D2 receptor occupancy by the neuroleptic that balances the antipsychotic efficacy and the dysphoric side effects of D2 antagonism (de Haan et al. 2000). The newer atypical antipsychotics are often cited for their lower affinity for the D2 receptor. One atypical neuroleptic in particular, clozapine, is often cited in the scientific literature as demonstrating reduction in suicide rate. Prospective studies have demonstrated that clozapine reduces impulsive aggression and suicidality compared with haloperidol treatment (Spivak et al. 2003). A multicenter, prospective, randomized treatment trial has also demonstrated superior efficacy of clozapine compared with olanzapine in reducing suicidal behavior (Meltzer et al. 2003). More basic and clinical research is required to specify the mechanism of action of clozapine in minimizing suicidality in this high-risk group. Nonetheless, these studies offer yet another reason for the consideration of atypical neuroleptics as first-line agents in the treatment of schizophrenia.
Case Example 2: Elevated Suicide Risk in a Patient With Chronic Schizophrenia and Comorbid Substance Abuse LC is a 35-year-old single male with schizophrenia since the age of 21. His psychiatric treatment has been sporadic and characterized by brief periods of treatment with neuroleptics inside and outside of the hospital. LC has had difficulty maintaining a treatment alliance with virtually every psychiatrist he has encountered. Consequently, LC has been chronically without a primary psychiatrist or treatment team at the local public mental health clinic. His illness is also exacerbated by his inability to control his dependence on cocaine. LC’s parents, one of whom is a surgeon, became worn out by his inability to maintain abstinence and to consistently follow through with his psychiatric treatment. The parents now refuse to provide housing for him in their home, and they maintain only distant involvement in LC’s life and psychiatric care. Without a stable support network, LC is often homeless and abusing drugs.
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For this particular episode, LC brings himself to the emergency department reporting suicidal urges brought on by derogatory auditory hallucinations that constantly tell him to kill himself and depressed mood that began after the end of a cocaine binge. On examination, LC appears very disheveled and malodorous, gaunt, internally preoccupied, and guarded. He is also withdrawn, with psychomotor slowing and diminished spontaneity in speech and movements. Urine toxicology is positive for cocaine. LC is placed on an involuntary 72-hour hold and admitted to the dual-diagnosis psychiatric unit. The staff at the emergency department and the hospital’s dual-diagnosis unit know LC very well, because this is one of many contacts with him involving psychostimulant abuse, psychosis, and suicidal ideation. What is especially noteworthy about his hospitalizations is the high degree of ambivalence LC displays toward psychiatric treatment. Typically, at the time of admission LC voluntarily seeks out care and is compliant with recommendations for the initiation of neuroleptics to control his psychosis. However, after 2 days of treatment, he becomes increasingly resistant, negative, oppositional, and frankly paranoid toward clinicians, challenging his diagnosis of schizophrenia and the need for long-term psychotropic treatment. He equates psychiatric medications with mind control and accuses clinicians of merely complying with his father’s orders. At the end of the 72hour period of involuntary detainment, LC petitions for his release from the psychiatric hospital. In most instances, LC is granted his petition over the objections of his treating psychiatrists. Once discharged, LC does not follow up with outpatient treatment appointments and loses contact with mental health services until his next inpatient admission. At baseline, LC frequently experiences auditory hallucinations and many forms of persecutory delusions. However, he does not display prominent thought disorder. He can hold long conversations that are goal directed, and he can appear rational when he is discussing topics unrelated to his paranoia. His mental status is also notable for a high degree of hostility toward others, especially authority figures. However, he does not have any history of severe physical violence toward others. Each time LC is admitted to the dual-diagnosis unit, he engenders strong antipathy from the staff. The attending psychiatrist is often given subtle and not-so-subtle suggestions from staff members to quickly discharge the patient. Some staff members openly deride his suicidality and accuse him of manipulating the system. A strong sense of futility surrounds his admissions, with staff members expressing their belief that any effort by them to help LC would not have any appreciable benefit on his short- or long-term course. Despite this skepticism and animosity, the emergency department staff treats LC’s suicidal threats very seriously because of the increased risk of suicide posed by his documented history of past suicide attempts of high potential lethality, ongoing substance abuse, and depression.
In the case of CM, we discussed some of the unique suicide risk factors and treatment issues related to new-onset schizophrenia, such as the increased risk associated with postpsychotic depression and the difficulties
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of detecting depression in patients with schizophrenia. The case of LC illustrates some of the pertinent factors in assessing and treating suicidality of the patient with established-diagnosis schizophrenia and substance abuse. Patients with schizophrenia are much like others in that the expression of suicidality has many layers of meaning. In this case, suicidality may in fact be a way for LC to temporarily obtain food and shelter. On a more psychodynamic level, threats of suicide may also represent LC’s primitive method of expressing anger toward self and others and ambivalence about his life. Despite these potential layers of meaning, it is clear that LC is a very-high-risk case for suicide for a variety of reasons. Before discussing these risk factors, a critical aspect of providing care for a patient such as this is to be mindful of not minimizing his risks due to negative countertransference or to give in to the strong sense of futility engendered by his many intractable problems. Comorbid substance abuse is a risk factor for suicide in this condition (Palmer et al. 2005; Potkin et al. 2003). Rate of substance abuse among individuals with schizophrenia remains very high, with a lifetime prevalence rate in the United States estimated to approach 50% (Regier et al. 1990). As in other patient populations, individuals with schizophrenia are at high risk of committing suicide in the acute intoxicated state due to impaired judgment and impulse control. People with schizophrenia are especially vulnerable to the disinhibiting properties of drugs because a core feature of the illness itself may be the dysfunction of the prefrontal cortex, a region of the brain thought to subserve impulse control and judgment. Substance abuse with psychostimulants such as cocaine or amphetamine increases suicide risk not only during the acute intoxication phase but also in the withdrawal phase. It is common for psychostimulant abusers to experience a depressive syndrome after a period of sustained drug intake (Kosten 2002). This withdrawal-related depression can be severe, with prominent vegetative symptoms such as psychomotor slowing, increased sleep, diminished appetite, and increased suicidal ideation (Sofuoglu et al. 2003). However, the withdrawal syndrome is usually time limited. Given the high prevalence of comorbid substance abuse in this patient population and the important role of substance abuse in suicide risk, the treatment of suicidality in patients with schizophrenia and comorbid substance abuse must involve the coordinated treatment of both conditions. Paradoxically, intact higher-order cognitive capacity may be a relative risk factor for suicide in individuals with schizophrenia. Cognitive deficits in schizophrenia are characterized by abnormalities in executive functions such as planning. Consequently, individuals with severe cognitive deficits
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may lack the ability to effectively plan and execute suicidal acts. Conversely, individuals such as LC, with relatively intact cognitive abilities as evidenced by lack of disorganization or formal thought disorder, would have the ability to successfully plan and carry out a suicidal act. Finally, this case should be taken as a cautionary tale highlighting the importance of early intervention and treatment of psychosis and schizophrenia. The cause of LC’s hostility toward mental health clinicians and authority figures is most likely complex and multifactorial. Regardless of the etiology, his maladaptive pattern of relating to health care providers has become engrained, and it would be very difficult for any one clinician or single point of contact to undo this. This emphasizes the importance of establishing a more productive pattern of relating to and engaging with mental health providers and services early in the course of the illness so that the necessary treatment and services can be mobilized to minimize the negative outcomes that can result from this illness. There is accumulating evidence that the duration of untreated psychosis early in the course of illness can have a tremendous impact on various levels and indices of functioning (Bottlender et al. 2000, 2003). In the case of LC, early and aggressive treatment of his persecutory delusions would have maximized his chances of establishing a more productive relationship with clinicians, who would then be in a better position to assist LC. A recent meta-analysis identified poor therapeutic alliance and inadequate discharge planning as major factors associated with poor treatment compliance (Lacro 2002). It appears that a multidisciplinary approach that addresses behavioral, psychological, psychoeducational, and social needs of the patient with schizophrenia early in the illness can have significant benefits in terms of improved adherence to treatment (Dolder et al. 2003).
❏ Key Points ■
Have a high index of suspicion and a low threshold for assessment and treatment of patients with schizophrenia, who represent a high-risk group.
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Remember that a window of especially high risk exists in the first few years after diagnosis.
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In addition to the presence of depression, substance abuse, and hopelessness, more disease-specific risk factors for suicide may include higher cognitive ability, awareness of loss of function imposed by illness, and difficulty accepting decline in socioeconomic status.
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Use lowest effective dosages of neuroleptics to minimize dopamine D2 receptor blockade.
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Consider that clozapine may have a special role in management of suicide risk in patients with schizophrenia.
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Aggressively assess and treat comorbid depression. Use strategies that gauge in-the-moment experience of pleasure to assess anhedonia.
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In early intervention, minimize the duration of psychosis, and promote a more healthy pattern of engagement with mental health system and professionals.
References Black DW, Winokur G: Age, mortality and chronic schizophrenia. Schizophr Res 1:267–272, 1988 Bottlender R, Strauss A, Moller HJ: Impact of duration of symptoms prior to first hospitalization on acute outcome in 998 schizophrenic patients. Schizophr Res 44:145–150, 2000 Bottlender R, Sato T, Jager M, et al: The impact of the duration of untreated psychosis prior to first psychiatric admission on the 15-year outcome in schizophrenia. Schizophr Res 62:37–44, 2003 Bourgeois M, Swendsen J, Young F, et al: InterSePT Study Group: Awareness of disorder and suicide risk in the treatment of schizophrenia: results of the international suicide prevention trial. Am J Psychiatry 161:1494–1496, 2004 Bressan RA, Costa DC, Jones HM, et al: Typical antipsychotic drugs: D2 receptor occupancy and depressive symptoms in schizophrenia. Schizophr Res 56:31–36, 2002 Cohen LJ, Test MA, Brown RL: Suicide and schizophrenia: data from a prospective community treatment study. Am J Psychiatry 147:602–607, 1990 Davidson L, McGlashan TH: The varied outcomes of schizophrenia. Can J Psychiatry 42:34–43, 1997 de Haan L, Lavalaye J, Linszen D, et al: Subjective experience and striatal dopamine D2 receptor occupancy in patients with schizophrenia stabilized by olanzapine or risperidone. Am J Psychiatry 157:1019–1020, 2000 Di Chiara G, Bassareo V, Fenu S, et al: Dopamine and drug addiction: the nucleus accumbens shell connection. Neuropharmacology 47(suppl):227–241, 2004 Dolder CR, Lacro JP, Leckband S, et al: Interventions to improve antipsychotic medication adherence: review of recent literature. J Clin Psychopharmacol 23:389–399, 2003 Earnst KS, Kring AM: Emotional responding in deficit and non-deficit schizophrenia. Psychiatry Res 88:191–207, 1999 Kim CH, Jayathilake K, Meltzer HY: Hopelessness, neurocognitive function, and insight in schizophrenia: relationship to suicidal behavior. Schizophr Res 60:71–80, 2003
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Kosten TR: Pathophysiology and treatment of cocaine dependence, in Neuropsychopharmacology: The Fifth Generation of Progress. Edited by Davis K, Charney D, Coyle JT, et al. Baltimore, MD, Lippincott Williams & Wilkins, 2002, pp 1461–1473 Kring AM, Kerr SL, Smith DA, et al: Flat affect in schizophrenia does not reflect diminished subjective experience of emotion. J Abnorm Psychol 102:507– 517, 1993 Kua J, Wong DI, Kua EH, et al: A 20-year follow-up study on schizophrenia in Singapore. Acta Psychiatr Scand 108:118–125, 2003 Lacro JP, Dunn LB, Dolder CR, et al: Prevalence of and risk factors for medication nonadherence in patients with schizophrenia: a comprehensive review of recent literature. J Clin Psychiatry 63:892–909, 2002 Meltzer HY, Alphs L, Green AI, et al: International Suicide Prevention Trial Study Group: Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT). Arch Gen Psychiatry 60:82– 91, 2003 Palmer BA, Pankratz VS, Bostwick JM: The lifetime risk of suicide in schizophrenia: a reexamination. Arch Gen Psychiatry 62:247–253, 2005 Potkin SG, Alphs L, Hsu C, et al: InterSePT Study Group: predicting suicidal risk in schizophrenic and schizoaffective patients in a prospective two-year trial. Biol Psychiatry 54:444–452, 2003 Regier DA, Farmer ME, Rae DS, et al: Comorbidity of mental disorders with alcohol and other drug abuse: results from the Epidemiologic Catchment Area (ECA) study. JAMA 264:2511–2518, 1990 Sofuoglu M, Dudish-Poulsen S, Brown SB, et al: Association of cocaine withdrawal symptoms with more severe dependence and enhanced subjective response to cocaine. Drug Alcohol Depend 69:273–282, 2003 Spivak B, Shabash E, Sheitman B, et al: The effects of clozapine versus haloperidol on measures of impulsive aggression and suicidality in chronic schizophrenia patients: an open, nonrandomized, 6-month study. J Clin Psychiatry 64:755–760, 2003
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Anxiety Disorders Daphne Simeon, M.D. Eric Hollander, M.D.
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nxiety disorders are common psychiatric illnesses that can result in considerable functional impairment and distress (Hollander and Simeon 2003). Working with patients who have an anxiety disorder can be highly gratifying for the informed psychiatrist, because these patients can respond well to proper treatment and return to a higher level of functioning. In treating patients with anxiety disorders, suicide risk is often not in the forefront of the clinician’s mind as it can be for conditions such as major depression, bipolar disorder, substance abuse, personality disorders, and schizophrenia. However, a minority of anxiety disorder patients develop serious suicidal ideation and even make suicide attempts, sometimes successfully (Allgulander and Lavori 1991; Hollander et al. 1997; Oquendo et al. 2005; Schneier et al. 1992; Zimmerman and Chelminski 2003). Each of the anxiety disorders discussed in this chapter—panic disorder, generalized anxiety disorder (GAD), social phobia, obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD)—is introduced with a case example followed by a discussion of suicide risk in patients with that particular disorder.
Panic Disorder Case Example Maria was a 27-year-old single woman who lived in a small apartment alone, just a couple of blocks from her widowed mother. She grew up as an only child, and after her father’s sudden death from a heart attack
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when she was 3 years old, she experienced intense separation anxiety from her mother. She developed panic attacks at the age of 13. Her adolescence was turbulent, marked by contentious relationships with her girlfriends and clinging neediness to her boyfriends. After graduating from high school, she moved away from home to college and lived in a dormitory. She took up drinking, and within a couple of years her drinking pattern escalated dramatically. She found that alcohol gave her transient relief both from her intense anxiety and from her painful intense relationship with a steady boyfriend. Over the years Maria had been in psychotherapy and had received medication treatment for her panic disorder, with a modest response. She tended to be noncompliant with both treatments, growing intensely dependent on her therapists and eventually becoming disappointed and alienated from them and discontinuing medications on her own. Her college performance steadily declined over time, and after she broke up with her college boyfriend, she felt overwhelmed and frighteningly out of control. She quit school and returned to live with her mother. She got a clerical job in a nearby office and began to live an increasingly isolated life between work and home. She became agoraphobic and gradually isolated herself more and more, eventually venturing out of home only escorted by her mother. After a few years of this increasingly unfulfilling existence, she decided to make a clean start, stopped drinking, joined Alcoholics Anonymous, and began a twice-weekly treatment for her anxiety at a local clinic. She had begun to make slow gains when her mother became ill and was diagnosed with terminal cancer. Maria’s panic attacks became more frequent and intense. She was more terrified than ever to leave home and had to quit her job. She took up drinking again and became increasingly demoralized, seeing no way out. Although she felt depressed and had little interest in anything, she did not meet criteria for major depression. At times she felt intolerably out of control, shaking with anxiety and fearful that after her mother’s death she would be left all alone or go crazy. Dying started to cross her mind, and she became increasingly preoccupied with the idea of suicide when overwhelmingly anxious. When her mother decided to discontinue her cancer treatments because they were making her very sick and were of little benefit, Maria took an overdose of her medication. She informed her mother, who called Maria’s therapist. The therapist arranged for Maria to be admitted to a local psychiatric hospital.
The association between panic disorder and increased suicide risk was first identified more than two decades ago. Allgulander and Lavori (1991) conducted a large retrospective survey in Sweden and found an increased suicide risk in panic disorder in the absence of comorbid diagnoses. U.S. epidemiologic data initially appeared to support this finding, because the original Epidemiologic Catchment Area (ECA) study analyses reported a 47% rate of suicidal ideation and a 20% rate of suicide attempts in adults with a lifetime diagnosis of panic disorder (Weissman et al. 1989). Subsequently, the same data were reanalyzed to account for comorbidity, and it
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was determined that panic disorder patients with major depression had a 19.5% rate of suicide attempts in contrast with a much lower 7% in uncomplicated panic. Still, this lower rate was higher than that encountered in the general population and was comparable with the 8% rate in uncomplicated major depression (Johnson et al. 1990). Further reanalysis of the ECA data, after controlling for all comorbidity rather than one disorder at a time, could no longer show an association between panic and suicide attempts (Hornig and McNally 1995). A recent report attempted to illuminate the association between panic disorder and suicide attempts initially reported by the National Comorbidity Survey, another large epidemiologic study. This reanalysis established that lifetime panic disorder, in the presence of other disorders, was unrelated to elevated risk of suicide attempt and did not account for additional variance; participants with panic disorder alone were also not at increased suicide attempt risk (Vickers and McNally 2004). Clinical samples have revealed similar patterns and inconsistencies. In a clinical sample of panic disorder patients, a 17% incidence of suicide attempts was found for those without comorbid major depression or substance abuse, but these patients did have other comorbidity such as some depressive symptoms or personality disorders (Lepine et al. 1993). In a sample of 88 consecutive outpatients with panic disorder and agoraphobia, those with histories of suicidal ideation (about 28% of the total sample) had more severe panic disorder symptoms and were more likely to have comorbid Axis I and II disorders—indeed, all ideators had such comorbidity. Four predictors of suicide attempts were identified in this study: Cluster B (dramatic-emotional) personality disorder, Cluster C (anxious-fearful) personality disorder, comorbid mood disorder, and severity of panic disorder (Starcevic et al. 1999). Similarly, a study of another outpatient psychiatric clinic sample of 101 panic disorder patients revealed that history of substance abuse and comorbid depression predicted suicidality (Friedman et al. 1999). In a study of 122 adults with panic disorder, comorbid paranoid and borderline personality disorder predicted suicide attempts, whereas comorbid depression and avoidant personality predicted suicidal ideation (Ozkan and Altindag 2005). More rigorously confirming these associations in a clinical setting, a sample of 498 patients with panic disorder was followed prospectively for 5 years, during which time the patients exhibited a 6% probability of suicidal behavior. Five risk factors were identified for such behavior: affective disorders, substance abuse, eating disorders, personality disorders, and female gender. The study concluded that there was no association between panic and suicide risk in the absence of these other risk factors (Warshaw et al. 2000). This finding was replicated in a large sample (N=1,979) of chil-
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dren and adolescents referred to an outpatient clinic with a variety of diagnoses: no anxiety disorder predicted suicidal ideation or attempts. Interestingly, for those younger than 15 years, suicide attempts were associated with significantly lower separation anxiety disorder (Strauss et al. 2000). Still, findings suggesting some degree of association between panic and suicidality even in the absence of extraneous factors continue to appear. Goodwin et al. (2001) reported that in a probability sample of 1,009 primary care patients, patients with panic attacks or panic disorder had a significantly elevated risk of suicidal ideation, after major depression, substance use disorder, and sociodemographic variables were controlled for simultaneously. Schmidt et al. (2001) attempted to specifically tease out the association between panic-specific cognitive and clinical variables and suicidality in a sample of 146 panic disorder patients. They reported that after controlling for mood disorder and mood symptoms, five panicspecific variables significantly predicted suicidal ideation: overall anxiety, anticipatory anxiety, avoidance of bodily sensations, attentional vigilance to bodily changes, and fear of going crazy. However, none of these variables was predictive of suicide attempts. All studies taken together then suggest that, for the most part, suicide attempts in panic disorder are strongly associated with mood disorder, personality disorder, and substance use comorbidity. Suicidal ideation in the absence of attempts may be more specifically associated with the experience and impact of the panic disorder itself. The association between pure panic disorder and suicide attempts is still controversial. As demonstrated in the case example of Maria, a history of early trauma, dependent and borderline personality traits, and substance abuse all contributed to her deteriorating functional course. More acutely, her mother’s terminal illness and Maria’s worsening panic symptoms and the overwhelming experience of no longer being in any control of her life precipitated her suicide attempt. By the end of her hospitalization, Maria was able to make a stronger commitment to her psychotherapy and medication treatment. The frequency of her visits was increased, and the treatment became more focused on helping Maria to cope with the impending death of her mother and to develop more effective techniques for dealing with those moments when she felt overwhelmingly anxious and out of control.
Generalized Anxiety Disorder Case Example Tom was a 30-year-old accountant and a father of two children who was separated from his wife. He had been an anxious child as far back as he
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could remember. In grade school he recalled worrying excessively about doing his homework and getting report cards. As a teenager, he worried all the time about his diabetic mother’s health and about his father’s openly discussed financial troubles. He attended college and got a graduate degree in accounting. He went on to get married to a successful businesswoman and soon had two sons. Over the years his worrying became pervasive, from the school adjustment of his children, to his career, to the health of his aging parents. Although he got a job with a big accounting firm, his insecurities and inhibitions prevented him from advancing in the firm and obtaining promotions. At home, his wife eventually became more and more disillusioned with her husband’s constant fearfulness and hesitancy. She herself was a successful go-getter who was rapidly achieving status in her corporation and also carried most of the responsibilities at home with raising the children and balancing finances. Over time, she became increasingly contemptuous of her husband, at times even openly ridiculing him for his anxieties in front of friends. When their older child was 5 years old, she decided to separate from her husband, and Tom left his home and children to move by himself into a small apartment. He became increasingly ineffectual at work and was threatened with the possibility of layoff. During this time, he also began to feel more and more depressed, and despite continuing on with his daily routine, he struggled with poor sleep, fluctuating appetite, low energy, and concentration difficulties. He felt increasingly anxious and out of control and began to ponder that he had wasted the best years of his life and he would never to able to get back on track. His wife resented him, and he feared his children would start to look down on him as he had looked down on his own ineffectual father. Tom began to really wonder whether his life was worth living, and over a period of several months he developed persistent suicidal ideation. Even though he had no immediate intent to hurt himself, waking up to face the day became intolerable. He decided, for the first time, that he needed help and arranged to consult with a psychiatrist.
Suicidality in GAD has not been well studied, and findings are often confounded by the presence of depression. In one large survey of GAD and major depression in a primary care setting, it was found that comorbid GAD and major depression were associated with higher suicidality than either diagnosis alone (Wittchen et al. 2002). In adolescents, GAD has been found to be associated with suicidal ideation but not with suicide attempts (Strauss et al. 2000). The recent Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial reported that patients with anxious major depression are more likely to be suicidal than those with nonanxious depression, and they often have GAD comorbidity (Fava et al. 2004). As in the STAR*D trial, another study of 332 psychiatric outpatients with major depression found that those with comorbid GAD, even if occurring only in the context of the depressive episode,
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had poorer functioning and greater suicidal ideation, and GAD was more likely to be found in their first-degree relatives (Zimmerman and Chelminski 2003). Although we know little about suicidality in GAD, it appears that two major correlates of suicidality in GAD are comorbidity with major depression and deterioration in functioning. Tom’s case vividly illustrates both of these points. Despite his childhood-onset history of generalized anxiety and worry, he did not become suicidal until much later in life, when he also developed a major depression and felt threatened with losing his job and his family. Tom’s treatment proved quite successful, and in retrospect he wondered what had prevented him from seeking help earlier. He was started on an antidepressant that quickly treated his depression and lessened his anxiety, and he was engaged in a psychotherapy that began to address issues related to his chronic inhibitions and low self-esteem. His job performance improved, and he was able to establish and maintain regular enjoyable contact with his children.
Social Phobia Case Example Daisy was a 40-year-old single woman living alone and employed as a highly successful lawyer. She had always been a shy child, terrified of speaking up in class from grade school on. Although she had always had a couple of good friends from a young age, she felt like a social outcast, invisible to her peers and never part of the “in” crowd. These feelings painfully intensified during her adolescence; boys hardly ever asked her out, as she was widely regarded as being very bright but way too serious, snobbish according to some, and not that much fun to be with. Despite her performance anxiety, she excelled in school, and teachers sometimes commented on her report cards that her potential was great but that her timidity hindered her from fully living up to it. Her socially outgoing and critical mother fully concurred, often nagging her daughter about her social inhibitions. Daisy attended an Ivy League college where she excelled despite remaining socially isolated, not dating, and silently suffering over her unfulfilled yearning for social and romantic contact. She subsequently attended one of the top law schools in the country and had several offers from top law firms before graduation. She went on to become a highly successful young partner, known for her unsurpassable skills and tireless dedication. As she grew older, she gradually gave up any hope of establishing meaningful romantic relationships. A couple of brief flings had ended painfully, because her dates quickly lost interest in her constricted interactions. At 39, Daisy fell hopelessly in love with a newly hired lawyer at
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the firm, Jerry, who was single and 3 years younger than she. The two developed a warm relationship as they worked together for long hours on a case, and she began to feel optimistic that something might come of their relationship. She loved children and still held on to a little hope that someday she would marry and have children. She acutely felt her “biological clock” ticking away. Several months into her acquaintance with Jerry, he became enamored with another woman whom he began to seriously date. Daisy lost all hope for a relationship, not only with Jerry but with any man. She felt trapped and doomed to live a life of social scrutiny and unfulfilled isolation. She also began to feel increasingly depressed and hopeless. Although she was religious and believed that suicide was a sin, she began to feel more and more strongly that her life was not worth living. She wondered if there might be ways to kill herself that would be definitely misconstrued as accidents, thus sparing her living parents and brother and salvaging her professional reputation. After months of rumination, she revealed these thoughts to her only close girlfriend, at whose urging she decided to see a psychiatrist.
Schneier et al. (1992) examined the morbidity associated with social phobia in a large sample of 13,000 adults who participated in the ECA study. Suicidal ideation rate was significantly elevated in social phobia even after comorbidity was controlled for. The suicide attempt rate was significantly elevated only in the presence of comorbidity (15.7%) but was comparable to the rate in those without psychiatric illness in uncomplicated social phobia (0.9%). The latter finding of elevated suicide risk in social phobia in the presence of other psychiatric disorders has been corroborated by other studies (Nelson et al. 2000; Weissman et al. 1996). A clinical study of 41 adult patients with social phobia employed the five ECA suicide questions and reported a 12% rate of lifetime suicide attempts (Cox et al. 1994). The authors found attempts to be higher in women (21%) than in men (4.5%); women also had higher suicidal ideation (47%) than did men (23%). The patients who had made attempts were significantly more likely to report that they had received past treatment for depression and that they had been psychiatrically hospitalized, whereas those who experienced suicidal ideation had higher depression scores. Two twin community studies have both identified social phobia as a major psychiatric correlate of suicide attempts (Glowinski et al. 2001; Statham et al. 1998). Statham et al. (1998) examined lifetime prevalence of suicidal thoughts and behavior in a large community-based sample of monozygotic and dizygotic twin pairs. With respect to psychiatric disorders, it was found that history of social phobia was strongly associated with suicide attempts in women (odds ratio = 15.6) but not in
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men. When all psychiatric disorders were examined together, major depression was the strongest predictor of suicidality, yet social phobia remained a significant predictor. It therefore seems that social phobia—both on its own and in the presence of comorbidity, especially depression—bears an elevated suicide attempt risk, possibly more so in women. Features of such a presentation are illustrated in the case of Daisy, whose suicidality risk was considerable given her lifetime of severe social anxiety symptoms and tremendous associated social impairment, her lost hopes for marriage and children at a critical time in her life, an evolving major depression, and of course no psychiatric treatment. Daisy was eager to engage in treatment, which proved quite effective. She experienced rapid relief from her depression and some relief of her social anxiety on a high dose of selective serotonin reuptake inhibitor medication, was helped with psychotherapy to reframe her current life trajectory as one that still offered hopes and options, and was also referred to an effective social skills weekly group.
Obsessive-Compulsive Disorder Case Example Michael was a 52-year-old man who lived with his 80-year-old mother. He had developed OCD at the age of 10, with counting and checking rituals that severely interfered with his school performance and that, at the time, no one could understand and explain. His mother used to advise him to just stop, whereas the school counselor warned him that he was at perpetual risk of failing. Michael’s friends began to notice that he would act strangely, walking in unusual counting patterns and opening his desk many times a day to check what was inside. Eventually Michael became more and more isolated from his friends. In high school he was referred to a psychiatrist, and with the help of medications and therapy he was able to get his symptoms under moderate control. With difficulty, he completed college with mediocre standing; his rituals significantly got in the way of his completing his work and betrayed a strangeness in his interviews and social contacts. He was able to get a job after college graduation as a human resources supervisor at a large company. Widely regarded as dependable but odd and slow, he maintained his job for years, struggling to keep up, and was passed over for promotions. Medication adjustments and a course of intensive cognitive-behavioral therapy in his mid-30s brought about some improvement, but he remained quite impaired. Despite Michael’s stubborn repeated attempts at dating of an almost compulsive intensity, most would end uneventfully after the first few encounters at best. Dates were frequently of-
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fended or disinterested when he compulsively checked and calculated restaurant bills on the first date or compulsively elaborated mundane stories from his work. Michael joined a local OCD support group as well as a social skills group that somewhat increased his relatedness and confidence but did not substantially affect his impairment. By his late 40s he gave up on dating. His daily routine became more and more rigid and constricted, consisting of waking up early and taking care of his ailing mother’s morning needs, taking the train to work, working until 7 or 8 P.M. every night to make up for his slow compulsive checking rituals, returning home by 9 P.M., helping his mother with some household chores, and watching a favorite television show before bed. He spent most weekends taking walks with his mother or watching television. Despite a medication regimen that now consisted of a serotonin reuptake inhibitor, a benzodiazepine, and an atypical antipsychotic, he continued to experience strong anxiety throughout much of the day, endlessly hoping that he would become better able to resist the crippling rituals that consumed at least 8 hours of his waking time yet hardly being able to control them. One night he watched a documentary about OCD. The show discussed the prognosis of the disorder, including some of the less hopeful cases that were marked by a steadily deteriorating anxiety-ridden course. He saw little hope ahead and began to wonder if he could be brave enough to end it all. Not telling his psychiatrist, he proceeded to formulate a meticulously thought-out suicide plan. One evening when his mother was out visiting a friend, he took an overdose of several medications, shut himself in the garage, and turned on the car engine. To ensure that his attempt would be successful, he placed a plastic bag around his head just as he was sedated enough from the overdose as to have little ability to remove it, and then he wrapped it around his neck. He left his mother a meticulous note describing how he loved her and how he was better off dead, asking for her forgiveness. He was found dead in the front seat of his car a few hours later.
Suicidal ideation and suicide attempts may be more common in OCD than one might expect. A large survey of 701 OCD patients, although subjective in nature, revealed that over half of the sample had thought about suicide and about one-eighth had actually attempted suicide secondary to their obsessive-compulsive symptoms (Hollander et al. 1997). Although the precipitants of suicide attempts were not specifically stated in this report, suicidality appeared related to the large toll that the disorder can take on psychosocial functioning. Compromised functioning was widely endorsed by survey participants, who frequently reported probable or definite OCD interference with their career aspirations (66%), marital relationships (64%), academic achievements (60%), loss of intimate relationships (43%), and loss of work (22%). On the other hand, in a clinic-based sample of 1,979 children and adolescents, elevated suicidality was not found for OCD (Strauss et al.
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2000). Even adolescent inpatients with OCD have been reported to have very low rates of suicide attempt histories (Apter et al. 2003). It seems reasonable to hypothesize that OCD usually takes a more chronic and gradual toll, with steady deterioration in relationships and vocation that can occur over many years and eventually lead to suicidality. This pattern is clearly illustrated in Michael’s case, as is the methodical, compulsive, and highly lethal nature of his attempt.
Posttraumatic Stress Disorder Case Example Sarah was a 26-year-old mother of a 2-year-old son who lived with her husband of 3 years in a large metropolitan city. Sarah was raised in a strict, controlling family, but otherwise her childhood had been uneventful until her teenage years, when she had been raped by a casual date when she was 15. She had been at a party and then got a ride with her date in his car. He approached her sexually and, despite her protests, threatened her if she resisted and violently raped her. Sarah told no one about the rape; she felt ashamed and blamed herself for having accepted the ride. She knew that her conservative parents would be devastated to find out and would largely hold her responsible. After the rape she developed PTSD, and her symptoms persisted for years, gradually fading with time to about 50% of their original severity by the time Sarah was 22. Meanwhile, she went on to graduate from high school, hardly ever dated, and started college. At 22, she fell in love with a classmate who seemed enamored with her and 1 year later became pregnant. She decided to marry and to keep the baby. After college she took a break from school to be with her baby son. Her husband, Dan, got a marketing job after finishing college, and the three lived in a small cramped apartment to make ends meet. Sarah never revealed to her husband what had happened to her when she was a teenager. The baby was colicky and hard to care for. Sarah gradually became increasingly irritable and depressed, and her newlywed husband had little patience for her or for the child. Initially he was verbally abusive, but then one night Dan hit Sarah because the baby was incessantly crying and Sarah had insisted that she needed sleep and that Dan should care for the baby. Over the next several months, there were repeated incidents of physical violence, and Sarah began to experience a resurgence of her PTSD symptoms. Her symptoms got worse than they had ever been after the rape, with nightmares that woke her up from sleep almost every night. She kept the abuse a secret, just as she had done with the rape, and despised herself for not having known what “kind of a man” Dan was. Finally, after one evening when he shoved and kicked her violently, she informed him that if this happened again, she would leave him. He then threatened that if she did, he would find and take the baby and she
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would never see her boy again. Terrified and paralyzed to act, Sarah got more and more depressed. She became hypervigilant, attempting to spend every moment in sight of her baby son to protect him. It did cross her mind to seek professional help or to tell her parents what was going on, but she was now too scared to do so, fearing that her husband might find out and take revenge. She began to feel that the only way out was to take her life, and one day after Dan hit her again and then left enraged, she took a razor, slashed both her wrists, and called 911.
Suicidal ideation and suicidal attempts are well known to occur in the context of PTSD. In a national sample of women who had been sexually assaulted during childhood or adulthood, a significantly greater likelihood of suicide attempts was identified, controlling for demographic factors and other psychosocial characteristics (Ullman and Brecklin 2002). Clinical samples concur on the marked prevalence of suicidality in PTSD patients. In male veterans, suicidal thoughts were reported in 70% and suicide attempts in up to 25% (Butterfield et al. 2005). In chronic civilian PTSD, suicidal ideation was reported in 38% and suicide attempts in 10% of the sample (Tarrier and Gregg 2004). Even adolescent (Mazza 2000) and childhood (De Bellis et al. 1999) PTSD has been associated with greater suicidality. A variety of biological, psychiatric, and social factors have been associated with suicide risk in PTSD. Butterfield et al. (2005) reported significantly elevated dihydroepiandrosterone levels in male veterans who had attempted suicide compared with those who had not. Thomas and De Bellis (2004) reported larger pituitary volumes in pubertal children with PTSD and suicidal ideation compared with those without, again implicating neurosteroids in suicidality. On the other hand, another report failed to find an association between suicidal behavior and plasma cortisol level in a sample of patients with depression, PTSD, or both disorders compared with healthy volunteers (Oquendo et al. 2003). Several studies have examined the impact of comorbidity and trauma history on the relationship between PTSD and suicidality. Oquendo et al. (2005) reported that in a sample of 230 patients with major depression, of whom about one-quarter had comorbid PTSD, PTSD comorbidity was significantly associated with suicide attempt history. The PTSD comorbid group had greater severity of depression, impulsivity, and hostility; more Cluster B personality disorder comorbidity; and greater childhood abuse histories. Of all predictors, Cluster B personality disorder was the only independent variable related to lifetime suicide attempts. In a sample of patients with chronic civilian PTSD, suicidal behavior was associated with impaired functioning, depression, and
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prescribed psychotropic medications (Tarrier and Gregg 2004). In a national sample of sexually assaulted women, number of lifetime traumatic events and depression were each associated with the likelihood of suicide attempts (Ullman and Breckin 2002). In a female sample of physical partner abuse, PTSD was found to mediate the relationship between the abuse and suicide attempts (Thompson et al. 1999). In a comparison of subjects with PTSD, other anxiety disorders, and normal volunteers, patients with PTSD were found to have the greatest suicide risk; impulsivity increased the risk, whereas social support mitigated it (Kotler et al. 2001). In a study of 106 adolescents in an urban high school, controlling for depression and gender, PTSD symptoms were significantly associated with suicidal ideation and marginally associated with attempts; severity of PTSD also was associated with suicidality (Mazza 2000). In summary, PTSD may be more clearly associated with suicidality than any other anxiety disorder. Factors associated with such suicidality are depression, Cluster B personality traits, greater childhood and lifetime trauma, severity of PTSD symptoms, and poor social supports. Sarah’s case illustrates a number of these points. She had experienced a major adolescent trauma, rape, that was rekindled by domestic violence later on; her symptoms became unmanageable, and her fear and shame prevented her from sharing her experiences with anyone. Sarah’s desperate cry for help by slashing her wrists and calling 911 had a positive outcome; she was briefly psychiatrically hospitalized, and the baby was placed in her parents’ care. To Sarah’s surprise, her parents were more supportive than she expected and were genuinely concerned about her well-being. She moved in with them temporarily after discharge, got an order of protection from her husband, and started intensive PTSD outpatient treatment with exposure and cognitive reprocessing as well as medication management.
Conclusion In contrast to other psychiatric illnesses such as mood, psychotic, substance use, and personality disorders, there are more discrepancies, uncertainties, and limitations in the available data regarding suicidality in the anxiety disorders (Khan et al. 2002). There are several possible explanations for this, such as the common impression that suicidality is not as much of an issue in anxiety disorders, accuracy of diagnostic and suicidality assessment and types of samples studied, and reliability in the diagnosis of comorbid disorders. A recent meta-analysis of the U.S. Food and Drug Administration database of 20,076 patients participating in anxiety disorder treatment trials revealed an annual completed
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TABLE 15–1. Factors associated with suicidality in the anxiety disorders Worsening severity of anxiety disorder symptoms Deteriorating quality of life Increasing functional impairment Poor social supports Acute life crises New-onset or worsening depression Feelings of overwhelming anxiety and loss of control Comorbid Cluster B or C personality disorders Comorbid substance use disorders
suicide risk rate of 1.93/1,000 and an annual suicide attempt risk of 13.5/1,000 (Khan et al. 2002). These estimates are possibly conservative given all the restrictions of clinical trials and highlight that suicidality may be higher in anxiety patients than previously thought.
❏ Key Points ■
Patients with anxiety disorders need to be seriously evaluated for suicide risk from the start and during ongoing treatment.
■
Numerous factors are commonly associated with heightened suicidality in individuals with anxiety disorders and warrant particular attention (Table 15–1).
References Allgulander C, Lavori PW: Excess mortality among 3302 patients with “pure” anxiety neurosis. Arch Gen Psychiatry 48:599–602, 1991 Apter A, Horesh N, Gothelf D, et al: Depression and suicidal behavior in adolescent inpatients with obsessive compulsive disorder. J Affect Disord 75: 181–189, 2003 Butterfield MI, Stechuchak KM, Connor KM, et al: Neuroactive steroids and suicidality in posttraumatic stress disorder. Am J Psychiatry 162:380–382, 2005 Cox BJ, Direnfeld BA, Swinson MD, et al: Suicidal ideation and suicide attempts in panic disorder and social phobia. Am J Psychiatry 151:882–887, 1994 De Bellis MD, Baum AS, Birmaher B, et al: A.E. Bennett Research Award: developmental traumatology, Part I: biological stress systems. Biol Psychiatry 45:1259–1270, 1999 Fava M, Alpert JE, Carmin CN, et al: Clinical correlates and symptom patterns of anxious depression among patients with major depressive disorder in STAR*D. Psychol Med 34:1299–1308, 2004
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Friedman S, Smith L, Fogel A: Suicidality in panic disorder: a comparison with schizophrenic, depressed, and other anxiety disorder patients. J Anxiety Disord 13:447–461, 1999 Glowinski AL, Bucholz KK, Nelson EC, et al: Suicide attempts in an adolescent female twin sample. J Am Acad Child Adolesc Psychiatry 40:1300–1307, 2001 Goodwin R, Olfson M, Feder A, et al: Panic and suicidal ideation in primary care. Depress Anxiety 14:244–246, 2001 Hollander E, Simeon D: Anxiety disorders, in The American Psychiatric Press Textbook of Psychiatry, 4th Edition. Edited by Hales RE, Yudofsky SC. American Psychiatric Publishing, Washington, DC, 2003, pp 543–630 Hollander E, Stein DJ, Kwon JH, et al: Psychosocial function and economic costs of obsessive-compulsive disorder. CNS Spectr 2:16–25, 1997 Hornig CD, McNally RJ: Panic disorder and suicide attempt: a reanalysis of data from the Epidemiologic Catchment Area study. Br J Psychiatry 167:76– 79, 1995 Johnson J, Weissman MM, Klerman GL: Panic disorder, comorbidity, and suicide attempts. Arch Gen Psychiatry 47:805–808, 1990 Khan A, Leventhal RM, Khan S, et al: Suicide risk in patients with anxiety disorders: a meta-analysis of the FDA database. J Affect Disord 68:183–190, 2002 Kotler M, Iancu I, Efroni R, et al: Anger, impulsivity, social support and suicide risk in patients with posttraumatic stress disorder. J Nerv Ment Dis 189: 162–167, 2001 Lepine JP, Chignon JM, Teherani M: Suicide attempts in patients with panic disorder. Arch Gen Psychiatry 50:144–149, 1993 Mazza JJ: The relationship between posttraumatic stress symptomatology and suicidal behavior in school-based adolescents. Suicide Life Threat Behav 30:91–103, 2000 Nelson EC, Grant JD, Bucholz KK, et al: Social phobia in a population-based female adolescent twin sample: co-morbidity and associated suicide related symptoms. Psychol Med 30:797–804, 2000 Oquendo MA, Echavarria G, Galfalvy HC, et al: Lower cortisol levels in depressed patients with comorbid posttraumatic stress disorder. Neuropsychopharmacol 28:591–598, 2003 Oquendo M, Brent DA, Birmaher B, et al: Posttraumatic stress disorder comorbid with major depression: factors mediating the association with suicidal behavior. Am J Psychiatry 162:560–566, 2005 Ozkan M, Altindag A: Comorbid personality disorders in subjects with personality disorder: do personality disorders increase clinical severity? Compr Psychiatry 46:20–26, 2005 Schmidt NB, Woolaway-Bickel K, Bates M: Evaluating panic-specific factors in the relationship between suicide and panic disorder. Behav Res Ther 39: 635–649, 2001 Schneier FR, Johnson J, Hornig CD, et al: Comorbidity and morbidity in an epidemiologic sample. Arch Gen Psychiatry 49:282–288, 1992 Starcevic V, Bogojevic G, Marinkovic J, et al: Axis I and axis II comorbiidy in panic-agoraphobic patients with and without suicidal ideation. Psychiatr Res 88:153–161, 1999
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Statham DJ, Heath AC, Madden PA, et al: Suicidal behavior: an epidemiological and genetic study. Psychol Med 28:839–855, 1998 Strauss J, Birmaher B, Bridge J, et al: Anxiety disorders in suicidal youth. Can J Psychiatry 45:739–745, 2000 Tarrier N, Gregg L: Suicide risk in civilian PTSD patients: predictors of suicidal ideation, planning, and attempts. Soc Psychiatry Psychiatr Epidemiol 39: 655–661, 2004 Thomas LA, De Bellis MD: Pituitary volumes in pediatric maltreatment-related posttraumatic stress disorder. Biol Psychiatry 55:752–758, 2004 Thompson MP, Kaslow NJ, Kingree JB, et al: Partner abuse and posttaumatic stress disorder as risk factors for suicide attempts in a sample of lowincome, inner-city women. J Trauma Stress 12:59–72, 1999 Ullman SE, Brecklin LR: Sexual assault history and suicidal behavior in a national sample of women. Suicide Life Threat Behav 32:117–130, 2002 Vickers K, McNally RJ: Panic disorder and suicide attempt in the National Comorbidity Survey. J Abnorm Psychol 113:582–591, 2004 Warshaw MG, Dolan RT, Keller MB: Suicidal behavior in patients with current or past panic disorder: five years of prospective data from the Harvard/ Brown Anxiety Research Program. Am J Psychiatry 157:1876–1878, 2000 Weissman MM, Klerman GL, Markowitz JS, et al: Suicidal ideation and suicide attempts in panic disorder and attacks. N Engl J Med 321:1209–1214, 1989 Weissman MM, Bland RC, Canino GJ, et al: The cross-national epidemiology of social phobia: a preliminary report. Int Clin Psychopharmacol 11 (suppl 3): 9–14, 1996 Wittchen HU, Kessler RC, Beesdo K, et al: Generalized anxiety and depression in primary care: prevalence, recognition, and management. J Clin Psychiatry 63 (suppl 8):24–34, 2002 Zimmerman M, Chelminski I: Generalized anxiety disorder in patients with major depression: is DSM-IV’s hierarchy correct? Am J Psychiatry 160:504– 512, 2003
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Personality Disorders Maria A. Oquendo, M.D. Juan Jose Carballo, M.D. Barbara Stanley, Ph.D. Beth S. Brodsky, Ph.D.
The prevalence of personality disorders in the general population is estimated to be as high as 15% (Bodlund et al. 1998; Ucok et al. 1998). Rates in psychiatric outpatient settings range from 12.9% to 59% (Bodlund et al. 1998; Casey and Tyrer 1990; Fabrega et al. 1993). Among hospitalized patients, the rates are even higher, ranging from 11% to 91% (Linehan et al. 1991). Suicide is a tragic and potentially preventable public health problem that is currently the eleventh leading cause of death in the United States (Mann 2003). Personality disorders are associated with estimated lifetime rates of suicide ranging from 3% to 9% (American Psychiatric Association 2003). Compared with the general population, the estimated risk for suicide is about 7 times greater in persons with personality disorder (Harris and Barraclough 1997) and about 13-fold for formerly hospitalized patients with personality disorders (Black and Winokur 1986; Zilber et al. 1989). From a different vantage point, psychological autopsy studies have shown that about 30% of those who die by suicide had at least one personality disorder (Isometsa et al. 1996; Lesage et al. 1994). The prevalence of personality disorders among adolescent and young adult suicide com329
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pleters has been reported to be even higher, with nearly half having a personality disorder (Apter et al. 1993; Brent et al. 1994; Lesage et al. 1994; Linehan et al. 2005). Similarly, among psychiatric outpatients, half of patients who die by suicide had a personality disorder (Baxter and Appleby 1999; Brown et al. 2000). Some authors suggest that personality disorders in this population have been underreported, citing a bias toward giving an Axis I principal diagnosis instead of an Axis II diagnosis when a suicide has occurred (Linehan et al. 2005). The occurrence of suicide attempts and self-injurious behavior is an equally staggering clinical problem, and it is estimated that among those with personality disorders, suicide attempts may occur in up to 84% (Black et al. 2004). This estimation varies depending on the type of personality disorder (Cluster A, B, or C or individual disorders; see Table 16–1) or on the presence of comorbidities, especially mood and substance use disorders. Of note, self-injurious behavior is an important risk factor for suicidal behavior, because 55%–85% of patients with self-injurious behavior have made at least one suicide attempt (Stanley and Brodsky 2005).
Suicidal Behavior in Personality Disorders Deliberate self-harm comprises several forms of self-destructive behavior: suicide or suicide attempt and self-injurious behavior. Suicide is a death resulting from an individual’s own actions in which the individual intended to end his or her life. A suicide attempt is an intentionally self-destructive act performed with at least some intent to die. Although this definition is apparently straightforward, intent may be difficult to determine through direct inquiry, because retrospective reports can be influenced by reinterpretation of motivation and outcome and may no longer represent accurate descriptions of the individual’s state of mind at the time of the self-injury. Clinically, suicidal intent is often deduced by external behaviors or factors, such as how medically lethal the self-injury was, or the circumstances surrounding the act, such as the unlikelihood of discovery during and immediately following the act. This can lead to erroneous assumptions, particularly among individuals with borderline personality disorder (BPD) who have a history of self-injury without intent to die and in whom intent to die may be ambiguous. Perception of intent can also be distorted by a history of previous nonlethal attempts (Stanley et al. 2001). Self-injurious behavior is defined as intentional self-destructive behavior performed with no intent to die. Self-injurious behavior with no suicidal intent can be understood as an effort to regulate emotions. Although suicidal intent is often ascribed to these behaviors by clinicians
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TABLE 16–1. DSM-IV-TR classification of personality disorders Cluster A
Cluster B
Cluster C
Paranoid personality disorder Schizoid personality disorder Schizotypal personality disorder
Antisocial personality disorder Borderline personality disorder Histrionic personality disorder Narcissistic personality disorder
Avoidant personality disorder Dependent personality disorder Obsessive-compulsive personality disorder
and family members, individuals who engage in these behaviors are often quite clear that these behaviors “help” them feel better. Two other terms warrant mention: self-mutilation and parasuicide. Although self-mutilation is used to describe nonsuicidal self-harm, some forms of self-injury such as head banging and hitting oneself do not involve mutilation. Thus, this definition is not inclusive enough. The term parasuicide was originally defined as any self-injurious behavior with or without suicidal intent that did not result in death. However, the term is often mistakenly used to include only behaviors without suicide intent. We do not use these two terms in this chapter. We have proposed two different types of models to understand suicidal acts and self-injurious behavior, respectively. For understanding suicidal acts in the context of Axis I and II psychiatric disorders, we have proposed a stress-diathesis model (Corbitt et al. 1996; Mann and Arango 1992; Mann et al. 1999; Oquendo et al. 1997, 2004) that explains how different risk factors interact, resulting in suicide or suicide attempts (Figure 16–1). According to this model, the diathesis refers to the propensity for manifesting suicidal behavior, is considered trait related, and appears to be independent of the main psychiatric diagnosis (Mann 2003). In contrast, triggers are precipitants or stressors that determine the timing and probability of suicidal acts. Thus, triggers may be considered state related. In this vein, risk factors for suicidal behavior in patients with personality disorder may be categorized according to whether they affect the diathesis or the trigger (Oquendo et al. 1997). Some personality traits, such as aggression and impulsivity, are important components of the diathesis for suicidal behavior regardless of the presence of personality disorder (Mann et al. 1999). Familial, genetic, and biological factors;
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Management of suicidal behavior in BPD
Diathesis (trait)
Interventions to reduce the diathesis
BPD
Interventions for intrapsychic distress in BPD
Triggers (state)
Interventions for triggers
SelfRegulation Model
Stress-Diathesis Model
FIGURE 16–1. Management of suicidal behavior in patients with borderline personality disorder. substance and alcohol abuse; early traumatic experiences; early parental loss; social isolation; low self-esteem; sex; religion; and other factors also influence the diathesis for suicidal behavior. In contrast, major depressive episode; acute substance intoxication; social, financial, or family crises; and contagion may act as triggers (Oquendo et al. 1997) in individuals with personality disorder.
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Stanley and Brodsky (2005) propose a parallel model for understanding the intrapsychic phenomena that lead to suicidal behavior and selfinjury in BPD. The Self-Regulation Model posits that self-injury and suicidal behavior serve a dual function in BPD. They both inflict physical harm and regulate the self, particularly emotions, to restore a sense of equilibrium and well-being. In this model, unbearable emotions, particularly anxiety, and thoughts are experienced as out of control and as never-ending, even though they may last only a few hours. Self-condemnation for feeling out of control frequently ensues. In response to this state, individuals feel they must act to alter how they feel. Suicide attempt or self-injury is perceived as a reasonable solution. After the episode, individuals usually feel calmer and often regain a sense of emotional equilibrium. Thus, the suicide attempt or self-injury episode is “successful.” This may explain why individuals with BPD feel better after self-injury episodes and suicide attempts and frequently repeat the behavior. It also explains why, in some cases, hospitalization after a self-destructive episode may not be clinically indicated.
Cluster A Personality Disorders In a psychological autopsy study (Apter et al. 1993), the most common Axis II personality disorder in completed suicide is schizoid personality disorder (37.2%). Cluster A personality disorders (paranoid, schizoid, schizotypal) are also reported to be associated with suicide attempt (Markar et al. 1991), even after controlling for the presence or severity of depression (Chioqueta and Stiles 2004). Another study (Bornstein et al. 1988) showed that 60% of subjects with schizotypal personality disorder report at least one suicide attempt in their lifetime. Thus, a relationship between Cluster A personality disorders and both suicide completions and attempts exists.
Cluster C Personality Disorders Few studies have investigated the association between Cluster C personality disorders (obsessive-compulsive, avoidant, and dependent) and suicidal behavior. A psychological autopsy study of adolescents (Brent et al. 1994) showed a higher prevalence of probable or definite Cluster C personality disorders among persons who commit suicide than in community control subjects. Similarly, in an adult psychological autopsy study (Isometsa et al. 1996), 10% of all suicides occurring in Finland in a 1-year period met criteria for Cluster C personality disorders. In terms of suicide attempts, a longitudinal study of a community sample (Johnson et al. 1999) found that patients with Cluster C person-
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ality disorders were at increased risk for suicide attempts and thoughts, even after affective disorders were controlled for. Thus, there appears to be greater risk for suicide attempts and completions in Cluster C personality disorders than in the general population.
Cluster B Personality Disorders Cluster B personality disorders (antisocial, narcissistic, histrionic, and borderline) are associated with suicide completion (Corbitt et al. 1996; Engstrom et al. 1997; Isometsa et al. 1996; Lecrubier 2001; Zanarini et al. 2004). Moreover, patients with these disorders are generally prone to affective disorders (Engstrom et al. 1997; Zanarini et al. 2004), which may also increase their risk for suicidal acts. Studying the co-occurrence of suicidal behavior and Cluster B personality disorders poses problems, especially given that BPD has suicidal behavior as one of its diagnostic criteria. We review suicidal behavior in all the Cluster B personality disorders except histrionic personality disorder, for which we could find no data separate from those for Cluster B personality disorder, using a computerized literature search.
Antisocial Personality Disorder Only a few studies have documented the lifetime risk of suicide of individuals with antisocial personality disorder. Maddocks (1970) estimated a 5% lifetime risk of suicide during a 5-year follow-up study. However, among causes of death of 1,000 delinquent and nondelinquent males ages 14–65 years, suicide occurred in equal proportions in each group (Laub and Vaillant 2000), contradicting findings from the previous study. The relationship between antisocial personality disorder and suicide attempts appears to be more consistent. Although as many as 72% of patients with antisocial personality disorder attempt suicide (for review, see Pompili et al. 2004), it is possible that it is the presence of comorbid antisocial personality disorder and BPD that actually increases the risk of suicidal acts (Stone et al. 1987). Additional risk factors among subjects with antisocial personality disorder include separation from parent, parental alcohol abuse, parental violence, alcohol abuse or dependence, and comorbid mental disorder, especially cocaine and hallucinogen use disorder (Links et al. 2003).
Narcissistic Personality Disorder Narcissistic personality disorder patients are significantly more likely to commit suicide than are those without narcissistic personality disorder diagnosis or narcissistic traits (Stone 1989). Of note, a study of adoles-
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cents (Links et al. 2003) found that patients with antisocial personality disorder and BPD are at risk for suicidal behavior when depressed, whereas patients with narcissistic personality disorder are also at suicide risk when not depressed.
Borderline Personality Disorder Patients with BPD represent 9%–33% of all completed suicides (Black et al. 2004), suggesting that BPD is one of the most important psychiatric disorders related to suicide (Ahrens and Haug 1996). Furthermore, as many as 84% of subjects with BPD report at least one previous suicide attempt (Black et al. 2004), and many individuals with BPD experience frequent nonsuicidal self-injury, along with chronic suicidal ideation, suicide threats, and intermittent nonlethal suicide attempts. It is not surprising, then, that most research on suicidality in personality disorders has focused on this group. Psychiatric comorbidity is one of the most important risk factors for suicide attempt in BPD (see Black et al. 2004 for a review). Depressed borderline patients attempt suicide more frequently than depressed patients, both with or without other Axis II disorders (Corbitt et al. 1996). Comorbid antisocial personality disorder or substance abuse is reported to be a risk factor for suicide attempts in BPD (Black et al. 2004). Moreover, comorbid major depression and substance abuse are shown to increase both the number and seriousness of suicide attempts (Black et al. 2004). In addition, several clinical characteristics have been identified as risk factors for suicidal behavior in BPD and include impulsivity (Brodsky et al. 1997), the number of previous suicide attempts (Black et al. 2004), childhood physical or sexual abuse (Brodsky et al. 1997; Soloff et al. 2002), early childhood parental loss, parental separation, and higher level of education. School and/or legal problems, longer hospitalizations, lack of treatment and violating treatment contract have been associated with suicide completion in BPD (Black et al. 2004). Moreover, the intrapsychic experience in BPD also contributes to the risk of deliberate self-harm. Compared with individuals with other personality disorders, those with BPD spend a higher percentage of time feeling emotions such as being overwhelmed, worthless, angry, empty, abandoned, betrayed, or enraged (Zanarini et al. 1998). It has been estimated that individuals with BPD spend about 44% of the time experiencing cognitions of being misunderstood, thinking that no one cares, thinking about killing themselves, or thinking that they are “bad” or damaged. Thus, selfworth is tenuous, and they rely on external proof of worthiness. This reliance on others for self-worth results in magnifying the pain experienced in
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the context of interpersonal difficulties. Frantic distress in response to interpersonal conflict and dysregulated anger at both the cause of upset and the self are common responses. These feelings of “badness,” anger at self, and self-criticism for being so vulnerable often lead to suicidality and selfinjury. Thus, clinical, environmental, and intrapsychic factors in BPD contribute to the risk for self-injurious behavior and suicide attempts. It is worth noting that studies of suicidal acts and personality disorders generally have not excluded comorbidity of other personality disorders such as Cluster B personality disorders. This is critical because comorbidity of two or more personality disorders could affect the association of a given personality disorder with suicidal behavior. Indeed, this methodological problem is underscored by findings from a community sample (Johnson et al. 1999), in which 32% of those meeting criteria for any personality disorder had diagnoses in two or more personality disorder clusters.
Case Examples Case Example 1 Ms. A is a 22-year-old woman with BPD who has made more than eight suicide attempts since adolescence. The bulk of these attempts required emergency department or hospital admission. Many of the suicide attempts occurred in the absence of depressive symptoms. Ms. A views suicide attempts and suicidal ideation as a way to manage overwhelming feelings and to avoid confrontation and responsibility. In her latest attempt, Ms. A reports that after a telephone conversation with her mother, she became enraged at her mother but did not want to confront her. She could not stop thinking about how thoughtless and inconsiderate her mother had been, and instead of feeling better with the passage of time, Ms. A felt increasingly angry. The anger soon became overwhelming, and Ms. A became anxious and fearful that she was going to “lose it.” She felt she could not tolerate feeling this way and decided to “get it over with.” She decided to take an overdose of her medications and began ingesting pills one after the other. After taking about 35 pills, Ms. A “realized she blew it” and called her therapist. She did not tell the therapist directly what had happened but hinted that she was in trouble. She reports she cannot remember what happened after that. The therapist, unable to reach Ms. A when she called later in the day to check on her, contacted emergency services. The medics arrived and took Ms. A for medical care at the local emergency department. Paradoxically, as was often the case, Ms. A felt less anxious and almost “bright” after the suicide attempt. Ms. A stated that she was motivated for change and was willing to set goals for the future. Of note, Ms. A reported regret that she had hurt and worried her loved ones. Ms. A’s mother seemed more interested in her daughter’s feelings and appeared to be trying hard to understand her. Thus, as a consequence of the attempt, Ms. A felt closer to her mother and less lonely and overwhelmed.
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Case Example 2 Ms. B is a 31-year-old woman with BPD who uses self-injurious behavior to manage overwhelming feelings of anger, anxiety, and guilt. She states that when she is angry, she feels immediately guilty and that she does not have the right to be so mad. These feelings of guilt make her feel worthless and loathsome. As these feelings intensify, Ms. B becomes convinced that she cannot tolerate the self-hate. It is in this context that she scratches her skin to elicit physical pain. Sometimes the intense scratching draws blood. The sight of the blood gives her relief, and she reports that it feels that she now has “something to show” for how badly she feels. Ms. B feels “back in control” after the scratching. She is quite clear that this behavior has nothing to do with wanting to die; rather, she is just seeking relief. Ms. B also describes a suicide attempt that she distinguishes from the self-injurious behavior. On the anniversary of her father’s death, she became angry that her boyfriend appeared to have “no clue” that this was a very difficult day for her. Ms. B felt that not only was her boyfriend unable to understand her today but also that he would never “get it.” She felt hopeless, convinced that she would always feel the aching loss of her father. She could not imagine that anyone could help her recover from that loss. It seemed insurmountable. Overcome with grief, feelings of loss, emptiness, and anger, she decided to take an overdose to kill herself. However, after taking a handful of pills, she felt relieved. The suicide attempt was an action that helped her feel like she did have some control and that she could “do something.” Feeling more in control, Ms. B’s wish to die subsided. She fell asleep until the next morning when she felt much better.
Discussion Following the Self-Regulation Model, several aspects of the self-destructive behavior should be evaluated. Rather than assuming that the intent of nonsuicidal self-injury is purely manipulative and attention-seeking, evaluation to detect other functions of the self-injury, such as emotion regulation, self-punishment, and self-validation, may be useful. Awareness of the multiple functions of self-harm behavior, as was illustrated in the case of Ms. B in her wish to die and to escape unbearable feelings, can target treatment approaches focused on the development of skills to achieve these goals. Moreover, patients may have distorted beliefs that lead to selfinjury. For example, as mentioned by both Ms. A and Ms. B in the vignettes, patients may believe they cannot tolerate emotional pain or that the only way to handle their emotional state is through self-injury. Such beliefs can be modified through cognitive restructuring. The therapeutic dyad can work together to understand how intense emotional
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arousal leads to distorted cognitions or interpretations of external events. Therapeutic interventions can increase awareness of how past traumatic events can distort perceptions of current reality. On the other hand, identifying reinforcing consequences of the behavior, as was observed in Ms. A’s case where her mother became more interested in Ms. A’s feelings after the self-harm, provides information about ways to modify these reinforcement patterns so as to promote more skillful behaviors. Distinguishing between intended and unintended consequences can aid both patient and clinician to clarify original intent compared with learned intent. Patients can gain insight into how their behaviors affect people in their lives, providing an opportunity for improved interpersonal effectiveness.
Risk Assessment and the Decision to Hospitalize In deciding whether to hospitalize a patient, the twin goals of decreasing suicide risk and increasing the patient’s capacity to safely tolerate chronic suicidal ideation on his or her own are paramount. Decisions regarding hospitalization can be complicated in cases in which there is chronic suicidal ideation and/or nonsuicidal self-injurious behavior. On the one hand, if the family or the clinician experiences the self-harm as attention-seeking, regardless of the patient’s intention, reduced sensitivity to risk may ensue. Similarly, becoming inured to the day-to-day emotional pain experienced by individuals with BPD can lead to underrecognition of suicide risk. On the other hand, chronic suicidal ideation and nonsuicidal self-injury also can lead to multiple hospitalizations that severely disrupt the individual’s ability to function, in addition to not being always helpful in decreasing suicide risk (Stanley and Brodsky 2005). Thus, assessment of the subjective experience of deliberate self-harm can aid in the decision to hospitalize. As illustrated in the two cases, suicidal ideation and self-injurious behavior in BPD do not necessarily indicate a strong intent to die. Instead, they may be the patient’s attempt to relieve an intolerable emotional state. An outpatient treatment that addresses the need for relief and provides support for the individual to manage these states safely can reduce the need for frequent hospital admissions. However, if hospitalization or emergency department admission is to be used, as was the situation with Ms. A, brief stays during times of extreme distress that would normally lead to a suicide attempt are optimal. Thus, hospitalization would block self-harm and help the individual to tolerate the emotions until they subside.
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Empirically Tested Treatments for Self-Harm in Borderline Personality Disorder Two treatment models have been shown to lower rates of attempted suicide among BPD patients: psychoanalytic/psychodynamic therapy and dialectical behavior therapy (DBT). Direct comparisons of these two approaches have not been conducted. Both treatments have some elements in common: weekly meetings with an individual therapist, one or more weekly group sessions, and meetings of therapists for consultation/supervision (American Psychiatric Association 2001). A randomized controlled trial compared the effectiveness of psychoanalytically oriented partial hospitalization with standard care for patients with BPD (Bateman and Fonagy 1999). Patients who were partially hospitalized showed improvement in depressive symptoms, a decrease in suicidal and self-mutilatory acts, and reduced inpatient days compared with the other group. Improvement in social and interpersonal function began at 6 months and continued until the end of treatment at 18 months. Patients who completed the partial hospitalization program not only maintained substantial gains at an 18-month followup evaluation but also showed continued improvement on most measures, in contrast to patients treated with standard psychiatric care (Bateman and Fonagy 2001). In addition, fewer patients who completed the partial hospitalization program attempted suicide or presented selfmutilating acts. The effectiveness of a twice-weekly psychodynamic therapy for outpatients with BPD (Stevenson and Meares 1992) has been evaluated by comparing 1 year of the patient’s life before treatment with 1 year after. The most frequently observed changes were reductions in impulsivity, affective instability, anger, and suicidal behavior when comparing the same outpatients with an outpatient waiting-list control group (Meares et al. 1999). Patients who received the psychodynamic intervention had a better outcome than control subjects. However, it is unclear whether better outcome was due to the type of therapy or the greater amount of treatment received (American Psychiatric Association 2001).
Dialectical Behavior Therapy Most published reports of cognitive-behavioral treatment for patients with BPD are uncontrolled clinical or single case studies (American Psychiatric Association 2001). However, in recent decades several controlled studies have been done, particularly of a form of cognitivebehavioral therapy called dialectical behavior therapy.
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DBT was developed as a treatment for chronically parasuicidal women (Linehan 1987). The most fundamental dialectic addressed by the treatment is that of acceptance and change. Treatment attempts to help these patients, who ordinarily have trouble accepting themselves and others, to develop acceptance-oriented skills and change-oriented skills. Several randomized controlled trials have investigated the efficacy of DBT for treating women with BPD. Two (Koons et al. 2001; Linehan et al. 1991) out of three (Linehan et al. 1994) studies suggest that DBT compared with treatment as usual in the community may decrease deliberate self-harm, although whether these effects are enduring is an open question (American Psychiatric Association 2001). The third study showed decreases in anger—an outcome that may relate to how DBT decreases self-harm behaviors (Linehan et al. 1994). These studies suggest that DBT is helpful in reducing self-injury and suicidal behavior and related traits in BPD. However, it is possible that the superior effects of DBT are related to weakness in the treatment-as-usual condition (Robins and Chapman 2004).
Cognitive Therapy Another psychotherapy that has been adapted to treat BPD is cognitive therapy. Cognitive therapy has been empirically tested to treat a variety of Axis I disorders such as depression and has been reported to be useful in the treatment of patients with personality disorders (see Brown et al. 2004 for a review). Although Layden et al. (1993) have prepared a detailed cognitive therapy manual specifically for BPD, to our knowledge there have been no published randomized, controlled trials that empirically support this approach. However, in a recent open clinical trial, Brown et al. (2004) reported that BPD patients who received weekly cognitive therapy over a 1-year period showed significant decreases on measures of suicidal ideation, hopelessness, depression, number of borderline symptoms, and dysfunctional beliefs at termination and 18month assessment interviews.
Pharmacotherapy Although about 40% of patients with BPD take three or more psychotropic medications concurrently, only a few open-label or controlled medication trials of patients with BPD have been conducted (See Zanarini 2004 for a review). In the following discussion, we summarize medication trials that have found effects on suicidal behavior or on behaviors related to the likelihood of suicidal acts such as aggression or impulsivity.
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Selective Serotonin Reuptake Inhibitors Studies of selective serotonin reuptake inhibitors (SSRIs) suggest that aggression, irritability (Coccaro and Kavoussi 1997), depressed mood, and self-mutilation respond to SSRIs. Of note, improvement in impulsive behaviors may appear as early as the first week of treatment independently of effects on depression and anxiety (Coccaro and Kavoussi 1997), and if discontinuation or nonadherence occurs, improvement disappears (American Psychiatric Association 2001). Some of the SSRIs that have been studied are fluoxetine (up to 80 mg/day), venlafaxine (up to 400 mg/day), and sertraline (up to 200 mg/day) (American Psychiatric Association 2001).
Mood Stabilizers Preliminary evidence suggests that lithium carbonate and divalproex may be useful in treating behavioral dyscontrol and affective dysregulation in some BPD patients (American Psychiatric Association 2001). Lithium may have mood-stabilizing and antiaggressive effects in patients with BPD (American Psychiatric Association 2001) and general antisuicidal effects (Tondo and Baldessarini 2000). Of course, lithium use should be closely monitored in patients at risk for suicide because of its potential fatality in overdose. Reductions in aggression and depression are reported among patients treated with divalproex sodium (Hollander et al. 2001), although dropout rates hamper interpretability of this study. Nonetheless, open-label studies suggest antiaggressive and antianxiety effects of divalproex sodium (Zanarini 2004).
Anxiolytic Agents Two studies regarding the use of anxiolytic medications in treating BPD patients yielded conflicting results, showing both increases in suicidality and self-mutilation (Gardner and Cowdry 1985) and decreases in impulsivity, violent outbursts, and anxiety (American Psychiatric Association 2001). Thus, this class of medication should be used with caution in suicidal patients with personality disorders.
Opiate Antagonists Opiate antagonists have been used in an attempt to diminish mutilation-induced analgesia and euphoria associated with self-injurious behavior with the goal of reducing such behavior. However, there is no clear evidence that they are effective in reducing self-injurious behavior among BPD patients (American Psychiatric Association 2001).
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Antipsychotics There is support for the use of low-dose antipsychotics for the acute management of global symptom severity (American Psychiatric Association 2001), schizotypal symptoms, psychoticism, anger, and hostility. In BPD, olanzapine may reduce obsessive-compulsive symptoms, interpersonal sensitivity, depression, anger-hostility, anxiety, paranoia, psychoticism, and overall psychopathology (Schulz et al. 1999; Zanarini and Frankenburg 2001). Similar reports exist from case studies of risperidone use, although controlled trials have not verified these effects (Zanarini 2004). Of note, a continuation study of recurrently parasuicidal patients with BPD and histrionic personality disorder treated with flupenthixol 20 mg once a month reported a significant decrease in suicidal behaviors compared with the placebo group. However, this important study awaits replication (American Psychiatric Association 2001). Thus, only a few controlled studies of medication report benefits against suicidal behavior. Clinicians are therefore in the position of having to base treatment on expert consensus practice guidelines. The American Psychiatric Association’s (2001) practice guideline for treatment of patients with BPD states that the primary treatment for BPD is psychotherapy, complemented by symptom-targeted pharmacotherapy (American Psychiatric Association 2001). In addition, management includes establishing and maintaining a therapeutic framework and alliance as well as providing crisis intervention and monitoring patient safety. Providing education about BPD and its treatment, coordinating treatment provided by multiple clinicians with attention to potential problems involving splitting and boundaries, monitoring progress, and reassessing the effectiveness of the treatment plan are also key (American Psychiatric Association 2001). The practice guideline notes that suicidal and self-destructive behaviors should be addressed as the highest priorities, along with conducting ongoing risk assessment and helping the patient find ways to maintain safety (American Psychiatric Association 2001).
❏ Key Points ■
Cluster B personality disorders have an increased suicide risk. Up to 84% of subjects with BPD report at least one previous suicide attempt.
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Deliberate self-harm includes two forms of self-destructive behavior: one with an intent to die and one in which the self-inflicted damage does not have this intent. A suicide attempt is defined as an
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intentionally self-destructive act performed with at least partial intent to die. Nonsuicidal self-injury, sometimes called self-mutilation, is defined as intentional self-destructive behavior performed with no intent to die. ■
In the treatment of BPD, self-harm behaviors must be addressed as the highest priorities, with an effort from the therapist to both evaluate risk for these behaviors and help the patient find ways to maintain safety.
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Recognizing the various functions of deliberate self-harm, and not simply assuming the intent to be solely manipulative, while maintaining awareness of the day-to-day emotional pain experienced by individuals with BPD can reduce the underrecognition of suicide risk.
References Ahrens B, Haug HJ: Suicidality in hospitalized patients with a primary diagnosis of personality disorder. Crisis 17:59–63, 1996 American Psychiatric Association: Practice guideline for the treatment of patients with borderline personality disorder. Am J Psychiatry 158(suppl): 1–52, 2001 American Psychiatric Association: Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry 160(suppl): 1–60, 2003 Apter A, Bleich A, King RA, et al: Death without warning? A clinical postmortem study of suicide in 43 Israeli adolescent males. Arch Gen Psychiatry 50: 138–142, 1993 Bateman A, Fonagy P: Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. Am J Psychiatry 156:1563–1569, 1999 Bateman A, Fonagy P: Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 18-month follow-up. Am J Psychiatry 158:36–42, 2001 Baxter D, Appleby L: Case register study of suicide risk in mental disorders. Br J Psychiatry 175:322–326, 1999 Black DW, Winokur G: Prospective studies of suicide and mortality in psychiatric patients. Ann NY Acad Sci 487:106–113, 1986 Black DW, Blum N, Pfohl B, et al: Suicidal behavior in borderline personality disorder: prevalence, risk factors, prediction, and prevention. J Personal Disord 18:226–239, 2004 Bodlund O, Grann M, Ottosson H, et al: Validation of the self-report questionnaire DIP-Q in diagnosing DSM-IV personality disorders: a comparison of three psychiatric samples. Acta Psychiatr Scand 97:433–439, 1998 Bornstein RF, Klein DN, Mallon JC, et al: Schizotypal personality disorder in an outpatient population: incidence and clinical characteristics. J Clin Psychol 44:322–325, 1988
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Brent DA, Johnson BA, Perper J, et al: Personality disorder, personality traits, impulsive violence, and completed suicide in adolescents. J Am Acad Child Adolesc Psychiatry 33:1080–1086, 1994 Brodsky BS, Malone KM, Ellis SP, et al: Characteristics of borderline personality disorder associated with suicidal behavior. Am J Psychiatry 154:1715–1719, 1997 Brown GK, Beck AT, Steer RA, et al: Risk factors for suicide in psychiatric outpatients: a 20-year prospective study. J Consult Clin Psychol 68:371–377, 2000 Brown GK, Newman CF, Charlesworth SE, et al: An open clinical trial of cognitive therapy for borderline personality disorder. J Personal Disord 18:257– 271, 2004 Casey PR, Tyrer P: Personality disorder and psychiatric illness in general practice. Br J Psychiatry 156:261–265, 1990 Chioqueta AP, Stiles TC: Assessing suicide risk in cluster C personality disorders. Crisis 25:128–133, 2004 Coccaro EF, Kavoussi RJ: Fluoxetine and impulsive aggressive behavior in personality-disordered subjects. Arch Gen Psychiatry 54:1081–1088, 1997 Corbitt EM, Malone KM, Haas GL, et al: Suicidal behavior in patients with major depression and comorbid personality disorders. J Affect Disord 39:61– 72, 1996 Engstrom G, Alling C, Gustavsson P, et al: Clinical characteristics and biological parameters in temperamental clusters of suicide attempters. J Affect Disord 44:45–55, 1997 Fabrega H Jr, Ulrich R, Pilkonis P, et al: Personality disorders diagnosed at intake at a public psychiatric facility. Hosp Community Psychiatry 44:159– 162, 1993 Gardner DL, Cowdry RW: Alprazolam-induced dyscontrol in borderline personality disorder. Am J Psychiatry 142:98–100, 1985 Harris EC, Barraclough B: Suicide as an outcome for mental disorders: a metaanalysis. Br J Psychiatry 170:205–228, 1997 Hollander E, Allen A, Lopez RP, et al: A preliminary double-blind, placebocontrolled trial of divalproex sodium in borderline personality disorder. J Clin Psychiatry 62:199–203, 2001 Isometsa ET, Henriksson MM, Heikkinen ME, et al: Suicide among subjects with personality disorders. Am J Psychiatry 153:667–673, 1996 Johnson JG, Cohen P, Skodol AE, et al: Personality disorders in adolescence and risk of major mental disorders and suicidality during adulthood. Arch Gen Psychiatry 56:805–811, 1999 Koons C, Robins C, Tweed JL, et al: Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behav Ther 32:390, 2001 Laub JH, Vaillant GE: Delinquency and mortality: a 50-year follow-up study of 1,000 delinquent and nondelinquent boys. Am J Psychiatry 157:96–102, 2000 Layden MA, Newman CF, Freeman A, et al: Cognitive Therapy of Borderline Personality Disorder. Needham Heights, MA, Allyn & Bacon, 1993 Lecrubier Y: The influence of comorbidity on the prevalence of suicidal behaviour. Eur Psychiatry 16:395–399, 2001
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Lesage AD, Boyer R, Grunberg F, et al: Suicide and mental disorders: a casecontrol study of young men. Am J Psychiatry 151:1063–1068, 1994 Linehan MM: Dialectical behavior therapy for borderline personality disorder: theory and method. Bull Menninger Clin 51:261–276, 1987 Linehan MM, Armstrong HE, Suarez A, et al: Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry 48:1060– 1064, 1991 Linehan MM, Tutek DA, Heard HL, et al: Interpersonal outcome of cognitive behavioral treatment for chronically suicidal borderline patients. Am J Psychiatry 151:1771–1776, 1994 Linehan MM, Rizvi SL, Welch SS: Psychiatric aspects of suicidal behavior: personality disorder, in The International Handbook of Suicide and Attempted Suicide. Edited by Hawton K, van Heering K. Chichester, England, Wiley, 2005, pp 147–178 Links PS, Gould B, Ratnayake R: Assessing suicidal youth with antisocial, borderline, or narcissistic personality disorder. Can J Psychiatry 48:301–310, 2003 Maddocks PD: A five year follow-up of untreated psychopaths. Br J Psychiatry 116:511–515, 1970 Mann JJ: Neurobiology of suicidal behaviour. Nat Rev Neurosci 4:819–828, 2003 Mann JJ, Arango V: Integration of neurobiology and psychopathology in a unified model of suicidal behavior. J Clin Psychopharmacol 12:2S–7S, 1992 Mann JJ, Waternaux C, Haas GL, et al: Toward a clinical model of suicidal behavior in psychiatric patients. Am J Psychiatry 156:181–189, 1999 Markar HR, Williams JM, Wells J, et al: Occurrence of schizotypal and borderline symptoms in parasuicide patients: comparison between subjective and objective indices. Psychol Med 21:385–392, 1991 Meares R, Stevenson J, Comerford A: Psychotherapy with borderline patients, I: a comparison between treated and untreated cohorts. Aust N Z J Psychiatry 33:467–472, 1999 Oquendo MA, Malone KM, Mann JJ: Suicide: risk factors and prevention in refractory major depression. Depress Anxiety 5:202–211, 1997 Oquendo MA, Galfalvy H, Russo S, et al: Prospective study of clinical predictors of suicidal acts after a major depressive episode in patients with major depressive disorder or bipolar disorder. Am J Psychiatry 161:1433–1441, 2004 Pompili M, Ruberto A, Girardi P, et al: Suicidality in DSM-IV Cluster B personality disorders: an overview. Ann Ist Super Sanita 40:475–483, 2004 Robins CJ, Chapman AL: Dialectical behavior therapy: current status, recent developments, and future directions. J Personal Disord 2004 18:73–89, 2004 Schulz SC, Camlin KL, Berry SA, et al: Olanzapine safety and efficacy in patients with borderline personality disorder and comorbid dysthymia. Biol Psychiatry 46:1429–1435, 1999 Soloff PH, Lynch KG, Kelly TM: Childhood abuse as a risk factor for suicidal behavior in borderline personality disorder. J Personal Disord 16:201–214, 2002 Stanley B, Brodsky B: Suicidal and self-injurious behavior in borderline personality disorder: a self-regulation model, in Understanding and Treating Borderline Personality Disorder: A Guide for Professionals and Families. Washington, DC, American Psychiatric Publishing, 2005, pp 43–63
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Stanley B, Gameroff MJ, Michalsen V, et al: Are suicide attempters who selfmutilate a unique population? Am J Psychiatry 158:427–432, 2001 Stevenson J, Meares R: An outcome study of psychotherapy for patients with borderline personality disorder. Am J Psychiatry 149:358–362, 1992 Stone MH: Long-term follow-up of narcissistic/borderline patients. Psychiatr Clin North Am 12:621–641, 1989 Stone MH, Stone DK, Hurt SW: Natural history of borderline patients treated by intensive hospitalization. Psychiatr Clin North Am 10:185–206, 1987 Tondo L, Baldessarini RJ: Reduced suicide risk during lithium maintenance treatment. J Clin Psychiatry 61(suppl):97–104, 2000 Ucok A, Karaveli D, Kundakci T, et al: Comorbidity of personality disorders with bipolar mood disorders. Compr Psychiatry 39:72–74, 1998 Zanarini MC: Update on pharmacotherapy of borderline personality disorder. Curr Psychiatry Rep 6:66–70, 2004 Zanarini MC, Frankenburg FR: Olanzapine treatment of female borderline personality disorder patients: a double-blind, placebo-controlled pilot study. J Clin Psychiatry 62:849–854, 2001 Zanarini MC, Frankenburg FR, Dubo ED, et al: Axis I comorbidity of borderline personality disorder. Am J Psychiatry 155:1733–1739, 1998 Zanarini MC, Frankenburg FR, Hennen J, et al: Axis I comorbidity in patients with borderline personality disorder: 6-year follow-up and prediction of time to remission. Am J Psychiatry 161:2108–2114, 2004 Zilber N, Schufman N, Lerner Y: Mortality among psychiatric patients: the groups at risk. Acta Psychiatr Scand 79:248–256, 1989
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Substance-Related Disorders Avram H. Mack, M.D. Hallie A. Lightdale, M.D.
Risk of suicide is limited neither to individuals with mood disorders nor simply to those with mood disorders who also use substances: the probability of completed suicide as an outcome in alcohol dependence (7%) is greater than in affective disorder (6%) (Inskip et al. 1998). Those who treat substance users must pay the highest attention to suicidality. When substance use disorders (substance-related disorders) co-occur with other psychiatric disorders, the management is more complex and the risks are higher. As a result, a clinical approach to the substance-using suicidal patient requires considerations that are both basic and “outside the box.” Clinicians should generally be aware of the association between substances and all forms of violence (of which suicide is a type) or between substances and mood disorders and should manage suicidality as delineated in sources such as this text or the guides on suicide of the American Psychiatric Association (2003) and the American Academy of Child and Adolescent Psychiatry (2001). To think outside the box, clinicians must be aware of the less recognized pathways by which substances and potentially lethal behaviors meet—pathways that can be intercepted, managed, or prevented. As examples, impulsivity and agitation, among states listed in Table 17–1, are behavioral “final common 347
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TABLE 17–1. Direct substance-induced contributors to suicidality Disinhibition (dose dependent) Agitation Psychosis (e.g., “bad trips”) Impulsivity Irritability Depression Violence Overdose Physiological withdrawal Hopelessness
pathways” to suicide. This chapter reviews the risks of suicide associated with substance use generally and with specific substances and then discusses important points in the management of such patients. An inherent challenge in addressing substance use disorders is that the term covers a large range of clinical states. “Addiction,” “polysubstance abuse,” “alcoholism,” and “cocainism” are vague yet ubiquitously used terms. On the other hand, DSM-IV-TR (American Psychiatric Association 2000) contains more than 100 unique, operationally defined categories of clinical significance related to substances that differ in terms of etiology, course, presentation, and treatment. In practice, when faced with the need to act quickly with limited clinical information, the clinician may find it difficult to establish a specific diagnosis. Nevertheless, he or she must approach any use of a substance as a risk for suicide because each condition for each substance may have specific psychopathology that impacts suicidality, from the agitation of nicotine withdrawal to the grandiose psychosis of cocaine intoxication. Any of these states may be associated with self-destructive behaviors and must be considered individually. Furthermore, these states vary by age and culture and may be managed in a variety of settings, including inpatient psychiatry, medical/surgical floors, nonpsychiatric addiction units, crisis stabilization units, day or partial programs, and psychiatric or nonpsychiatric outpatient care. Any use may lead to a substance-induced disorder, and any use is significant in the consideration of suicide risk. This chapter deals with suicidal behavior that involves active suicidal intent, which sets aside two categories of morbidity or mortality due to substances: “unintentional injury” and “passive suicidality.” In each U.S. age group from ages 1 to 44, deaths resulting from unintentional injuries exceed deaths from all other causes, including suicide
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(Centers for Disease Control and Prevention 2005). This might also include the intentional behavior that represents “thrill seeking” (a part of substance use). Deaths may result from substances or from activities attempted while intoxicated; falls, traffic accidents, violence, and shortand long-term medical consequences are dangers associated with substances generally. The potential for accidental death by overdose varies by substance: easy for opioids and barbiturates, difficult for alcohol and benzodiazepines. How many such deaths represent suicidal intent is unknown, but they are a potential source of uncounted suicides. Passive suicidality refers to the use of substances with the wish that the substances themselves will eventually lead to death through a medical complication of the use (Flavin et al. 1990). After all, substances of abuse are poisons that can kill immediately or after a long time of use, and it is not uncommon to hear anecdotes of individuals who are said to be trying to commit suicide over a long term by ongoing use of a substance. Given the typical progression toward medical complications, Karl Menninger (1938) recognized alcoholism as “a slow form of suicide.” Such passive self-injury may be rapid, as in the adolescent who takes “ecstasy” while dancing at a “rave” and whose life is then threatened by dehydration, hyperthermia, or rhabdomyolysis. Awareness of risktaking aspects of behavior may help the patient to change. The lethal potential of both passive suicidality and unintentional injuries hinders the establishment of epidemiological findings in this population. It is unclear whether psychological autopsies are valid in such cases. There are some who claim to be able to diagnose “addiction” postmortem using hepatic pathology or serum or cerebrospinal fluid (CSF) biochemical or hematological values to indicate the presence of suicidal intent. One study applied the Michigan Alcohol Screening Test retrospectively to completed cases (Pirkola et al. 1999). The solution will be in ensuring that appropriate data are used in psychological autopsies.
Neurobiological and Genetic Factors Common to Both Suicide and Addiction There are several lines of investigation into whether there are neurobiological features common both to suicide and to addiction. Such research includes genetics (Hesselbrock et al. 2004), neurochemistry (particularly serotonin metabolism) (Limosin et al. 2005), and neuroanatomy (Tarter et al. 2004). These studies have specifically included mood and personality disorders (such as antisocial personality disorder). To do so makes sense: there is immense promise in neurobiological and genetic findings related to each of these conditions independently of
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the other. At this time the impact of these factors on an individual’s suicide risk is no greater than the sum of the parts, but future findings may ultimately demonstrate methods to identify those at the greatest risk.
Case Examples Case Example 1: Jane Jane was a highly intelligent 22-year-old female with a family history of alcohol dependence. She had been drinking in binges on her own during junior high school, and in fact she was asked to leave an elite boarding school as a result, disrupting her social ties. During college she began to use alcohol every day. She was able to maintain excellent marks but continued to increase her tolerance for alcohol and was socially isolated. She quit college and sought work but experienced worsening bouts of depression. During one of these periods, she stabbed at her wrists but then aborted her attempt to die and sought no medical attention. Ultimately, at age 24, she began to attend Alcoholics Anonymous meetings, successfully became sober, and later resumed her education and ties with her family.
Case Example 2: Bill Bill was a 60-year-old recently divorced hedge fund manager. He recently had learned that his company pension fund was not intact and that he would receive a much smaller benefit than he had expected. At his weekend home during most of every day, he drank pints of alcohol and later learned that he had developed cirrhosis when he went to the doctor for assessment of worsening arthritis. His pain worsened, and then one day he obtained his shotgun and shot himself. He survived the attempt and was hospitalized on a surgical floor. He developed severe alcohol withdrawal, which led to delirium tremens, and died of a pulmonary embolism.
Case Example 3: Carl Carl was a 20-year-old African American male who smoked three to five marijuana “joints” daily. He occasionally laced the marijuana with phencyclidine (PCP), and he smoked half a pack of cigarettes each day. He had been arrested multiple times in the past for violent crimes as well as for truancy as a juvenile (he had been truant from special education classes). After smoking PCP-laced marijuana one day, he and friends left his home “looking for someone to mess up.” After mugging and assaulting an individual, he was arrested and brought to the city lockup, where he was informed that this offense passed the state threshold (e.g., “three strikes and you’re out”) and that he could be punished with greater severity for this offense. Overnight he became despondent and also felt jittery, agitated, and anxious. He hung himself.
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Case Example 4: Paul One evening a resident was called to the emergency department to assess Paul a 45-year-old male with suicidal ideation. On further evaluation, the resident learned that Paul was homeless, was intoxicated with alcohol, and had been told that afternoon that he could no longer stay at the shelter. Paul adamantly insisted that he was suicidal and that he had had the intent “for years,” and he described “lots of” plans, including running into traffic or jumping off a bridge.
These cases highlight a number of the issues, statistical findings, and clinical problems related to suicide in those with substance-related disorders. We review these findings more extensively in the following sections.
Phenomenology of Suicide With Substance-Related Disorders: When Is There Convergence? For those with or without a psychiatric diagnosis, exposure to substances of abuse may cause particular behavioral states in which suicide risk is increased. A list of these states includes both direct (Table 17–1) and indirect (Table 17–2) effects of substances. For example, in general, substances are associated with violence (Hoaken and Stewart 2003); unsurprisingly, this is well documented for alcohol (Graham et al. 1998). There also is a relationship between violence and other substances, including nicotine and cannabis (Budney et al. 2004). When assessing suicide risk, the clinician should recognize and address these effects and consider their added weight to the risks inherent in an individual’s psychiatric disorder. By this perspective one can appreciate how substances alone may be associated with suicide risk. TABLE 17–2. Substance-associated factors contributing to suicide risk Central nervous system injury (especially to frontal lobes) Medical illness and injuries Social stressors: illegal behaviors; gambling debts; fraud; legal, social, or occupational problems; accidents; arrests Poor/estranged social supports Tendency for thrill-seeking behavior Past exposure to traumatic or violent situations
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General Issues Estimates of the epidemiology of suicide in those misusing substances have undergone refinement over the past 3 decades. Data have shown that substances are present among suicides in rates exceeding those seen in the general population. Following Guze and Robins’s (1970) estimates, Miles (1977) calculated that around 15% of abusers commit suicide. Although Miles’s figures may have been an overestimate, the frequency of suicide attempts and completions is nonetheless substantially higher, probably three to four times higher, among patients with substance-related disorders than in the general population (Murphy et al. 1992). According to a 2004 World Health Organization study, substance-related disorders are involved in 17% of completed suicides (Bertolote et al. 2004). A carefully performed data reanalysis found the lifetime suicide risk for individuals with affective disorders, alcoholism, and schizophrenia to be 6%, 7%, and 4%, respectively (Inskip et al. 1998). Data specific to psychiatric syndromes, substances, and other groups are described further in the next two sections.
Psychiatric Syndromes Mood Disorders Substance use and mood disorders frequently co-occur. According to the National Comorbidity Study, 24% of alcohol-dependent men (and 49% of alcohol-dependent women) have depression (Kessler et al. 1997). Between 10% and 30% of cocaine users have a depressive disorder (Kleber and Gawin 1984), and opioid-dependent individuals frequently have depression. Potash et al. (2000) compared bipolar patients with and without alcohol use and found a nearly doubled rate of suicide (21.7% versus 38.4%).
Anxiety Anxiety disorders are frequently comorbid with depressive disorders and with substance use, but except for panic disorder or posttraumatic stress disorder, anxiety disorders infrequently lead to suicide. Because exposure to violence is associated with future violence, patients with posttraumatic stress disorder often are at higher risk of suicidal ideation.
Personality Disorders Personality disorders involving frequent alterations of mood, impulsivity, or morbid thoughts are often associated with suicide, and some are fre-
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quently present in substance users, especially those with Cluster B disorders. Patients with comorbid borderline or antisocial personality disorder appear to have a greater suicide risk (Stone 1993). Antisocial personality disorder is present in 14.3% of those with an alcohol use disorder and in 17.8% of those with drug use disorders (Regier et al. 1990). Among alcohol-dependent patients who attempt suicide, 66% have antisocial personality disorder (Hesselbrock et al. 1988). The Epidemiologic Catchment Area study showed that those with antisocial personality disorder were 21 times as likely to develop abuse of or dependence on alcohol during their lives (Moeller and Dougherty 2001).
Adjustment Disorders Coping with a stressor (e.g., the stressors listed in Table 17–2) may lead one to contemplate suicide, to utilize substances, or both. Whatever the stress—job loss, concern about newly diagnosed HIV—disorders of adjustment are common among substance users.
Substances of Abuse Alcohol Different retrospective and prospective investigations have demonstrated an excess suicide risk among alcohol users compared with both the general and non-substance-using psychiatric populations. Suicide risk among alcohol-dependent individuals has been estimated to be 7% (comparable with 6% for mood disorders; Inskip et al. 1998). Of 40,000 Norwegian conscripts followed prospectively over 40 years, the probability of suicide was 4.76% (relative risk=6.9) among those classified as alcohol abusers compared with 0.63% for nondrinkers (Rossow and Amundsen 1995). Similar findings have been made worldwide (Foster 2001). Alcohol has a central role among suicides. In a study of 50 suicides, an alcohol use disorder was the primary diagnosis in 23% and a cooccurring diagnosis in 37% (Murphy et al. 1992). In one New York City study, alcohol misuse was present in the history of 56% of individuals who completed suicide (Conwell et al. 1996). Recent alcohol use increases suicide risk dramatically in comparison with risk in abstinent individuals, and some investigators claim that immediate intoxication is a greater risk than long-term use (Borges and Rosovsky 1996). What features of the alcohol-using individual are of greatest concern regarding risk of suicide? Preuss et al. (2003) studied cases of alcoholdependent suicide attempters and found that most had prior attempts, had earlier onset of addiction, had more severe dependence, had dependence on other substances, were separated or divorced, were more likely
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TABLE 17–3. Factors associated with suicide attempts or completion among alcohol-dependent individuals Alcohol-dependent suicide attemptersa Prior attempts Earlier onset of addiction More severe dependence Dependence on other substances Separated or divorced History of prior treatment Panic symptoms Additional diagnosis of a substance-induced psychiatric disorder Alcohol-dependent suicide completersb Heavy drinking behavior in the days and months prior to suicide Poor social support Living alone Having talked to others about suicide Serious medical consequences Unemployment a
Preuss et al. 2003. et al. 1992.
bMurphy
to have had treatment, had more panic symptoms, and were more likely to have been diagnosed with a substance-induced psychiatric disorder. Among alcohol-dependent suicide completers, Murphy et al. (1992) discerned six specific risk factors among alcohol-dependent suicide completers that predicted suicide (Table 17–3): exhibiting heavy drinking behavior in the days and months prior to suicide, having poor social support, living alone, having talked to others about suicide, having serious medical consequences, and being unemployed. Aside from psychiatric comorbidities, certain associated medical conditions, namely cirrhosis (Miles 1977) and peptic ulcer disease, have been correlated with suicide among alcohol users (Harris and Barraclough 1997).
Opioids The pharmacology of opioids affects their ability to engender distress and any resulting suicidality. Withdrawal from opioids can be extremely distressing. The medical consequences of taking too much prescribed opiate medication can include dysphoria, loss of appetite, and fatigue, which present as symptoms of depression. Risk for suicide associated with such medical conditions may be complicated by other chronic
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TABLE 17–4. Factors associated with suicide attempts among cocaine users Female gender Family history of suicidal behavior Reported childhood trauma Introverted Neurotic Hostile Co-occurring alcohol dependence Co-occurring opiate dependence Co-occuring major depression Co-occurring medical disorders Source.
Adapted from Roy 2001.
stressors such as pain syndromes, medical illnesses, and physical disability. As is noted later, misuse of prescribed medications carries a great risk for suicide (Harris and Barraclough 1997). Little research has been performed on suicide among those with opioid use disorders, but some findings may have clinical utility. Among recovering opioid users who are maintained on methadone, risk of suicide attempts was correlated with female gender, violent behavior in the past 30 days and over the lifetime, and less education, whereas current suicidal ideation was correlated with present family conflict and depression severity (Phillips et al. 2004). A high degree of female gender also was found among opioid-dependent patients who had ever attempted suicide (Roy 2002).
Cocaine The role of cocaine in suicide should not be underestimated. Marzuk et al. (1992) found that 29% of suicide victims in New York ages 21–30 tested positive for cocaine, and data from 13,673 participants in the Epidemiologic Catchment Area study in the United States showed that cocaine abusers had a significantly greater risk of attempting suicide (Petronis et al. 1990). Another group compared cocaine-dependent patients who attempted suicide with those without past attempts and found a number of characteristics (Roy 2001) (see Table 17–4).
Inhalants Suicide risk among those who use inhalants has been documented. Inhalants are usually used by adolescents in a sporadic geographic distri-
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bution. Adolescents who have used inhalants (a group likely using other substances as well) tend to have had a significantly greater number of past suicide attempts than adolescents not using inhalants (Sakai et al. 2004), and one study found this to be especially so among girls (Wilcox and Anthony 2004).
Stimulants/Amphetamines, Hallucinogens, Ketamine/Phencyclidine, and Gamma-Hydroxybutyrate There is little literature on the convergence of use of stimulants/amphetamines, hallucinogens, ketamine/PCP, and gamma-hydroxybutyrate (GHB) with suicidality, but each may produce physiological disturbances that can be fatal, or they can produce either psychotic symptoms or other states (Table 17–1) that may lead to suicidal behavior.
Cannabis There is increasing documentation that cannabis use is associated with antisocial behavior and violence (Brook et al. 2003). In the study by Harris and Barraclough (1997), cannabis users had a suicide risk four times that of nonusers. This group had a great deal of comorbid use; inquiries about other substances should be made during assessment of cannabis users.
Nicotine There is an “unmistakable” dose-dependent association between nicotine use and suicide (based on studies including approximately 500,000 individuals) that persists even after income, race, prior myocardial infarctions, diabetes, and alcohol use are controlled for (Malone et al. 2003). This has been found for children and adolescents (Wu et al. 2004) as well as among adults. The mechanism of this link has not been elucidated, but nicotine’s serotonin effects have been suggested as a cause (Malone et al. 2003). Nicotine withdrawal can be agitating, as may have occurred with Carl, whose case was described earlier.
Sedative-Hypnotics Harris and Barraclough (1997) found a relative risk of 20 for suicide among those misusing sedative-hypnotic medications. Interestingly, this risk was 16 times that expected for those using such medications and alcohol, but it rose to 44 times that expected among those using such medications with any illicit drug. The abuse of prescription medications in combination with alcohol or with illicit drugs also carries with it an additive risk for accidental overdose. Overdose is a common form of suicide attempt, especially in females, and such overdoses can
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of course be toxic and/or fatal. Although no data exist to link the tendency to overuse prescribed sedative-hypnotics with the risk for intentional overdose on the same pills, such a risk must be considered whenever a patient is found to be abusing sedative-hypnotics.
Assessment General Issues In general, assessment for both substance use and suicidality is a mainstay of any psychiatric evaluation in all settings (see also Chapter 1, “Suicide Risk: Assessing the Unpredictable”; Chapter 26, “Legal Perspective on Suicide Assessment and Management”). The presence of substance use should lead to detailed probing for suicidal ideation, and vice versa. Detailed assessment should include the substance(s) used, the associated substance use disorder, the setting, the behavioral and psychological effects, and secondary or comorbid psychiatric conditions. Corroborative or family input is vital in these situations. New stressors or narcissistic injuries that affect substance use or suicidality should be elicited. Medical conditions affecting a physiological equilibrium for a substance or medication should be evaluated.
Special Populations at Risk Individuals in Correctional Settings Substance-related disorders play a role in suicide in correctional settings, particularly the shortest-term correctional setting, the “lockup,” where individuals are first brought after arrest. The confluence of various factors related to arrest while intoxicated (e.g., the impulsivity of antisocial personality disorder, dysphoria of shame, disinhibition of intoxication, or agitation of withdrawal) is dangerous to the individual and those around him or her.
Adolescents Substances are central in adolescent suicidal behavior. An Institute of Medicine (2002) report tied the recent increase in adolescent suicide rates to increased substance use. Among adolescents, a link between suicide attempts and either alcohol use disorders or nicotine use disorders remained even after depression (Wu et al. 2004) or different use patterns were controlled for. The developmentally appropriate feelings of omnipotence and invulnerability place adolescents at higher risk. Those who are impulsive, including but not limited to those with dis-
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ruptive behavior disorders (such as attention-deficit/hyperactivity disorder [ADHD] or conduct disorder), are also at risk for dangerous behavior. Substance use among those with ADHD is greatest when the ADHD is comorbid with conduct disorder.
Women Among those with substance-related disorders, a number of differences in suicidal behavior between women and men have been found, although their clinical utility is unclear. In Henriksson et al.’s (1993) randomized study of completed suicides, DSM-III-R (American Psychiatric Association 1987) alcohol dependence or alcohol abuse was present in 43% of cases but was more than twice as common among men than women. On the other hand, other studies have shown that the risk for suicide in those with alcohol use disorders is greater among females (Harris and Barraclough 1997). The established variations between the sexes in both substance use and suicide risk should remain the clinician’s guiding principles until further data are available.
The Elderly The tenet that suicide risk increases with age is amplified when substances, especially alcohol, are present. One Swedish study specifically studied suicides among those older than 65 and found a strong association with alcohol dependence, suggesting that intervention is essential in alcohol users in that age group (Waern 2003).
Clinical Management Treatment of substance-using individuals at risk for suicide should follow general guidelines for the management of suicidal or parasuicidal patients (American Academy of Child and Adolescent Psychiatry 2001; American Psychiatric Association 2003), but additional points should be emphasized. Management of these patients involves, at a minimum, five essential components: safety, protection during detoxification, abstinence, treatment of comorbid conditions, and relapse prevention (Table 17–5). Clinicians also should support prevention efforts.
Safety Providing safety is the first step in the management of any suicidal individual. There is a need for protection not only of the individual but also of the public. Much self-injurious behavior is made by healthy adults who deny intent once sober, but this does not alleviate the duty to ensure safety so
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TABLE 17–5. Essential components of management of the suicidal substance user 1. 2. 3. 4. 5.
Safety Safe detoxification Abstinence Treatment of comorbid conditions Prevention of relapse
long as ideation or intent is present. In the case of Paul, for example, in which an alcohol-dependent homeless man’s suicidal intent could not be fully assessed, the best action to take is to provide safety at all times. Alcohol-related disorders and co-occurring disorders should be addressed synchronously (in parallel) rather than sequentially. For example, a suicidal patient requiring the protection of a locked psychiatric unit may also need detoxification simultaneous with efforts to protect from self-harm.
Safe Detoxification The dependent individual should be detoxified to prevent withdrawal and any agitation or distress that may accompany it. For cocaine, withdrawal may include depression. Withdrawal from opioids is not usually lifethreatening, but it is typically uncomfortable. Many centers now apply protocols for opioid withdrawal that utilize clonidine and other adjunctive medicine, such as dicyclomine (Bentyl) for gastrointestinal pain, nonsteroidal anti-inflammatory drugs for myalgias, and antiemetics, rather than opioids. When failed suicide attempts among individuals with substancerelated disorders require immediate medical or surgical hospitalization, the treating teams may minimize either the substance use disorder or the suicidality, as in the case of Bill described earlier.
Abstinence The third goal should be abstinence (Flavin et al. 1990). The importance of complete abstinence from all substances (except for maintenance replacement and substitution therapies) in the treatment of substance use disorders cannot be overestimated as a goal. Partial abstinence, although not ideal, does reduce morbidity and mortality and may be considered an improvement. Nevertheless, although many recovering patients want to continue using alcohol, it is impossible to identify those few for whom controlled drinking is safe. Total abstinence from all substances provides the best prognosis, and all treatment plans should
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include means to assess for relapse. For those who misuse substances, and especially those whose misuse has been associated with self-harm, abstinence is the only safe option.
Treatment of Comorbid Conditions The treatment of suicidality in substance users with co-occurring disorders follows guidelines for treating those “dual” conditions (Busch et al. 2005). A therapeutic alliance is essential.
Psychotic Disorders Suicidality among psychotic substance-using patients is a tremendous therapeutic challenge that requires hospitalization and optimization of all aspects of the patient’s care. Although some groups have proposed clozapine as a first-line agent for suicidal substance-using patients with chronic psychotic disorders because of its putative reduction of suicide risk (Meltzer et al. 2003), no single antipsychotic has been shown to be superior in this specific clinical situation. Thus, the choice of medication should reflect the clinician’s usual considerations for antipsychotic therapy.
Bipolar Disorder The presence of suicidality among patients with bipolar depression is common, and more so when substances are being used. This situation requires significant clinical attention. Clinical experience may suggest that when mania precedes addiction, the suicide risk is higher. Lithium is often not as well accepted by alcoholic patients, and it is not as effective for rapid cycling and mixed states. Antiepileptic drugs such as valproate appear helpful (Brady et al. 1995), although there have been no double-blind, placebo-controlled studies on the efficacy of mood stabilizers or antipsychotics in adults with bipolar disorder.
Depressive Disorder Disagreement persists regarding whether to treat depressed substance-using patients with medications. Some new studies suggest pharmacotherapy may be satisfactory; these include the study by Cornelius et al. (1993) regarding fluoxetine and the study by Mason and Kocsis (1991) regarding desipramine. However, our firm perspective is that abstinence should be achieved first before the clinician proceeds with a definitive primary depressive disorder diagnosis and antidepressant therapy. Nunes and Levin (2004), in a meta-analysis of antidepressant medication efficacy for the treatment of co-occurring depression and substance use disorder, indicated
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that in this patient population, the efficacy of antidepressants is comparable with that seen in patients with depression alone.
Personality Disorders Evidence suggests that standard dialectical behavioral therapy, a system of highly interactive therapy based on behavioral and cognitive tenets developed for use with borderline personality disorder, is efficacious for a variety of risks associated with that disorder, including selfinjurious behavior, suicide attempts, suicidal ideation, hopelessness, depression, and bulimia (Rosenthal et al. 2005).
Relapse Prevention Relapse prevention includes both psychosocial and biological therapies and usually also includes involvement in self-help groups such as Alcoholics Anonymous or Narcotics Anonymous. Some attention must be given to the potential to intentionally cause a disulfiram reaction or to overdose on naltrexone or acamprosate; although there are no data on the frequency of these events, they are a part of the clinical experience of many clinicians.
Primary and Secondary Prevention Efforts There is a growing awareness that suicide screening and educational awareness programs have lacked emphasis on the place of substancerelated disorders and the need to integrate substance-related disorders into their work (Department of Health and Human Services 2001; Foster 2001). Youth suicide has been found to be reduced in response to restricted access to alcohol (Birckmayer and Hemenway 1999), suggesting that prevention of intoxication may prevent suicide mortality.
❏ Key Points ■
Exposure to substances increases suicide risk independently of psychiatric condition.
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Substances themselves may be fatal.
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Substance use may be a part of different facets of suicidal behavior.
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Some specific substance-using populations, especially users of nicotine and alcohol, are at higher risk than others.
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The first three considerations of care of a substance-using suicidal individual are safety, abstinence, and protection from withdrawal syndromes.
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Clinicians who deal solely with patients with substance use disorder must remain vigilant for suicidality and other psychiatric states.
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Public health efforts should include substance-related disorders as risk factors for suicide.
References American Academy of Child and Adolescent Psychiatry: Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. J Am Acad Child Adolesc Psychiatry 40(suppl):24S–51S, 2001 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised. Washington, DC, American Psychiatric Association, 1987 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000 American Psychiatric Association: Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry 160(suppl): 1–60, 2003 Bertolote JM, Fleischmann A, De Leo D, et al: Psychiatric diagnoses and suicide: revisiting the evidence. Crisis 25:147–155, 2004 Birckmayer J, Hemenway D: Minimum-age drinking laws and youth suicide, 1970–1990. Am J Public Health 89:1365–1368, 1999 Borges G, Rosovsky H: Suicide attempts and alcohol consumption in an emergency room sample. J Stud Alcohol 57:543–548, 1996 Brady KT, Sonne SC, Anton R, et al: Valproate in the treatment of acute bipolar affective episodes complicated by substance abuse: a pilot study. J Clin Psychiatry 56:118–121, 1995 Brook JS, Brook DW, Rosen Z, et al: Earlier marijuana use and later problem behavior in Colombian youths. J Am Acad Child Adolesc Psychiatry 42:485– 492, 2003 Budney AJ, Hughes JR, Moore BA, et al: Review of the validity and significance of cannabis withdrawal syndrome. Am J Psychiatry 161:1967–1977, 2004 Busch AB, Weiss R, Najavits L: Co-occurring substance use disorders and other psychiatric disorders, in Clinical Textbook of Addictive Disorders. Edited by Frances R, Miller SI, Mack AH. New York, Guilford, 2005, pp 271–302 Centers for Disease Control and Prevention: LCWK2. Deaths, percent of total deaths, and death rates for the 15 leading causes of death in 10-year age groups, by race and sex: United States, 2002. Available at http://www. cdc.gov/nchs/data/dvs/LCWK2_2002.pdf. Accessed August 10, 2005. Conwell Y, Duberstein PR, Cox C, et al: Relationships of age and Axis I diagnoses in victims of completed suicide: a psychological autopsy study. Am J Psychiatry 153:1001–1008, 1996 Cornelius JR, Salloum IM, Cornelius MD, et al: Fluoxetine trial in suicidal depressed alcoholics. Psychopharmacol Bull 29:195–199, 1993 Department of Health and Human Services: National Strategy for Suicide Prevention: Goals and Objectives for Action. Rockville, MD, U.S. Department of Health and Human Services, Public Health Service, 2001
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Flavin DK, Franklin JE, Frances RJ: Substance abuse and suicidal behavior, in Suicide Over the Life Cycle: Risk Factors, Assessment, and Treatment of Suicidal Patients. Edited by Blumenthal SJ, Kupfer DJ. Washington, DC, American Psychiatric Press, 1990, pp 177–204 Foster T: Dying for a drink. BMJ 323:817–818, 2001 Graham K, Leonard KE, Room R, et al: Alcohol and aggression: current directions in research on understanding and preventing intoxicated aggression. Addiction 93:659–676, 1998 Guze SB, Robins E: Suicide and primary affective disorders. Br J Psychiatry 117: 431–438, 1970 Harris EC, Barraclough B: Suicide as an outcome for mental disorders. Br J Psychiatry 170:205–228, 1997 Henriksson MM, Aro HM, Marttunen MJ, et al: Mental disorders and comorbidity in suicide. Am J Psychiatry 150:935–940, 1993 Hesselbrock M, Hesselbrock V, Syzmanski K, et al: Suicide attempts and alcoholism. J Stud Alcohol 49:436–442, 1988 Hesselbrock V, Dick D, Hesselbrock M, et al: The search for genetic risk factors associated with suicidal behavior. Alcohol Clin Exp Res 28(suppl):70S–76S, 2004 Hoaken PNS, Stewart SH: Drugs of abuse and the elicitation of human aggressive behavior. Addict Behav 28:1533–1554, 2003 Inskip HM, Harris EC, Barraclough B: Lifetime risk of suicide for affective disorder, alcoholism and schizophrenia. Br J Psychiatry 172:35–37, 1998 Institute of Medicine: Reducing Suicide: A National Imperative. Washington, DC, National Academies Press, 2002 Kessler RC, Crum RM, Warner LA, et al: Lifetime co-occurrence of DSM-III-R alcohol abuse and dependence with other psychiatric disorders in the National Comorbidity Survey. Arch Gen Psychiatry 54:313–321, 1997 Kleber HD, Gawin FH: The spectrum of cocaine abuse and its treatment. J Clin Psychiatry 45:18–23, 1984 Limosin F, Loze JY, Boni C, et al: Male-specific association between the 5-HTTLPR S allele and suicide attempts in alcohol-dependent subjects. J Psychiatr Res 39:179–182, 2005 Malone KM, Waternaux C, Haas GL, et al: Cigarette smoking, suicidal behavior, and serotonin function in major psychiatric disorders. Am J Psychiatry 160: 773–779, 2003 Marzuk PM, Tardiff K, Leon AC, et al: Prevalence of cocaine use among residents of New York City who committed suicide during a one-year period. Am J Psychiatry 149:371–375, 1992 Mason BJ, Kocsis JH: Desipramine treatment of alcoholism. Psychopharmacol Bull 27:155–161, 1991 Meltzer HY, Alphs L, Green AI, et al: Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT). Arch Gen Psychiatry 60:82–91, 2003 Menninger KA: Man Against Himself. New York, Harcourt Brace, 1938 Miles CP: Conditions predisposing to suicide: a review. J Nerv Ment Dis 164: 231–246, 1977 Moeller FG, Dougherty DM: Antisocial personality disorder, alcohol, and aggression. Alcohol Res Health 25:5–11, 2001
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Murphy GE, Wetzel RD, Robins E, et al: Multiple risk factors predict suicide in alcoholism. Arch Gen Psychiatry 49:439–443, 1992 Nunes EV, Levin FR: Treatment of depression in patients with alcohol or other drug dependence: a meta-analysis. JAMA 291:1887–1896, 2004 Petronis K, Samuels J, Moscicki E, et al: An epidemiologic investigation of potential risk factors for suicide attempts. Soc Psychiatry Psychiatr Epidemiol 25:193–199, 1990 Phillips J, Carpenter KM, Nunes EV: Suicide risk in depressed methadonemaintained patients: associations with clinical and demographic characteristics. Am J Addict 13:327–332, 2004 Pirkola SP, Marttunen MJ, Henriksson MM, et al: Alcohol-related problems among adolescent suicides in Finland. Alcohol Alcohol 34:320–329, 1999 Potash JB, Kane HS, Chiu YF, et al: Attempted suicide and alcoholism in bipolar disorder: clinical and familial relationships. Am J Psychiatry 157:2048– 2050, 2000 Preuss UW, Schuckit MA, Smith TL, et al: Predictors and correlates of suicide attempts over 5 years in 1,237 alcohol-dependent men and women. Am J Psychiatry 160:56–63, 2003 Regier DA, Farmer ME, Rae DS, et al: Comorbidity of mental disorders with alcohol and other drug abuse: results from the Epidemiologic Catchment Area (ECA) study. JAMA 264:2511–2518, 1990 Rosenthal MZ, Lynch TR, Linehan MM: Dialectical behavior therapy for individuals with borderline personality disorder and substance use disorder, in Clinical Textbook of Addictive Disorders. Edited by Frances R. Miller SI, Mack AH. New York, Guilford, 2005, pp 615–636 Rossow I, Amundsen A: Alcohol abuse and suicide: a 40-year prospective study of Norwegian conscripts. Addiction 90:685–691, 1995 Roy A: Characteristics of cocaine-dependent patients who attempt suicide. Am J Psychiatry 158:1215–1219, 2001 Roy A: Characteristics of opiate dependent patients who attempt suicide. J Clin Psychiatry 63:403–407, 2002 Sakai JT, Hall SK, Mikulich-Gilbertson SK, et al: Inhalant use, abuse, and dependence among adolescent patients: commonly comorbid problems. J Am Acad Child Adolesc Psychiatry 43:1080–1088, 2004 Stone MH: Long-term outcome in personality disorders. Br J Psychiatry 162: 299–313, 1993 Tarter RE, Kirisci L, Reynolds M, et al: Neurobehavior disinhibition in childhood predicts suicide potential and substance use disorder by young adulthood. Drug Alcohol Depend 76(suppl):S45–S52, 2004 Waern M: Alcohol dependence and misuse in elderly suicides. Alcohol Alcohol 38:249–254, 2003 Wilcox HC, Anthony JC: The development of suicide ideation and attempts: an epidemiologic study of first graders followed into young adulthood. Drug Alcohol Depend 76(suppl):S53–S67, 2004 Wu P, Hoven CW, Liu, et al: Substance use, suicidal ideation and attempts in children and adolescents. Suicide Life Threat Behav 34:408–420, 2004
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Outpatient Treatment John T. Maltsberger, M.D.
Alliance: The Heart of the Matter Treating outpatients at risk for suicide is a dicey undertaking for clinicians in more ways than one. In the first place, not everybody who refers such patients for treatment is likely to have the same agenda. Hospitals want to shorten lengths of stay and move patients into outpatient care quickly. Clinics, institutions, and families want the patient to “get better” and give up the suicide option. Insurance companies want that as well, but fast and on the cheap. Psychiatrists want to see the patients get better, but the patients themselves are often not so sure. In fact, many of them are uncertain as to whether they would be better off alive or dead. The first task of the therapist must be to establish a treatment alliance, however fragile, sometimes in the face of near hopelessness. The keystone of the alliance must be mutual intent to build up reasons for living, with patients’ commitment to set aside the suicide option and participate in the treatment, at least for the time being. Because these patients’ mental states may alter quickly and unexpectedly, the alliance usually fluctuates episodically, sometimes weakening or even breaking down. With other patients for whom life and death are not at stake, broken alliances are less critical. With suicidal patients, however, everything depends on alliance, and for that reason, it must be explicitly addressed from the beginning and systematically monitored as treatment progresses. Linehan (1993) grasped this principle and centrally integrated it into dialectical behavioral treatment. Following her practice, practitioners of all kinds are well advised to take up patients’ commitment to living at the 367
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very beginning, vigorously and supportively negotiating an agreement to keep alive while pledging the best help with it they can, before embarking on treatment. This is the first order of business, just as the second is systematically monitoring the state of the alliance throughout the treatment. “No-suicide contracts” have little use as suicide preventatives (Miller 1999), but the patient must understand that the purpose of the treatment is to prevent suicide and, accordingly, to make a serious commitment to the treatment team to work hard to that end. Patients must be persuaded to agree that suicide is “off the table” as a choice, understanding that if they feel they cannot keep this commitment as the treatment goes forward, they will call for help. Clinicians should be well aware that commitments of this kind cannot be relied on to prevent suicides, but patients’ commitment to staying alive and working with the treatment team is indispensable from the beginning. It is the heart of the alliance.
When Does Outpatient Treatment Make Sense? Outpatient treatment is not suitable for patients clearly unwilling to commit themselves to staying alive, but ambivalent or fragile commitment is usually inevitable at first. The clinician should, of course, acknowledge that the commitment is difficult to make and offer the patient reasonable and possible help to keep it, but absent sincere even if frail patient commitment, the clinician who begins outpatient treatment of a suicidal patient will be living out the Zen koan: “What is the sound of one hand trying to clap?” Negotiating this agreement may not be achievable in one session, but no suicidal person, inpatient or outpatient, can really be “in treatment” until the commitment is made. Outpatient care should not begin before a good suicide risk assessment has been carried out, justifying the conclusion that the patient has a reasonable likelihood of entering and participating in treatment without committing suicide before a therapeutic alliance has a chance to form and begin consolidating. Making a suicide risk assessment is described in Chapter 26 (“Legal Perspective on Suicide Assessment and Management”) of this book as well as in the practice guideline of the American Psychiatric Association (2003). One should make sure that the patient is competent to understand and give consent to the treatment offered after its risks and benefits have been explained. A written record of mental capacity, explanation, and consent should be preserved. When circumstances permit, it is generally desirable for the next of kin to sign the consent as well. When patients are minors, parental consent is of course necessary before un-
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dertaking any treatment. Patients and families should understand that outpatient treatment of suicidal patients has its hazards. Before outpatient treatment is undertaken, the therapist should make sure reasonable backup will be available in the event of a future suicidal crisis. What available exterior sustaining resources does the patient have? Who are the people on whom the patient relies for support and validation? The therapist should make a record of their names, whereabouts, and telephone numbers to be prepared if the patient worsens. Unless the clinician is confident that brisk admission to a psychiatric unit will be possible should a suicide crisis evolve, outpatient management may be unwise, and perhaps the patient should be referred to someone else with a hospital-based practice.
Establishing the Treatment Team Much of the time recently suicidal patients, or those who are vulnerable to suicide, need more structure for their treatment than occasional office visits can provide. At least in the beginning of their treatment, a partial hospital or day program may be advisable, with continuing group therapy as the patient moves toward greater independence in the community. When substance abuse has been a part of the problem, the therapist should insist the patient participate in Alcoholics Anonymous or some other rehabilitation program. Enrollment of family and friends in support groups is often very desirable, but in any case, there should be some regular avenue for communication to the therapist from those on whom the patient relies for support. Although the patient and the involved, supportive others should all understand that—except in an emergency—what the patient says to the treatment team is confidential, those close to the patient must have a reliable means for getting any information they may think important through to the team in general and to the patient’s therapist in particular. This may involve calling a predesignated member of the treatment team from time to time. The family and friends involved in the patient’s treatment should be educated at the outset about danger signs that might point to a developing suicidal crisis. In contemporary practice it is common to split the treatment between a psychotherapist and a psychopharmacologist. Whatever advantages such a division affords, perils are implicit in it: What a patient tells one member of a treatment team, he may represent differently to others. This is especially true with a suicidal patient, and truer yet if the patient has borderline personality disorder. A patient may report developing suicide plans to the therapist while smoothly assuring the psy-
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chopharmacologist that all is well. Another may discuss funeral arrangements with family but deny hopelessness to the therapist. The first principle of team treatment is that communication between all participants should be open, frequent, and regular. Hendin et al. (2006) found that in 9 of 36 suicides that occurred while patients were in treatment, poor communication between treating clinicians was a major factor in the fatal outcomes. In one treatment of many months, the psychotherapist and psychopharmacologist never spoke with each other before the patient’s death, although both worked in the same clinic. A final if occasional member of the treatment team might well be a consultant colleague with whom the treatment is reviewed either regularly or from time to time as the need arises. Suicidal patients make extraordinary demands on clinicians’ stamina and emotional balance. Consultation can serve as a helpful check to make sure nothing is overlooked and as a helpful validation of ongoing clinical judgment. Before the treatment begins, all clinicians involved should understand who is the team leader, or captain. Usually this will be the person who sees the patient most intensively, presumably the psychotherapist, who optimally may be the psychopharmacologist at the same time. Responsibility for keeping the team together and in good communication with each other rests with the captain. This is often no small task. The captain needs to be as vigilant as a good sheep dog in tending to this task, keeping tabs on everyone and rounding up strays. Although to some such an arrangement may seem anticollaborative and too authoritarian, the designation of a team captain is essential because the responsibility for keeping the treatment on track and the team working together must lie somewhere. The crews of sailboats well understand that smooth and safe operation of the ship requires clear delineation of responsibility with a captain in charge of the enterprise. Under the law, physicians must answer for the conduct of others who collaborate in the treatment of patients under their care, and when suicides occur, it is generally the physician whom families want to hold accountable, whether the doctor considers himself captain of the team or not. Physicians cannot abdicate final responsibility for any patients for whom they prescribe.
Beginning the Treatment Suicidal patients are currently treated according to a variety of different psychotherapeutic methods. Empirical study has shown a number of them to be effective, some more so than others. The empirically supported treatments include interpersonal psychotherapy (IPT) (Neu et al. 1978; Weissman et al. 1981), cognitive therapy (Beck et al. 1979), dia-
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lectical behavior therapy (Linehan 1993), mentalization therapy (Bateman and Fonagy 2004), transference-based psychotherapy (Clarkin et al. 1999), and psychoanalytic (psychodynamic) psychotherapy (Maltsberger and Weinberg 2005). Currently there is much discussion and debate as to what makes these treatments work and what they have in common. From the clinical perspective, an active, empathically engaged therapist who is supportive and validating is common to all. The therapist concentrates on patients’ affective experiences and encourages verbalization and mental exploration of feelings in the context in which they arise. Interpretation, clarification, and education are common to most of these treatments. Most stress the importance of confronting self-defeating behavior, and most attend seriously to the realities of the therapeutic relationship and patients’ distortions of it. Suicide is statistically most likely in the first weeks after hospital discharge (Qin and Nordentoft 2005), a period when mental state is likely to fluctuate. For this reason, patients should be seen frequently to consolidate the therapeutic alliance and monitor progress. The frequency of visits will depend on the individual patient, but once weekly is not too often just after discharge. Nothing more than psychopharmacological follow-up at infrequent intervals is hard to justify (Hollon et al. 2005); best care requires relatively frequent visits of combined psychotherapy and medication.
Tracking the Treatment The patient’s progress (or lack thereof) should be systematically monitored, and the team leader is responsible for correlating, recording, and communicating significant observations to all members of the treatment team. Patients’ level of commitment to the treatment may be gauged not only by what they say about it but also by the appearance of treatment-interfering behaviors—these would include, among other things, not keeping appointments, coming late, failing to pay the bill, not complying with medication prescription, substance abuse, and dropping out of substance abuse programs. These behaviors should be supportively confronted in the psychotherapy as departures from the commitment to work at staying alive (Linehan 1993). In the course of suicide risk assessment, the exterior resources patients need to keep in balance should be identified. An exterior sustaining resource is someone or something else (perhaps a work position or maybe a pet) that the patient relies on to maintain affective regulation and self-integrity (Maltsberger 1988). Suicide crises can be precipitated by losses, or threatened losses, of such resources, and the history may reflect that previous attempts fast followed on an affective storm that blew
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up when an important someone or something fell away, or was driven away, by the patient (Maltsberger et al. 2003). The therapist should keep a sharp lookout for these resources. If the treatment team watches for the evolution of suicidal crises, suicide attempts can often be avoided. The herald of such a crisis is often (not always) a precipitating event that triggers a flood of intense, painful, unendurable affect other than depression. Sometimes the appearance or the worsening of a sleep disturbance hints at the emergence of a suicide crisis or an incipient mixed-state episode in an affective disorder. A deterioration of the patient’s connection to and integration with his social, family, and work situation follows. As the crisis worsens, there will be suicidal hints, communications, or behaviors, coupled with increasing substance abuse or loss of self-control (Hendin et al. 2001). The affects to watch for, especially as they worsen, are intense anxiety, hopelessness, desperation, rage, abandonment, and self-hate. Desperation is an experience of anguish so intolerable it cries out for immediate relief (Hendin et al. 2004). Combinations of despair (total hopelessness), severe self-hate, and desperation are very dangerous and require immediate attention. Fawcett et al. (1990) have shown that severe anhedonia and intense anxiety are markers of suicide. Combinations of these intense feelings can lead to a sense of entrapment from which patients think suicide is the only escape. Bear in mind that the subjective experiences described here may not be evident to casual inspection of patients’ general appearance and behavior—they must be inquired after and are perhaps even more important than what the patient says about current suicidal intent. Of course, increasing suicidal preoccupation and the appearance and strengthening of impulses are important and should be tracked, but suicide does not occur for most patients until they are overwhelmed by mental pain (Shneidman 1993). Suicidal ideation is therefore secondary; suicide comes to mind as a way out of a trap. Intolerable affect drives it most of the time. As suicide looms, dissociative experiences may appear, signaling incipient self-breakup. Patients can then experience their bodies as something apart from their essential selves, as things to be jettisoned (Maltsberger 2004). Frank delusional thinking can appear—some patients believe they can, through killing themselves, rejoin important others and escape from this intolerable world. There is much to be said for keeping a tabular record, and a form for doing so is shown in Table 18–1. Regular tabulation of this kind not only reminds one of what to monitor, but it lends itself to ready sharing by the treatment team, even by e-mail. This can enhance collaboration, consultation, and concentrate collective attention.
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TABLE 18–1. Elements for systematic monitoring Rate level of disturbance as none (0), mild (1), moderate (2), or severe (3). Enter date: Date 1 Date 2 Date 3 Date N Therapeutic alliance Exterior sustaining resources Interpersonal stability (people, work) Suicide hints/communications Sleep quality Substance/alcohol abuse Mental state Hopelessness Anguish Rage Aloneness/abandonment Anxiety Self-hate Dissociative experiences Entrapment Anhedonia Suicide ideation/preoccupation Impulses to self-harm
Of course, written communications, although helpful, can never take the place of regular oral conferences. Conferences are difficult to arrange in busy clinic settings, but they need not take long and can be scheduled regularly in advance.
Problems and Difficulties Many problems in the outpatient care of suicidal patients can be avoided if the treatment team sees them coming ahead of time. Relying on what patients say about present suicide intent instead of following the mental state as the primary guide is always tempting, especially when the clinical picture is cloudy. Bear in mind that many patients tell the doctor they do not intend to kill themselves but soon do it anyway. Many patients who have made “no-suicide contracts” die of suicide regardless (Busch et al. 2003). Let the clinician be skeptical whenever a patient denies suicide intent or promises no self-harm while experiencing agitation or any combination of the intense painful affects that suggest desperation.
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Anguish as a subjective experience has some component of anxiety. Some patients refer to horror or terror in describing it. Clinicians are often reluctant to treat this symptom aggressively with benzodiazepines, especially if there is a history of substance abuse. It remains necessary, however, to get patients out of the desperation zone to prevent suicide attempts. Selective serotonin reuptake inhibitors are currently much favored as anxiolytic agents, but these drugs may take many days to act, and in the face of hypomanic potential, they may increase distress instead of relieving it. Intense affective distress needs immediate relief, if not with benzodiazepine prescription, then perhaps with one of the newer antipsychotic agents such as quetiapine. In urgent states electroconvulsive treatment may be lifesaving. Those suicidal patients vulnerable to fluctuations of mood and prone to fall into very painful mixed states are much helped by the prescription of mood stabilizers, especially lithium salts (Tondo et al. 2003).
Case Example 1 Anthony, a 20-year-old college student, falls into an agitated depression after his estranged parents both blamed him for a fracas they set going over a holiday vacation. A month later Anthony is overwhelmed with anguish and talking about suicide to his roommates. On several occasions he goes out onto the roof of his dormitory “just to see what it would be like” if he decides to jump. The nurse practitioner at the health service where his friends take him gives him a prescription for sertraline, even though he has an unrecognized family history of bipolar disorder. (The responsible clinic psychiatrist never meets Anthony, and nobody ever records a suicide risk assessment.) He grows much worse. Within a week, while preparing for a dangerous jump, he luckily is interrupted. Finally another psychiatrist examines him, discovers how suicidal and depersonalized Anthony is, and admits him, in spite of protestations, to a psychiatric unit. The sertraline is stopped, and olanzapine is prescribed. Anthony’s recovery is rapid. He readily agrees to outpatient psychotherapy, accepts a prescription for a mood stabilizer, and is treated quite successfully, managing after a time to disentangle himself from his parents’ long-standing quarrel.
In the absence of close monitoring, therapists sometimes overlook or forget about troublesome symptoms that the patient may not mention. Certainly the management of anxiety and agitation is of paramount importance, but so indeed is the treatment of psychotic symptoms. Antidepressant drugs can be very helpful, but they are often prescribed in insufficient dosages. Substance abuse, a frequently neglected problem, should not be allowed to continue without supportive but systematic confrontation. Getting substance abuse under control and under treatment is vital.
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Sometimes inadequate prescription of appropriate medicines occurs because patients object to side effects or simply do not want to take medicine. Psychiatrists should not resign themselves to such situations but instead should work with these patients to find some acceptable compromise regimen. Letting the patient control the psychopharmacology is but one example of a common problem. When the patient or the patient’s family takes charge of the treatment in whatever sector, matters can get out of hand. In one instance, at the insistence of a patient’s relative, an important community leader, a patient was allowed to leave the ward to go out to lunch against the psychiatrist’s better judgment. He eloped from the restaurant and committed suicide. Outpatients should not have the last word about going into the hospital. When a well-conducted risk assessment shows a suicide attempt is in the offing, the psychiatrist must insist on admission and not agree to let the patient go home and “think it over.” Psychiatrists must sometimes find the courage to act decisively and sign an involuntary petition. Remember, he who hesitates is not only lost but can find himself several miles from the next freeway exit. Impending suicide is a medical emergency, and like the surgeon who knows appendicitis requires immediate intervention, the psychiatrist should stand by his diagnosis. Every clinician wants to avoid signing unnecessary involuntary petitions, but when mistakes are made, they are almost always in the other direction—not signing them. A few days in an inpatient unit are much preferable to a few in an intensive care unit or to death. Sometimes clinicians do not understand that the patient does not have to acknowledge immediate suicidal intent to qualify for involuntary admission, although ignorant insurance company representatives may claim this is so. Admissibility on an involuntary paper in virtually every jurisdiction in the United States requires no more than a physician’s informed judgment that an attempt is imminent (more probable than not, and soon) in a patient with mental illness. Patients are lost to suicide from time to time because clinicians lack confidence in their own assessment of risk. Outpatient treatment of suicidal patients requires familiarity with the principles of risk assessment, and sufficient tolerance for the implicit ambiguities thereof, if one is not to be frozen by indecision at critical moments. Working with a mutually supportive team and keeping a clear clinical assessment in mind at all times are the best protections against therapeutic paralysis. Finally, therapists’ anxiety can cause them to stumble. Suicidal patients often struggle to control their environments, insisting on control of one or another aspect of their treatment. Few patients will agree out
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of hand when the clinician recommends hospitalization. That is why, in first broaching the subject, one recommends the hospital as a temporary step for the relief of a transient crisis, an occasion for respite, consultation, and regrouping. Only as a last resort should the psychiatrist take an opposing point of view about going into inpatient care. When necessary, however, the psychiatrist should insist on hospitalization as a nonnegotiable step and not back down. After all, just as the physician bears final responsibility for the patient’s safety, it is the physician who must have the last word; the final authority over hospitalization is his.
Case Example 2 Professor S, a 55-year-old classicist and internationally recognized scholar, is being treated as an outpatient in a university clinic by Dr. C, a psychiatrist who provides both psychotherapy and psychopharmacology. The patient is very depressed and appears to be worsening. Several years previously he attempted suicide. His wife is also depressed and has been discussing suicide with her therapist, another psychiatrist in the same clinic. One day she reports that Professor S proposed a suicide pact and has been speaking of getting a gun. The wife’s therapist passes this information on to Dr. C, who decides that hospitalization will probably be in order and takes some preliminary preparatory measures. When Professor S arrives for his appointment that day, Dr. C gently raises the matter of his hopelessness and brings up the matter of the gun and the suicide pact. Professor S acknowledges that he has given up hope and that he does indeed have a gun, but he claims he will not kill himself unless his wife agrees to die with him. He disagrees with Dr. C’s suggestion of a hospital admission and insists that he should go home. He says maybe he will talk over going into the hospital with his wife. Dr. C refuses to allow Professor S to leave the clinic, whereupon the patient threatens to get him fired from the university. Still insisting, Dr. C calls the security personnel. They have to forcibly restrain Professor S and carry him kicking and screaming through the clinic waiting room, filled with startled members of the university community, out into an ambulance. On an involuntary certificate Professor S is admitted to a psychiatric unit, where after a few days he agrees to receive a course of electroconvulsive treatment and makes a rapid recovery. Professor S resumes treatment with Dr. C on discharge from the hospital. For many years afterward, he writes Dr. C a note on the anniversary of his hospital admission, thanking him for saving his life.
Occasionally therapists find themselves in control struggles about hospitalization, prescription compliance, frequency of visits, fees, or other matters. Control-sensitive patients can prove obdurate once control battles are engaged. Negotiation should be one’s watchword, but not limitless negotiation. If treatment is to succeed, ultimately the patient must cooperate with the essentials of what is laid out in the treatment plan. Most
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of the time there is room for discussion, temporizing, and, often, compromise. The temptation to get into unnecessary power struggles often arises because therapists, without quite being aware of it, feel helpless and want to flex their muscles, as it were, to reassure themselves that they are in charge (Adler 1972; Gabbard 1999). We must choose our skirmishes wisely and even be prepared to lose a few if treatment is to succeed and prove effective. On the one hand, we must guard against passive surrender, giving in to what patients want or demand when essentials are at stake. On the other, we must avoid getting into needless struggles in an effort to show patients (and ourselves) who is boss. Ultimately patients must comply with the essential parts of the treatment plan: psychotherapy, psychopharmacology, substance abuse treatment, and sometimes hospitalization. When patients refuse to cooperate in the essentials, however, the original treatment alliance to live and to build up a life has been compromised and perhaps has failed. If that commitment cannot be reclaimed and patients refuse to commit themselves to it anew, termination may be necessary. Termination can sometimes be managed on an outpatient basis, but sometimes safety concerns require hospital admission and inpatient renegotiation of the treatment commitment, sometimes with another team.
❏ Key Points ■
Before starting outpatient care, make a good suicide risk assessment and keep it up-to-date.
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Remember that Informed consent and a risk-benefit analysis are essential.
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Do not accept for outpatient management any patient who is unwilling to make a commitment to keep alive and give the treatment a chance.
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Ensure the availability of prompt inpatient admission. Good backup is essential. Treating suicidal patients outside the hospital means that prompt inpatient admission should be possible should the need arise.
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Identify and keep track of the patient’s external sustaining resources.
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Choose a captain to hold the treatment team together.
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Keep in good communication as a team. This is one of the team captain’s main responsibilities.
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Do not let the patient control the treatment. Keep the essential components of the treatment clearly in mind and under review with
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the patient and the team. These components are cooperation in psychotherapy, psychopharmacology, substance abuse treatment, and sometimes hospitalization. Compromise of the essentials is not negotiable. ■
Monitor the patient’s life adaptation and mental state systematically.
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When in doubt, get consultation.
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Keep good records.
References Adler G: Helplessness in the helpers. Br J Med Psychol 45:315–326, 1972 American Psychiatric Association: Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry 160(suppl): 1–60, 2003 Bateman A, Fonagy P: Psychotherapy for Borderline Personality Disorder: Mentalization Based Treatment. Oxford, England, Oxford University Press, 2004 Beck AT, Rush AJ, Shaw BF, et al: Cognitive Therapy of Depression. New York, Guilford, 1979 Busch KA, Fawcett J, Jacobs DG: Clinical correlates of inpatient suicide. J Clin Psychiatry 64:14–19, 2003 Clarkin JF, Yeomans FE, Kernberg OF: Psychotherapy for Borderline Personality. New York, Wiley, 1999 Fawcett J, Scheftner WA, Fogg L, et al: Time-related predictors of suicide in major affective disorder. Am J Psychiatry 147:1189–1194, 1990 Gabbard GO (ed): Countertransference Issues in Psychiatric Treatment. Washington, DC, American Psychiatric Press, 1999 Hendin H, Maltsberger JT, Lipschitz A, et al: Recognizing and responding to a suicide crisis. Suicide Life Threat Behav 31:115–128, 2001 Hendin H, Maltsberger JT, Haas AP, et al: Desperation and other affective states in suicidal patients. Suicide Life Threat Behav 34:386–394, 2004 Hendin H, Haas AP, Maltsberger JT, et al: Problems in psychotherapy with suicidal patients. Am J Psychiatry 163:67–72, 2006 Hollon SD, Jarrett RB, Nierenberg AA, et al: Psychotherapy and medication in the treatment of adult and geriatric depression: which monotherapy or combined treatment? J Clin Psychiatry 66:455–458, 2005 Linehan MM: Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York, Guilford, 1993 Maltsberger JT: Suicide danger: clinical estimation and decision. Suicide Life Threat Behav 18:47–54, 1988 Maltsberger JT: The descent into suicide. Int J Psychoanal 85:653–668, 2004 Maltsberger JT, Weinberg I: Psychoanalytic perspectives on the treatment of an acute suicidal crisis. J Clin Psychol, December 9, 2005 (Epub ahead of print) Maltsberger JT, Hendin H, Haas AP, et al: Determination of precipitating events in the suicide of psychiatric patients. Suicide Life Threat Behav 33:111–119, 2003
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Miller MM: Suicide-prevention contracts: advantages, disadvantages, and an alternative approach, in The Harvard Medical School Guide to Suicide Assessment and Intervention. Edited by Jacobs DG. San Francisco, CA, Jossey-Bass, 1999, pp 463–481 Neu C, Prusoff BA, Klerman GL: Measuring the interventions used in the shortterm interpersonal psychotherapy of depression. Am J Orthopsychiatry 48:629–636, 1978 Qin P, Nordentoft M: Suicide risk in relation to psychiatric hospitalization: evidence based on longitudinal registers. Arch Gen Psychiatry 62:427–432, 2005 Shneidman ES: Suicide as psychache. J Nerv Ment Dis 181:145–147, 1993 Tondo L, Isacsson G, Baldessarini R: Suicidal behaviour in bipolar disorder: risk and prevention. CNS Drugs 17:491–511, 2003 Weissman MM, Klerman GL, Prusoff BA, et al: Depressed outpatients: results one year after treatment with drugs and/or interpersonal psychotherapy. Arch Gen Psychiatry 38:51–55, 1981
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Emergency Services Laura J. Fochtmann, M.D.
The assessment and clinical management of suicide risk can pose considerable challenges in emergency settings. Although the general principles of assessment remain applicable (American Psychiatric Association 2003; Simon 2004; see also see Chapter 1, “Suicide Risk: Assessing the Unpredictable,” this volume), evaluation and decision making in emergency settings are often constrained by the need to care for many acutely ill patients simultaneously. In addition, it is rare for the patient to have an ongoing therapeutic relationship with the individual who performs the emergency evaluation. It is therefore especially important to rapidly establish rapport with the patient and gain as much information as possible within a relatively short period of time. Because many emergency visits occur outside of weekday hours, obtaining information from the patient’s primary care providers, psychiatrists, or other mental health professionals can also be difficult. Depending on the nature of the crisis that prompted the emergency visit, patients or their family members may be emotionally distressed and unable or unwilling to participate in the evaluation and planning of care. Legal and administrative factors that are more relevant to emergency settings also require consideration. Insofar as the setting of emergency psychiatric care is concerned, there is substantial variability across facilities (Breslow et al. 2000). For example, in some institutions, emergency psychiatric assessments are primarily performed by emergency department physicians. In other facilities, emergency physicians obtain consultation from on-call psychiatrists or from other mental health professionals (who are sometimes referred to as crisis counselors). Still other hospitals have specialized 381
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psychiatric emergency programs that are staffed by psychiatrists and other mental health professionals. Different models may also be used in individual hospitals depending on patient needs or the time of day. For example, specialized psychiatric emergency programs will typically provide consultation to emergency physicians when patients are still medically unstable (e.g., following a suicide attempt), or a facility may use a consultative model on day and evening shifts but have assessments primarily done by emergency physicians on night shifts. Such staffing plans are generally determined by the size of the facility, the numbers of patients presenting with psychiatric needs, and the availability of appropriately trained staff in the geographic area. The staffing plan may also dictate the specific duties that each staff member will perform in evaluating and treating a suicidal patient. For example, within a specialized psychiatric emergency service, a psychiatrist may provide the primary psychiatric and medical evaluation and psychiatric social workers may interface with family members and arrange hospitalization or community referrals. Within a consultative model, the consultant’s role may be broader and can also include providing an educational or liaison function with emergency physicians. Regardless of the model of emergency care used, virtually all individuals who present to an emergency department with psychiatric concerns or symptoms are at increased risk of suicide and will benefit from a formal assessment of suicide risk (American Psychiatric Association 2003; Simon 2004). A significant number will specifically present with suicidal ideas, plans, or intentions or after a suicide attempt or other self-injurious behavior (Dhossche 2000; Hazlett et al. 2004). Others will present with agitation or aggressive behaviors, heightened anxiety, prominent mood disturbance, or acute or subacute worsening of psychosis (American Psychiatric Association 2003; Radomsky et al. 1999). Recent use of alcohol or other substances is often an accompanying factor (Adams and Overholser 1992; Conner and Duberstein 2004; Dhossche 2000; Taylor et al. 1999). Each of these features can contribute to an increased risk of suicide (American Psychiatric Association 2003; Simon 2004; see also specific chapters in this textbook). In longitudinal follow-up studies, increased rates of suicide have been observed for patients receiving emergency psychiatric evaluations (Hillard et al. 1983) as well as for patients evaluated after a suicide attempt (Ekeberg et al. 1994; Nordstrom et al. 1995; Suokas et al. 2001). In addition, under the Emergency Medical Treatment and Active Labor Act (EMTALA) (2005), an assessment for suicide risk is an important part of the medical screening evaluation for individuals who present with psychiatric concerns or symptoms (Bitterman 2001; Quinn et al. 2002).
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Case Example Mr. Patterson is a 36-year-old African American man who is brought to the emergency department by police after he called 911, stating, “I’m afraid I might do something to hurt myself.” Upon arrival, he is assessed by the emergency department triage nurse, and his vital signs include a pulse of 112, a blood pressure of 145/86, a respiratory rate of 18, and a temperature of 99.5°F (37.5°C). His skin is dry and his pupils are dilated but equal and reactive. A fingerstick blood glucose determination is 98 mg/dL. He is taken to one of the emergency department treatment rooms, and because he mentioned thoughts of harming himself, a member of the hospital staff is assigned to sit with him until an evaluation can be performed. Dr. Jordan, the emergency department physician, meets with Mr. Patterson and learns that Mr. Patterson is currently in treatment for schizophrenia at a community mental health clinic and is taking clozapine 300 mg orally at bedtime and benztropine 0.5 mg orally twice daily. He recently was found to have an elevated cholesterol level and was prescribed atorvastatin 20 mg orally once daily, which he began to take. He does not take vitamins, herbs, or other over-the-counter products and reports no allergies or other physical illnesses. Mr. Patterson reports smoking about two packs of cigarettes each day and having done so for the past 20 years. He rarely uses alcohol, as it is not permitted in the community residence where he resides; however, he reports having had three beers earlier in the evening at a local bar. While in his teens, he often used alcohol to excess, and he had one arrest for disorderly conduct while intoxicated. He also reported using marijuana as a young adult, smoking it about once a month from ages 16 to 24. He tried crack cocaine and ecstasy on several occasions in his early 20s but never used opiates or intravenous substances. He has never been in an alcohol or substance treatment program and has not used any substances other than tobacco or alcohol for the past 10 years. Mr. Patterson describes calling the police after beginning to wonder whether he was “being monitored by organized crime” because he had begun to hear “whispers” outside his room at night and had noted a blue van pass by his residence on several occasions in the past week. He was worried that he had been “targeted” and that the occupants of the van intended to torture him. Because he did not wish to experience “the agony of interrogation,” he had begun to think of suicide as a way out. He went to a local bar, thinking that “a few drinks might be relaxing.” Although he had not made any efforts to harm himself, he had grown increasingly fearful that he might attempt suicide and so contacted police. He was also
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concerned that his housing may be in jeopardy because he went out drinking in violation of his community residence’s policy. Dr. Jordan examines Mr. Patterson and notes a well-healed scar about 6 cm in length on the left side of Mr. Patterson’s neck. With the exception of the tachycardia, mildly elevated temperature, and dilated pupils noted by the triage nurse, no other abnormalities are present. Because Mr. Patterson is taking both clozapine and benztropine, each of which has anticholinergic effects, Dr. Jordan thinks this is the most likely cause of the tachycardia and dilated pupils. Mr. Patterson also seems somewhat anxious, and Dr. Jordan thinks this may have contributed to the patient’s tachycardia. The mild elevation in temperature does not seem significant, because Mr. Patterson has no physical signs or symptoms suggestive of infection. Viewing Mr. Patterson as being medically stable for psychiatric assessment, Dr. Jordan contacts the oncall psychiatrist, Dr. Braxton. During his evaluation, Dr. Braxton learns that Mr. Patterson was first hospitalized at age 21 when he began hearing “voices” that he attributed to members of an organized crime group. The “voices” commented on his behavior and also discussed their plans to torture and kill him and his family members. As the “voices” increased in intensity, he became more reclusive and began putting foil over the windows of his room to reduce the likelihood of their monitoring his thoughts. In the hospital, his symptoms responded to treatment with haloperidol, but he did not like taking the medication because of its side effects. Over the next 10 years, Mr. Patterson was hospitalized repeatedly (“about eight or nine times”) for similar exacerbations of illness that seemed to be associated with decreased treatment adherence. Mr. Patterson’s first suicide attempt occurred at age 26, when he heard the “voices” tell him that his family would be “spared” if he were dead. After stockpiling his medications for several weeks, Mr. Patterson went to a hotel and took an overdose of haloperidol, benztropine, and clonazepam. When discovered by the housekeeper, he was unconscious and was taken to the hospital, where he spent 5 days in intensive care before being transferred to the inpatient psychiatric service. At age 32, Mr. Patterson discontinued his medications and again became increasingly symptomatic. Attempting to kill himself, he took a carving knife from the kitchen drawer and cut his neck. His sister came home unexpectedly and called for an ambulance. He was taken to the hospital, where he underwent exploratory neck surgery and was found to have narrowly missed his carotid artery; it took approximately 30 sutures to repair the laceration. During the subsequent psychiatric hospitalization, he began taking clozapine and was discharged to a community resi-
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dence program with follow-up by an assertive community treatment program. With this more intensive treatment plan, Mr. Patterson has been able to adhere to his medication regimen, progress from a supervised community residence to a more independent supervised apartment program (with daily visits by counselors), and begin a supported employment program. He has not required hospitalization for the past 4 years. Mr. Patterson has been receiving psychiatric disability since the time of his first hospitalization. After dropping out of high school in the 11th grade, he was finally able to complete his General Education Development (GED) program. He has a supported employment position doing landscaping and greenhouse work that he enjoys. His parents, his sister, and one of his brothers live nearby. Mr. Patterson sees his relationship with them as a positive and supportive; he often visits with his family on weekends. There is no family history of suicide, substance abuse, or other psychiatric illness. Although he does not attend church regularly, Mr. Patterson identifies himself as a Christian and often prays for help in dealing with his symptoms. On mental status examination, Dr. Braxton notes Mr. Patterson to be a cooperative, neatly dressed, and well-groomed young man who appears younger than his stated age and who has difficulty making eye contact. He is restless and appears anxious but has no adventitious movements or apparent responses to hallucinations during the interview. He is alert and oriented in all spheres and exhibits a stable level of consciousness. Mr. Patterson’s speech is soft, but of regular rate and rhythm and is coherent. He describes his mood as “sad” because he fears his family is at risk because of him. His affect is stable but restricted in range. He describes “whispering” auditory hallucinations that comment on his behavior and that threaten to torture him or his family. He believes that the hallucinations are related to the monitoring devices that were “planted by various crime groups” to keep track of his thoughts and his movements. He does not think the devices are inserting, withdrawing, or broadcasting his thoughts, although they have controlled his thoughts and his body in the past. Mr. Patterson has no thoughts of harming or killing others and says, “I’m a gentle person.” He does, however, have thoughts of suicide, which led him to call police. He has no specific plan and does not wish to act on these thoughts. He realizes that suicide goes against his religious beliefs and may have “eternal consequences,” but he would rather experience those consequences than allow his family to suffer at the hands of “the kingpin.” Mr. Patterson notes that he would feel hopeful about his future as long as the organized crime factions leave him alone. His insight and judg-
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ment appear good in recognizing a need for treatment and in seeking help for his suicidal thoughts when he became worried that he would be tempted to harm himself. Dr. Braxton requests Mr. Patterson’s permission to speak with his sister as well as with the counselor at his community residence program and his outpatient psychiatrist. Mr. Patterson gives permission to contact his outpatient psychiatrist. However, he says he feels too embarrassed to let his family or his counselor know that he is having problems again, and he does not want them to be contacted. Dr. Braxton explains to Mr. Patterson that it is important for the staff be able to speak with someone from his family and his community residence about his recent symptoms. Mr. Patterson says that he still does not want them called but that if someone needs to be contacted, he would prefer that his sister be called and not his parents. Mr. Patterson’s sister confirms the history that her brother has provided, including the serious nature of his prior suicide attempts. She notes that he has seemed more withdrawn than usual and has called their parents frequently to check on their safety. This behavior is similar to that which he exhibited during prior exacerbations of his illness. Ms. Randolph, the supervisor at the community residence, notes that Mr. Patterson has been increasingly suspicious of his roommates, has been leaving his radio playing at night to “confuse the monitoring devices,” and has been pacing back and forth at night. Because of a mix-up at the pharmacy, the community residence staff thought that Mr. Patterson might have missed his clozapine for several days the previous week. Based on the impulsiveness and severity of his previous suicide attempts and his tendency to minimize rather than exaggerate his symptoms, Ms. Randolph is concerned that Mr. Patterson would harm himself if he returned home. She states that his use of alcohol would need to be discussed further but would probably not cause him to be dismissed from the program, because he has not used alcohol or other substances recently and typically follows all of the program rules. When Dr. Braxton inquires about the presence of guns or other weapons in the home, Ms. Randolph notes that none are permitted. Dr. Braxton also tries to contact the community mental health clinic psychiatrist but finds she is not available after hours. Based on Mr. Patterson’s exacerbation of psychotic symptoms and associated suicidal thoughts, which previously resulted in medically serious suicide attempts with clear suicidal intent, Dr. Braxton assesses Mr. Patterson as being at high risk for suicide and recommends hospitalization to provide an increased level of supervision while treatment of his psychotic exacerbation proceeds. Mr. Patterson agrees that he
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would feel safer in the hospital and is agreeable to a voluntary admission, but he requests permission to go outside the emergency department to have a cigarette first. Dr. Braxton explains that it will not be possible to go outside but offers nicotine gum, which Mr. Patterson finds acceptable. Dr. Braxton next contacts Mr. Patterson’s managed care plan to obtain authorization for hospitalization. The managed care reviewer, Ms. Whitley, does not wish to authorize inpatient treatment because Mr. Patterson has not made a recent attempt and does not have a current suicide plan. Ms. Whitley asks Dr. Braxton whether Mr. Patterson is willing to “contract for safety.” Dr. Braxton explains that because this is an emergency setting and he does not have an ongoing therapeutic alliance with the patient, a suicide prevention contract is not indicated and would not protect the patient from acting on his suicidal thoughts. Dr. Braxton reiterates to Ms. Whitley the reasons that he judges Mr. Patterson to be at significant suicide risk, including Mr. Patterson’s diagnosis of schizophrenia, his prior serious suicide attempts in response to his psychotic symptoms, his recent increase in psychosis and recent uncharacteristic use of alcohol in an effort to cope with his symptoms, his anxiety during the interview and pacing about the house at night, and his fear of acting on his suicidal ideas that culminated in his contacting police. On the basis of this additional information, Ms. Whitley authorizes the admission on the condition that a more complete review be conducted the following morning. Because the hospital’s psychiatric unit does not have a bed available, Dr. Braxton contacts a nearby hospital that is willing to accept Mr. Patterson for admission. Dr. Braxton documents the name of the accepting physician and arranges for an ambulance to transport Mr. Patterson.
Emergency Psychiatric Assessment Medical Status The initial step of an emergency psychiatric assessment involves assessing the patient’s medical stability (American Psychiatric Association 2003; Zun 2005). Serial assessments of vital signs and level of consciousness may also be needed over the course of the emergency department visit. Because individuals are often ambivalent about suicide, a suicide attempt may already have occurred yet may not be reported accurately or spontaneously by the patient (Skelton et al. 1998). Thus, significant blood loss from a self-inflicted laceration or an intentional overdose of medication may be reflected by abnormal vital signs (e.g., hypotension,
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hypertension, respiratory depression, bradycardia, tachycardia, or other heart rate irregularities suggesting arrhythmia), pupillary dilation or constriction, diaphoresis, poorly articulated speech, unsteady gait, or excessive sedation (Buckley et al. 2002). Although some of these signs may accompany intoxication with alcohol or other substances, it remains important to assess for other etiologies because patients may have made a suicide attempt while intoxicated. Hypoglycemia, either spontaneous or as a result of insulin or oral hypoglycemic agent use or overdose, may also present with many of these signs and can be assessed through a fingerstick measurement of blood glucose. In individuals with a history of alcohol or substance use, withdrawal syndromes may also require treatment. Other physical disorders may present with or co-occur with psychiatric symptoms or syndromes and similarly require assessment and stabilization (DeLeo et al. 1999; Olshaker et al. 1997; Zun 2005). Under EMTALA, stabilization of any acute medical or obstetrical conditions is needed before transfer or discharge from the emergency department, regardless of the patient’s presenting concern (Bitterman 2001; Quinn et al. 2002). In evaluating Mr. Patterson, Dr. Jordan and the emergency department staff determined that his vital signs were somewhat abnormal but did not require emergency intervention. Because Mr. Patterson did not report a history of significant daily alcohol use, development of alcohol withdrawal was unlikely. In addition, he did not report making a suicide attempt, although it was still possible that Mr. Patterson may have taken an overdose of medications that could contribute to his tachycardia, dilated pupils, and mildly elevated temperature. Thus Mr. Patterson’s vital signs and level of consciousness would have continued to be monitored during his stay in the emergency department.
Patient Safety Throughout the psychiatric emergency evaluation, attention will need to be given to the patient’s safety (American Psychiatric Association 2003; Simon 2004). Patients and their belongings may need to be screened for potentially harmful items, and police officers coming to the emergency department may need to secure their weapons before entering. As was instituted with Mr. Patterson, continuous monitoring (either by one-toone observation or closed-circuit television monitoring) may also be indicated, because individuals with suicidal ideas or intentions may attempt to harm themselves using hazardous items from their belongings or from examination or interview rooms. At times, patients may try to leave the emergency department while the assessment is in progress or after it has
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been determined that hospitalization is needed. Although Mr. Patterson asked to go outside to smoke a cigarette, he understood the reasons that this was not possible and did not attempt to leave. However, when individuals do try to leave, staff may need to intervene if there is evidence, from either history or examination, that the patient poses a risk to self or others. Under such circumstances, patients will need to be prevented from leaving the emergency department until a full assessment can occur or admission can be arranged. Seclusion, restraint, or pharmacological treatment may occasionally be needed to maintain patient safety when individuals are extremely agitated, are at risk of harming self or others, and have not responded to verbal communication or other interventions (American Psychiatric Association et al. 2003; Battaglia 2005). At the same time, patients may identify a desire for staff to offer oral medications (rather than injectable medications) and to communicate and collaborate with them in their care (Allen et al. 2003). Attending to patients’ other needs (e.g., food, blankets, updates on reasons for delays) and working to help them feel comfortable can aid in developing rapport and can often minimize a need for more restrictive interventions.
Additional History and Examination In addition to assessing a patient’s vital signs, additional history and examination will determine whether other physical conditions are present that may influence clinical diagnosis and decision making (American Psychiatric Association 2003; Zun 2005). General batteries of screening tests are typically of low yield (Olshaker et al. 1997; Skelton et al. 1998; Zun 2005), although other laboratory, radiological, or diagnostic tests may also be indicated to identify acute physical disorders or assess for injury. Because medications may need to be administered during the emergency department visit, it is particularly important to determine whether the patient has experienced allergic reactions or severe adverse effects (e.g., dystonic reactions to high-potency antipsychotic agents) with medications. If the patient is taking medications, the names and dosages of prescribed and over-the-counter medications (including vitamins, herbs, and other natural products) should be determined whenever possible. This information is often helpful in assessing for side effects of treatment, considering possible drug–drug interactions, and determining whether specific medication blood levels are needed for therapeutic monitoring or to rule out toxicity (e.g., due to intentional overdose). With Mr. Patterson, knowing about his medication regimen was essential because clozapine can induce tachycardia, myocarditis, hyperglycemia, neutropenia, or agranulocytosis.
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Alcohol and Substance Use Many individuals present to emergency departments while intoxicated with alcohol or other substances (Adams and Overholser 1992; American Psychiatric Association 2003; Skelton et al. 1998). Some are specifically referred because they have made a suicidal statement or attempt while intoxicated, whereas others become agitated or are involved in motor vehicle accidents and then require assessment. Depending on the patient’s level of intoxication and ability to cooperate, the full assessment of the patient’s suicidal risk may need to be postponed until the intoxication resolves. Once assessment is possible, a more detailed assessment of substance use and suicide risk is indicated. Although intoxicated suicidal patients may be less likely to receive psychiatric assessment or referrals for inpatient or outpatient treatment (Suokas and Lonnqvist 1995), their mortality rates appear comparable with those of non-intoxicated suicidal patients (Suokas et al. 2001). In addition, diagnoses of alcohol or other substance use disorders are associated with increased rates of suicide, particularly in the context of significant psychosocial stressors (Conner and Duberstein 2004; Rich et al. 1991). Even in those without substance use disorders, intoxication may accompany self-injurious or suicidal behaviors (Varadaraj and Mendonca 1987). Thus, it is useful to determine patterns of past and current alcohol or other substance use in emergency psychiatric patients as well as identify whether such use has been associated with suicidal thoughts, plans, intentions, or behaviors. Mr. Patterson had used a variety of substances, including alcohol, in the past and may have a history of alcohol abuse. The emotional distress that he experienced in conjunction with his psychosis probably contributed to his decision to drink after a period of minimal use and despite potential negative consequences (i.e., possible eviction from his housing). In addition, under the influence of alcohol, he may have had more difficulty controlling self-injurious impulses. If Mr. Patterson were discharged from the emergency department, transportation would have needed to be arranged for him so that he would not endanger himself or others by operating a vehicle. It would also have been important to address his use of alcohol, because a return to heavier use of alcohol or other substances would have augmented Mr. Patterson’s suicide risk.
Psychosocial Factors Some aspects of an individual patient’s suicide risk will relate to nonmodifiable factors such as demographic variables, family history of suicide, and the patient’s own history of psychiatric illness, self-injurious
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behaviors, or suicidal attempts. However, many of the determinants of a patient’s acute suicide risk will relate to the presenting problem and current mental state (American Psychiatric Association 2003; Simon 2004; see also Chapter 1, “Suicide Risk: Assessing the Unpredictable,” and Chapter 17, “Substance-Related Disorders,”this volume). These features of the history and examination may also suggest interventions aimed at modifying specific risk factors and reducing overall suicide risk. In delineating the patient’s presenting problem, the reasons for the emergency department visit are often informative. Specific precipitants to the current crisis may include interpersonal difficulties, financial problems, legal charges, school or employment issues, and other psychosocial stressors (Conner and Duberstein 2004; Heikkinen et al. 1994; Maltsberger et al. 2003; Rich et al. 1991). In assessing the significance of precipitating factors, the patient’s subjective perceptions may be just as important as the objective magnitude of the stressors. Occasionally patients may make suicidal statements in an effort to gain admission and obtain housing or escape undesirable situations (e.g., legal charges, interpersonal conflicts), but it is more common for psychosocial stressors to contribute to depression, hopelessness, or suicidal thoughts or behaviors. Thus recent psychosocial stressors are important to elicit as part of the emergency psychiatric evaluation. Just as significant in assessing relative suicide risk are potential protective factors such as family or social supports, cultural or spiritual beliefs, or the presence of a strong therapeutic alliance with a psychiatrist or therapist. Although Mr. Patterson’s spiritual beliefs are important to him and shape his views on the consequences of suicide, these values have not kept him from making serious suicide attempts in the past. Thus their protective effects should not be overestimated in evaluating Mr. Patterson’s risk for suicide.
Psychiatric History Other features of the recent history may suggest the presence of specific psychiatric symptoms or syndromes that would influence suicide risk (e.g., anxiety, mood, or psychotic disorders; borderline or antisocial personality disorders). The patient’s history will also provide information on past suicidal ideation, including its frequency and severity, as well as previous self-injurious behaviors or suicide attempts and their possible contributors, severity, and associated intent. By the same token, the mental status examination will provide information on the patient’s current suicidal thoughts, plans, and intentions as well as identify other signs and symptoms that may influence suicide risk (e.g., anxiety, agi-
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tation, hopelessness, psychosis) or suggest a specific psychiatric diagnosis. A parallel assessment of thoughts, plans, or intentions of harming or killing others is also needed in order to satisfy the requirements of EMTALA (Bitterman 2001; Quinn et al. 2002), determine an appropriate setting for treatment, and intervene to reduce the risk of harm to others. Mr. Patterson had a history of schizophrenia, and his current hallucinations and delusions were consistent with this diagnosis. He also had two prior suicide attempts that were nearly lethal and associated with clear-cut suicidal intent. The fact that Mr. Patterson’s previous suicide attempts were related to his delusional beliefs increased his likelihood of making another suicide attempt while he was actively experiencing similar delusions. His symptoms of anxiety, agitation, and hopelessness in response to his delusional perceptions may have further increased Mr. Patterson’s risk.
Collateral Information As part of the emergency evaluation process, obtaining collateral information is often essential (American Psychiatric Association 2003; Simon 2004). Patients may not always be willing to share information about their recent symptoms or behaviors, and they may intentionally hide aspects of recent suicidal statements or behaviors. Individuals who were intoxicated when making a suicidal statement or attempt may not always recall their actions. Patients may also present in a manner that is at odds with the apparent reason for the emergency department visit. For example, some patients may request admission because of suicidal thoughts but appear cheerful and relaxed, whereas other patients are referred after a serious suicide attempt yet deny having any problems and demand release. In all of these circumstances, other informants may be able to corroborate or expand on key aspects of the patient’s history (e.g., recent symptoms and behavior, psychiatric history, medications, presence or absence of weapons in the home). Useful information is often provided by involved family members, others who live with the patient or accompany the patient to the hospital (e.g., police, case managers), and treating or referring psychiatrists, primary care physicians, therapists, or other mental health professionals. When communicating with other individuals, it is best to gain the patient’s permission first. However, efforts to maintain the safety of the patient and others must be balanced against importance of confidentiality. To protect the patient or others from harm, there are some emergency circumstances in which it may be necessary to communicate confidential information (American Psychiatric Association 2001). It is also important to note that emergency physicians, psychiatrists, and
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other mental health professionals can always listen to information provided by other informants yet not violate confidentiality by revealing information about the patient. Even though Mr. Patterson was cooperative with the emergency evaluation, his sister and his community residence counselor were able to provide additional information (e.g., recent missed medication doses, nighttime pacing, and social withdrawal; unusual nature of his alcohol use; absence of guns in the home; similarities of current symptoms to those before his suicide attempts) that was invaluable to the clinical decision making. This emphasizes the importance of obtaining collateral information as part of the emergency assessment. Some patients are reluctant for contact with other informants to be made, but most will appreciate the need for such contact once it is explained to them. In rare instances when patients remain adamant, informants may still need to be contacted, and this is permissible. As with most emergency contacts, the conversation will focus on obtaining information about the patient’s recent behavior and history. The amount of information that is conveyed to others will be more dependent on the patient’s wishes, unless issues of medical stability or safety are paramount.
Decision to Hospitalize In simplistic terms, the primary goals of the emergency psychiatric evaluation involve assessing the need for emergency stabilization, performing any acute interventions that may be indicated, and then determining the appropriate setting for subsequent care. Decisions about the most appropriate treatment setting first require determining whether the patient requires a structured inpatient environment or can be managed outside of a hospital setting (American Psychiatric Association 2003; Simon 2004; see also Chapter 21, “Patient Safety Versus Freedom of Movement,” and Chapter 22, “Safety Interventions,” this volume). Estimating the patient’s risk of suicide or self-injury is one step in deciding about admission. However, other factors, including the patient’s potential for harming others, the severity of psychosis or disorganized behavior, the overall level of functioning, the ability to provide self-care and adhere to outpatient treatment, and the availability of sociocultural and community supports, also need to be weighed. The patient’s treatment history and available outpatient treatment resources as well as the presence of co-occurring physical disorders or specific psychiatric diagnoses (including substance use disorders) may also suggest a need for an increased degree of supervision or treatment intensity (Baca-Garcia et al. 2004; George et al. 2002; McNiel et al. 1992; Rabinowitz et al. 1995; Segal et al. 1988). In addition to considering the po-
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tential benefits of hospitalization, admission may also have negative effects that need to be kept in mind (e.g., financial stressors, psychosocial disruptions, discrimination based on stigmas of hospital admission, limiting of recovery by fostering overdependence on the mental health system). Thus, decisions about hospitalization remain a matter of clinical judgment, requiring a great deal of attention to the individual aspects of a patient’s history, clinical presentation, and personal strengths and vulnerabilities, including sociocultural and community supports. The decision to recommend hospitalization for Mr. Patterson was a complex one. He had significant community supports, a strong religious belief system, had been functioning at a relatively high level, showed good insight into the need for treatment, and had been generally adhering to treatment until the problem in getting his medications from the pharmacy. In addition, he had no specific plan of suicide and stated he did not want to harm himself. Given his significant period of stability and the fact that he was embarrassed by the return of his symptoms, he may have become demoralized by being readmitted. At the same time, Mr. Patterson was quite psychotic with prominent delusions that he had acted on in the past, resulting in medically serious suicide attempts. He had also resumed using alcohol in an apparent effort to cope with his psychotic experiences. His significant anxiety, agitation, and hopelessness were additional modifiable risk factors that would benefit from aggressive intervention. Although some have suggested that a patient’s ability to “contract for safety” be used in determining the need for hospitalization, suicide prevention contracts have little value in emergency settings because patients are often disorganized, psychotic, or otherwise acutely ill and have no preexisting therapeutic alliance with the interviewer (American Psychiatric Association 2003; Simon 2004; Stanford et al. 1994). Dr. Braxton explained these issues to Ms. Whitley, the managed care reviewer, when she asked whether Mr. Patterson could “contract for safety,” and it is not uncommon to need to educate others about these potential pitfalls of suicide prevention contracts. Furthermore, such contracts have no documented evidence of efficacy, are not legally binding or exculpatory, and cannot substitute for a formal assessment of suicide risk (Simon 2004). Rather than determining whether a patient is willing to promise not to attempt suicide, it is sometimes helpful to inquire whether an individual would feel safe outside of a supervised setting or whether they would be fearful of acting on suicidal thoughts or impulses. Those who are concerned that they may act impulsively or feel a lack of control over their suicidal urges may require a more structured level of care.
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At times, the evaluator’s response to the patient may confound the risk assessment process and decision making about hospitalization (Dressler et al. 1975; Gillig et al. 1990; Suokas and Lonnqvist 1989). For example, a patient who is suicidal while intoxicated or who repeatedly presents with self-injurious or suicidal behavior may generate anger, frustration, helplessness, or indifference in emergency department staff. When other professionals present with suicidal thoughts or attempts, empathy or denial may similarly result in downplaying the patient’s actual suicide risk. An awareness of one’s own emotional responses to patients may help mitigate these difficulties. If hospitalization is indicated, state-specific legal criteria will influence whether it should occur on a voluntary or involuntary basis (McCormick and Currier 1999). However, relevant factors will include the patient’s degree of insight and willingness to seek voluntary admission as well as the estimated likelihood of harm to self or others (Engleman et al. 1998). With Mr. Patterson, his willingness to be hospitalized voluntarily obviated the need to consider involuntary admission. However, given Mr. Patterson’s significant psychosis and risk for suicide, involuntary admission would have been indicated if he had refused voluntary hospitalization.
Follow-up Outpatient Treatment For patients who do not require hospitalization, recommended outpatient treatment may vary in frequency and intensity and can include office-based follow-up, intensive outpatient or partial hospital programs, or assertive community treatment programs, among other options (American Psychiatric Association 2003; Schnyder et al. 1999; Simon 2004; Way et al. 1992). With individuals who are not currently engaged in outpatient treatment, a specific appointment may be difficult to arrange from the emergency department (Craig et al. 1974; Hillard et al. 1983). However, follow-up instructions should be given; some facilities ask patients’ permission to contact them at a later time to determine whether follow-up was able to be obtained. In addition, it may be useful to provide patients with phone numbers for help in arranging appointments or for emergency assistance (e.g., emergency department, crisis hotline).
Recommended Interventions Regardless of the recommended setting of care, documentation will need to include a discussion of the assessment of suicide risk and recommendations for interventions to address modifiable aspects of risk (American Psychiatric Association 2003; Simon 2004; see also Chapters 1, 21, and 22,
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this volume). Such interventions may include an increased level of supervision or treatment intensity, adjustments in medications to address specific psychiatric disorders or symptoms, and enhanced sociocultural supports. When portions of the evaluation and documentation are performed by different individuals, discussion and review of documentation are important in developing a consensus about the estimated level of suicide risk and about the recommended plan for the patient. Under some circumstances, the initial evaluation will be done by an emergency physician or nonphysician mental health professional and discussed by phone with a psychiatric consultant. A face-to-face evaluation of the patient by the consultant may also be necessary, particularly if there are disagreements between evaluators.
Transfer to Another Facility At times, patients who are being hospitalized may need to be transferred to another facility for care. This may be at the patient’s request due to geographic or financial considerations or past inpatient experiences. Alternatively, the emergency facility may not be affiliated with a psychiatric inpatient unit, or an affiliated unit may not have the capacity to treat the patient (e.g., due to a lack of available beds, staff, or services to adequately meet the patient’s physical or psychiatric needs). Under all such circumstances, transfers of patients to other facilities should adhere to the regulatory provisions of EMTALA (Bitterman 2001; Quinn et al. 2002). In addition, the patient should continue to be maintained in an appropriately structured or monitored environment until transfer by ambulette (i.e., nonemergency wheelchair-accessible transport van) or ambulance can be achieved. Thus, upon arranging for Mr. Patterson to be transferred to another hospital, Dr. Braxton obtained the name of an accepting physician as required by EMTALA and maintained Mr. Patterson on one-toone observation until an ambulance arrived.
❏ Key Points ■
Begin assessments of patients in emergency settings by determining vital signs and making an initial assessment of acute physical disorders that may require emergency intervention.
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While the evaluation proceeds, take measures to address the safety of the patient. These measures may include continuous observation, removal of potentially hazardous items from patient belongings or examination rooms, elopement precautions, and, with agitated patients, seclusion or restraint.
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Conduct an assessment of suicide risk for any patient presenting for an emergency psychiatric evaluation.
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Explore the patient’s presenting problem in detail, including delineation of precipitating factors (e.g., stressors, treatment adherence) and ameliorating factors (e.g., supports, strong therapeutic alliance, cultural or spiritual factors).
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In assessing suicide risk in emergency settings, cover the same elements as when evaluating suicide risk in other settings, including determination of the patient’s previous suicide attempts; intensity of the most severe prior suicidal ideation or behavior; factors that contributed to prior attempts; current suicidal ideation, plan, or intent; and presence of specific diagnoses (e.g., mood disorders, schizophrenia, substance use disorders) or other signs or symptoms (e.g., anxiety, hopelessness, psychosis) that may influence risk.
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Assess the patient’s potential for harming others as part of the emergency evaluation.
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Determine the patient’s usual and recent pattern of alcohol and other substance use. Use, abuse, or dependence on alcohol or other substances can contribute to suicide risk.
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Identify current physical illnesses, because some may be relevant to possible treatment decisions, contribute to psychiatric symptoms, and influence suicide risk. Allergies and current medications (both prescribed and unprescribed) are similarly important to ascertain.
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Obtain collateral information when possible. In learning about the patient’s history, recent behavior, and potential access to weapons, essential collateral information can be obtained from involved family members and others who live with the patient or accompany the patient to the hospital (e.g., police, case managers) and from treating or referring psychiatrists, primary care physicians, therapists, or other mental health professionals. Such contacts can also help to mobilize ongoing supports and treatment for the patient.
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Balance the importance of confidentiality against efforts to provide needed medical care and protect the patient or others from harm, each of which may require communication of confidential information. It is always permissible to listen to input from informants without breaching confidentiality by providing information to them.
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After determining whether the patient has access to guns, discuss the risks of gun availability, provide instructions for the removal of any accessible weapons, and document the specific actions taken to disable or remove accessible weapons.
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Base decisions about the appropriate setting for the patient’s care on the weighing of multiple factors including the estimated risk of the patient to self or others, the patient’s degree of psychosis or disorganization, the presence of physical illnesses or substance use disorders, and the ability to attend to self-care needs and adhere to treatment in the community.
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Base decisions about whether voluntary or involuntary admission is needed on the patient’s level of insight and capacity and on jurisdictional laws or regulations.
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Do not have a patient “contract for safety,” which is sometimes known as a suicide prevention contract. Such a process is not helpful in emergency settings and should not be used as a criterion for discharge.
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Be aware that both positive and negative emotional reactions to patients can influence decision making.
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For all patients who present for psychiatric evaluation in the emergency department, document the factors contributing to suicide risk or risk of harm to others, and describe the interventions aimed at ameliorating those risk factors and implement those interventions.
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In your emergency psychiatric assessment, as specified by EMTALA regulations, include an evaluation of suicide risk and risk to others, as well as a medical screening examination and any indicated stabilization, prior to discharge or transfer.
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For individuals who require admission to another facility, obtain approval for the transfer from an accepting physician at the receiving hospital; maintain the patient in a structured setting until ambulette or ambulance transfer can be arranged.
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For individuals who are being discharged from the emergency department, give the patient a clear plan of follow-up, and document that you have done so.
References Adams DM, Overholser JC: Suicidal behavior and history of substance abuse. Am J Drug Alcohol Abuse 18:343–354, 1992 Allen MH, Carpenter D, Sheets JL, et al: What do consumers say they want and need during a psychiatric emergency? J Psychiatr Pract 9:39–58, 2003 American Psychiatric Association: Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry. Washington, DC, American Psychiatric Association, 2001 American Psychiatric Association: Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry 160(suppl): 1–60, 2003
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American Psychiatric Association, American Psychiatric Nurses Association, and National Association of Psychiatric Health Systems: Learning From Each Other: Success Stories and Ideas for Reducing Restraint/Seclusion in Behavioral Health. Washington, DC, American Psychiatric Association, 2003. Available at: http://www.psych.org/psych_pract/treatg/pg/ learningfromeachother.cfm. Accessed July 29, 2005. Baca-Garcia E, Diaz-Sastre C, Resa EG, et al: Variables associated with hospitalization decisions by emergency psychiatrists after a patient’s suicide attempt. Psychiatr Serv 55:792–797, 2004 Battaglia J: Pharmacological management of acute agitation. Drugs 65:1207– 1222, 2005 Bitterman RA: Providing Emergency Care Under Federal Law: EMTALA. Dallas, TX, American College of Emergency Physicians, 2001 Breslow RE, Erickson BJ, Cavanaugh KC: The psychiatric emergency service: where we’ve been and where we’re going. Psychiatr Q 71:101–121, 2000 Buckley NA, Whyte IM, Dawson AH: Diagnostic data in clinical toxicology: should we use a Bayesian approach? J Toxicol Clin Toxicol 40:213–222, 2002 Conner KR, Duberstein PR: Predisposing and precipitating factors for suicide among alcoholics: empirical review and conceptual integration. Alcohol Clin Exp Res 28:6S–17S, 2004 Craig TJ, Huffine CL, Brooks M: Completion of referral to psychiatric services by inner city residents. Arch Gen Psychiatry 31:353–357, 1974 DeLeo D, Scocco P, Marietta P, et al: Physical illness and parasuicide: evidence from the European Parasuicide Study Interview Schedule (EPSIS/WHOEURO). Int J Psychiatry Med 29:149–163, 1999 Dhossche DM: Suicidal behavior in psychiatric emergency room patients. South Med J 93:310–314, 2000 Dressler DM, Prusoff B, Mark H, et al: Clinician attitudes toward the suicide attempter. J Nerv Ment Dis 160:146–155, 1975 Ekeberg O, Ellingsen O, Jacobsen D: Mortality and causes of death in a 10-year follow-up of patients treated for self-poisonings in Oslo. Suicide Life Threat Behav 24:398–405, 1994 Emergency Medical Treatment and Active Labor Act of 1986, 42 U.S.C. § 1395dd, as amended in 2005 Engleman NB, Jobes DA, Berman AL, et al: Clinicians’ decision making about involuntary commitment. Psychiatr Serv 49:941–945, 1998 George L, Durbin J, Sheldon T, et al: Patient and contextual factors related to the decision to hospitalize patients from emergency psychiatric services. Psychiatr Serv 53:1586–1591, 2002 Gillig PM, Hillard JR, Deddens JA, et al: Clinicians’ self-reported reactions to psychiatric emergency patients: effect on treatment decisions. Psychiatr Q 61:155–162, 1990 Hazlett SB, McCarthy ML, Londner MS, et al: Epidemiology of adult psychiatric visits to US emergency departments. Acad Emerg Med 11:193–195, 2004 Heikkinen M, Aro H, Lonnqvist J: Recent life events, social support and suicide. Acta Psychiatr Scand Suppl 377:65–72, 1994 Hillard JR, Ramm D, Zung WW, et al: Suicide in a psychiatric emergency room population. Am J Psychiatry 140:459–462, 1983 Maltsberger JT, Hendin H, Haas AP, et al: Determination of precipitating events in the suicide of psychiatric patients. Suicide Life Threat Behav 33:111–119, 2003
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McCormick JJ, Currier GW: Emergency medicine and mental health law. Top Emerg Med 21:28–37, 1999 McNiel DE, Myers RS, Zeiner HK, et al: The role of violence in decisions about hospitalization from the psychiatric emergency room. Am J Psychiatry 149: 207–212, 1992 Nordstrom P, Samuelsson M, Asberg M: Survival analysis of suicide risk after attempted suicide. Acta Psychiatr Scand 91:336–340, 1995 Olshaker JS, Browne B, Jerrard DA, et al: Medical clearance and screening of psychiatric patients in emergency department. Acad Emerg Med 4:124–128, 1997 Quinn DK, Geppert CM, Maggiore WA: The Emergency Medical Treatment and Active Labor Act of 1985 and the practice of psychiatry. Psychiatr Serv 53: 1301–1307, 2002 Rabinowitz J, Slyuzberg M, Salamon I, et al: A method for understanding admission decision making in a psychiatric emergency room. Psychiatr Serv 46:1055–1060, 1995 Radomsky ED, Haas GL, Mann JJ, et al: Suicidal behavior in patients with schizophrenia and other psychotic disorders. Am J Psychiatry 156:1590–1595, 1999 Rich CL, Warstadt GM, Nemiroff RA, et al: Suicide, stressors, and the life cycle. Am J Psychiatry 148:524–527, 1991 Schnyder U, Klaghofer R, Leuthold A, et al: Characteristics of psychiatric emergencies and the choice of intervention strategies. Acta Psychiatr Scand 99: 179–187, 1999 Segal SP, Watson MA, Goldfinger SM, et al: Civil commitment in the psychiatric emergency room, III: disposition as a function of mental disorder and dangerousness indicators. Arch Gen Psychiatry 45:759–763, 1988 Simon RI: Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management. Washington, DC, American Psychiatric Publishing, 2004 Skelton H, Dann LM, Ong RT, et al: Drug screening of patients who deliberately harm themselves admitted to the emergency department. Ther Drug Monit 20:98–103, 1998 Stanford EJ, Goetz RR, Bloom JD: The no harm contract in the emergency assessment of suicidal risk. J Clin Psychiatry 55:344–348, 1994 Suokas J, Lonnqvist J: Work stress has negative effects on the attitudes of emergency personnel towards patients who attempt suicide. Acta Psychiatr Scand 79:474–480, 1989 Suokas J, Lonnqvist J: Suicide attempts in which alcohol is involved: a special group in general hospital emergency rooms. Acta Psychiatr Scand 91:36–40, 1995 Suokas J, Suominen K, Isometsa E, et al: Long-term risk factors for suicide mortality after attempted suicide: findings of a 14-year follow-up study. Acta Psychiatr Scand 104:117–121, 2001 Taylor C, Cooper J, Appleby L: Is suicide risk taken seriously in heavy drinkers who harm themselves? Acta Psychiatr Scand 100:309–311, 1999 Varadaraj R, Mendonca J: A survey of blood-alcohol levels in self-poisoning cases. Adv Alcohol Subst Abuse 7:63–69, 1987 Way BB, Evans ME, Banks SM: Factors predicting referral to inpatient or outpatient treatment from psychiatric emergency services. Hosp Community Psychiatry 43:703–708, 1992 Zun LS: Evidence-based evaluation of psychiatric patients. J Emerg Med 28:35– 39, 2005
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Inpatient Treatment and Partial Hospitalization Gregory Sokolov, M.D. Donald M. Hilty, M.D. Martin Leamon, M.D. Robert E. Hales, M.D., M.B.A.
Suicide is a major public health problem accounting for approximately 1% of deaths nationwide, which makes it the eleventh leading cause of death in the United States (Comtois et al. 2004). More than 90% of suicide attempts are associated with a mental disorder (Institute of Medicine 2002). Patients sent for, or receiving, inpatient psychiatric treatments have many disorders associated with a high risk for suicide, including bipolar, depressive, substance, and schizophrenic disorders. The modern hospitalization and day treatment service has been progressively shaped and reshaped by clinical, social, legal, and economic events in the mental health system since the 1950s. These services became more directly affected by the quality of outpatient services and the current economic environment faced by the public mental health sector (Goldman 1983; Talbott 1985). Social forces, legal limits on involuntary treatment, and the advent of medication contributed to deinstitutionalization, which gave patients greater control over their treatment and focused treatment on acute care and short-term stabilization. The average inpatient length of stay declined from 421 days in 1969 to 189 in 1978 401
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(Brown 1985) to 6–7 days currently in most inpatient units, and the public hospital census fell from 559,000 in the mid-1950s to 43,959 in 2001 (National Association of State Mental Health Program Directors Research Institute 2002). No longer does inpatient care exist in isolation, as each service of the treatment continuum became interdependent. With inadequate outpatient services in place at the time of deinstitutionalization, inadvertent consequences included higher rates of recidivism (Pages et al. 1998; Welte et al. 1981) and discharges against medical advice (Brook et al., in press). Systems with integration today between inpatient, partial hospitalization, outpatient, case management, and other services have the best chance of success for all patients and particularly those at high risk of suicide. Indeed, the advent of partial hospitalization has been a major treatment intervention in several regards: as a “step-up” service for outpatients becoming more ill (sometimes avoiding hospitalization and allowing more time at home) and as a “step-down” service for patients too ill to return to outpatient services alone (American Psychiatric Association 2003). Clinicians, educators, and administrators on inpatient and partial hospitalization units have many challenges, especially at the time of discharge. Assessment is increasingly important because close observation is often required. Electroconvulsive treatment (ECT) and rapid medication stabilization protocols often reduce symptoms quickly. These treatments do not alleviate all symptoms (e.g., cognitive symptoms in schizophrenia) or reduce the patient’s social stressors, which in turn limits the clinician’s assessment of a patient’s readiness for discharge, particularly in organizations with limited outpatient services. One review found that history of suicidal behavior and recent hospitalization best predicted suicide completion (Gunnell and Frankel 1994). This chapter, in relation to inpatient and partial hospital settings, 1) briefly reviews the epidemiology of suicide; 2) discusses assessment of patients new to, and potentially leaving, inpatient units; 3) provides treatment principles and interventions; 4) discusses objectives, goals, and methods for the education of inpatient treatment staff regarding suicide assessment and prevention; and 5) highlights organizational and system issues that may influence and reduce the likelihood of suicide.
Epidemiology Approximately 5%–6% of the 30,000 suicides per year in the United States occur in hospitals (Busch et al. 2003). The suicide risk per year for psychiatric inpatients with a history of attempting suicide is more than twice
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that of patients with mood disorders with no history of prior of suicide attempts (Bostwick and Pankratz 2000). Additional risk factors for suicide among inpatients include mood disorders, family history of psychiatric symptoms, and documentation of suicide risk in chart notes (Sharma et al. 1998). In addition, the 1-month period after discharge from psychiatric hospitalization has been identified as a high-risk time for suicide in patients with depression (Geddes et al. 1997; Goldacre et al. 1993).
Assessment Case Example 1 George, a 46-year-old man, is brought to the hospital emergency department by ambulance after he was found in his car in his garage, cyanotic, with his head slumped against the steering wheel. He was discovered by his neighbor, who became concerned after he detected exhaust fumes. The neighbor quickly opened the garage door, removed George from the car, and called 911. A suicide note was found in the front seat of the car, which stated: “I hope this will finally make her understand.” According to his neighbor, George has become more withdrawn and isolated since his wife left him 4 months earlier and moved in with another man. They have no children. George’s closest living relative, an aunt, died the previous year. George has no known prior history of psychiatric hospitalizations or treatment. His neighbor reported that in the weeks prior to his suicide attempt, George complained to him of feeling “on the edge” and believed that his wife was trying to poison him to “get rid of me for good.” After George is evaluated by the emergency department physician for any medical complications from his attempted suicide, he is referred to an on-call psychiatrist, to whom he says, “I feel better now… it was all a stupid mistake what I did. I just want to go home and get some rest now.”
As the preceding case example illustrates, the decision for a psychiatrist to hospitalize a patient with suicidal ideations or who has made a recent suicide attempt is based on an assessment that addresses multiple suicide risk factors (Table 20–1). In the case example, the patient had the following significant suicide risk factors that would warrant an acute inpatient hospitalization: male gender over the age of 45 years, recent onset of psychiatric symptoms, loss of marital relationship, limited social support, a near-lethal attempt, and limited insight into the seriousness of his attempt. Once inpatient hospitalization of a suicidal patient is indicated, the psychiatrist must determine whether the admission will be on an involuntary or voluntary basis. In general, most states have involuntary psychiatric
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TABLE 20–1. Inpatient admission guidelines for patients who have attempted suicide Epidemiology and social history Male Older than 45 Continued substance abuse Recent family loss (death, divorce, or separation) Limited social support Unstable living conditions Psychiatric symptoms New onset Psychosis Severe agitation Recent change in mental status Impulsive behavior Impaired judgment Lack of insight Refusal of help Persistent plan or intent Attempt Violent Near lethal Premeditated Precautions taken to avoid rescue or discovery Increased distress following attempt Source.
Adapted from American Psychiatric Association 2003.
admission criteria that include provisions for dangerousness to oneself. If suicidal patients initially agree to voluntary psychiatric hospitalization and then later want to leave the hospital, they must be reassessed at that time by a psychiatrist to determine whether they meet involuntary criteria, especially if their insight into the need for mental health treatment is impaired by cognitive, psychotic, or affective symptoms. Of particular concern with suicidal inpatients is when they are discharged against medical advice (AMA) from the hospital. Studies have shown that AMA discharges tend to occur at greater rates for patients admitted on a Friday or during a weekend and that there is an increased incidence of AMA discharges during evening or night shifts (Brook et al., in press). In addition, if there are periods when on-call or covering psychiatrists are treating patients (such as on weekends or holidays), the attending psychiatrist of record should leave detailed “sign-outs”
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about patients’ clinical histories and hospital course to covering psychiatrists, especially if the attending psychiatrist is requesting to not have a patient discharged before further assessment by the regular treatment team can occur. If involuntary hospitalization criteria are not met and patients must be released AMA, psychiatrists should inform patients about the risks of premature discharge and the benefits of continued hospitalization, assess their level of understanding, and document these discussions. Signed AMA discharge forms provide little or no defense against malpractice liability (Gerbasi and Simon 2003). For those patients who are acutely intoxicated from alcohol or drugs and are making suicidal threats, attempts should be made (if possible) to at first observe the patient for acute withdrawal symptoms, with reevaluation of suicidal intent when sober, prior to psychiatric hospitalization. An analysis of personality and other mental disorders, preexisting or concurrent, is necessary in these cases. Assessments for planned discharge from inpatient hospitalization should include a documented analysis of the risks and benefits of both discharge and continued hospitalization. A hospital discharge treatment plan should include outpatient care referrals to a level of care that is consistent with the patient’s situation and abilities, including financial and insurance constraints (Table 20–2). For patients who are referred to a partial hospital or intensive outpatient treatment program but who also continue to be followed by a regular therapist or psychiatrist, communication among all the treatment professionals is crucial for an ongoing comprehensive suicide risk assessment (American Psychiatric Association 2003). TABLE 20–2. Mental health outpatient treatment levels of care Traditional outpatient care Intensive outpatient treatment Partial hospital care
Source.
Provide various forms of individual and group psychotherapy for patients who require treatment once a week or less frequently. Provide multidisciplinary therapy and counseling for patients who need treatment several hours a week. Provide intense psychiatric, nursing, and other multidisciplinary services for patients who require care for less than 24 hours a day. Patients usually attend for a minimum of 4 hours a day, several days a week.
Adapted from Fauman 2002.
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In addition, a concerted effort should be made to include family members and/or significant others in the discharge planning process, especially with regard to access to firearms in the home because studies have concluded that there is a strong relationship between firearms in the home and risk of suicide (Brent 2001). According to public health data, only 2% of gun-related deaths in the home are the result of a homeowner’s shooting an intruder, whereas 83% are the result of suicide (Murphy 2000). Therefore, family members of a suicidal patient should be asked to take charge of firearms in the home prior to the patient’s discharge from the hospital. A responsible family member should be asked to look for all guns in the home and remove them and then call the psychiatrist at a specified time to verify that this has been done. In some states, such as California, patients who are hospitalized for being a danger to self are prohibited from owning, possessing, controlling, receiving, or purchasing any firearm for a specific time period (i.e., 5 years) after discharge. One of the challenges psychiatrists face in the current era of mental health care economics is how to effectively and safely treat a hospitalized suicidal patient covered by a managed care system. In particular, requests for hospital admission or continued inpatient treatment may be denied despite the clinical opinion of the psychiatrist. In Table 20–3, clinical guidelines are outlined that may help the psychiatrist in dealing with discussions of managed care utilization reviews of suicidal hospital patients. When there is doubt, treatment in the appropriate setting and safety should take precedence. TABLE 20–3. Clinical guidelines for the psychiatrist who is treating a suicidal patient covered by a managed care system If calling to request an admission or additional inpatient treatment, do not hesitate, when appropriate, to ask to speak with a clinician. Use the language of medical necessity when asking for authorization for admission or additional inpatient treatment. For suicidal patients, remember that universal considerations are the level of risk for danger to oneself and failure of less intensive treatment settings to provide adequate protection from this risk. If admission or further inpatient treatment is not authorized, consider several options: 1. Ask for a consultation. 2. Ask for a “second level” review by a psychiatrist. 3. Ask for an explanation of the appeals process. Source.
Adapted from Feldman and Finguerra 2001.
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Additional steps may be helpful in situations that are particularly unclear or complex. One option is to get a second opinion from another clinician. This is done in difficult cases regardless (e.g., evaluation for ECT, medication combinations). Another option is to organize a clinical case conference in which all relevant information from various multidisciplinary sources can be consolidated on a given patient and different treatment recommendations can be obtained from clinicians with a range of clinical training and experience.
Treatment and Interventions Completed suicides in hospital units generally tend to occur within the first week after admission (Qin and Nordentoft 2005); therefore, suicidal patients should be closely supervised by hospital staff during this time period. Patients at highest risk are those who have a history of prior attempts in hospitals, have feelings of extreme hopelessness, or are experiencing significant anxiety and panic attacks. Levels of enhanced staff supervision may range from one-to-one supervision at arm’s length; constant in-line-of-sight observation; and checks every 15 minutes or 30 minutes. In addition, suicide attempts in the hospital are more likely to occur during times of staff rotation or disorganization, and many patients make attempts when they are in off-ward activities or on passes (Hirschfeld 2001), although the practice of giving hospitalized patients off-unit passes is becoming increasingly rare; most managed care companies will not authorize continued inpatient hospitalization if the patient is able to receive a pass because the patient does not meet a “medical necessity” level of care. Increased frequency of patient observation should be instituted strictly, with realistic expectations and tailored to the individual patient. Many psychiatric units routinely check on the location and activity of all patients every 30–60 minutes, so the first level of increased observation is that the patient be checked every 15 minutes. This interval provides limited risk reduction because fatal hanging or cutting can occur in less time. Every 15 minutes, the assigned staff physically views the patient. Although every effort is made to respect patient dignity, the patient must be clearly observed, whether in a therapy group, in the shower, or when using the toilet, to ensure no self-injurious behaviors are occurring. A patient who is in bed should be observed more closely, because the covers may be used to hide self-injury from view. Accordingly, some patients, in addition to increased observation, may require restriction to open areas of the inpatient unit. Suicidal patients who are acutely agitated, possibly due to psychotic or manic symptoms, and who
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are at high risk to harm themselves or others may require the use of emergency seclusion and/or restraints. Psychiatrists and medical administrators must have a thorough working knowledge of the relevant county, state, federal, and other regulations governing the use of seclusion and restraints in their facility, because the applicable regulations can vary significantly between locales and institutions. The same principles apply to other levels of increased observation including line of sight, where the patient is always in view, generally at a distance; and one to one, where the monitoring staff is much closer, generally within reach or a few steps away. The specific level chosen will depend on the acuity and nature of the patient’s symptoms, the patient’s activity and level of participation in staff-led group activities, the physical layout of the unit, and the number of available staff members. The hospital treatment team also needs to decide on the level and therapeutic purpose of interpersonal interaction between the patient and the “observing” staff. Some patients may benefit from ongoing conversation or interaction with an escort; for others, less frequent contact while maintaining close observation may be indicated. Coordination between psychiatrist, nursing staff, and other members of the treatment team is essential. Above all, increased staffing of a patient must be patient specific, must be an integrated part of that patient’s treatment, and must be able to be modulated in response to changes in the patient’s clinical status. Pharmacotherapy interventions during an inpatient hospitalization for suicidal patients should be focused on the acute stabilization of symptoms, including anxiety, psychosis, and manic or mixed mood symptoms. The aggressive treatment of severe anxiety and acute agitation with anxiolytic medications (i.e., benzodiazepines) may reduce the acute suicide risk even before depressive symptoms are in full remission (Busch et al. 2003). In addition, lithium therapy has been shown to reduce suicidal attempts in both bipolar disorder and unipolar major depression, particularly in those in a structured clinic setting (Baldessarini et al. 2003; Tondo et al. 2001). These studies suggest that lithium has “antisuicidal” effects independent of its mood-stabilizing properties, perhaps due to its effects in modulating aggressive behaviors through serotonin-mediated pathways. For those suicidal patients who are started on antidepressant therapy during hospitalization, especially those with history of hypomanic or mixed symptoms, there should be close monitoring of any abrupt changes in sleep patterns, level of activity, and mood. Patients who are exhibiting a rapidly fluctuating course during hospitalization, including mood lability, may be in a mixed episode of bipolar disorder and are
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more likely to respond to mood stabilizer therapy alone (Sharma et al. 1998). In addition, consideration should be given to the use of “rapidloading” strategies for mood stabilizers and atypical antipsychotics in suicidal bipolar patients with manic symptoms (Keck et al. 2000). Although ECT is generally used only after medication failures, its use on an emergent basis should be considered in the inpatient setting for suicidal patients who are severely malnourished or dehydrated due to depressive symptoms, are medically ill and unable to take oral medications, have a previous positive response to ECT, or are pregnant in the first trimester. Patients must be able to give competent informed consent to treatment with ECT. Some states mandate an independent review by another psychiatrist, even for patients who have agreed to treatment, before ECT treatment can be initiated. The treatment of acute psychotic symptoms in hospitalized suicidal patients with schizophrenia, including command auditory hallucinations, should be focused on the first-line use of atypical or secondgeneration antipsychotic agents due to their lower incidence of extrapyramidal symptoms, including akathisia; their mood-stabilizing effects; and their propensity to improve cognitive symptoms, especially when compared with typical or first-generation antipsychotic agents. Akathisia has been reported to be associated with suicidal ideation and suicide attempts and depersonalization in patients with schizophrenia. More specifically, suicidal attempts may be related to internal feelings of distress that are concomitantly expressed both as subjective restlessness and as hopelessness and suicidal ideation; consequently, akathisia may have both affective and anxious features as well as a motor component (Cem-Atbasoglu et al. 2001). The initiation of clozapine therapy has also been shown to cause a significant decrease in suicidal ideation and attempts in patients with chronic treatment-resistant schizophrenia or schizoaffective disorder (Meltzer and Okayli 1995). In addition, clozapine has been reported to be effective in reducing symptoms of mania and depression in treatment-refractory schizoaffective disorder (McElroy et al. 1991). If a hospitalized patient is refusing to take psychotropic medication and a psychiatric emergency exists, usually defined legally as a change in a patient’s mental condition so that action is immediately necessary for the preservation of the life or the prevention of serious bodily harm to the patient or others, psychotropic medication (i.e., parenteral antipsychotics or benzodiazepines) may be administered as long as the emergency exists. Increasing attention has been given to the relationship between the initiation of psychotropic medications, specifically antidepressants, and
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suicide. This phenomenon, which is complex and difficult to evaluate, is particularly relevant to inpatient and partial hospitalization settings. Many factors other than medication may be involved (and overlooked), and each needs to be considered for hospitalized patients. These factors include a past history of attempts, acuity of presenting symptoms, epidemiological risk factors, and the natural history of the illness. For instance, severe depression without suicidal thoughts may subsequently worsen to include such thoughts or psychosis. Psychoeducation for the patient and, when possible, family or significant others is desirable. Such educational efforts should openly discuss that inpatients and patients in partial hospitalization are at high risk for suicide. Responsibility for a plan to minimize risks, obtain adequate care, be prepared for emergencies, and monitor the patient’s course is shared by the patient and the psychiatrist. In particular, a discussion is helpful at discharge to discuss which symptoms have improved and which have not and to develop a plan to help the patient compensate (e.g., patient with memory not fully back to normal, but otherwise doing well). Clinical changes temporally related to medication (whether good or bad) should also be documented. Goals of inpatient and partial hospitalization psychotherapy for suicidal patients, particularly early in the stages of mental illness, should focus on educating the patient about the symptoms of mental illness and be supportive in nature, because denial of illness and lack of insight into the need for treatment are likely to be prominent (American Psychiatric Association 2003). Inpatient supportive psychotherapy may consist of either individual or group therapy and may briefly address the patients’ past responses to stress, current risk factors for suicide, vulnerability to life-threatening affects, use of external resources, and capacity for reality testing (Maltsberger 1988). Dialectical behavior therapy (DBT) is an individual and group therapy program for patients with borderline personality disorder. Its main goals are to reduce self-injurious and suicidal behaviors and to reduce inpatient hospitalizations (Linehan et al. 1991). Due to its long duration of treatment (up to at least 1 year), DBT is most appropriate for a partial hospital or intensive outpatient program setting. Psychoeducational therapy, which is used to support and educate patients and families about ways to manage and understand patients’ suicidality and associated symptoms, may be initiated in the inpatient setting and then continued in a partial hospital or outpatient treatment program after discharge. Psychoeducational inpatient therapy for patients and their families has been shown to be associated with clinically significant improvement up to 6 months after discharge for patients with chronic schizophrenia and bipolar disorder (Glick et al. 1993).
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Case Example 2 Melanie, a 24-year-old Caucasian woman, is diagnosed in the hospital with major depression with psychotic features after a 3-month course of severely depressed mood, labile mood, hypersomnia, hyperphagia, suicidal ideation, dulled cognition, poor sleep, tangential thought, and decreased self-care. She begins taking an antidepressant at a therapeutic dosage and a low-dosage atypical antipsychotic for her symptoms of tangential thinking and labile mood. Her symptoms improve, and she is discharged from the inpatient unit after 1 week, but she is admitted to a partial hospitalization day treatment program because of lingering thoughts of death and dulled cognition. She becomes increasingly angry, irritable, distractible, impulsive, and preoccupied with death, leading to rehospitalization for a presumed mixed episode of bipolar disorder. Urine toxicology is negative.
As the preceding case illustrates, a partial hospitalization program setting allows for an additional level of enhanced assessment, above that of regular outpatient follow-up, if a recently discharged hospital patient’s symptoms are decreasing or changing in nature. In the case example, a patient who had initially had symptoms of an atypical depression (i.e., hypersomnia and hyperphagia) in the acute inpatient setting was later diagnosed, through closer monitoring in a partial hospital program, with a mixed episode of bipolar disorder, warranting a reevaluation of the patient’s treatment regimen. Advantages of a partial hospital program are that partial hospital admissions may be somewhat longer than inpatient stays and therefore may allow for greater opportunity to understand the dynamic factors that contribute to patients’ crises, and this can be used to reduce suicide risk (Harney 2001). Partial hospitalization, as a level of intensive outpatient care and as an intervention in the treatment of suicide attempts, is increasingly studied. One study examined 44 patients with borderline personality disorder in a therapy-oriented partial hospitalization program (Bateman and Fonagy 2001). Study completers had a lower frequency of suicide attempts and acts of self-harm, a reduction in the number and duration of inpatient admissions, and a reduction in self-reported measures of depression and anxiety over an 18-month follow-up period.
Training and Education Competency of trainees, staff, and attending psychiatrists is a multistep, multilevel, and longitudinal process. Key knowledge and skills include ability to obtain patient history and to interview, assess risk, triage, and intervene, although the American Psychiatric Association (2003)
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practice guideline on suicidal behaviors goes into much more detail. Individuals, even within a given discipline, may differ with regard to knowledge, skill, and experience. These differences may require the instructor to assess educational needs before training sessions to establish competency in an area. In line with lifelong learning themes in psychiatry and other fields, a plan for initial and longitudinal training is indicated. Longitudinal training about suicide is indicated after obtaining a professional degree and generally occurs at least annually at most institutions. This training may include, but is not limited to, assessment for involuntary treatment, risk factors for suicide, interviewing skills, and review of data for the institution on rates of suicidal and parasuicidal behaviors. It is advisable to look at systemwide issues across services, because important events may be overlooked or minimized when evaluated in a vacuum. Several administrative interventions are important steps in the educational, emotional, and professional development of trainees, staff, attending psychiatrists, administrators, and the institution. First, incident debriefings are particularly important after an attempted suicide in the hospital or partial hospitalization setting. Staff require a timely and safe environment to voice concerns, to reflect on the incident, and to process events that occurred. Second, morbidity and mortality conferences may be indicated in the weeks or months after a patient commits suicide in the treatment setting or after leaving the setting. This detailed presentation and discussion helps address clinician, unit, and system issues and indirectly pays respect to the person who died. Occupational health issues include implementing stress reduction programs, screening for at-risk employees, and providing education for staff. The American Psychiatric Association and many community mental health centers are working in collaboration with public institutions (e.g., health clinics, schools, churches) to increase awareness of risk factors for suicide and to develop prevention strategies (Grandin et al. 2001).
Organizational and Systems Issues Another important aspect of treating suicidal patients on an inpatient unit pertains not to the individual patient characteristics and risk factors but to the features of the system in which the patient is treated. The studies specifically examining system influences on inpatient suicides are few. New York State looked at 84 inpatient suicides in a 6-year period in the early 1980s (New York State Commission on Quality of Care for the Mentally Disabled 1989). The Joint Commission on Accredita-
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tion of Healthcare Organizations (JCAHO) recommends that accredited organizations report patient suicides as “sentinel events” and that each suicide be followed by a thorough investigation into contributing organizational factors via a “root cause analysis” process (Joint Commission on Accreditation of Healthcare Organizations 2004). From 1995, at the inception of sentinel event reporting, through 2004, 415 inpatient suicides were reported to JCAHO. The observations and recommendations presented here are based on these reports and on expert consensus presented elsewhere in the literature (Lieberman et al. 2004; Sullivan et al. 2005). JCAHO identified environmental safety/security issues as contributing root causes in over 85% of inpatient suicides (Joint Commission on Accreditation of Healthcare Organizations 2004), and the New York study reached similar conclusions (New York State Commission on Quality of Care for the Mentally Disabled 1989). Because the majority of suicides have been by hanging, recommendations include reducing scaffolding opportunities through the use of breakaway fixtures, concealing pipes and utility conduits, and properly designing shower facilities and firesafety sprinkler systems. Because strangulation hanging can occur with a minimal suspension distance of a foot or two, attention must also be given to the design of furniture and door hardware. Accessibility of cords or other materials that could be used for strangulation or ligature, such as art therapy supplies, shoe laces, belts, and other personal clothing items such as bras and other undergarments, should also be curtailed. These restrictions must balance the potential risk with the potential loss of patients’ personal dignity and autonomy. To reduce the risk of self-cutting, nonbreakable glass should be used and attention given to control of sharp objects (e.g., razors, pick-type combs, silverware, scissors). To reduce the risk of toxic ingestions by patients, janitorial and other staff must monitor access to cleaning products, and nursing staff must monitor the taking of medications to prevent hoarding of pills for overdose. Efforts need to be made not just to reduce the likelihood of serious injury or death when an inpatient engages in self-injurious behavior; therapeutic progress requires that the behavior be prevented and its incidence reduced. Indeed, substandard patient assessment was the second most common root cause identified by JCAHO, contributing in just over 80% of inpatient suicides (Joint Commission on Accreditation of Healthcare Organizations 2004). In addition to the other assessment recommendations presented in this chapter, ongoing assessments should be conducted by all disciplines on the inpatient treatment team, not just by psychiatrists and nurses. Although the different disciplines may
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conduct assessments of different intensity and at different intervals, a system must be in place to ensure that assessment responsibilities and results are communicated quickly and reliably to other treatment team members. Temkin and Crotty (2004) recommended the use of a graphic flow sheet (Figure 20–1). The patient’s medical record must be used not just to document care but to communicate findings with other members of the treatment team. The psychiatrist relies on input from nursing staff chart entries across the day to assess the patient’s ongoing progress, and nursing and other direct care staff rely on written treatment plans and psychiatrist notes to understand the rationale and overall goals of care for the patient. Depending on the structure of the service delivery system on a particular inpatient unit, the psychiatrist may attend nursing reports, co-lead chart rounds, schedule treatment team meetings, or have discussions with direct care staff to facilitate verbal communication with treatment team staff regarding their clinical observations of patients. Additionally, procedural mechanisms should establish reliable communication from one nursing shift to another. For example, the sample flow sheet (Figure 20–1) is designed to continue across the typical times nursing shifts change. A formal change-of-shift nursing report, a written brief shift report, and clinical manager staffing that crosses shift changes (i.e., nursing shifts change at 7 A.M., 3 P.M., and 11 P.M. while senior clinical nurse managers change at 8 A.M., 4 P.M., and midnight) are all additional possible methods. Although most institutions have patient observation levels of differing intensity, the policies on patient observation should be clear and specific, and all staff must be trained in their implementation (Bowers et al. 2000). Physicians and clinical managers must strive, through modeling, policy development, and formal and informal performance rewards, to promote and maintain a work culture on the inpatient unit that respects, values, and seeks treatment input from all clinical staff. In such an environment, staff assigned to close patient observation duties can move beyond providing perfunctory custodial care, adding valuable treatment data and interacting with the patient in a therapeutic manner. The facility must also have personnel policies that facilitate prompt staffing augmentation when needed for close individual patient observation. The clinical status of a suicidal patient can deteriorate quickly at any time, especially during nights or weekends. There should always be an on-site manager who has the authority to call in extra personnel or redeploy existing staff within an hour or two if a patient requires increased staffing. Obviously, the facility must also establish and manage a pool of
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FIGURE 20–1. Source.
Portion of sample depression/activation chart.
Adapted from Temkin and Crotty 2004.
on-call or on-site staff available to be (re-)assigned on short notice. With the decreases in inpatient length of stay, the indications for use of the therapeutic pass, during which the patient leaves the hospital unaccompanied by inpatient staff for a number of hours for a specific therapeutic purpose, have diminished. In some facilities, it is used almost exclusively for patients who will be discharged to new community living placements (e.g., group homes, residential treatment programs) and need to be interviewed by staff at those facilities. Such patients have improved clinically and are almost ready for discharge because their risk for suicide may be decreased. A therapeutic pass is rarely indicated for a short-stay inpatient with active suicidal concerns. The more common situation may be when a patient must leave a secure inpatient setting for general medical treatment or diagnostic procedures (e.g., hemodialysis, neuroimaging stud-
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ies). Nevertheless, attention must be given to the policies and procedures for this type of pass as well. The opportunities for self-harm, elopement, or acquisition of items that could later be used for self-harm are typically greater away from the secure inpatient setting, even if a patient is escorted by staff. Additionally, a patient for whom suicide has never been a concern, but who leaves and returns to the unit, may be tempted to bring back items that could be taken by a suicidal patient and used for self-injury. For hospitalized patients, all significant clinical decisions, such as those involving the altering of privileges or the granting of passes, should have adequate risk/benefit analysis documented in the chart (Keyes 2001). Policies on passes regarding permission decisions, checkout, supervision, check-in, and searching for contraband should also be clear and familiar to staff. Off-unit passes may, however, be granted in special circumstances (e.g., family funeral, tour of a housing facility for postdischarge planning). Although unit psychiatrists may order passes, nursing and line staff must be empowered to recommend to the psychiatrist a delay or cancellation of the order if there is an acute change in the patient’s condition. Escort staff must be familiar with the patient and be updated on the patient’s status before departure. Escort staff should also review with the patient the purpose of the pass and behavioral expectations before leaving the unit. Psychiatric, nursing, and escort staff must also be knowledgeable about their local jurisdictional limits on what measures escort staff may employ if a patient attempts to elope while away from the unit. Such limits can vary even from county to county within a state depending on the scope of applicable judicial interpretations and case law. There should also be the clear expectation, both in written policy and in unit culture, that all decisions, assessments, and events around a patient being off the inpatient unit are clearly documented in the medical record and that the record is read by treatment staff at all levels. When the patient returns to the unit, reassessment protocols and checks for unauthorized possessions should be similar to those for new admissions. Last, a facility should have an automatic and thorough procedure in place for reviewing all inpatient suicide attempts and suicides. The JCAHO Root Cause Analysis process is one example of this (Joint Commission on Accreditation of Healthcare Organizations 2004). Institutions that fall outside the JCAHO accreditation umbrella may wish to develop similar procedures or adapt the JCAHO policies to their own situation. Through such a review and analysis, process and system factors may be identified for improvement to reduce the risk of future patient self-injury and suicide.
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❏ Key Points ■
The first week after admission to an inpatient unit is a high-risk time period for suicidal patients, and therefore close supervision by staff is necessary.
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Acute pharmacotherapy interventions on an inpatient unit should focus on the stabilization of anxiety, psychosis, and manic or mixed symptoms.
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Referral to available partial hospital or intensive outpatient followup after discharge allows for an additional level of enhanced assessment for suicidal patients.
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For patients who are discharged AMA, the risks and benefits of the discharge should be discussed with the patient and documented by the psychiatrist.
References American Psychiatric Association: Practice Guideline on Suicidal Behaviors. Washington, DC, American Psychiatric Publishing, 2003 Baldessarini RJ, Tondo L, Hennen J: Lithium treatment and suicide risk in major affective disorders: update and new findings. J Clin Psychiatry 64(suppl): 44–52, 2003 Bateman A, Fonagy P: Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 18-month follow-up. Am J Psychiatry 158:36–42, 2001 Bostwick JM, Pankratz VS: Affective disorders and suicide risk: a re-examination. Am J Psychiatry 157:1925–1932, 2000 Bowers L, Gournay K, Duffy D: Suicide and self-harm in inpatient psychiatric units: a national survey of observational policies. J Adv Nurs 32:437–444, 2000 Brook M, Hilty DM, Hales RE: Psychiatric discharges against medical advice: a review of the literature. Psychiatr Serv (in press) Brent DA: Firearms and suicide. Ann NY Acad Sci 932:225–239, 2001 Brown P: The Transfer of Care: Psychiatric Deinstitutionalization and Its Aftermath. Boston, MA, Routledge and Kegan Paul, 1985 Busch KA, Fawcett J, Jacobs DG: Clinical correlates of inpatient suicide. J Clin Psychiatry 64:14–19, 2003 Cem-Atbasoglu E, Schultz SK, Andreasen NC: The relationship of akathisia with suicidality and depersonalization among patients with schizophrenia. J Neuropsychiatry Clin Neurosci 13:336–341, 2001 Comtois KA, Russo JE, Roy-Byrne P, et al: Clinicians’ assessments of bipolar disorder and substance abuse as predictors of suicidal behavior in acutely hospitalized psychiatric inpatients. Biol Psychiatry 56:757–763, 2004 Fauman MA: Negotiating Managed Care. Washington DC, American Psychiatric Publishing, 2002
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Feldman J, Finguerra L: Managed crisis care for suicidal patients, in Treatment of Suicidal Patients in Managed Care. Edited by Ellison JM. Washington, DC, American Psychiatric Publishing, 2001, pp 34–35 Geddes JR, Juszczak E, O’Brien F, et al: Suicide in the 12 months after discharge from psychiatric inpatient care, Scotland 1968–1992. J Epidemiol Community Health 51:430–434, 1997 Gerbasi J, Simon R: Patients rights and psychiatrists duties: discharging patients against medical advice. Harv Rev Psychiatry 11:333–343, 2003 Glick ID, Clarkin JF, Haas GL, et al: Clinical significance of inpatient family intervention: conclusions from a clinical trial. Hosp Community Psychiatry 44:869– 873, 1993 Goldacre M, Seagroatt V, Hawton K: Suicide after discharge from psychiatric inpatient care. Lancet 342:283–286, 1993 Goldman HH: The demography of deinstitutionalization, in Deinstitutionalization. Edited by Bachrach LL. San Francisco, CA, Jossey-Bass, 1983, pp 20–24 Grandin LD, Yan LJ, Gray SM, et al: Suicide prevention: increasing education and awareness. J Clin Psychiatry 62(suppl):12–16, 2001 Gunnell D, Frankel S: Prevention of suicide: aspirations and evidence. BMJ 308:1227–1233, 1994 Harney PA: Managed care, brief hospitalization, and alternatives to hospitalization in the care of suicidal patients, in Treatment of Suicidal Patients in Managed Care. Edited by Ellison JM. Washington, DC, American Psychiatric Publishing, 2001, pp 50–51 Hirschfeld RM: When to hospitalize patients at risk for suicide. Ann NY Acad Sci 932:188–196, 2001 Institute of Medicine: Reducing Suicide: A National Imperative. Washington, DC, National Academies Press, 2002 Joint Commission on Accreditation of Healthcare Organizations: Sentinel event statistics, December 31, 2004. Available at: http://www.jcaho.org/accredited+ organizations/sentinel+event/sentinel+event+statistics.htm. Accessed October 18, 2005. Keck PE Jr, McElroy SL, Bennett JA: Pharmacologic loading in the treatment of acute mania. Bipolar Disord 2:42–46, 2000 Keyes C: Risk management issues for clinicians who treat suicidal patients in managed systems, in Treatment of Suicidal Patients in Managed Care. Edited by Ellison JM. Washington, DC, American Psychiatric Publishing, 2001, pp 153–172 Lieberman DZ, Resnik HLP, Holder-Perkins V: Environmental risk factors in hospital suicide. Suicide Life Threat Behav 34:448–453, 2004 Linehan MM, Armstrong HE, Suarez A, et al: Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry 48:1060– 1064, 1991 Maltsberger JT: Suicide danger: clinical estimation and decision. Suicide Life Threat Behav 18:47–54, 1988 McElroy SL, Dessain EC, Pope HG Jr, et al: Clozapine in the treatment of psychotic mood disorders, schizoaffective disorder, and schizophrenia. J Clin Psychiatry 52:411–414, 1991 Meltzer HY, Okayli G: Reduction of suicidality during clozapine treatment of neuroleptic-resistant schizophrenia: impact on risk-benefit assessment. Am J Psychiatry 152:183–190, 1995
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Murphy SL: Deaths: final data for 1998. Natl Vital Stat Rep 48:1–105, 2000 National Association of State Mental Health Program Directors Research Institute: Length of stay in state psychiatric hospitals, in State Profile Highlights, Vol 2. Alexandria, VA, National Association of State Mental Health Program Directors Research Institute, 2002, pp 1–4 New York State Commission on Quality of Care for the Mentally Disabled: Preventing inpatient suicides: an analysis of 84 suicides by hanging in New York state psychiatric facilities, 1980–1985. May 1989, Available at: http:// www.cqc.state.ny.us/publications/pubinsui.htm. Accessed March 30, 2005. Pages KP, Russo JE, Wingerson DK, et al: Predictors and outcome of discharge against medical advice from the psychiatric units of a general hospital. Psychiatr Serv 49:1187–1192, 1998 Qin P, Nordentoft M: Suicide risk in relation to psychiatric hospitalization. Arch Gen Psychiatry 62:427–432, 2005 Sharma V, Persad E, Kueneman K: A closer look at inpatient suicide. J Affect Disord 47:123–129, 1998 Sullivan AM, Barron CT, Bezmen J, et al: The safe treatment of the suicidal patient in an adult inpatient setting: a proactive preventive approach. Psychiatr Q 76:67–83, 2005 Talbott JA: The fate of the public psychiatric system. Hosp Community Psychiatry 36:46–50, 1985 Temkin TM, Crotty M: Suicide and other risk monitoring in inpatient psychiatry. J Am Psychiatr Nurses Assoc 10:73–80, 2004 Tondo L, Hennen J, Baldessarini RJ: Lower suicide rates with long-term lithium treatment in major affective illness: a meta-analysis. Acta Psychiatr Scand 104:163–172, 2001 Welte JW, Hynes G, Sokolow L, et al: Comparison of clients completing inpatient alcoholism treatment with clients who left prematurely. Alcohol Clin Exp Res 5:393–399, 1981
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Patient Safety Versus Freedom of Movement Coping With Uncertainty Robert I. Simon, M.D.
In the safety management of suicidal patients, the tension between providing safety and allowing freedom of movement creates uncertainty. Clinicians also experience dissonance between the need to provide adequate supervision for patients at risk for suicide and the denial of insurance coverage by third-party payers for these services. The only certainty is that effective treatment and safety management of the suicidal patient require the clinician’s full commitment of time and effort. After careful assessment, the safety management of the suicidal patient is an informed judgment call. The provision of absolute safety is obviously an impossible task. Patients who are determined to commit suicide will find a way. They view the clinician as their enemy (Resnick 2002). Deception and lack of patient cooperation complicate safety assessments. As in all medical specialties, psychiatrists will have patients die. This adverse outcome is inherent in the practice of medicine. A patient’s
I thank Lynne Lucas-Dreiss, A.P.R.N.–P.M.H., for her review of the manuscript. Portions of this chapter are adapted with permission from Simon RI: Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management. Washington, DC, American Psychiatric Publishing, 2004.
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death is a tragedy; however, it is not evidence per se of professional negligence. Nonetheless, malpractice suits against psychiatrists remain an occupational hazard. The treatment and safety management of suicidal patients can be anxiety provoking and fatiguing. Some clinicians limit the number of patients at risk of suicide under their care. Others try to avoid treating suicidal patients altogether. Clinicians should realistically assess their ability to tolerate the uncertainty inherent in the treatment of suicidal patients.
Outpatients The ability to exercise control over outpatients at risk for suicide, including those attending partial hospitalization programs, is limited. In outpatient settings, patient safety is usually managed by clinical intervention such as increasing the frequency of visits, strengthening the therapeutic alliance, providing or adjusting medication, and involving family or other concerned persons if the patient permits. Appropriate treatment of the patient is an integral aspect of safety management. Voluntary or, if necessary, involuntary hospitalization remains an option for suicidal patients at high suicide risk who can no longer be safely treated as outpatients. Most suicidal patients at moderate suicide risk and even some patients at high risk are treated in outpatient settings. When to hospitalize a patient can be a trying decision for the clinician. The decision is considerably more complicated when the need for hospitalization is clear but the patient refuses. The action that the clinician takes at this point is critical for the patient’s treatment and for risk management.
Hospitalization The clinician, after systematic suicide risk assessment, determines that the suicidal patient requires hospitalization (see Chapter 1, “Suicide Risk: Assessing the Unpredictable,” this volume). The risks and benefits of continuing outpatient treatment are weighed against the risks and benefits of hospitalization and shared with the patient. If the patient agrees, arrangements for immediate hospitalization are made. The patient must go directly to the hospital, accompanied by a responsible person. The patient should not stop to do errands, get clothing, or make last-minute arrangements. A detour may provide the patient with the opportunity to attempt or to commit suicide. If the patient is driven to the hospital, a safety locking mechanism under the sole control of the driver, if available, may help prevent the patient from jumping out of the car. An additional passenger may be needed to accompany the pa-
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tient. In some instances, clinicians have accompanied the patient to the hospital. The clinician, however, has no legal duty to assume physical custody of the patient (Farwell v. Un 1990). If the patient rejects the clinician’s recommendation for hospitalization, the matter is immediately addressed as a treatment issue. Because the need for hospitalization is acute, a prolonged inquiry into the patient’s reasons for rejecting the recommendation for hospitalization is not feasible. Furthermore, the therapeutic alliance may be strained. Consultation and referral are options for the clinician to consider, if time and the patient’s condition permit. It is this situation that tries the professional and personal mettle of the clinician. The failure to involuntarily hospitalize a suicidal patient who subsequently attempts or commits suicide is a source of malpractice suits against outpatient clinicians. The uncompensated time required, the inconvenience, the disruption of the clinician’s schedule, the possibility of a court appearance, and the fear of a lawsuit by the patient may dissuade the clinician from initiating involuntary hospitalization. State commitment statutes grant clinicians immunity from liability when they use reasonable judgment, follow statutory commitment procedures, and act in good faith. Documenting the suicide risk assessment and the rationale for involuntary hospitalization represents good clinical care as well as sound risk management. When involuntary hospitalization is sought, psychiatrists should leave it to the courts to resolve uncertainty about commitment. The clinician’s proper focus is the patient’s safety.
Split Treatment Collaboration and communication between psychiatrist and psychotherapist in split treatment settings are essential in assessing and managing the patient at risk for suicide. The essence of collaborative treatment is effective communication. The operative principle should be “We are in it together” (Meyer and Simon 1999a, 1999b; see also Chapter 11, “Split Treatment,” this volume). Psychiatrists and psychotherapists with split treatment practices may not take the time or have the time to adequately collaborate. For example, a psychiatrist who sees 4 patients for medication management every hour, 8 hours a day for 5 days a week, will treat 160 patients a week. Assuming the psychiatrist receives 20 patient telephone calls a day from a patient base of 500, the psychiatrist will receive 100 telephone calls a week, not including weekend calls. Extremely busy, highvolume medication management practices are common. How will the psychiatrist find the time to collaborate?
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Collaboration takes time and effort. Communication is necessary to prevent the suicidal patient from falling between the cracks of split treatment (Gutheil and Simon 2003). Clinical responsibilities should be clearly demarcated to prevent role confusion and uncertainty, potentially increasing the patient’s risk for suicide. Adequate communication and collaboration between psychiatrist and psychotherapist are standard practice, especially for patients at risk for suicide (see Chapter 28, “Clinically Based Risk Management of the Suicidal Patient,” this volume).
Inpatients In the managed care era, only the severely mentally ill are admitted to acute-care psychiatric facilities (Simon 1997). The criteria for voluntary admission often exceed the substantive standards required for involuntary hospitalization. Most patients are acutely suicidal or violent toward others or both. Hospitalization is usually brief; the average stay in most short-term psychiatric facilities is between 3 and 5 days. The purpose of hospitalization is crisis intervention, patient safety, and stabilization (Simon 1998). Patients who are potentially dangerous to themselves and others may be prematurely discharged (Simon 1998). The rapid admission, crisis management, and discharge of severely ill patients may not allow an overburdened staff enough time to thoroughly evaluate the new patient. Brief safety checks made by a succession of mental health personnel may be insufficient to know and develop a relationship with the patient. Relying solely on a “promise” or no-harm contract that the patient will not attempt suicide constitutes inadequate safety management. The level of supervision of suicidal patients is determined after systematic assessment of suicide risk (Simon 1998). Suicide risk assessment is a process, not a single event, that reduces the uncertainty surrounding patient treatment and safety management. Suicide prevention contracts should not be used in lieu of adequate suicide risk assessment. The treatment team has emerged as an important provider of care for psychiatric inpatients. Among its many advantages, the treatment team has “a thousand eyes” to focus on the safety supervision of suicidal patients. Nonetheless, the treatment team can develop blind spots when communication among team members is faulty, thus increasing the patient’s risk for suicide. Inpatient suicides tend to occur shortly after admission, during staff shift changes, and after discharge (a few hours, days, or weeks later; Qin
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and Nordentoft 2005). A newly admitted, severely mentally ill patient at significant risk for suicide who is untreated and unknown to the clinical staff should be placed on suicide precautions. Nurses can exercise their discretion to place patients on suicide precautions or increase the precaution level if the psychiatrist cannot be reached or until the psychiatrist has an opportunity to call or to examine the patient. If suicide precautions are imposed by the nursing staff, the psychiatrist should assess the patient prior to discontinuance of the precaution and document the rationale for discontinuance or write an order to continue the precautions. Nurses cannot lower or discontinue suicide precautions. Psychiatrists frequently receive phone calls from the nursing staff requesting a change or discontinuation of safety precautions regarding patients previously examined. Psychiatrists routinely make safety management decisions by phone based on adequate on-the-spot suicide risk assessments performed by the clinical staff.
Observation Levels Systematic suicide risk assessment of the patient at admission informs the level of suicide precautions. For example, does the patient require one-to-one, arms-length, or close visual observation? Are safety checks every 15 or 30 minutes necessary, or is routine unit observation (usually every 30 minutes or hourly) sufficient? Psychiatrists should know the definition of close observation. Definitions of close observation often differ among hospitals. It is usually easier to place a patient on suicide safety precautions than it is to reduce or discontinue precautions. Patients who are still on one-to-one or 15-minute safety observations should not be immediately discharged. A period of observation of the patient off safety precautions that precedes discharge should be standard practice. The usual practice is to initiate 15-minute checks on admission, with adjustment of the safety management as necessary. Automatic 15minute checks, however, may not correspond to the patient’s safety requirements. Patients can and do kill themselves between 15-minute checks. A patient who has made a near-lethal suicide attempt just prior to admission may require one-to-one supervision following the assessment. High-volume admissions of acutely suicidal patients place a heavy burden on inpatient staffs. Limitation of services is a reality in the current managed care environment. Moreover, a patient determined to commit suicide can do it on one-to-one safety precautions. Busch et al. (2003), in a review of 76 inpatient suicides, found that 42 of these patients were on 15-minute suicide checks. Nine percent of patients were
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on one-to-one observation with a staff member at the time of suicide. They concluded that no specific suicide precautions are 100% effective. When a patient at high risk for suicide is identified, one-to-one supervision may not be ordered because insurance coverage for such services is not available. Moreover, the hospital staff, stretched thin, may not be able to provide one-to-one patient supervision. The patient or family may be unable or unwilling to pay out-of-pocket for a “sitter.” The psychiatrist or clinical staff should not place a high-risk patient in seclusion or restraint merely to obtain insurance coverage for one-toone supervision. The use of seclusion and restraint is governed by strict clinical and procedural criteria. An acutely suicidal patient placed in seclusion and/or restraints requires one-to-one supervision. The temptation to obtain insurance coverage for such supervision by resorting to the questionable use of seclusion and restraint should be resisted. Constant observation should be discontinued as soon as possible, consistent with the patient’s safety requirement. The psychiatric unit is not a jail. Although safety is a primary concern, the decision to employ close observation must be balanced against the psychological distress it can cause the patient. For example, privacy in the performance of natural functions is lost. The patient cannot go to the bathroom or shower without the presence of an observer. Patients often experience intense embarrassment and humiliation that can increase hopelessness, depression, and suicide risk. Also, constant observation by a stranger is unnerving and intimidating, especially to a paranoid patient. During periods of peak activity on the psychiatric unit, sufficient staff may not be available to provide one-to-one close observation. Without violating patient freedom-of-movement regulations, staff may “zone” the patient to an area in front of the nurses’ station or to a specific location on the psychiatric unit where the patient can be kept under visual observation. Moreover, the clinical staff may not be able to provide time and labor-intensive safety precautions at 5- or 10-minute intervals. Other patients are also on suicide precautions. Five- or 10-minute safety checks and documentation may be overlooked, with potential liability consequences. If 5- to 10-minute checks are required, it may be better to place the patient on constant visual observation or on one-to-one arm’slength observation, monitored by either a staff member or a responsible, trained “sitter.” After adequate initial assessment and observation, the newly admitted patient at risk for suicide who attends group meetings, socializes with other patients, and is visible on the unit usually has 15-minute checks discontinued. The patient is placed on standard ward supervision. In contrast, patients who are at high risk for suicide, withdrawn, and isolative
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may require one-to-one close observation. The persistently withdrawn, nonparticipating patient needs to be distinguished from a newly admitted patient who is initially isolated and withdrawn but after a day or so feels more comfortable about being on a psychiatric unit. This adjustment occurs as the patient gradually establishes a relationship with staff members and peers. The observation level needs to be flexible. For example, a patient with melancholic depression may need closer supervision in the morning, when depressive symptoms are often worse. Patients who have decided to commit suicide, however, may actually feel better or feign improvement. These patients usually “improve” suddenly, often dramatically, in contrast to patients who improve gradually but haltingly. Core symptoms of psychiatric disorder (e.g., insomnia, anorexia, restlessness, and other symptoms of anxiety and depression) often persist. Distinguishing suicidal patients whose improvement is illusory from patients who are actually improving is one of the most difficult evaluations that psychiatrists must undertake. Psychiatrists’ expectations that patients will improve while under their care can create a blind spot in safety assessment and management. During peak periods of activity or shift changes on the unit, a suicidal patient may take advantage of the staff’s distraction to attempt or commit suicide. The multidisciplinary team must be able to maintain consistent safety vigilance, even though it is stretched. If the psychiatric staff is understaffed or is overwhelmed by an influx of suicidal patients, temporary closure of the psychiatric unit to new admissions may be necessary. Just a few agitated, high-risk suicidal patients can fully occupy and quickly exhaust the clinical staff.
Imminent Suicide Psychiatrists have difficulty gauging the imminence of suicide. Imminence is not a psychiatric diagnosis. No risk factor or risk factors identify imminence of suicide (Simon, in press). Suicide risk can vary by the minute, by the hour, or by the day. Patients are often considered to be at “imminent” risk for suicide when found hiding lethal instruments or when vocal about committing suicide at their first opportunity. Nonetheless, suicidal individuals perched on bridges or with guns placed to their heads have been dissuaded from committing an intended lethal act. Some of the two dozen or so survivors who jumped from the Golden Gate Bridge changed their minds after they stepped off the bridge. Of 515 individuals restrained from jumping, 94% were still alive many years later (Seiden 1978). It is imperative to carefully assess, treat, and manage acute high-risk factors that are driving a suicide crisis rather than to
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attempt the impossible task of predicting when or whether a patient will attempt suicide.
Intensive Care Unit (Critical Care Unit) The patient admitted to an intensive care unit (ICU) after a suicide attempt may be awaiting transfer to a psychiatric unit. In many hospitals, “sitters” are required to constantly attend the patient. A patient may seize an opportune moment to jump through an unsecured window of an ICU or medical/surgical unit or to walk off the ICU unit. Untrained “sitters” or family members rarely provide constant safety supervision. They often assume that the patient is compliant rather than devious in finding a way to commit suicide. They are reluctant to follow the suicidal patient into the bathroom. The patient may be able to commit suicide, usually by strangulation, while in the bathroom. Medical/surgical units provide many opportunities for the patient to commit suicide with unsecured equipment and other safety hazards. ICUs are not designed for the safety management of the psychiatric patient at risk for suicide. Transfer of the patient to the psychiatric unit should be a priority admission.
Seclusion and Restraint The federal government’s Center for Medicare and Medicaid Services (CMS)—formerly the Health Care Financing Administration (HCFA) (42 C.F.R. 1999)—the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (2001), and most states have developed requirements designed to minimize and avoid the use of seclusion and restraint wherever possible (Simon 2001). Federal requirements may be superseded by more restrictive state laws. Seclusion is the involuntary confinement of a person alone in a room where the person is physically prevented from leaving or the separation of the patient from others in a safe, contained, controlled environment. Restraint is the direct application of physical force to an individual, with or without the individual’s permission, to restrict his or her freedom of movement. Physical force may involve human touch, mechanical devices, or a combination thereof. Use of these interventions presents an inherent risk to the patient’s physical safety and well-being and therefore must be used only when there is “imminent risk” that the patient may inflict harm to self or others. Statutory language may include the use of drugs in the definition of restraint (Simon 2001). Seclusion and restraint should be used only as a last resort and never for the convenience of staff. The overarching therapeutic goal is to protect the patient’s safety and dignity.
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Qualified staff members may initiate seclusion or restraint for the safety and protection of the patient and staff; however, they must obtain an order from the licensed independent practitioner as soon as possible within 1 hour of initiation. Stringent requirements for face-to-face evaluation of the patient within 1 hour of initiation and for assessment, frequency of reassessment, monitoring, time-limited orders, notification of family members, discontinuation at the earliest possible opportunity, and debriefing with patient and staff members have been carefully defined by the CMS and JCAHO. The treatment of psychiatric inpatients has changed in the managed care era. Most psychiatric units, particularly those in general hospitals, have become short-stay, acute-care psychiatric facilities. Generally, only suicidal, homicidal, and gravely disabled patients with major psychiatric disorders pass strict precertification review for hospitalization. Approximately half of these patients have comorbid substance-related disorders. The purpose of hospitalization is crisis intervention and management to stabilize patients and ensure their safety as soon as possible (Simon 2001). The clinical staff can become temporarily overwhelmed by the rapid admission of very sick patients. The psychiatric unit may need to briefly restrict or curtail new admissions. Patients should not be placed in seclusion or restraint for the convenience of the staff or because of insufficient staffing. The indications and safety precautions for seclusion and restraint should be thoroughly documented. Seclusion and restraint should be used only when all other treatment and safety measures have failed. The indications and contraindications for seclusion and restraint are discussed elsewhere (American Psychiatric Association 1985). Seclusion and restraint may be necessary for the patient assessed at high risk for suicide in order to prevent self-harm. If the patient can be engaged by the staff shortly after admission, a nascent therapeutic alliance may develop. Appropriate medications given at therapeutic levels often stabilize the high-risk patient. If the suicidal patient is placed in seclusion and restraint, direct observation is required, according to regulatory and hospital policies. Seclusion rooms should have windows or audiovisual surveillance capability (Lieberman et al. 2004). Open-door seclusion is preferable when clinically appropriate.
Freedom of Movement There must be a rational nexus between patient autonomy in the hospital setting and the patient’s diagnosis, treatment, and safety needs. With patients at risk for suicide, standard safety precautions must be ob-
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served, such as removal of shoelaces, belts, sharps, glass products, and even pillowcases that can be used for suffocation. A thorough search for contraband on admission is standard procedure. Psychiatric units are usually fitted, at a minimum, with non-weight-bearing fixtures and shower curtain rods, very short cords for electrical beds (properly insulated), cordless telephones or telephones with safety cords, jump-proof windows, barricade-proof doors, and closed-circuit video cameras. The most common and available method of committing suicide by inpatients is strangulation, usually accomplished by a bed sheet hooked up to the patient’s bed, door, or bathroom fixtures. Safe installation of plumbing pipes for toilets and use of solid ceilings are necessary to diminish the risk of hanging. The most dangerous place on the psychiatric unit is the patient’s room, especially the bathroom. Determining safety precautions is complicated by court directives that require highly disturbed patients to be treated by the least restrictive means (Simon 2000). In Johnson v. United States (1976/1978/1981), the court noted that an “open-door” policy creates a higher potential for danger. The court went on to say: Modern psychiatry has recognized the importance of making every effort to return a patient to an active and productive life. Thus, the patient is encouraged to develop his self-confidence by adjusting to the demands of every day existence. Particularly because the prediction of danger is difficult, undue reliance on hospitalization might lead to prolonged incarceration of potentially useful members of society.
The tension between promoting individual freedom and preventing self-injury introduces an inherent uncertainty in the safety management of suicidal patients (Amchin et al. 1990). In malpractice suits, the individual facts of the case and the reasonableness of the staff’s application of the open-door policy are determinative.
Policies and Procedures Hospital policies and procedures require the patient to be evaluated by the psychiatrist within a specified period of time after admission. Departures from policies and procedures by the psychiatrist deserve a documented explanation. If the psychiatrist departs from the policies and procedures and the patient is harmed, a malpractice suit filed against the psychiatrist may be difficult to defend (Eaglin v. Cook County Hospital 1992). Official policies and procedures are consensus statements that often reflect the standard of care. However, they may propound “best practices” rather than the “ordinarily employed” standard care.
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Departmental policy may require that a newly admitted patient remain on the psychiatric unit for a specified period of time, usually 24 hours. It is prudent not to issue off-ward privileges to new patients until their psychiatric evaluations are completed and safety needs determined. Emergency admissions of patients often occur late at night or in the early hours of the morning. Severely ill patients at high risk for suicide should be examined by the psychiatrist within a reasonable time after admission. The nursing staff has a duty to contact the psychiatrist in a timely manner after a patient is admitted. In the managed care era, unaccompanied off-ward privileges or overnight passes for patients are a rarity. Staff-accompanied off-ward passes for in-hospital diagnostic procedures occur frequently. Depending on the urgency of medical problems and the level of assessed suicide risk, adequate supervision must be provided. For example, more than one staff member may be required to accompany the patient. Newly admitted patients who smoke will often pressure the staff for a pass to go off-ward individually or with a smokers’ group. A nicotine patch or inhaler may be rejected. No off-ward pass should be issued unless the patient is cleared to have one after adequate assessment of suicide risk.
Premature Discharge Patients leave the psychiatric unit against medical advice for a variety of reasons. Some smokers leave if they are not allowed to smoke on the unit. Patients with substance abuse disorders often sign out against medical advice (AMA), sometimes in the middle of the night. Informal (pure voluntary) and formal (conditional voluntary) admission policies determine whether the suicidal patient who demands to leave can be held for a period of evaluation. Purely voluntary patients cannot be held against their will. Only moral suasion can be used to encourage continued hospitalization. Only a few states continue to use informal admission procedures. In some hospitals, both psychiatric and addicted patients are admitted to the psychiatric unit. Patients admitted for substance detoxification may be informal admissions, whereas psychiatric patients on the same unit are formal admissions. Generally, substanceabusing patients without a comorbid psychiatric disorder cannot be held against their will, whereas substance-using patients with comorbid psychiatric disorders usually can be held against their will. The psychiatrist may not have had the opportunity to examine the patient and perform a suicide risk assessment before the patient decides to leave against medical advice. Reliance is placed on clinical staff members to conduct an adequate suicide risk assessment and to inform the
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psychiatrist of their evaluation. Conditional voluntary patients at significant risk for suicide can be held for a specified period of time for further evaluation. During the holding period, some patients withdraw their requests to leave and decide to stay. Other patients at low risk for suicide may be allowed to leave AMA or may be involuntarily hospitalized if they remain at significant risk for suicide. The decision to release or retain a suicidal patient who signs out AMA depends on the assessed level of risk (Gerbasi and Simon 2003). Some patients at moderate to high suicide risk are currently treated as outpatients, especially when a working therapeutic alliance with an outpatient treater exists and other substantial protective factors are present. Acutely suicidal patients seen in the emergency department who refuse hospitalization are usually confronted with making a choice between voluntary or involuntary hospitalization. Some patients opt for voluntary hospitalization only to seek discharge after a brief stay on the psychiatric unit. If the “revolving door” patient is a conditional (formal) voluntary admission, he or she can be held for further evaluation as prescribed by state statute.
Suicide Warnings The clinician has no legal duty to inform others that a patient is at risk for suicide (Bellah v. Greenson 1978). The Tarasoff duty to warn and protect endangered third parties, which exists in a number of jurisdictions, applies only if the threats of physical harm are directed toward others, not toward patients themselves (Tarasoff v. Regents of the University of California 1976). In Gross v. Allen (1994), however, a 1994 California appellate court case, the court held that if a patient has a history of dangerousness to self, the original caretaker is legally responsible for informing the new caretaker of this history. The court applied a Tarasoff analysis, extending the duty to warn and protect to threats of suicide. Gross v. Allen does not appear to create a new duty for psychiatrist in the safety management of patients at risk for suicide. Clinicians often communicate with new treaters after obtaining patients’ permission. Standard safety measures include communicating with significant others about the patient’s condition, attempting to modify pathological interactions between the patient and family members, and mobilizing family support (e.g., removing lethal weapons, poisons, and drugs; administering and monitoring prescribed medications). Good clinical practice may require that significant others be apprised of the patient’s risk of suicide or even to include them in the treatment, provided the patient agrees to such interventions. The patient, however, may not grant
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permission for disclosure. Just listening to others does not violate the patient’s confidentiality. The patient should be informed of the contact. Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry (American Psychiatric Association 2001) states, “Psychiatrists at times may find it necessary, in order to protect the patient or the community from imminent danger, to reveal confidential information disclosed by the patient” (Section 4, Annotation 8). Some states provide for statutory waiver of confidential information when a patient threatens self-harm (Simon 1992).
Significant Others Cooperation and support of significant others in the patient’s care are essential. Significant others include family members (spouse, mother, father, sibling, offspring, grandparent, other relatives) and nonfamily members (roommate, friend, fiancé, other) (Dervic et al. 2004). The family is often the patient’s main support and protective factor against suicide. Postdischarge planning addresses the stability of the patient, the stability of the family, and the nature of the interaction between patient and family as important parts of the discharge risk/benefit assessment. There are potential problems with families providing patient supervision. First, the interaction between the patient and the family may be seriously impaired. Mentally ill patients frequently come from families that display significant psychological impairment. Moreover, some members of the patient’s family may be more unstable than the patient. Family members may dissuade the patient from taking necessary medication because of their denial of the patient’s mental illness. Disturbed families can become a risk factor for patient suicide. Educating the family about the patient’s illness may help decrease destructive attitudes and behaviors that undermine the patient’s stability and safety. Psychoeducation is important in postdischarge safety planning. Family members are not trained to manage suicidal patients. Patients who are intent on killing themselves are ingenious in finding ways to attempt or commit suicide. Asking family members to keep a constant watch on the patient usually fails. Most family members will not follow the patient into the bathroom or be able to stay up all night to observe the patient. Moreover, family members find reasons to make exceptions to constant surveillance due to denial, fatigue, or the need to attend to other pressing matters. For example, one family who was told to keep the patient under constant watch allowed her to drive to church alone. She drove 30 miles to a bridge and jumped to her death.
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There is an important role for the family, but it is not as a substitute for the constant safety management provided by trained mental health professionals on an inpatient psychiatric unit. Early discharge of an inpatient based on reliance on family supervision can be precarious. If an outpatient at suicide risk requires constant family supervision, then psychiatric hospitalization may be indicated. Families, however, can be instructed to observe and report specific symptoms and behaviors displayed by the patient that often precede suicide attempts. Family support of the patient and feedback about the patient’s thoughts and behaviors are appropriate, helpful roles. Family members who have a supportive relationship with the patient are often sensitive to important reportable changes in the patient’s mental condition.
Clinically Based Risk Management The fear of being sued can undermine patient safety management when clinically indicated interventions are compromised by avoidant defensive practices. The diffident, fearful clinician attempts to avoid the inherent uncertainties in the safety management of suicidal patients by adopting unduly defensive practices (Simon 1985, 1987). An affirmative, full commitment to the patient’s care is lost. For example, a clinician who fails to involuntarily hospitalize a litigious treatment-refusing patient at high risk for suicide because he or she fears being sued increases his or her liability exposure if the patient attempts or commits suicide. Risk management is a reality of psychiatric practice, especially in the assessment and management of patients at risk for suicide. Risk management guidelines usually recommend ideal or best practices, whereas the actual standard of care is ordinary or reasonable care. Moreover, suicide cases are challenging, multifaceted, and nuanced, making it difficult to provide precise assessment and management guidelines. Clinically based risk management is patient centered (see Chapter 28, “Clinically Based Risk Management of the Suicidal Patient”); it supports the treatment process and the therapeutic alliance (see Table 21–1). At a minimum, it follows the fundamental ethical principle in medicine to “first do no harm.” A working knowledge of the legal regulation of psychiatry enables the practitioner to manage psychiatric-legal issues more effectively. Clinically based risk management also provides the practitioner with a significant measure of practice comfort that supports the clinician’s treatment role with patients at risk for suicide. Defensive practices that can undermine patient safety management are reduced.
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TABLE 21–1. Basic elements of clinically based risk management Patient centered Clinically appropriate Supportive of treatment and the therapeutic alliance Working knowledge of legal regulation of psychiatry Clinical management of psychiatric-legal issues Wellness, not legal, agenda “First do no harm” ethic Source. Reprinted from Simon RI: Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management. Washington, DC, American Psychiatric Publishing, 2004, p. 19. Copyright 2004, American Psychiatric Publishing. Used with permission.
Conclusion The clinician’s full commitment of time and effort to the care of the suicidal patient is the single most important factor in reducing the clinical uncertainties surrounding safety management. Uncertainty about clinical judgment calls is inevitable. Clinicians should assess their limits in coping with uncertainty and anxiety and the emotional and physical fatigue associated with the care of suicidal patients. Some clinicians limit the number of suicidal patients under their care or simply do not accept patients known to be at risk for suicide.
❏ Key Points ■
Effective treatment and safety management of the suicidal patient require the full commitment of time and effort from the clinician.
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Safety management is part of an overall effective treatment plan.
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Suicide risk assessment is a process, not an event. It is key to determining informed, ongoing treatment and safety management. It is performed on all patients at suicide risk.
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Reliance on suicide prevention contracts with new, unknown patients who are acutely ill is unwarranted. Suicide prevention contracts can create the illusion of safety where none exists.
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Do not use suicide prevention contracts in the place of adequate suicide risk assessment.
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Good clinical care, not the fear of being sued, directs the clinician’s decision making about involuntary hospitalization.
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Provide appropriate levels of patient safety management despite third-party payer denial of coverage for the cost of close supervision.
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Appeal denials of coverage for the supervision requirements of a patient at high suicide risk. Rejection of coverage or the appeal by third-party payers must not determine the level of supervision provided to the patient. This is the clinician’s responsibility.
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The entire treatment team participates in the supervision of the patient at suicide risk. The proper supervision of patients at risk for suicide in rapid-turnover inpatient settings cannot be the responsibility of only a few people.
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Families and other caretakers play an important role in safety management of the patient, especially when educated about their appropriate role. Most families, however, cannot provide constant supervision of the patient.
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If constant supervision is required, consider hospitalizing the patient or delaying discharge from the hospital until the patient is stabilized.
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Do not worry alone. Consultation is always an option.
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Clinical risk management preserves the clinician’s treatment role with the patient. It is patient centered, incorporates an understanding of legal matters affecting clinical practice, and pursues a wellness, not a legal, agenda.
References 42 Code of Federal Regulation 482.13 (f)3 (II) (C) (1999) Amchin J, Wettstein RM, Roth LH: Suicide, ethics, and the law, in Suicide Over the Life Cycle. Edited by Blumenthal SJ, Kupfer DJ. Washington, DC, American Psychiatric Press, 1990, pp 637–663 American Psychiatric Association: The Psychiatric Uses of Seclusion and Restraint (Task Force Report No 22). Washington, DC, American Psychiatric Association, 1985 American Psychiatric Association: Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry. Washington, DC, American Psychiatric Association, 2001 Bellah v Greenson, 81 Cal App 3d 614, 146, Cal Rptr 525 (1978) Busch KA, Fawcett J, Jacobs DG: Clinical correlates of inpatient suicide. J Clin Psychiatry 64:14–19, 2003 Dervic K, Oquendo MA, Grunebaum MF, et al: Religious affiliation and suicide attempt. Am J Psychiatry 161:2303–2308, 2004 Eaglin v Cook County Hosp., 227 Ill App 3d 724, 592 NE2d 205 (1992) Farwell v Un, 902 F2d 282 (4th Cir. 1990) Gerbasi JB, Simon RI: When patients leave the hospital against medical advice: patient’s rights and psychiatrists’ duties. Harv Rev Psychiatry 11:333–334, 2003 Gross v Allen, 22 Cal App 4th 345, 27 Cal Rptr 2d 429 (1994)
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Gutheil TG, Simon RI: Abandonment of patients in split treatment. Harv Rev Psychiatry 11:175–179, 2003 Johnson v United States, 409 F Supp 1283 (MD Fla 1976), rev’d 576 F2d 606 (5th Cir 1978), cert denied, 451 U.S. 1019 (1981) Joint Commission on Accreditation of Healthcare Organizations: Comprehensive Accreditation Manual for Behavioral Health Care: Restraint and Seclusion Standards for Behavioral Health. Chicago, IL, Joint Commission Accreditation of Healthcare Organizations, 2001, pp TX 7.1.5, TX 7.1.6 Lieberman DZ, Resnik HLP, Holder-Perkins V: Environmental risk factors in hospital suicide. Suicide Life Threat Behav 34:448–453, 2004 Meyer DJ, Simon RI: Split treatment: clarity between psychiatrists and psychotherapists, Part I. Psychiatr Ann 29:241–245, 1999a Meyer DJ, Simon RI: Split treatment: clarity between psychiatrists and psychotherapists, Part II. Psychiatr Ann 29:327–332, 1999b Qin P, Nordentoft M: Suicide risk in relation to psychiatric hospitalization. Arch Gen Psychiatry 62:427–432, 2005 Resnick PJ: Recognizing that the suicidal patient views you as an adversary. Current Psychiatry 1:8, 2002 Seiden RH: Where are they now? A follow-up study of suicide attempters from the Golden Gate Bridge. Suicide Life Threat Behav 8(4):203–216, 1978 Simon RI: Coping strategies for the defensive psychiatrist. Med Law 4:551–561, 1985 Simon RI: A clinical philosophy for the (unduly) defensive psychiatrist. Psychiatr Ann 17:197–200, 1987 Simon RI: Clinical Psychiatry and the Law, 2nd Edition. Washington, DC, American Psychiatric Press, 1992 Simon RI: Discharging sicker, potentially violent psychiatric inpatients in the managed care era: standard of care and risk management. Psychiatr Ann 17:726–733, 1997 Simon RI: Psychiatrists’ duties in discharging sicker and potentially violent inpatients in the managed care era. Psychiatr Serv 49:62–67, 1998 Simon RI: Taking the “sue” out of suicide: a forensic psychiatrist’s perspective. Psychiatr Ann 30:399–407, 2000 Simon RI: Psychiatry and Law for Clinicians, 3rd Edition. Washington, DC, American Psychiatric Publishing, 2001 Simon RI: Imminent suicide: the illusion of short-term prediction. Suicide Life Threat Behav (in press) Tarasoff v Regents of the University of California. 17 Cal 3d 425, 551 P2d 334, 131 Cal Rptr 14 (1976)
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Safety Interventions John A. Chiles, M.D. Kirk D. Strosahl, Ph.D.
The purpose of this chapter is to increase a sense of safe practice for psychiatrists and other mental health professionals who work in various clinical settings. In all these venues patients inevitably are dealing with suicide—thinking about it, attempting it, and sometimes committing it. The techniques discussed here can be used in any type of practice—inpatient, outpatient, or forensic. The legal system often seems to assume that, but for a physician’s neglect, injury or death by suicidal behavior would not occur. This assumption is not true. Many patients who die by suicide do so despite good psychiatric treatment, not because of a lack of it. A safer practice will not absolutely prevent suicide. It will, however, enhance your ability to be an effective therapist with suicidal patients and your capacity to deal with legal issues. This chapter focuses on three important areas of safe practice in treating suicidal patients. First, we examine attitudes and perceptions about suicide and discuss ways in which you can recognize and deal with emotions and cognitions that might interfere with your own ability to safely treat a suicidal patient. Second, we review strategies and tactics for increasing the safety factor in various components of practice. Third, we discuss safety concerns in managing psychiatric emergencies. Each of these areas is discussed in significantly greater detail in Clinical Manual for Assessment and Treatment of Suicidal Patients (Chiles and Strosahl 2005). We end with a brief review of safety issues in dealing with the survivors of suicide and the significant need for more research on suicidal patients. 441
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First Do No Harm Primum non nocere is an admonition learned by every medical student. Psychoanalytic psychiatry, basing the discussion on the concept of countertransference, has long warned that a clinician’s negative reactions to suicidal behavior can make things worse for a suicidal patient (Maltsberger and Buie 1974). At the moment of crisis, when patients need their psychiatrist the most, the psychiatrist may suddenly find himself or herself feeling frustrated, angry, depressed, or hopeless. Being at one’s emotional and cognitive worst when the need is to be at one’s most effective is a major safety issue. This is best dealt with by understanding negative responses to suicidal behavior now, before dealing with inevitable suicidal crises. Almost all cultures have written about suicide. Many psychiatrists, while in high school, were exposed to Plato’s discourse on the death by suicide of Socrates. As humans have pondered this act, a range of statements about suicide has evolved, from suicide as unequivocally wrong at one pole to suicide being an intrinsically positive act at the other. The spectrum of moral- and value-based stances is summarized in Table 22–1. You should examine your personal values and moral stance on suicide. Upbringing, life experiences, and personal struggles create a set of beliefs. These beliefs will strongly influence your behavioral, evaluative, and emotional responses to suicidal patients, and accordingly it is quite important to understand them. Among the questions to ask are, Do you see suicide as a wise choice sometimes? Does it make you angry? Is it a difficult topic for you to talk about? If you feel some trouble or concern, talk it over with colleagues. Seek counseling for yourself if you feel that would help. Again, the worst time to deal with these issues is when a patient is in a crisis. Assess yourself, and if working with suicidal patients is not for you, then do not do it. What follows is an exercise that highlights some issues. Imagine someone who is difficult to understand and somewhat unpredictable. This person is often moody and is intensely involved with other people. Her involvement is often supportive and even flattering, but it can take a dark turn. She can suddenly, and sometimes for very little reason, become quite angry. The anger is usually transient, but on one or two occasions it may become permanent. This person can turn on a friend and may never speak to that person again. Your own relationship with this person is that of an acquaintance. Your interactions have been social and cordial. Imagine first your feelings about this person as we have just described her. Pause a second, and then imagine that you have just heard that this person has made a suicide attempt. Following the
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TABLE 22–1. Moral- and value-based stances on suicide Suicide is wrong. It violates the fundamental rules of reason, human nature, religion, and/or the body politic. Suicide is sometimes permissible. For example, the individual may believe that the emotional or physical alternatives are unbearable. Suicide is not a moral or ethical issue. It is a morally neutral issue, and every person has a free will and the right to move and act according to that will. Suicide is a positive response to certain conditions. For example, when life ceases to be enjoyable, one has the right to end that life. Suicide has intrinsic positive value. It can be a way of saving face and avoiding dishonor. It can be the means to enter a desirable afterlife.
breakup of a stormy relationship, she cut her wrist, was rushed by friends to the hospital, and was admitted to a psychiatric unit. Imagine now what your emotional reaction is. To finish out this sequence, you find out that she has a history of at least three other suicide attempts, one by wrist cutting and two by overdosing. These have taken place over 10 years, and all have involved a breakup in an interpersonal relationship. Now think about your emotional reactions to this person. Most individuals find that their responses in this kind of exercise change as more about the imaginary person becomes known. This kind of “learn about your emotional hot buttons” exercise can be useful, especially when used in groups in training programs, and is discussed in more detail elsewhere (Chiles and Strosahl 2005). Two instruments that can give additional help with self-examination are the Consequences of Suicidal Behavior Questionnaire and the Reasons for Living Inventory (Chiles and Strosahl 2005). With the Consequences of Suicidal Behavior Questionnaire, imagine being in a suicidal frame of mind. When you finish, go back through the results. How closely do your answers correlate with your philosophies about suicidal behavior? Did you find any unexpected good or bad in the consequences of your imagined suicidality? The Reasons for Living Inventory evaluates the positive side of suicidal ambivalence as it poses the question “If I were thinking of suicide, what are the reasons I would have for not killing myself?” Your responses to the six dimensions evaluated in this inventory (Chiles and Strosahl 2005) can give you further insight into your thinking and emotions as they relate to suicide.
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Make Your Practice Safe Safe clinical practice is both good and meticulous, with attention to detail in a variety of areas. It provides the best care for your patients and provides you with the tools needed to manage the risk of lawsuits. The things that can go wrong in the treatment of a suicidal patient are numerous and can occur despite the most competent interventions. The complaints found in civil lawsuits concerning a suicidal patient generally fall into one or more of seven areas that are summarized in Table 22–2. The following guidelines for a safe clinical practice are derived both from experience in evaluating civil lawsuits and from clinical common sense.
Conduct a Competent Clinical Assessment and Document the Plan Good clinical practice involves conducting a reasonably thorough initial assessment of the patient’s suicidal behavior. The goal is not to make a prediction about suicide; the goal is to conduct a useful assessment of suicidal behaviors. Instrumentation for conducting such assessments and interpreting the results is provided elsewhere (Chiles and Strosahl 2005). Suicidal behaviors assessment should include a review of past suicidal behavior, recent suicidal ideation or behavior leading to the patient’s seeking therapy, and a review of the patient’s beliefs about the efficacy of suicide as a problem-solving strategy. This assessment should be done in a way that is direct, matter-of-fact, and emotionally supportive. It is reassuring to patients struggling with suicidal thinking or behavior to see a physician approaching these behaviors in a nonalarming, straightforward way. TABLE 22–2. Common reasons for civil lawsuits involving suicidal patients Inappropriate or inadequate assessment Failure to hospitalize or treat aggressively Failure to refer for consultation Failure of communication between providers Failure to reassess suicidality Failure to follow patient protection protocols Failure of facility safeguards
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It is important to document in the patient’s chart what the suicidal behaviors assessment reveals and how this will be addressed (or not addressed) in the treatment plan. If the decision is to continue with outpatient treatment or to involve family members in some way, make sure this is written in the chart. Psychiatrists are expected to make clinical decisions based on their professional judgment. Legal risk is reduced when the data leading to a clinical decision are clearly documented, even if the outcome is adverse. A common problem encountered in the courtroom is incomplete documentation of what assessment data were collected, how these data led to a clinical decision, and how that decision was converted into a treatment plan. Remember this legal mantra: If it is not written in the chart note, it did not happen. The following sample chart note may serve as a guide to follow in documenting your treatment: The patient returns today for a 50-minute follow-up appointment. He continues to report some depression, insomnia, loss of appetite, and anhedonia. He states he is taking his antidepressant medication as prescribed and has been following his behavioral activation plan (exercise × 6 weekly; two social contacts weekly). His mood is improved since the initiation of treatment. He has had episodes of suicidal ideation over the past several days but denies any suicide attempts. These episodes are brief and sporadic and last about 15–20 minutes. On a 1–10 scale of severity, he rates the worst episode a 4, but more generally, they are 2–3. He denies any current intent to engage in self-destructive behavior. He does not see suicide as a solution to his problems. Based on this information, I do not feel he is at risk for self-destructive behavior at this time and is most appropriately treated on an outpatient basis. We reviewed the crisis response plan that will allow him to call me or the emergency services unit should his functioning deteriorate. Plan is to return in one week for 1:1 outpatient treatment.
Seek Informed Consent It is useful to seek informed consent at the first contact and document what was discussed with the patient in terms of treatment options, risks and benefits, agreed-upon protocols for addressing suicidal emergencies, and the patient’s choices regarding selection of various treatment alternatives. This documentation helps to offset any notion that the patient and/or significant others were not allowed to participate in the treatment planning process. In civil lawsuits, the plaintiffs may claim that the patient and significant others were not fully informed about the various treatment options available, nor were they educated about the risks and benefits of each option. Inpatient hospitalization, in particular, is one treatment alternative that is the subject of such claims. Documen-
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tation of the treatment alternatives discussed, and of what was agreed to by the patient and/or significant others, is a very good countermeasures.
Reassess Suicidal Behavior Over Time Whether someone enters treatment with suicidal behavior as a presenting problem or develops suicidality during the course of treatment, it is important to assess that patient’s suicidal behavior at each session. This brief assessment, done in an open, emotionally neutral, matter-of-fact way, collects data about the patient’s status since the last session. If there is a change in the patient’s status, note the change and any clinical decisions that are made. It is important to remember that the appearance or reappearance of suicidality is not an automatic indication that the treatment is not working. The treatment plan may not need to be revised. If the treatment plan is revised (e.g., some additional sessions are scheduled), note the revision in the chart. Remember that the chart note will be the best method for recalling what care was given, and why, if a legal challenge is made.
Make Evidence-Based Treatment Decisions In developing a treatment plan, it is often helpful to add in a sentence or two about how the scientific evidence supports the treatment being delivered. The literature provides a basis for expecting specific outcomes from a variety of pharmacotherapies and psychotherapies (American Psychiatric Association 2004). Additionally, collect evidence at each treatment session that documents whether particular therapies are working. Psychiatrists who show a commitment to delivering treatments that are supported by science and monitored by evidence collected at each session are engaging in a safe practice technique. Expert witnesses generally try to impress with their knowledge of the evidence, so it is a positive strategy to behave like an expert in documenting evidence-based care treatment rationales.
Know the Limits of Suicide Prevention Measures No interventions have been shown to prevent suicide on a regular and predictable basis; thus there is no “vaccination” that will prevent death by suicide. Well-designed studies looking at both psychotherapy (Linehan et al. 1991) and pharmacotherapy (Meltzer et al. 2003) interventions with suicidal populations have shown reductions in nonlethal behaviors but not in lethal behaviors. Suicide prevention strategies based on protocols such as “no-suicide contracts” can lull the physician into thinking that the level of
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suicide risk has been reduced for the longer term when in fact the reduction, if present, may be only a short-term effect. This false sense of security can decrease the likelihood that clinicians will maintain the appropriate level of vigilance with patients demonstrating recent increases in suicidal behavior. Patient suicides have occurred shortly after the implementation of classic suicide prevention strategies. If the decision is made to use such interventions, they should always be regarded as interim and time-limited measures. Just because a no-suicide contract was obtained at session one does not mean it is still in force at session two. Some lawsuits have focused on the fact that a suicide prevention strategy is initiated but then not reviewed and reaffirmed at each subsequent contact. Generally, such interventions should be documented at each session if they are going to be used at all. Again, prevention measures are not treatment, but they may be part of an integrated treatment plan. In the next section, we discuss an alternative to the no-suicide contract.
Reduce Policy- and Procedure-Driven Services A psychiatrist may be found negligent simply for failing to follow agency policies and procedures, even if those policies incorporate clinically unproven or even useless strategies for treating the suicidal patient. A psychiatrist can provide reasonable standard of care treatment but be found guilty of negligence for violating agency policies and procedures. There is a danger in codifying too many risk management strategies into practice standards. These policies become the de facto standard of care in relation to a claim of negligence. The plaintiff will claim that the policies constitute a separate standard of care that can be applied to any clinical activity covered by the policy. Generally, it is advisable to limit the number of required clinical interventions. Instead, craft risk management policies and procedures so that they are evidence based and emphasize the singular role of clinical judgment in determining what specific interventions are called for. For example, an agency policy that requires inpatient hospitalization for a patient who refuses to sign a no-suicide contract can be an invitation to a plaintiff’s verdict. It is better to describe a range of factors that may or may not contribute to a clinical decision to hospitalize a patient.
Know How to Manage Emergencies Emergency management is the act of planning, in collaboration with your patient, a response to either the immediate suicidal episode or the possibility of recurring suicidal behavior. The complexity of effective emergency management is based on the same factors that make suicidal
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behavior a multidimensional entity. Some patients you encounter will be in the midst of a highly contained suicidal crisis that is clearly the result of life stresses (e.g., divorce, discovery of a terminal illness, death of a spouse, being fired from a job) or a discrete episode of a treatable mental disorder. The patient’s premorbid level of functioning is high, and there may be substantial social support available. At the other end of the emergency management continuum are patients who are always experiencing some degree of suicidal thoughts or behaviors, although the intensity level often varies from week to week. One cannot downplay the significance of any suicidal communication or behavior; however, these two kinds of presenting situations require different clinical responses. For example, it is not productive to view repetitive and intractable ideation as a suicidal crisis per se. For a number of suicidal patients, suicidal ideation is a daily reality, an everpresent symptom. Physicians must balance their crisis intervention response to the recurring suicidal behavior with the ongoing treatment and the community resource needs of the patient. On the other hand, a patient with the sudden emergence of suicidal thoughts or actions would be regarded as being in suicidal crisis. The notion of crisis means a significant upturn in suicidality to levels well beyond the previous typical range in that individual. A chronically suicidal patient can exhibit a suicidal crisis, but it must entail levels of suicidal ideation or behavior that are significantly increased beyond those typically manifested. When a patient needs help with a suicidal crisis, your endeavors at safe and successful intervention should be governed by the following four principles: 1. Suicidal behavior is designed to solve specific problems that a patient views as inescapable, interminable, and/or emotionally intolerable. Successful crisis intervention helps the patient work through the suicidal crisis by using both short- and intermediate-term problem-solving strategies. 2. Your demeanor plays a critical role in accelerating or decelerating the crisis. Approach the suicidal crisis in a direct, matter-of-fact, candid fashion, and avoid appearing nervous, frightened, or apprehensive about what may happen next. 3. Suicidal crises are usually self-limiting. Few individuals can maintain a high level of suicidal thinking or behavior for more than 24–48 hours without going into an adaptive period of emotional exhaustion. Treatment should be centered on getting the patient through the next several days while anticipating that the focus will then shift to the underlying problems that provoked the crisis.
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4. The final objective in crisis intervention is to help the patient solve problems in nonsuicidal ways. Intervention techniques should never reinforce suicidal behavior by making it appear that you are most responsive to your patient when he or she is in a crisis. The goal is neither to punish nor reward suicidality but to help the patient deal with problems in a constructive and life-affirming manner. Part of the assessment of a patient’s problem-solving flexibility is to monitor for the presence of psychotic or thought-disordered symptoms. Generally, the more disordered a patient’s thinking, the less workable is a self-directed problem-solving plan. A psychotic illness always needs to be treated. A patient with a psychotic disorder may benefit from the increased structure of a short-term hospitalization or a longer-term hospitalization targeting the underlying psychotic symptoms. Assessment of mood-related symptoms is an important step in understanding the patient’s crisis. Mood-related symptoms strongly influence a patient’s motivation and energy level. A depressed patient may have trouble following through with a problem-solving plan because the energy is not there to accomplish it. An anxious, agitated patient has energy to expend but may experience trouble focusing on a plan of attack. Mood is the key to understanding a patient’s needs: for example, to decide whether the initial plan is aimed at teaching the patient to tolerate suffering or solving the problem(s) that triggered the crisis. It is also important to assess a patient’s current use or potential for abuse of alcohol and/or drugs. Many suicidal people use alcohol or drugs as a way to deal with emotional pain. If drug or alcohol abuse plays a role, avoid lecturing or moralizing about the negative effects of substance abuse. Instead, form a problem-solving plan that is incompatible with the passive approach that leads to drug or alcohol use, abuse, and/or dependency. For example, schedule constructive activities during the time the patient is prone to drink or take drugs, or consider follow-up calls at a time when your patient might be tempted to use. Also ask about high-risk times when drugs or alcohol was not used. Find out how your patient was able to devise better solutions, and then focus on the increased use of these strategies. It is often useful to enlist the aid of others in your patient’s social network to help restrict access to alcohol or drugs or to support or initiate activities that are incompatible with heavy use. If a drug and alcohol program is available, encourage and assist your patient in enrolling. The suicide risk assessment questions included in Table 22–3 should be included in a patient assessment (Chiles and Strosahl 2005).
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TABLE 22–3. Risk assessment questions How strong is your patient’s belief that suicidal behavior will solve problems? What is your patient’s ability to stand or tolerate significant emotional pain? What are your patient’s reasons for not committing suicide should the opportunity present itself? How strong is your patient’s ability to see a future that is more positive and life enhancing? What is your patient’s history of using suicidal behavior as a means of solving problems?
Reframe suicidal behavior as a problem-solving behavior so that your patient’s first impression of treatment is oriented toward solving real-life problems. This approach helps remove the stigma of suicidal behavior and gets your patient thinking about symptoms from a different perspective. Work hard to get the message across that suicidal behavior is not a sign of abnormality. It is an outcome of a legitimate problem-solving process. This tactic in itself will help defuse a suicidal crisis.
Anticipate the Crisis Early in treatment, discuss with the patient the possibility that suicidal behavior may emerge, and jointly establish a protocol for that eventuality. The protocol must be understood and agreed to by your patient, consistent with both of your beliefs and values, and the patient must view it as a fair and workable arrangement. Although such an instrument needs to be individually tailored and may contain unique elements, the points included in Table 22–4 should be covered in most protocols. A few of these items require further discussion. TABLE 22–4. Components of a jointly developed suicide protocol to use during a crisis Define ways to prevent alcohol use. Define the nature of additional sessions that may be required. Develop a Crisis Card.a Discuss conditions under which hospitalization is advisable. Make clear your own policies regarding involuntary hospitalization. a
A one-page set of instructions for the patient to follow when he or she feels a suicidal moment coming on. The card lists a competent social support network and four or five self-help strategies the patient can commit to trying. See text for details.
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If additional sessions are required, these sessions should focus on positive behaviors and solutions and should not provide increased attention for the suicidal behavior per se. A Crisis Card is a one-page set of instructions for the patient to follow when he or she feels a suicidal moment coming on. This card has two components. The first defines a competent social support network—people who can be contacted who will provide helpful support and validation. Here, the patient should develop family and community resources, so your name should be last on the list. Second, list four or five self-help strategies your patient can commit to trying. Here are items from a sample card: • “Don’t drink. If I am drinking, stop.” • “Relax. Take 10 deep breaths and then count to 50.” • “Repeat several times ‘I am a strong person and have weathered moments like this before.’” • “I need to step back and take a fresh look at this problem I am having right now.” In addition to discussing conditions under which hospitalization is advisable, you should also discuss the value of goal-oriented shortterm admissions over longer, vaguely defined admissions. Be alert to the fact that hospitalizations can reduce a patient’s sense of self-efficacy. Discussing the possibility beforehand and giving your patient a say in the matter will maximize his or her sense of self-control.
Be Aware of Safety Concerns Regarding the “No-Suicide Contract” The no-suicide contract, now used in a multitude of inpatient and outpatient settings, has made its way into clinical lore as a way to remove the threat of suicide. Patients are asked to state in writing that they will not engage in suicidal behavior for a set period of time. This contract was originally conceived as an inpatient management technique (Drye et al. 1973). It has subsequently been used in other settings and situations, often, unfortunately, with scant effort to evaluate efficacy or even examine theoretical underpinnings. Some systems have used this contract as a hospitalization plan (i.e., one has to promise not to be suicidal to be discharged). Other systems use a patient’s refusal to sign as a criterion for involuntary hospitalization. The no-suicide contract can deceive the clinician into believing that the patient is better. No research studies have shown that suicide is less likely in people who have agreed to a no-suicide pact or that this strategy reduces suicidal behavior over the longer term (Egan 1997).
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Theoretically, this contracting could increase risk of suicidal behavior if the patient is not able to abide by the agreement, feels guilty, and does not disclose this fact to the psychiatrist. An alternative is a positive action plan, similar in structure to the Crisis Card previously described. In brief, patients are asked to engage in positive, constructive behaviors for a defined interval. This change in emphasis, from what you should not do to what you should do, models precisely the positive, life-affirming behaviors you want your patient to engage in. No strategy guarantees the removal of suicidal potential. Your goal is to create a positive context for short-term problem solving. The no-suicide pact has been used as a requirement for a patient to be transferred from one treatment system into another system. Would you require a depressed person not to be depressed in order to be discharged from an inpatient setting? If the depressed person were able to be nondepressed simply because of that type of pressure, would not the patient have done it already? If the suicidal patient were really able to agree not to be suicidal, would not it seem reasonable to assume that the patient would have done it already? Patient flow between parts of a comprehensive system of care needs to be based on an assessment of level of intensity and need, not on the extraction of a statement that can have a misleading effect on clinicians.
If a Suicide Does Occur in Your Practice Upon learning of the death by suicide of a patient, many psychiatrists find themselves in a state of emotional shock and disbelief. In most cases, the suicide is an unexpected event. In the midst of this turmoil, it is important to remember that the behavior of the providers and the responses of others in an agency or clinic can have a significant impact on the likelihood of a lawsuit. In addition to immediately notifying the liability insurance carrier of the adverse event (allowing them the opportunity to do a risk management appraisal of the case), you should also try following the guidelines below.
Reach Out to the Survivors Make contact with the immediate survivors of the deceased patient, and encourage them to participate in some form of grief counseling. If an agency is involved, the agency should make every effort to allow the survivors access to all records pertinent to the patient’s care. Efforts to sequester records from survivors can generate suspicion that the provider or agency is hiding something. Consider relieving the survivors
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of all financial responsibility for clinical services approximating the suicide attempt. This outreach response should be immediate, unequivocal, and nondefensive.
Do Not Alter the Clinical Record After the Fact If a patient commits suicide, avoid the temptation to alter existing chart notes (e.g., to specifically mention that you had assessed the patient’s suicidal risk in the last session) or to add new chart notes containing retrospective analyses. Do not, after the fact, analyze the process of care in the patient’s chart. This specifically includes making comments about what you think you missed or reflecting on clinical strategies you thought you should have used. Do not add notes about the actions of other clinicians. In general, it is important to be cautious about what goes in the patient’s chart after the suicide. Altered or added chart notes are very difficult to explain in court. They may not only discredit the patient’s primary provider but also provide ammunition for incriminating other providers as well.
Never Second-Guess a Decision When an adverse event like suicide has occurred, it is always easy to imagine what one might have done differently. All survivors think this way, and this includes the treating psychiatrist. Medicine has a rich tradition of learning from adverse outcomes. Clinical practice benefits from the psychological autopsy technique as applied to a patient’s death by suicide. This must be done, however, within the confines of a legally nondiscoverable session. Make sure your organization provides this environment. Otherwise, you will find yourself, in the legal process, explaining again and again why you thought you should have done something differently.
Base Your Practice in Evidence-Based Treatment Safe practice will benefit from more and better research on suicidal patients. Both the prediction literature and the treatment literature are sparse. Two large well-designed studies (Goldstein et al. 1991; Pokorny 1983) have tested suicide prediction models based on standard risk criteria. Neither demonstrated any ability to predict. Psychotherapies for nonlethal suicidal behavior have been developed in recent years, notably Linehan’s (1993) work with borderline personality disorder. It remains to be seen whether targeted psychotherapies will have a positive effect on completed suicide. Most pharmacotherapy studies routinely ex-
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clude suicidal patients. Analyses of large databases of pharmacological trials show that neither antipsychotics nor antidepressants differ from placebo in their effects on suicidal behavior (Khan et al. 2000, 2001). Concerns about negative effects of some antidepressants on suicidal behavior are increasing (Healy 2003), with the U.S. Food and Drug Administration now issuing warnings on this class of drugs (www.fda. gov). On the other hand, lithium has been shown to have a positive effect on lethal suicidal behavior (Cipriani et al. 2005). Although ethical concerns have been raised about research on suicidal patients, effective guidelines for this kind of research have now been developed (Oquendo et al. 2004). Safe treatment of our suicidal patients requires more evidence and evidence-based treatment.
❏ Key Points ■
Be aware of your emotional reactions, moral or religious response, and personal values about suicidality. If you are not aware of these, you will not treat your patients in a logical, consistent, and safe fashion.
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Have practice strategies in place that help protect you from the risk of malpractice litigation.
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Keep your personal reactions to suicide and your legal fears in check while pursuing a logical and evidence-based approach to working with suicidal behavior.
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Provide effective and safe crisis intervention to help your patients learn to solve problems and tolerate negative affect.
References American Psychiatric Association: Practice Guidelines for the Treatment of Psychiatric Disorders Compendium. Washington, DC, American Psychiatric Press, 2004 Chiles JA, Strosahl KD: Clinical Manual forAssessment and Treatment of Suicidal Patients. Washington, DC, American Psychiatric Publishing, 2005 Cipriani A, Pretty H, Hawton K, et al: Lithium in the prevention of suicidal behavior and all-cause mortality in patients with mood disorders: a systematic review of randomized trials. Am J Psychiatry 162(10):1805–1810, 2005 Drye RC, Goulding RL, Goulding ME: No suicide decisions: patient monitoring of suicidal risk. Am J Psychiatry 130:171–174, 1973 Egan MP: Contracting for safety: a conceptual analysis. Crisis 18:17–23, 1997 Goldstein RB, Black DW, Nasrallah A, et al: The prediction of suicide: sensitivity, specificity, and predictive value of a multivariate model applied to suicide among 1906 patients with affective disorders. Arch Gen Psychiatry 48: 412–422, 1991
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Healy D: Lines of evidence on the risk of suicide with selective serotonin reuptake inhibitors. Psychother Psychosom 72:71–79, 2003 Khan A, Warner HA, Brown WA: Symptom reduction and suicidal risk in patients treated with placebo in antidepressant clinical trials. Arch Gen Psychiatry 57:311–317, 2000 Khan A, Khan SR, Leventhal RM, et al: Symptom reduction and suicide risk among patients treated with placebo in antipsychotic clinical trials: an analysis of the Food and Drug Administration data base. Am J Psychiatry 158: 1449–1454, 2001 Linehan M: Cognitive Behavior Treatment of Borderline Personality. New York, Guilford, 1993 Linehan M, Armstrong HE, Suarez A, et al: Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry 48:1060– 1064, 1991 Maltsberger JT, Buie DH: Countertransference hate in the treatment of suicidal patients. Arch Gen Psychiatry 30:625–633, 1974 Meltzer HY, Alphs L, Green AI, et al: Clozapine treatment for suicidality in schizophrenia. Arch Gen Psychiatry 60:82–91, 2003 Pokorny AD: Prediction of suicide in psychiatric patients: report of a prospective study. Arch Gen Psychiatry 40:249–257, 1983 Oquendo MA, Stanley B, Ellis SP, et al: Protection of human subjects in intervention research for suicidal behavior. Am J Psychiatry 161:1558–1563, 2004
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Aftermath of Suicide The Clinician’s Role Frank R. Campbell, Ph.D., L.C.S.W., C.T.
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fter a death by suicide there are individuals who, because of their relationships to the deceased, will be affected. That group is collectively known as survivors of suicide. Historically only the immediate family members of the deceased are assigned the title “survivor.” This assignment happens most commonly through the obituary, which reports the name of the deceased and then states, “survived by...” By this notification to the public, a parameter of impact is drawn that somewhat artificially restricts who is considered a survivor; however, there are many others in any community who, by the nature of their relationships to the deceased, will be affected by the suicide. In the United States, suicidologists have estimated that between 6 (Shneidman 1969) and 24 (Campbell 2001) survivors are affected by each suicide; however, clinicians are not included in these estimates. It is realistic to note that any person engaged in providing treatment to the deceased will be affected, and these individuals should not be excluded from consideration when developing and providing resources to assist survivors. An estimated 12 clinicians lose a patient to suicide each week in the United States, necessitating interaction with survivors (Peterson et al. 2002). In the course of their practices at least half of psychiatrists can expect that a patient will die from suicide (American Psychiatric Association 2003). A variety of factors influence the clinician’s role in the 459
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aftermath of suicide, including barriers that may be both external and internal. An example of an internal barrier is the incorporation of specific gender responses to suicide that are products of the socialization process (Grad et al. 1997). External barriers include but are not limited to institutional policy and protocol, peer pressure, legal opinion, malpractice insurance constraints, and professional association recommendations. Therefore, the clinician has to overcome pressures that are both internal and external in order to contact the survivors and/or seek support for their own role as a survivor. It is well documented that survivors are at increased risk for suicide (Cain 1972) as well as other maladaptive coping behaviors. When a clinician has experienced the loss of a patient to suicide, what is considered appropriate among psychiatrists and other clinicians varies greatly by the setting in which they practice. For example, psychiatrists in the United States report a reluctance to contact survivors of the deceased for fear of being held responsible for failing to prevent the death. In other countries, however, treatment of the survivors by the attending psychiatrist following suicide is an accepted and often expected practice. Regardless of the range of efforts to assist the survivors, a poverty of care for clinicians is consistent. Herein lies the paradox for the clinician. Survivors have expressed desires to discuss their particular concerns and ask questions of the clinician. Clinicians, often conflicted by the need for self-care, care for survivors, and other internal and external constraints, are unsure of how to proceed. In reviewing the role of the clinician after the suicide of a patient, it is important to point out the barriers that may be real or assumed by the professionals. Institutional barriers are very real, and when imposed by hospitals or practice settings, they often prevent clinicians from providing services desired by survivors. Institutional barriers to caring for survivors stem from many factors, including ever-changing restraints concerning confidentiality, fear of retribution or blame, malpractice insurance limitations, and governmental guidelines, and result in policies and protocols that may hinder clinicians’ ability to respond to survivors. Some of the same realities that influence institutional response also affect clinicians’ personal beliefs about their roles following suicide. Governmental laws and guidelines, including licensure, malpractice insurance, and peer review, all contribute to clinicians’ interpretations about what constitutes appropriate care. Financial considerations and fear of damage to reputation also affect each clinician’s determination of how to practice their profession. Wrongful death suits after a suicide are the most predictable legal entanglements that psychiatrists will face during their careers. Training, mentors, peers, prior experience and practice, and
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personal and religious beliefs all contribute to the value system internalized by clinicians and must be examined as factors that also influence responses to survivors. Ironically, many of the things that influence a clinician’s response after a suicide create the barriers that are cited by survivors as the major factors in their decision to bring legal action against both institutions and clinicians. Because research is lacking regarding the efficacy of services for survivors, it remains unclear what is appropriate and what is needed for survivors, including clinicians. In the absence of rigorous research into efficacy of treatments for survivors, clinicians remain dependent on the anecdotal reports of stating what they want and need from the treatment provider after a suicide.
Active Postvention Model Having worked with survivors for more than 20 years and having developed an active postvention model (APM; Campbell 1997), I have accumulated an in-depth understanding of survivor needs. Since 1998, the APM has provided the opportunity for survivor-sensitive mental health professionals and paraprofessional survivor volunteers to respond to over 100 suicide scenes in order to deliver care and information about services to the new survivors. This environment, while the body is still present, allows the wants and needs of the newly bereaved to be expressed and recorded. APM is a volunteer service affiliated with the local coroner’s office and a free program of the Baton Rouge Crisis Intervention Center. It is staffed primarily by survivors, facilitating immediate acceptance at the scenes of suicides and a level of trust by the newly bereaved that might not otherwise be achieved if provided by clinicians alone. This service provided at the scenes of suicides is known as Local Outreach to Suicide Survivors, more commonly referred to as the LOSS Team. It is particularly noteworthy that the survivor team members have an instant rapport with the newly bereaved because they share a traumatic loss experience. This bonds the new survivors to the LOSS Team members and has resulted in a reduction of the elapsed time between the loss and seeking support services (Campbell et al. 2004). Prior to the LOSS Team program, survivors in a study waited an average of 4.5 years before seeking treatment (Campbell 1997). Six years into providing LOSS Team support, the mean elapsed time between death and seeking help for the newly bereaved who received the APM was 43 days. The anecdotal information is gathered from survivors, both at the scene and in individual intakes for services, in a more timely manner, thus increasing the validity and reliability of reporting.
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TABLE 23–1. Recommendations to clinicians for reaching out to survivors of suicide at the time of death Be assertive in contacting the survivors. Attend the funeral or visitation. Support ongoing help for survivors. Offer referrals or treatment if appropriate. Provide information about psychological autopsy. Be knowledgeable about survivor resources in your community.
Because of the APM and the unique opportunity it presents for reporting the wants and needs of the newly bereaved, certain themes have surfaced regarding the clinician’s role in the aftermath of suicide. Individuals who are in treatment, individuals who have received treatment in the past, and individuals who have never received treatment die by suicide. Although survivors of those who have never received treatment could contribute their insights into services, the discussion in this chapter is limited to deaths by suicide of individuals recently in treatment with a clinician. The insights derived from the APM study are in the category of postvention services and are specific to the field of suicidology. Shneidman (1972) defined postvention as “appropriate and helpful acts that come after a dire event” for the purpose of “alleviation of the effects of stress in the survivor-victims of suicidal deaths, whose lives are ever after benighted by that event” (p. x). Along with this definition in 1972, Shneidman stated that “postvention is prevention for the next generation.” If his statement is correct, then clinicians might justifiably seek to provide such “appropriate and helpful acts” to the survivors who seek counsel after a suicide as an effort to prevent future suicides. Until robust research into postvention is completed, Shneidman’s theories about helping survivors remain the only reasonable approach for clinicians to adopt after the suicide of a patient. In addition, clinicians must be diligent about caring for themselves during their treatment of and followup with suicidal patients and survivors of suicide. Survivors who received APM services at the scene of a suicide generated the recommendations in Table 23–1 by members of the LOSS Team of the Baton Rouge Crisis Intervention Center. Firsthand accounts are included in this chapter to illustrate, from the survivors’ perspectives, the importance of adopting these recommendations in your practice whenever possible. Each story is a case example representing a survivor’s answer to the question “What would you have wished that the clinician who was treating your loved one provided
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to you following the suicide?” These responses have not been altered in content and should be read in the context of e-mail correspondence. The first case example comes from a mental health professional who lost her sister (a therapist herself as well) and then, years later, her mother to suicide. Both of her family members were in treatment at the times of their deaths. When considering what I would have wished for from the clinicians who treated both my mother and sister at the times of their suicides it would be these two specific things: 1. Show up at the visitation or funeral (my sisters clinician did and my mother’s did not). 2. Offer to meet with me to discuss my concerns, and answer questions. Note: my sister’s therapist did offer to meet with me and I decided to honor my sister’s confidence with her therapist and not seek any information regarding her treatment…, but my appreciation of the offer can’t be underestimated. Had my mother’s psychiatrist made the offer, I would not have taken him up on it, either. Had I pursued a meeting with either therapist, the top two questions would have simply been: 1. What was she most fearful of in life? 2. What was she most angry about/resentful of in life?
It is important to note that this survivor assigned value to the attendance by one therapist and noted the absence of the other. Regardless of the clinician’s personal comfort or beliefs regarding attending the visitation or funeral of their patient, this survivor’s account represents the wishes of hundreds of survivors with whom I have had personal contact. LOSS Team members attend many of the visitations and funerals and corroborate the importance of the clinician making contact during visitation. The clinician’s attendance at the visitation or funeral provides another opportunity to encourage survivors to seek support or treatment by reassuring them about the availability and importance of postvention.
Outreach to Survivors (After the Initial Period Following Loss) Provide Follow-up After the initial visitation period, it is a valid consideration for the clinician to follow up on any referrals made to the survivors. A sincere inquiry into the survivors’ ability to cope with the activities of daily living
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(eating, sleeping, exercise, and concentration) is helpful in determining other referrals that might be needed. If a survivor reports compromised activities of daily living, then medication and/or individual treatment may be indicated. A survivor who is functioning in a depressed state may begin to overidentify with the deceased and experience suicidal ideation, therefore requiring thorough assessment. Follow-up reinforces not only the need for ongoing support for the survivor but also the clinician’s willingness to be a resource. Mental health centers throughout the United States may be a referral resource for the clinician to consider for survivors who are suicidal and lack other mental health resources (private insurance or ability to pay). For many survivors, psychological autopsy is a method of review that can answer specific questions regarding the deceased’s behavior, compliance to treatment, and complications to their successful treatment. The next case example demonstrates how an interview with the clinician of the deceased might have provided some insight for the survivor into the deceased’s ability to mask his symptoms. The following e-mail is from a survivor who lost her adult son to suicide. He had been in treatment for bipolar disorder prior to his death. Pete had seen a counselor about a week before he died, at our urging. We had tried to get him to see the psychiatrist that he had seen in the past or to go the mental health center, but he chose to see the counselor to just talk about the problem (he admitted to feeling depressed to us). He had promised us that he would go to the mental health center but changed his mind. He told us he had talked to the counselor and that all had gone well and that they felt he didn’t need medicine but would talk again the following week. (The next week was too late.) He had seen this counselor about a year ago for about 6 months when he was feeling stressed, to talk about the problems he was having. I wish I knew what occurred or how Pete hid his manic state so well from a professional. He was very good at hiding his true feelings so much of the time.
Had this parent been afforded the opportunity for psychological autopsy of her son, she might have gained answers into the stressors that precipitated his death and how he was able to disguise what to her appeared to be a manic state. Her son was considered high functioning and resourceful by other counselors who had assisted him over the years. The following e-mail came from his counselor, who had worked with him for more than 2 years at a vocational rehabilitation program: “I was shocked by the news of his passing. He was one of my favorite clients, and one of my most successful. I remember the last time I saw him we had a good talk. He was showing me his new tattoo and talking about his new girlfriend. I will miss him.”
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The rehabilitation counselor clearly acknowledges confusion over Pete’s ability to appear life oriented in a counseling session and yet later take his own life. This acknowledgment of the deceased’s ability to mask his thoughts of suicide validates the mother’s confusion over the same issue. One of the many benefits of psychological autopsy is providing an environment in which such questions can be explored. Providing other resources of which the survivor may not be aware is another benefit of follow up. Reading lists of survivor-focused materials create opportunities for bibliotherapy, which many survivors report as helpful. Because so much of the literature is relationship specific (e.g., loss of child, spouse, sibling), clinicians’ recommendations could be more effective and should be founded on their firsthand knowledge of the material and their assessments of the needs of the survivor. Some survivor literature features information directed to survivors regardless of their relationship to the deceased. Carla Fine’s (1997) book No Time to Say Goodbye contains both her personal journey as a survivor of her physician husband’s suicide and the stories of persons surviving the deaths of loved ones of other relationships. The opportunity to read (see “Suggested Readings” at the end of this chapter) about what helped so many survivors could help normalize the complicated process that follows suicide for the newly bereaved. Another possible outcome of reading survivor literature is a reduction in resistance to participating in survivors of suicide (SOS) support groups. Although SOS groups do not exist in every community, they are more common today and have provided a low- or no-cost local environment where many survivors gain support. Contact information about many of the SOS groups can be found in survivor literature. Should the survivor be interested in attending a SOS group, the clinician should be well informed about making referrals to the group and other services for survivors that may be provided. Another referral resource that might be considered by clinicians treating survivors is a local crisis line. These lines often provide support for suicidal callers and survivors of suicide experiencing compromised activities of daily living and other issues related to the suicide. Because they are available 24 hours a day, 7 days a week, the crisis line becomes a resource during off-hours for clinicians and other services. Many crisis lines also provide up-to-date information and referral to resources in the community. Since September 11, 2001, many communities have begun providing telephone access to current information and referral resources by a three-digit phone number known simply as 211. Like other three-digit resources (411 for directory assistance, 911 for emergency services), it is gaining in recognition and usage over time. Just as 911 is not available
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in all communities in the United States, 211 is presently limited, and clinicians can determine whether it is available in their communities by dialing 211 (cellular services are currently not mandated to provide access to this resource). Through the use of the Internet, Web sites hosted by survivors and agencies and programs that provide information specific to survivors are readily identified and are usually more current. Clinicians should include the Internet in their referrals to survivors because it provides an environment in which support, via e-mail and online chat rooms, is available. Such electronic support can reduce the isolation that many survivors, especially in rural settings, report due to their distance from the limited resources that may be available.
Acknowledge Significant Dates Survivors have indicated their appreciation of clinicians who identify important dates and difficult times (i.e., holidays and the deceased’s dates of birth and death) and use that information in tandem with a contact management program to follow up with ongoing support. This contact, although only a small gesture, may be a key to helping the survivor through a very complicated bereavement process. This personalized contact on key dates (for the survivors) helps mitigate the grief experienced during seasonal spikes that time alone cannot erase. The value to the survivor is incalculable. A spouse who lost her husband just prior to their anniversary noted the following example of such a follow-up approach: Each year on the anniversary of his death and during the holidays I get a simple card from the doctor who was treating my husband. He writes in his own hand something like, “I know this can be a difficult time of year and I hope you are taking care of yourself,” he then signs at the bottom. I have kept them all, and it means so much to me that he remembers. I realize it may be just a function of a mail out system that he has for his office but that really does not matter. What is important is that someone remembers my loss besides me.
Clinicians must be vigilant to ensure that any correspondence is appropriate and comforting. The following example illustrates how routine correspondence, such as billing for services, might cause pain and create animosity for survivors after suicide of a patient. The mother of an adult son who took his life while in treatment after 4 years with the same physician stated: About 2 weeks after the funeral I went to his apartment to pick up the last of the mail the landlord was keeping for me. There in the mail was
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a letter from his doctor. I assumed it was going to be some sort of acknowledgement about his death and offer to help; was I wrong! It was a note reminding him that “he had missed an appointment” (we called and notified the office that he had killed himself the same day he died) and that “the office policy requires payment if you do not cancel more than 48 hours before the appointment day.” Well, I was furious! I called and gave them a piece of my mind. I told the office manager that to get something like this in the mail was criminal. I also told her that if they wanted to “report his debt for collection” as they threatened in the letter, then they might want to know where he is buried so they can take it up with him in person. She was sorry and apologized, and when I hung up all I could do was cry. The poor landlord saw me in the parking lot and came out to see if he could help, if only the doctor’s office would have been more efficient, I would not have had to go through such a difficult and embarrassing experience.
Clinicians must be diligent in reviewing their accounts and marketing procedures and instructing their staff members to avoid being part of unintended harassment of survivors dealing with the financial and legal considerations after an unexpected death. Caring professionals who take the time to explain the processes and offer assistance can mitigate those taxing and painful concerns. The following case example tells how the spouse of the deceased dealt with the frustrations of such details: It seemed that daily I would get a call from some bank or insurance company to verify something with him, sell him something, or just want to talk to him. Each time I would have to explain that he was dead, and then they would want to know how he died, and I would just hang up. I called to cancel his cell phone, and they told me that I could not cancel it for him and I had to bring in a death certificate to prove he was dead. I just kept paying the bill for almost a year because the death certificate made it real and paying the bill let me pretend he was just away on a trip. I know that was crazy, but I could not get up the courage to go and face some cell phone person and show them his death certificate. A part of me wanted to ask them if he had called anyone in the past year!
Clinicians should take particular care to recommend hospital or institutional treatment for a patient where the clinician him- or herself will be available for consultation with the patient and supervision of the patient’s treatment plan while in the facility. Because family members and significant others of a suicidal patient become exhausted from hypervigilance over the suicidal patient, they can experience cognitive impairments, difficulty processing complex information, and caregiver ambivalence. They place immense trust in the clinician’s treatment recommendations and assume that all treatment will be safe and effective and that the admitting clinician will be present during admission and
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for their loved one’s treatment. When a suicide is completed in a hospital or institutional setting, loss of trust occurs for clinicians and the survivors. When a clinician recommends hospitalization and is then unable to see the patient for days following admission, the impact is confusing to the survivors. The following e-mail describes such a loss of trust by a surviving spouse: The doctor reassured me that hospitalization would be the best thing for him. He begged me not to sign the papers and have him committed. I had to trust the doctor; after he killed himself I found out they put him in a lockdown ward and left him there for the weekend. He was not given any medication to help him sleep or calm down. The doctor (I found out later) went away for the weekend and was not even available to be called if a consultation could have been arranged. He was put in a unit with several actively psychotic patients who would just walk in his room and wake him up (if he did manage to fall asleep). The following Monday the doctor returned and saw him for 10 minutes that morning and gave him a shot to “calm him down”; the next day he hanged himself with a belt left by another patient. How can I ever trust anyone again?
Clinicians must also disclose the limitations of any treatment recommendations. Defining limitations of treatment may not change the ultimate outcome of the treatment; however, it might eliminate the loss of trust that occurs when expectations are overestimated. When a suicide occurs in a hospital—a safe place as perceived by caregivers—their loss of trust is outweighed only by an elevated fear that something else bad will happen. That fear may remain elevated for years past the survivors’ renewed ability to trust. Clinicians could use the following example of a script that might have been a better alternative to handling the prior case: You are both exhausted! Your wife is exhausted from standing guard day and night, protecting you from yourself, and you are exhausted from the apparent suicidal depression you are fighting. By going into the hospital you might both get some rest; however, it will be difficult for both of you to cope with being away from each other, having been so close during this battle with suicide. The limitations I have in treating you include not being in town this weekend, and this means I will not be able to begin your treatment until Monday. The depression can get much worse before it gets better. Can you commit to beginning treatment under these limitations?
This approach allows the patient and family to be aware of the clinician’s limitations to begin treatment due to other prior responsibilities as well as acknowledging the need for everyone to share in the commit-
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ment to get help and rest. Treatment expectations may come from media, books, firsthand accounts, or from survivors’ own experiences in hospitals for physical complications. Loved ones may have unrealistic expectations of treatment options in inpatient settings. Expectations of patient, loved ones, and clinicians may be varied, making it necessary to prepare all parties for realistic goals and treatment outcomes. The following case example is from a spouse whose physician husband was admitted to a private psychiatric hospital, where he hanged himself within 48 hours of admission. Clinicians might discern from this example how to avoid long-term trauma for survivors stemming from the method and content of the notification of the suicide and the identification of the deceased: He has been dead 20 years, but I can remember that day as if it was yesterday. I remember very clearly his psychiatrist taking me to see his body and pulling back the sheet to show me the ligature marks. He then stated “they weren’t too bad,” as if that would give me some comfort.
Viewing the body can produce many intrusive images. The LOSS Team has discovered that whether the survivors choose to view the body or not, being given the choice is paramount in importance. Clinicians should make every effort to prepare the survivors by informing them about the condition of the body and how it will be presented (e.g., on a gurney, in a body bag, as it was found). Such preparation can reduce the negative consequences of viewing. Viewing only a small portion of the body may achieve what survivors desire (a mother said she just needed to see his hand, and then she would know this was her son). The case example continued with what the survivor wanted at the time of her physician husband’s inpatient suicide: The first thing I wanted from any ONE of them was an explanation of how this happened; he was in a private psychiatric hospital on “arm’s length” suicide watch, being checked every 30 minutes. Of course, now I realize this can be a legal question and very tricky, because I later brought a lawsuit against the hospital, et al. BUT I thought that putting him in a private, small, specialty hospital on suicide watch would lessen by far the chance of him carrying out his plans. And I am intelligent enough to realize that where there is a will, there is a way, and when he made his mind to die, nothing was going to hold him back; but this is after the fact. The hospital was very unclear on the circumstances of his death. I just wanted to talk, talk, talk, and THE PROFESSIONALS DID NOT WANT TO LISTEN. There was no SOS group in our city and in general the whole medical community was closed to me after his death, perhaps because he was a physician, and they did not want to admit that one of their own had done this.
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Her desire to get answers and to “talk, talk, talk” about her feelings and fears were her immediate needs and could have been accomplished with the support of caring and competent clinicians. However the lack of survivor-sensitive postvention care, the exposure to a traumatic sight (viewing the body), the limited availability to provide treatment by the clinician, and the lack of comprehension over how this could have happened in an inpatient setting were all factors in her decision to file a lawsuit: I brought a wrongful death lawsuit a year after he died because there was a 45-minute gap in the nurses’ notes about checking him, and that’s exactly when he took the opportunity to kill himself. The psychiatrist had pulled him off all his medications and was doing tests (mental and physical) to try to determine if it was a chemical imbalance in his brain that was causing the depression. We never got the chance to find out. I sued the hospital, the psychiatrist who was treating him, and the two nurses who were his main caregivers. I was in a courtroom for 12 awful days, on the stand myself for a day and a half, and lost the lawsuit. The hospital’s slick lawyer came up with a surprise defense only 24 hours before the trial started. He said that he died of autoerotic asphyxiation, and a jury of my peers believed him. His family testified for the defense. I think I would still have brought the lawsuit against them, because they were not doing their duty in checking him every 30 minutes. They treated him like a physician instead of a patient (asking him if he had suicidal ideations instead of doing their job and physically checking him). The fact that he had been pulled off all his medications didn’t help. Also, the chemical dependency unit (CDU) downstairs from him filled up, and on his second night there and he was given a roommate. His own belts and sharps had been taken, but his second-night roommate had his belt because he was from the CDU and not on suicide watch. So during the 45-minute gap in the nurses’ notes, he took his roommate’s belt, went all the way down to the end of the hall to a bathroom, locked the door, hooked the belt to a hook on the wall, and hung himself. Thirty minutes later someone reported to the nurses’ station that a shower had been running for a long time down the hall.
Her continued efforts to get answers and the ensuing lawsuit resulted in more trauma and distancing from supports. The legal implications of an apology to the survivors by the treating clinician make it a complex and difficult decision. The potential for the apology to be used against the clinician varies in the United States on a state-by-state basis. The following memorandum from a legal researcher (Adam Haney) to an attorney (Allen Posey) is an example of the paradigm shift that is ongoing in the United States on the issue of apology: Oregon and Colorado have statutory privileges regarding apologies in medical malpractice cases. The statutes state that apologies by or on be-
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half of medical professionals are inadmissible not only in court but also in arbitration and other alternative forums. The Vermont Supreme Court has also ruled that an apology by a physician for an “inadequate” operation is not an admission of liability. (Phinney v. Vinson [1992] 605 A.2d 849. The court similarly held that an apology for a serious mistake made during surgery does not establish an element of a malpractice claim. (Senesac v. Associates in Obstetrics and Gynecology [1982] 449 A.2d 900.) California also has a similar but less expansive statue. That state’s law is that general apologies or statements of regret are inadmissible to prove liability. However, if a person makes a statement outright admitting liability, that statement may be admissible. (Memorandum from Adam Haney, Capital Clerks to Attorney Allen Posey, April 25, 2005)
Many other states have bills in their legislatures or in committees that are attempting to address this issue. Thus, the clinician is caught in an ongoing transition that will affect their practice outcomes as well as redefine malpractice coverage. Until such legal issues are resolved, clinicians must not only know their particular jurisdictional limitations but also must be knowledgeable about the policies of their workplace and the restrictions set forth by their malpractice carrier. The following correspondence from Professor Ralph Slovenko, author of The Law and Psychiatry and Psychiatry and The Law, illustrates these very complex areas of apology: May 5, 2005 A number of states have enacted legislation, and a number of others are considering it, that excludes an expression of sorrow as an admission, but this legislation only ensures freedom to say one is sorry, but not of other types of admission. Thus, if someone says, “I’m sorry, this is all my fault, I was yelling at my wife on my cell phone and wasn’t looking,” everything after “I’m sorry” is admissible in evidence as an admission. It is also to be noted that an admission obviates the requirement of expert testimony that is ordinarily required to prove a case of malpractice. Moreover, liability insurance companies consider an admission by the insured party that he has done something wrong is failure of cooperation, voiding insurance coverage. Lawyers understand the importance of never admitting to anything—it’s the lawyer’s commandment. It is most important, at least from a legal perspective, to say nothing and particularly to admit no responsibility whatsoever. It’s typical lawyer advice: “if you start explaining or apologizing, you will be providing crucial evidence for a lawsuit.”
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The Japanese, who by culture apologize profusely, learn not to apologize when working in the United States. Regards, Ralph Slovenko
Because several states have begun to address the need for an “apology law” that allows clinicians to say they are sorry, it is imperative that clinicians know the statutes and policies that apply in the jurisdictions where they practice. This effort to facilitate an environment in which apology cannot be used to punish the clinician may be the result of all parties agreeing that both the clinician and the family benefit from such a condolence. Attorney George Anding, partner in the Baton Rouge law firm of Rainer, Anding, and McLindon, states: While some defense counsel or professional groups may advise against it, in my experience a physician’s sympathetic and concerned communication with a grieving family generally goes a lot farther toward avoiding a claim than inciting one. When a physician either fails or refuses to communicate with the family of the deceased, whether or not on advice of counsel, their frequent (and natural) assumption is that he or she may have something to hide, and that it’s probably inculpatory. Even in a situation where the physician may be at fault, caring communication with the family may prevent a claim that a lack of such contact may significantly encourage. (G.K. Anding, personal communication, May 2005)
Mr. Anding’s 30-year practice has included both the defense and prosecution of medical malpractice claims. His insight may be at the basis of legislative reform regarding the use of apology in legal cases in the United States. Survivors who file lawsuits may have a variety of reasons to pursue such “remedies,” including a desire to fix a mental health system that has failed to keep promises made (or assumed) regarding the safety and treatment of the deceased. They also hope to determine the responsible parties and perhaps prevent future suicides. The efforts to do so, whether successful or not, often result in significant financial and emotional tolls for survivors and clinicians. Perhaps the most deficient response to the aftermath of a patient suicide is in the clinician’s self-care. How the death of his or her patient affects the clinician’s own psychological well-being is often ignored and/ or routinely dismissed. Clinicians are trained in techniques to ameliorate the negative effects of exposure to a sudden and traumatic death. However, when it relates to oneself or to a colleague, the resolve to seek support and/or treatment seems lacking. This implies a paradoxical
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TABLE 23–2. Recommendations for clinicians for self-care after the suicide of a patient Seek survivor-sensitive peer support and/or consultation. Be knowledgeable about survivor symptoms that are role-specific to caregivers. Monitor your personal activities of daily living as well as any increased hypervigilance, cognitive confusion, or levels of dissociation. Be aware of any change in the incidence of hospitalization and/or referral of patients who present with issues or problems similar to those of the deceased patient (could be a projection issue). Be aware of any increased use of gallows humor, paranoia, or inappropriate affect and content. Avoid distancing, withdrawal, or isolation from supports. Note any increased use of maladaptive behaviors (e.g., drinking, eating, drug use).
understanding of the importance of treatment. Clinicians must be diligent to ensure their own self-care following the suicide of a patient by considering the recommendations in Table 23–2. Informed studies focusing on the needs of survivors and clinicians following suicide are needed and would certainly assist professionals in determining how to reduce the negative effects. Until such appropriate research is completed, clinicians must depend on anecdotal evidence to determine best practices in assessment of suicide and the ensuing follow-up.
References American Psychiatric Association: Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry 160(suppl): 1–60, 2003 Cain AC (ed): Survivors of Suicide. Springfield, IL, Charles C Thomas, 1972 Campbell FR: Changing the legacy of suicide. Suicide Life Threat Behav 27:329– 338, 1997 Campbell FR: Changing the legacy of suicide through an active model of postvention. Proceedings of the Irish Association of Suicidology 6:26–29, 2001 Campbell FR, Cataldie L, McIntosh J, et al: An active postvention program. Crisis 25:30–32, 2004 Fine C: No Time to Say Goodbye: Surviving the Suicide of a Loved One. New York, Doubleday, 1997 Grad OT, Zavasnik A, Groleger U: Suicide of a patient: gender differences in bereavement reactions of therapists. Suicide Life Threat Behav 27:379–386, 1997 Peterson EM, Luoma JB, Dunne ED: Suicide survivors’ perceptions of the treating clinician. Suicide Life Threat Behav 32:158–166, 2002
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Shneidman ES: On the Nature of Suicide. San Francisco, CA, Jossey-Bass, 1969 Shneidman ES: Foreword, in Survivors of Suicide. Edited by Cain AC. Springfield, IL, Charles C Thomas, 1972, pp ix–xi
Suggested Readings Allen BG, Calhoun LG, Cann A, et al: The effect of cause of death on responses to the bereaved: suicide compared to accident and natural causes. Journal of Death and Dying 28:39–48, 1993 Bailley SE, Kral MJ, Dunham K: Survivors of suicide do grieve differently: empirical support for a common sense proposition. Suicide Life Threat Behav 29:256–271, 1999 Barrett TW, Scott TB: Suicide bereavement and recovery patterns compared with non-suicide bereavement patterns. Suicide Life Threat Behav 20:1–15, 1990 Bengesser G, Sokoloff S: After suicide-postvention. Eur J Psychiatry 3: 116–118, 1989 Brent DA, Perper J, Moritz G, et al: Bereavement or depression? The impact of the loss of a friend to suicide. J Am Acad Child Adolesc Psychiatry 32:1189–1197, 1993 Brent DA, Perper JA, Moritz G, et al: Psychiatric risk factors for adolescent suicide victims: a case-control study. J Am Acad Child Adolesc Psychiatry 32:521–529, 1993 Brent DA, Moritz G, Bridge J, et al: The impact of adolescent suicide on siblings and parents: a longitudinal follow-up. Suicide Life Threat Behav 26:253–259, 1996 Callaghan J: Predictors and correlates of bereavement in suicide support group participants. Suicide Life Threat Behavior 30:104–124, 2000 Campbell FR: Suicide: an American form of family abuse. New Global Development XVI:88–93, 2000 Campbell FR: Changing the legacy of suicide through an active model of postvention. Proceedings of the Irish Association of Suicidology 6:26–29, 2001 Campbell FR: Living and working in the canyon of why. Proceedings of the Irish Association of Suicidology 6:96–97, 2001 Campbell FR, Cataldie L: Survivor support teams. Paper presented at the Survivors of Suicide Research Workshop Program, National Institute of Mental Health/National Institutes of Health Office of Rare Diseases and the American Foundation for Suicide Prevention, Bethesda, MD, May 2003 Dunne EJ, McIntosh JL, Dunne-Maxim K (eds): Suicide and Its Aftermath: Understanding and Counseling the Survivors. New York, WW Norton, 1987
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Dyregrov K: Assistance from local authorities versus survivors’ needs for support after suicide. Death Stud 26:647–668, 2002 Farberow NL, Gallagher-Thompson D, Gilewski M, et al: The role of social supports in the bereavement process of surviving spouses of suicide and natural deaths. Suicide Life Threat Behav 22:107–124, 1992 Goldsmith SK, Pellmar TC, Kleinman AM, et al (eds): Reducing Suicide: A National Imperative. Washington, DC, National Academies Press, 2002 Hendin H: Suicide in America: New and Expanded Edition. New York, WW Norton, 1995 Jordan JR: Is suicide bereavement different? A reassessment of the literature. Suicide Life Threat Behav 31:91–102, 2001 Jordan JR, McMenamy J: Interventions for suicide survivors: a review of the literature. Suicide Life Threat Behav 34:337–349, 2004 Knight KH, Elfenbein MH, Messina-Soares JA: College students’ perceptions of helpful responses to bereaved persons: effects of sex of bereaved persons and cause of death. Psychol Rep 83:627–636, 1998 Leenaars AA, Wenckstern S: Principles of postvention: applications to suicide and trauma in schools. Death Studies 22:357–391, 1998 Maltsberger JT, Hendin H, Haas A, et al: Determination of precipitating events in the suicide of psychiatric patients. Suicide Life Threat Behav 33:111–119, 2003 Maris RW, Berman AL, Silverman MM: Comprehensive Textbook of Suicidology. New York, Guilford, 2000 Ness DE, Pfeffer CR: Sequelae of bereavement resulting from suicide. Am J Psychiatry 147:279–285, 1990 Pfeffer CR, Karus D, Siegel K, et al: Child survivors of parental death from cancer or suicide: depressive and behavioral outcomes. Psycho-Oncology 9:1–10, 2000 Prigerson HG: Suicidal ideation among survivors of suicide. Paper presented at the Survivors of Suicide Research Workshop Program, National Institute of Mental Health/National Institutes of Health Office of Rare Diseases and the American Foundation for Suicide Prevention, Bethesda, MD, May 2003 Prigerson H, Jacobs S: Traumatic grief as a distinct disorder: a rationale, consensus, criteria, and a preliminary empirical test, in Handbook of Bereavement Research: Consequences, Coping and Care. Edited by Stroebe MS, Hansson RO, Stroebe W, et al. Washington, DC, American Psychological Association, 2001, pp 613–647 Provini C, Everett JR, Pfeffer C: Adults mourning suicide: self-reported concerns about bereavement, needs for assistance, and help-seeking behavior. Death Stud 24:1–20, 2000
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Range LM: When a loss is due to suicide: unique aspects of bereavement, in Perspectives on Loss: A Sourcebook. Edited by Harvey JH. Philadelphia, PA, Brunner-Mazel, 1998, pp 213–220 Runeson B, Asberg M: Family history of suicide among suicide victims. Am J Psychiatry 160:1525–1526, 2003 Saarinen P, Irmeli H, Hintikka J, et al: Psychological symptoms of close relatives of suicide victims. Eur J Psychiatry 13:33–39, 1999 Shneidman ES: On the Nature of Suicide. San Francisco, CA, JosseyBass, 1969 Shneidman ES: Deaths of Man. New York, Quadrangle Books, 1981 Shneidman ES: The Suicidal Mind. New York, Oxford University Press, 1996 Stephens BJ: Suicidal women and their relationships with husbands, boyfriends, and lovers. Suicide Life Threat Behav 15:77–89, 1985 Suicide Prevention Resource Center: What we offer: prevention support. Available at: http://www.sprc.org/whatweoffer/ps.asp. Accessed December 23, 2004. U.S. Department of Health and Human Services: The Surgeon General’s call to action to prevent suicide, 1999. Available at: http://www. surgeongeneral.gov/library/calltoaction/calltoaction.htm. Accessed December 23, 2004. U.S. Department of Health and Human Services: National Strategy for Suicide Prevention, 2001. Available at: http://www.mentalhealth. org/suicideprevention. Accessed December 23, 2004. World Health Organization: The World Health Report 2001. Mental Health: New Understanding, New Hope. Geneva, Switzerland, World Health Organization, 2001 Zisook S, Chentsova-Dutton Y, Shuchter SR: PTSD following bereavement. Ann Clin Psychiatry 10:157–163, 1998
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Psychiatrist Reactions to Patient Suicide Michael Gitlin, M.D.
The suicide of a patient in ongoing treatment is surely among the most traumatic events in the professional life of a psychiatrist. Despite this, systematic examinations of the prevalence of psychiatrists’ reactions to patient suicide, the specific reactions that are typically seen, predictors of these responses, and recommendations for optimal coping mechanisms in these situations are remarkably sparse in the psychiatric literature. This is especially noteworthy given that more than 30,000 individuals commit suicide yearly in the United States (Jamison 1999) and that more than half of these individuals have received care for their psychiatric problems in the year prior to their suicide (although nonpsychiatrists may have provided a substantial proportion of this care) (Jamison and Baldessarini 1999). Potential reasons for our field’s relative silence in considering what are frequently traumatic events for psychiatrists are also a topic of conjecture more than systematic examination. It has been suggested that some individuals become psychiatrists to avoid dealing with death (Sacks 1989). Consistent with this, an early study noted greater anxiety about death in medical students planning on specializing in psychiatry (Livingston and Zimet 1965). Additionally, even though a substantial percentage of psychiatrists will experience a patient’s suicide, it remains a relatively very-low-frequency event. As an example, in the study with the highest percentage of surveyed psychiatrists having experienced a 477
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patient suicide, 87% had experienced six or fewer patient suicides over an average career of 17.5 years, yielding an average of less than one suicide every 3 years (Alexander et al. 2000). With relatively few suicides per psychiatrist, the topic never becomes one that demands an agreedupon set of coping skills that has been shaped and taught over the generations. Finally, with death a more common outcome in most of the other medical specialties, medical schools treat it as a natural outcome of disorders that physicians treat and generally do not focus on suicide as playing a unique role in generating stress in the treating physicians. Nonetheless, a substantial proportion, estimated to range from 15% to 68%, of psychiatrists have experienced a patient suicide (Alexander et al. 2000; Chemtob et al. 1988b). Among trainees, even with their relatively brief experience in the field, approximately one-third have had a patient commit suicide (Brown 1987a, 1987b), with 5% of residents having more than one patient suicide during their training. (Beyond their lesser experience, this is not surprising given that residents typically take care of relatively sicker hospital-based patients compared with outpatient clinicians.) Thus, despite the relative infrequency of patient suicide over a psychiatrist’s professional lifetime, it occurs with regularity, especially with psychiatric residents. It behooves us, then, to better understand our own reactions and potential coping mechanisms.
General Reactions to Patient Suicide The few surveys that have examined psychiatrists’ reactions to patient suicides agree that, in general, a significant proportion of those affected show strong negative reactions, affecting professional and personal lives at levels of distress that are frequently comparable with those seen in clinical populations. In one survey of 88 psychotherapists, the most common cause of professional anxiety was patient suicide (Menninger 1991). Chemtob et al. (1988b), using the Impact of Event Scale, found that scores of both intrusive thoughts related to the event and avoidance of reminders were similar to those seen in patients seeking therapy after a parent’s death in more than half of the surveyed psychiatrists. These scores declined over time; by 6 months after the suicide, most psychiatrists’ scores had decreased to nonclinical levels. In a parallel study surveying psychologists, using the same Impact of Event Scale, half the clinicians had intrusion scores similar to a clinical population, but only 27% had comparable avoidance scores (Chemtob et al. 1988a). Residents polled after a patient suicide classified their reactions as strong or severe (Brown 1987b). In an evaluating of the degree of distress based on a rating scale, 38% of psychiatrists rated their distress af-
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ter patient suicide as 7 out of 10 or higher, classified as severe by Hendin et al. (2004). Finally, consideration of discontinuing practicing psychiatry would be a clear and rather dramatic expression of distress. In a recent survey of psychiatrists in Great Britain, one-third described patient suicide as having affected their personal lives; they became more irritable at home and coped less well with family problems. Fifteen percent of these psychiatrists considered taking early retirement; however, only 3% considered it seriously (Alexander et al. 2000). (The consideration of retirement is similar to the plan of a young psychiatrist in a single case report to change the city in which he practiced if a second patient committed suicide in his practice, reasoning that his professional community would never tolerate a psychiatrist who had had two patient suicides [Gitlin 1999].) Another fantasy of “having to leave town, shunned like a leper for the terrible act I had committed” has also been recorded (Perr 1968, p. 177). Although the issue is not well studied, after patient suicides many psychiatrists develop rather classic symptoms of anxiety, depression, or acute or posttraumatic stress symptoms. These include sleep difficulties, suicidal thoughts, accident proneness, intrusive thoughts, and exaggerated startle responses (Alexander et al. 2000; Chemtob et al. 1988b; Gitlin 1999; Sacks 1989). At least three papers (Gitlin 1999; Hendin et al. 2004; Sacks 1989) note that for up to 1 year or more afterward, some psychiatrists show an exaggerated startle response to late-night telephone calls or pages with the reflexive assumption that news about another patient suicide is impending. Finally, a few surveys have noted the remarkable vividness of feelings, specific memories, and dreams/fantasies surrounding a patient’s suicide, even years or decades later (Brown 1987b; Gitlin 1999; Hendin et al. 2000), indicating that despite the general healing that occurs over time, the experience often remains deeply etched in clinicians’ psyches.
Specific Reactions to Patient Suicide Beyond the general intensity of psychiatrists’ reactions to patients’ suicides, a characteristic set of psychological responses, shown in Table 24–1, can be identified (Brown 1987b; Gitlin 1999; Hendin et al. 2000; Litman 1965; Sacks 1989; Sacks et al. 1987). Of course, not every psychiatrist exhibits each of the typical reactions, nor is the evolution or order of the responses invariant. In general, these responses reflect universal responses to the death of another with whom we have deep emotional ties, altered by the special role of psy-
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TABLE 24–1. Reactions to patient suicide Initial reactions Shock Disbelief Denial Depersonalization Second-phase reactions Grief Shame Guilt Fear of blame Anger Relief Finding of omens and subsequent behavioral changes Conflicting feelings of specialness
chiatric physicians in our society (Litman 1965). Compared with other physicians, psychiatrists generally have deeper ties with their patients reflecting a more emotionally intimate knowledge of them, given that the medium of discussion is psychological feelings or symptoms rather than the more distanced physical symptoms. This may be true even with patients seen only in psychopharmacological treatment with whom discussions of mood or cognitions may still be experienced as intimate.
Initial Responses: Shock, Disbelief, Denial, Depersonalization Typically, initial responses revolve around the difficulties assimilating the new information about the patient’s suicide, the intense affective arousal that the suicide engenders, and the internal mechanisms used to diminish that intensity. Initial responses include comments such as “I could hardly believe it” (Litman 1965) and convictions such as “There must be a mistake” (Sacks et al. 1987). One psychiatrist asked about the probability of recovery after being told that his patient was brain dead after shooting himself in the head (Sacks 1989). Depersonalization feelings— numbness, a sense of unreality, or spaciness—frequently accompany or follow the initial shock. These descriptors are entirely consistent with the symptoms described in DSM-IV-TR as acute stress disorder (American Psychiatric Association 2000).
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Second-Phase Responses: Grief, Shame, Guilt, Fear of Blame Typically following, but often intermingling with, the initial disbelief responses are those reactions related to grief, shame, and guilt commonly associated with fear of blame. In one study, grief was the most commonly observed reaction in psychiatrists after patient suicide (Perr 1968). Grief can be related to a number of different simultaneous losses. First, of course, is that of losing a patient with whom the psychiatrist has often had a deep, meaningful relationship. This type of grief encompasses both the loss of the person and the loss of the possibility of the patient achieving the hoped-for positive goals of treatment. Another type of grief, however, reflects a different type of loss—that of the psychiatrist’s own fantasies of power, influence, and ability to make a difference in patients’ lives (Gitlin 1999; Sacks 1989). One psychiatrist acknowledged his own primitive fantasy that “with his skill, empathy, and good training, he would make a positive difference in all his patients’ lives. That [his patient] could kill himself despite [the psychiatrist’s] best efforts and judgments made the practice and outcome of psychiatric treatment far less certain” (Gitlin 1999, p. 1631). The loss of this youthful grandiosity is, in the long run, appropriate and necessary for optimal professional development. It is presumed (but not studied) that this second type of grief is more likely to occur when the treating psychiatrist is young and has been practicing for a relatively short period of time. Thus, although traumatic, this type of grief ultimately serves a larger, necessary purpose. The mourning of unrealistic youthful fantasies is analogous to the effect of other losses in one’s personal life, leading to a deeper appreciation of the finiteness of life. Of course, as with other losses, timing is critical, and it can be postulated that losses at a too-early stage of development can be deeply scarring. Shame and guilt are also very common reactions to patient suicide, with at least one observer suggesting these as the most universal responses (Sacks 1989). Questions arise such as “Did I listen to him?” or “How did I miss it?” (Litman 1965). Among the four factors identified in one study as the most common sources of severe distress, two related to technical decisions made regarding the patient’s care with subsequent feelings of (presumably) guilt (Hendin et al. 2004). The aforementioned fantasies of moving to another city or retiring are linked to the deep shame and guilt that some psychiatrists experience after patient suicide. At times, severe guilt has led to false confessions of wrongdoing. In one example, a psychiatrist gave an incorrectly low dosage of the antidepressant he had been prescribing with the (incorrect) implication of
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his having treated the patient inadequately (Sacks 1989). Another psychiatrist admitted prescribing the sleeping pills with which a patient committed suicide, even though another physician had prescribed them (Litman 1965). The shame and guilt reactions are inextricably linked to fear of blame or reprisal. Foremost among these is the fear of a potential malpractice suit (Gitlin 1999; Hendin et al. 2000, 2004). A corollary of this is the fear that even without a malpractice suit, colleagues will be deeply critical of a psychiatrist who has had a patient commit suicide and will stop referring patients and that one’s reputation and career will be ruined. Implied in these concerns is the common fantasy that a patient suicide, with or without subsequent litigation, is a very public event to colleagues, potential patients, and the community. Concerns about public exposure and humiliation are common and very powerful despite the fact that public discussions of these issues are rare.
Anger Although not as universal as grief, guilt, and shame, anger is a common and, in many ways, a more difficult psychological response for psychiatrists after a patient suicide. What differs among individuals is the object of the anger and the rationale for the anger. Among those treating outpatients, the likely objects of anger are the patient and his or her family. If an inpatient commits suicide, however, the list of potential objects lengthens to include nurses and administrators. If the treating psychiatrist is a trainee, others to be angry at might include supervisors and residency directors or the institution itself. Rationales for anger are similarly diffuse. Feelings of betrayal toward the patient who did not, for example, honor a therapeutic contract, such as calling the psychiatrist if intense suicidal feelings erupted, may emerge (Hendin et al. 2000). Some psychiatrists feel angry at the waste of the previous therapeutic work. Others feel angry at the patient for engendering such painful feelings in the psychiatrist as guilt and shame or for making the therapist look stupid in his or her own eyes. In one detailed case report, a young psychiatrist focused his anger on the patient’s having committed suicide by overdose of the antidepressant medications prescribed. It felt unfair to the psychiatrist that the patient had killed himself and caused great psychological pain to the psychiatrist using the “personal healing ministrations of the doctor, the actual means of his healing” (Gitlin 1999, p. 1632). When the suicide occurs in an institutional setting with the trainee as the treating psychiatrist, the theme of the anger in these cases is that
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of receiving inadequate support, help, or guidance or of being pressured to discharge a patient from a more protected setting such as an inpatient unit. (Of course, the supervisors may also be angry at the treating trainee.) As in so many other situations in which anger is a dominant affect, the anger often serves to protect the individual against excessive guilt or blame (“It’s their fault, not mine”).
Relief Less common, yet still conflictual when they arise, are feelings of relief. Relief is likely to be experienced after the suicide of a chronically suicidal patient who has exhausted those around him or her by endless threats or attempts. These feelings may also arise in the family members of chronically suicidal individuals who, like the treating psychiatrists, have often lived in dread of the late-night phone calls surrounding either suicidal threats or self-destructive behavior. In these cases, the mixture of the more classic feelings—sadness, grief, guilt, and self-blame— with feelings of anger and relief can make for a very difficult internally conflicted brew.
Finding of Omens and Behavioral Changes Among the more interesting psychological sequelae of patient suicide is the finding of omens (Sacks 1989) in which the psychiatrist retroactively considers signs signaling the coming suicide that were, of course, missed. These typically include rather trivial differences in nuance, such as an ending greeting of “good-bye” instead of “so long” or a different look at the end of the last session. The purpose of finding these omens is to provide an illusory sense of control to an event that makes the psychiatrist feel helpless. If signs exist, even if they were missed, then suicide is predictable and therefore preventable in the future. The finding of omens, or (more broadly) the examination of potentially missed signals of impending suicide and identifying high-risk situations based on a completed suicide, typically leads to behavioral changes. On the surface, as with the finding of omens, the purpose of these behavioral changes is to learn from the suicide and to prevent future suicides. In fact, more frequently these behavioral changes simply serve as rituals, repetitive behaviors that bind the caregivers’ anxiety and reduce the feelings of helplessness that accompany patient suicide. As an example, after a patient suicide, inpatient units may decrease the threshold for the intensive observation of suicide watch (e.g., 15-minute observation intervals) and require it for many more patients. After a patient suicide, one outpatient psychiatrist began to ritualistically ask all
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patients (even those who had never had suicidal ideation) at every visit about the presence of suicidal thoughts. Because his patient had committed suicide via an overdose of prescribed antidepressants, he also became excessively anxious about all his other patients and began ritualistically quizzing them about the exact amounts of medications at home and their thoughts of overdosing (even with those patients for whom overdosing had never been raised or considered) until a patient confronted him on his anxious questioning (Gitlin 1999).
Conflicting Feelings of Specialness In some situations, especially in institutional settings where there is frequent contact with other professionals, a psychiatrist experiencing a patient suicide develops feelings of isolation and specialness (Gitlin 1999; Sacks 1989). The isolation feelings reflect the irrational conviction that no one else has had the same experience—that one is “branded” as different by the suicide. If the suicide is not discussed openly, the treating psychiatrist may feel shunned. In association with these feelings, however, is also a sense of specialness, of having gone through a rite of passage, of becoming a member of a very special club in which only those who have had a similar experience could really understand, similar to that described by war veterans; “to survive it is testimony to one’s hardiness, endurance, and being a ‘real’ physician” (Sacks 1989, p. 568). Although overall the feelings of specialness generate isolation and shame, it is important to acknowledge the positive and adaptive, albeit defensive, nature of these feelings.
Predictors of Distress Among the predictors of increased distress among psychiatrists who experience a patient suicide, shown in Table 24–2, the most consistent are age and experience (which are, of course, highly correlated), with older age and more years of experience predicting somewhat less distress. This finding can be seen in the few data-based papers examining the topic (Chemtob et al. 1988b; Hendin et al. 2004) as well as in most impressionistic papers. The only contrasting finding was that of a lack of correlation between either age or years of practice and increasing distress after patient suicide in a survey of nonphysician therapists (Chemtob et al. 1988a). Age and experience as the most important factors in predicting distress are deeply intuitive. No differently than when coping with other losses or tragedies, psychiatrists develop perspectives
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TABLE 24–2. Potential predictors of distress after patient suicide Age (negative predictor) Experience (negative predictor) Intensity of involvement with patient Treatment setting Gender of psychiatrist Clinician’s personality Clinician’s history of depression and anxiety
over time that buffer them from greater pain after the loss of a patient. A number of papers have highlighted the greater vulnerability of trainees who experience a patient suicide. Trainees, the youngest and least experienced of our field, are uniquely vulnerable because they typically have not yet been able to internalize a self-image as competent professionals who can successfully treat some patients despite the tragedy of a patient suicide (Brown 1987a, 1987b; Goldstein and Buongiorno 1984; Sacks 1989). Another factor commonly assumed to predict greater distress after patient suicide is the intensity of involvement between the professional and the patient. Surprisingly, no data exist to support this assumption. (In the one study that examined this issue systematically, a patient’s length of time in treatment did not contribute to ratings of therapist distress [Hendin et al. 2004].) Nonetheless, greater emotional involvement with the patient is likely to be associated with greater distress. The involvement may not always be measurable by simply establishing the length of treatment time. Related factors might also be the sheer volume of time spent with the patient, with the possibility that the suicide of a therapy patient may have a deeper effect than that of a patient seen in medication management. At the same time, however, remarkably deep ties often develop between patients and psychiatrists whose role is purely as psychopharmacologists. Work setting—inpatient versus outpatient, private practice versus institutional setting—has also not been shown to be related to distress after patient suicide. However, treatment setting will certainly dictate the reaction of others to the suicide and will therefore have an impact on the treating psychiatrist. As noted earlier, in a private practice setting, only the psychiatrist and the patient’s family are ordinarily involved in the aftermath of the suicide. In an institutional setting, especially if the patient was either an inpatient or a partial hospital (day treatment) patient, other professionals and administrators become involved. If the treating physician is a trainee, supervisors and other faculty may be
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added to the list. In these situations, either greater support and cohesion or projected anger and blame could emerge. In one study, negative reaction by the therapist’s institution was one of four factors identified as sources of severe distress (Hendin et al. 2004). The different ways in which institutions respond to the suicide may play a role in explaining the inconsistent relationship between treatment setting and individual clinicians’ responses to patient suicide. In the two studies examining the issue, female psychiatrists were almost twice as likely to experience severe distress as their male counterparts after patient suicide in one study (Hendin et al. 2004) and exhibited higher rates of shame, guilt, and self-doubt in the other (Grad et al. 1997). This may reflect the observation that women experience bereavement in general more deeply (Cleiren et al. 1994). Of course, greater distress should not always be considered as a negative finding. Emotional denial and excessive repression may interfere with optimal learning from experience. Finally, among the most important factors in predicting reactions to patient suicide is the individual clinician’s personality and own psychiatric history. In one study, psychiatrists who were less distressed after a patient suicide were more likely to identify changes in treatment they might consider in the future, a possible marker for flexible thinking and the ability to learn from the suicide as opposed to feeling dominated by guilt and self-blame (Hendin et al. 2004). Although never studied, overall resilience—with its roots in both temperament/biology and prior experience—might be the single most important factor in predicting response to suicide. Other psychological factors, such as tendencies for introjection versus projection, are also likely to be important. Finally, the individual psychiatrist’s potential past history of depression and anxiety might also play a role in predicting individual vulnerability to greater distress. Although speculative, the finding of greater distress among female psychiatrists could reflect the greater likelihood of depressive disorders and most anxiety disorders among women versus men in general (Robins and Regier 1991).
Coping With Patient Suicide A number of methods for optimal coping with suicide have been suggested. These methods, shown in Table 24–3, may be broadly divided into four categories: decreasing isolation, using philosophical and cognitive approaches, effecting temporary behavioral changes, and instituting reparative, constructive behaviors (Gitlin 1999).
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TABLE 24–3. Optimal coping methods after patient suicide Decreasing isolation Using philosophical and cognitive approaches Effecting temporary behavioral changes Instituting reparative, constructive behaviors
Decreasing Isolation Despite a lack of data, reducing the feelings of isolation is the most commonly recommended method of combating the negative effects of a patient’s suicide (Alexander et al. 2000; Brown 1987b; Chemtob et al. 1988a; Gitlin 1999; Goldstein and Buongiorno 1984; Hendin et al. 2000, 2004; Sacks 1989; Sacks et al. 1987). This coping method, which can be accomplished in a broad variety of ways, is perfectly analogous to the suggestions we make to our patients after tragedies in their own lives. Talking to others one trusts and respects, whether lovers, friends, family, or colleagues, is likely to be helpful. Discussion with former or current supervisors (assuming they know something about this area) can be exceedingly helpful. It is surprising how few papers comment on the use of the psychiatrist’s own individual psychotherapy as a useful method of decreasing isolation. Colleagues sharing their own experiences with the suicide of a patient may be more helpful than the soothing comments about the inevitability of the death (Hendin et al. 2004). A specific method of decreasing isolation is meeting with the significant others of the person who committed suicide and/or going to the person’s funeral or memorial service. In one case series, two-thirds of psychiatrists saw their patients’ relatives after the suicides (Hendin et al. 2004). Although meeting with family members is typically described as positive, this is not always the case. Psychiatrists must be aware of the possibility that relatives will be angry because of the feeling that they do not know enough about the specifics of their relative’s psychopathology, because of projected anger, or because of well-meaning decisions by the psychiatrist that may indeed have not prevented or may have even contributed to the suicide. Therefore, a psychiatrist meeting with the relatives of a patient who committed suicide must be prepared for anger and must be able to respond in a nondefensive manner while not being too quick to accept blame caused by guilt feelings. Care must also be taken in these meetings with regard to patient confidentiality, which extends beyond the death of a patient. It is possible, although delicate, to provide sufficient feedback and discussion with family members without violating the core of the patient’s privileged information.
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As noted earlier, suicides within institutional settings provide unique opportunities for decreasing isolation or engaging in blaming behaviors. In many situations, the group setting provides greater support. As stated in one of the earliest papers on the topic, the helpfulness of an institution “is especially true if there was a spirit of mutual support, shared responsibility, and cooperative teamwork among the staff” (Litman 1965, p. 574). A psychological autopsy often occurs as a mandated suicide review in certain psychiatric hospitals. Its goal is to review the suicide, understand its causes, and learn so as to treat patients better in the future. When done properly, it should be a supportive, constructive learning experience. However, it is too easy for the psychological autopsy to become a public shaming by blaming the treating professional (Sacks 1989). The experience of the psychological autopsy as destructive seems to be perceived frequently when the treating psychiatrist is a trainee. As an example, in one of the earlier surveys, 12 of 20 trainees described that chart reviews and psychological autopsies compounded doubt rather than aided recovery, especially when performed very soon after the patient suicide (Goldstein and Buongiorno 1984). In a more recent study, the two therapists who felt that their institution’s response to the suicide of their patients contributed greatly to their distress were both trainees (Hendin et al. 2004). In psychiatric training programs, trainee groups may be useful in diminishing isolation in a nonblaming atmosphere (Kolodny et al. 1979).
Using Philosophical and Cognitive Approaches Understanding a patient’s suicide using philosophical and cognitive approaches is a second useful strategy. These approaches may sound trite when written but may be powerful when presented in interactive discussion. In many ways, they may be most helpful if they are inculcated during psychiatric training and before a suicide instead of after one. The first of these approaches acknowledges that psychiatrists who treat patients with serious psychiatric disorders—depression, bipolar disorder, drug and alcohol abuse, schizophrenia, borderline personality disorder—must embrace the expectation that some of their patients will die because of the natural course of their disorder. It must be understood that we cannot prevent the worst outcome of every case any more than can our colleagues in cardiology or oncology. Additionally, it must be understood that although there are clear demographic and clinical predictors of suicide among groups of patients, the field is unable to accurately predict suicidal risk for any individual patient (Porkorny 1983). These statements must not be used to foster a passivity, fatalism,
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or therapeutic nihilism in our therapeutic work; rather, they should be used to understand the inherent inconsistent effect of our best efforts (implied in the earlier discussion of the loss of omnipotence or grandiosity in young psychiatrists after a patient suicide). In working with trainees, the critical point must be to help them understand that clinical failures do not make them personal failures (Brown 1987a). (Hopefully, as psychiatrists mature in their career, this lesson is learned, at least to some degree.) Unfortunately, few training programs have integrated psychological preparation for patient suicides. Anticipating the possibility of a patient suicide during their careers, or even their training years, should be made explicit. This can and should be introduced and discussed early in the first or second postgraduate year (Brown 1987b). Discussing the likely reactions that a resident might feel after a patient suicide as delineated in this chapter would help block the potential shock if and when these feelings arise. Faculty who have had the experience of a patient suicide can provide experience, reduce feelings of isolation, and model a successful future after the event. Additionally, if a tradition arises in which more senior residents are available to more junior ones in these situations, a closer peer-oriented modeling would enhance buffering the experience.
Effecting Temporary Behavioral Changes Because of the frequency with which patient suicide adversely affects psychiatrists, a number of relatively simple, temporary behavioral changes can be effected to help diminish distress and to ensure that the psychiatrist continues to practice optimal care. In the immediate aftermath of a patient suicide, most psychiatrists, especially younger ones, feel distinctly less trusting of their own judgment. This typically leads to an overly conservative set of decisions and behaviors, such as more aggressively querying patients about suicide (in ways that are neither appropriate nor therapeutic) or too quickly hospitalizing other suicidal patients. If possible, therefore, after a patient suicide, it is often helpful to not accept patients who are euphemistically described as “challenging” or “interesting” and certainly not “difficult” until one has regained enough balance to utilize judgment based on the current case and not the suicide that occurred previously.
Instituting Reparative, Constructive Behaviors Although rarely utilized in the immediate aftermath of a patient suicide, helping others cope with similar incidents may be a remarkably effective and constructive long-term behavior. Such help would include being
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available to other, younger colleagues who have had a first patient commit suicide, presenting about the topics at conferences, or writing about the experience (Biermann 2003; Gitlin 1999). Because this type of activity requires some distance from the traumatic event itself, it usually becomes a viable option only months or even years later and typically in those who have achieved some maturity and experience in the field. Of course, being more open about personal experiences with patient suicide both decreases isolation in the presenter and in the audience, thereby effectively using two of the most important techniques of coping.
Conclusion A substantial proportion of psychiatrists will experience the suicide of a patient at some point in their careers. Trainees are at higher risk to have a patient commit suicide because they treat the patients with the greatest psychopathology. Responses to the suicide are similar to those seen in others who have lost an important person in their life, exacerbated by the shame, guilt, and fear of reprisal given the current climate of blame and malpractice threats in our country. In the immediate aftermath of a patient suicide, many psychiatrists will exhibit psychiatric distress and symptoms comparable with clinical populations. Typically, these symptoms diminish over the next few months. The most important predictor of greater distress after a patient suicide is the psychiatrist’s age and experience, with younger clinicians exhibiting greater difficulty. Optimal coping with a patient’s suicide involves a number of different interactions and techniques. First and foremost is to decrease the (irrational) feelings of isolation. This can be accomplished in a number of ways, no one of which is superior to the others. In institutional settings such as hospitals with training programs, group discussions should be handled in a constructive, supportive manner while still attempting to learn from the suicide. In these situations, care must be taken not to use the group discussions to establish blame for the event (typically directed toward the youngest, least experienced clinician involved). Anticipating suicides during one’s career, especially during training, would help psychiatrists prepare psychologically. Given how frequently residents experience patient suicide and how vulnerable they are to negative effects from these suicides, more attention needs to be paid to formal instruction in this area in training programs. It would also be helpful if senior psychiatrists were more open about their experiences in this area, modeling for younger psychiatrists and decreasing the sense of isolation common after patient suicides.
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❏ Key Points ■
A substantial proportion of psychiatrists will experience the suicide of a patient at some point in their careers.
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Responses to patient suicide resemble reactions to other meaningful losses, including denial, grief, and anger exacerbated by shame, guilt, and fear of blame.
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The most important predictor of distress after a patient suicide is younger age and lesser experience of the treating psychiatrist.
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The most important coping technique after patient suicide is decreasing isolation of the treating psychiatrist.
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Training programs should institute formal instruction for trainees in anticipating and coping with patient suicide.
References Alexander DA, Klein S, Gray NM, et al: Suicide by patients: questionnaire study of its effect on consultant psychiatrists. BMJ 320:1571–1574, 2000 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000 Biermann B: When depression becomes terminal: the impact of patient suicide during residency. J Am Acad Psychoanal Dyn Psychiatry 31:443–457, 2003 Brown HN: The impact of suicide on therapists in training. Compr Psychiatry 28:101–112, 1987a Brown HN: Patient suicide during residency training, I: incidence, implications, and program response. J Psychiatr Educ 11:201–216, 1987b Chemtob CM, Hamada RS, Bauer G, et al: Patient suicide: frequency and impact on psychologists. Prof Psychol Res Pr 19:416–420, 1988a Chemtob CM, Hamada RS, Bauer G, et al: Patients’ suicides: frequency and impact on psychiatrists. Am J Psychiatry 145:224–228, 1988b Cleiren MP, Diekstra RF, Kierkof AJ, et al: Mode of death and kinship in bereavement: focusing on “who” rather than “how.” Crisis 15:22–36, 1994 Gitlin MJ: Clinical case conference: a psychiatrist’s reaction to a patient’s suicide. Am J Psychiatry 156:1630–1634, 1999 Goldstein LS, Buongiorno PA: Psychotherapists as suicide survivors. Am J Psychother 38:392–398, 1984 Grad OT, Zavasnik A, Groleger U: Suicide of a patient: differences in bereavement reactions of therapists. Suicide Life Threat Behav 27:379–386, 1997 Hendin H, Ligpschitz A, Maltsberger JT, et al: Therapists’ reactions to patients’ suicides. Am J Psychiatry 157:2022–2027, 2000 Hendin H, Haas AP, Maltsberger JT, et al: Factors contributing to therapists’ distress after the suicide of a patient. Am J Psychiatry 161:1442–1446, 2004 Jamison KR: Night Falls Fast: Understanding Suicide. New York, Vintage Books, 1999
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Jamison KR, Baldessarini RJ: Effects of medical interventions on suicidal behaviors. J Clin Psychiatry 60:4–6, 1999 Kolodny S, Binder RL, Bronstein AA, et al: The working through of patients’ suicides by four therapists. Suicide Life Threat Behav 9:33–46, 1979 Litman RE: When patients commit suicide. Am J Psychother 19:570–576, 1965 Livingston P, Zimet CN: Death anxiety, authoritarianism and choice of specialty in medical students. J Nerv Ment Dis 140:222–230, 1965 Menninger WW: Patient suicide and its impact on the psychotherapist. Bull Menninger Clin 55:216–227, 1991 Perr HM: Suicide and the doctor-patient relationship. Am J Psychoanal 18:177– 188, 1968 Porkorny AD: Prediction of suicide in psychiatric patients. Arch Gen Psychiatry 40:249–257, 1983 Robins LN, Regier DA: Psychiatric Disorders in America. New York, Free Press, 1991 Sacks MH: When patients kill themselves, in American Psychiatric Press Review of Psychiatry, Vol 8. Edited by Tasman A, Hales RE, Frances AJ. Washington, DC, American Psychiatric Press, 1989, pp 563–579 Sacks MH, Kibel HD, Cohen AM, et al: Resident response to patient suicide. J Psychiatr Educ 11:217–226, 1987
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Combined Murder-Suicide Carl P. Malmquist, M.D., M.S.
Understanding murder followed by suicide has all the complexities of understanding each entity by itself as well as the added interaction between them. A mixture of motives and background factors has led to diverse attempts at classification, both by clinicians and by social scientists or epidemiologists. If the person attempting suicide survives, he or she is usually prosecuted legally for some degree of murder. A common typology used is to divide murder-suicide into four categories (Roberts 2003): 1. 2. 3. 4.
Domestic violence connected to a murder-suicide Elderly murder-suicide Infanticidal murder-suicide Murder-suicide related to mental illness
The difficulty with such a grouping is that psychiatric disorders are not a discrete group. In many cases, they overlap with the other entities. Diverse psychiatric diagnoses appear in the backgrounds of individuals in all of the other categories when data are available to study. Difficulties in classification thus appear to reflect problems encompassing the possibility of personal psychopathology as well as an adverse social environment that contributes to such a final outcome of a murder-suicide. A classification of murder-suicide based on victims is presented in Table 25–1, and motivational and diagnostic background of the perpetrators is discussed later in this chapter. 495
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TABLE 25–1. Classification of murder-suicide by victim I.
Domestic violence A. Spouse B. Partner 1. Male 2. Female
II.
Perpetrated by the elderly A. Spouse B. Offspring C. Companion
III. Minors A. Feticide B. Neonaticide C. Infanticide (up to 1 year) D. Pedicide (older than 1 year) IV. Mass murder-suicides A. Familicide B. Workplace murders C. School shootings D. Acts of revenge
Difficulties in Assessing Murder-Suicide A major, and obvious, limitation in assessment is that in most cases the perpetrator is dead. Hence the only opportunity to evaluate such individuals directly is through those who survive a suicide effort. In most cases, the behavior leading up to the final outcome needs to be reconstructed by outside information and from those in contact with the person. Another complication is that a standardized definition of murdersuicide does not exist. A question arises as to whether an attempted homicide followed by a suicide or a homicide followed by an incomplete suicide would qualify as murder-suicide. A second question pertains to how much time can have elapsed after the homicide to qualify for a murder-suicide. One position is that the acts need to be seen as one unitary event, occurring perhaps within minutes of each other. Others argue for the position that the suicide should be within a week’s time of the homicide (Marzuk et al. 1992). Problems in comparing studies arise when an arbitrary cutoff time sequence is used. An individual who has killed an intimate partner may first go into a state of hibernation and hiding and then commit suicide some time later
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when he or she is about to be apprehended. The emotional and legal significance of killing one’s lover may emerge only gradually. It may lead to a suicidal act when awaiting trial sometime later or even after a trial when incarcerated. A mother who has murdered her infant while in a state of psychotic depression may be treated for the depression while incarcerated. When her clinical psychotic state goes into remission, she reflects not only on her future situation of spending many years in prison but also on her guilt, which may lead to suicide. The phenomenon of mass killings—whether these are acts of familicide, school killings, or cult killings followed by suicides—presents yet other difficulties. Explanations for these events often involve different clinical and social features than in the murder-suicide of a couple in an intimate relationship.
Epidemiological Perspectives The following is a survey of articles and reports on murder-suicide. Some reports are from an earlier period, and some are from different countries and cultures. No standard methodology was used in these different reports. An early study in 1928 of 39 murder-suicides was followed by a dearth of studies (Cavan 1928). In the interval, there were individual case reports, and murder-suicide continued to be covered by the media. In a study of murder-suicide in England and Wales, West (1966) found that 1 in 3 murders was followed by a suicide, but only 1 in 100 suicides was coupled with a previous murder. Interestingly, he did not find any increased incidence of “insanity” in comparison with more common types of homicide. A 1980 study of murder-suicide in the United States found a rate of 6.22 per 100,000 (Palmer and Humphrey 1980). A review by Coid (1983) of 17 studies involving 10 countries, including the United States, from 1900 to 1979 focused on “abnormal homicides” (in which a verdict of not guilty by reason of insanity or diminished responsibility or its equivalent in the country of origin was found) and murder followed by suicide. The murder-suicide rates were quite similar and consistent in different countries, with an average of 0.20–0.30 per 100,000, despite considerable differences in the overall rates of homicide. It was found that the higher the rate of homicide in a given population, the lower the percentage of offenders who were seen as mentally abnormal or who committed suicide. However, it should be noted that similarity in rates does not indicate the percentage of murder-suicides of all homicides in a given country. The latter varies widely. Thus, the percentage of murder-suicide combinations in the United States was 4%, whereas in Denmark it was 42%. The variation is due to the principle that the higher the overall rate of homi-
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cide in a given country, such as the United States, the lower the proportion of murder-suicides. A more recent study from England and Wales examined 52 cases of homicide-suicide from 1975 to 1992. The rates varied from 0.05 in Scotland in comparison to 0.55 in Miami, Florida (Milroy 1995). However, this variation may not be that surprising given the number of elderly couples in the Miami region, where a partner may be terminally ill and facing continued suffering and isolation. The most common precipitating factor for a murder-suicide was the dissolution of a relationship, with the subsequent emergence of mental symptoms of depression or murderous jealousy. Alcohol abuse factored in 29% of the cases. A study compared two regions of Florida over 6 years regarding the incidence of murder-suicide rates for those younger than 55 years and those age 55 years and older (Cohen et al. 1998). The annual incidence rates ranged from 0.3 to 0.7 per 100,000 persons younger than 55 years, and they were 0.4–0.9 for those age 55 years and older, with higher rates found in the older group every year but two. The odds of an increased rate of suicide or homicide were studied for 16,245 homicides in the files of the Chicago Police Department for the years 1965 through 1990, during which 267 murder-suicides occurred (Stack 1997). After sociodemographic variables were controlled, murder of an ex-spouse or a lover increased the risk for suicide the most—by 12.68 times. Killing a child increased the risk by 12.28 times, killing a current spouse by 8.00 times, killing a girlfriend or boyfriend by 6.11 times, and killing a friend by 1.88 times. The conclusion of the study was that the principal source of frustration in murder-suicide cases is a chaotic intimate relationship marked by jealousy and ambivalence. Nock and Marzuk (1999) concluded that in the United States, 1.5% of all suicides and 5.0% of all homicides occur in the context of a murder-suicide. Various studies from different countries have continued to appear. Spousal murder-suicide was studied in Quebec, Canada, over 8 years (1991–1998). Among 388 cases of such deaths in the Quebec coroner’s office, 145 were conjugal homicides, and in 58 of these cases, the homicidal spouses killed themselves (Bourget et al. 2000). The perpetrators were mainly men who were separated from their spouses and who used a firearm. Most were seen as clinically depressed. A Swiss study of “doublesuicide” and homicide-suicide found that the precipitating factors were similar to those in suicides (Haenel and Elsasser 2000). Stressors such as physical illness, isolation, and social losses were correlated with clinical disturbances of depression, borderline, and narcissistic neuroses. An epidemiological study used death certificates for all those who died by homicide-suicide (in which the suicide followed the homicide
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within 3 days) in England and Wales (Barraclough and Harris 2002). In 144 incidents, 327 people died; 88% involved members of the same family, 75% of the victims were females, and 85% of the suspects were males. Car exhaust and firearms accounted for 40% of the victims’ and 50% of the suspects’ deaths. The conclusion was that in England and Wales, homicide-suicide is mostly a “family affair.” The findings of a study in Fiji that analyzed murder-suicide over a 10year period (Adinkrah 2003) were consistent with those in studies of Western developed countries, with the exception that perpetrators were equally divided between men and women, and no firearms were used. Another study, focusing on Hong Kong, was the first systematic research of murder-suicide in a Chinese society (Chan et al. 2004). According to records from the police and coroner’s court over a 10-year period, most cases involved spouses and lovers and were motivated by separation or the end of a marital relationship. Depression was the most common mental disorder, and economic factors were seen as having high relevance. In contrast to Western societies, firearms were used infrequently; the most frequent modes of killing were strangulation or suffocation (carried out in 26% of cases) and stabbing or chopping (14%). In Finland, the ratio of homicide-suicide to homicide has declined from 15% to 6% from the 1960s to 2000 (Kivivuori and Lehti 2003). The rates have declined in intimate-partner murders and parent–child killings but have consistently remained highest among those in the middle classes. More recent studies from the United States indicate a broadening of groups studied. A study in west-central Florida compared older men who committed suicide with those who committed homicide and then suicide (Malphurs et al. 2001). Depression was prominent in both groups, but the former had more physical illnesses, and 50% of the latter were in caregiving roles compared with 17% of the former. The same data suggested that homicide-suicide rates may be increasing in Florida and in other states with aging populations because of the older population (Cohen 2000). Data from the Hemlock Society indicated that most mercy killings are by an older man who kills his sick wife and then commits suicide (Canetto and Hollenshead 2001). A California study examined the murder of all intimate partners in one year to determine whether differences were seen when a suicide followed (Lund and Smorodinsky 2001). Forty percent committed suicide, and the differences noted were that those who completed suicide were all males, were older, almost always used a gun, and were less likely to be black men. Almost all of the oldest homicide perpetrators took their own lives, whereas fewer than half of those younger than 40 years did so, which suggests different bases for carrying out a homicide.
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A 5-year study of 16 cases of murder-suicide occurring within 1 week of the homicide was carried out in New Hampshire (Campanelli and Gilson 2002). New Hampshire is a state with a low homicide rate, and hence the combination accounted for 14.7% of all the homicides in the state. The findings were typical: 94% of the perpetrators were males, and firearms were used in most cases. School shootings also may involve suicides following homicides. The Centers for Disease Control and Prevention studied school-associated violence with a population-based surveillance from media databases, state and local agencies, and police and school officials for the period 1994–1999 (Anderson et al. 2001). The 220 events resulted in 253 deaths, with 11 of the cases being homicides-suicides. During the period of study, the homicide rates for students killed in multiple-victim events increased; 172 cases were by students, and in 120 of them, a note, threat, or other action indicating potential violence prior to the offense was found. A recurrent question in murder-suicide acts involves the use of alcohol or other drugs. Alcohol or drug use can play a role in bringing about the final act through the resulting poor judgment, impulsivity in deciding to act, and preexisting depressive and paranoid elements that may be present under the surface. Most studies did not include data on this variable. One study of murder-suicide did find that 10% of perpetrators and 7% of victims had been using street drugs (Cooper and Eaves 1996).
Clinical Factors Descriptive and motivational factors may vary depending on the type of murder-suicide. Many overlapping factors of perpetrators are commonly found, such as being clinically depressed, paranoid to some degree, jealous, or ambivalent; having past poor control of aggression; being influenced by alcohol or drugs; and feeling a sense of hopelessness in their lives. The latter may arise in diverse contexts, such as in a relationship per se involving unfaithfulness, despair in a terminally ill spouse, or a sensed betrayal by a superior at work. Consistent with homicide data, most perpetrators are men (about 90%), with the exception of filicidal mothers who murder and then commit suicide. In reviewing several studies, Felthous and Hempel (1995) found that about 80% of the victims in murder-suicide are females. Depression in connection with murder-suicide is viewed hypothetically as having more in common with suicidal acts than with homicidal acts. The loss of hope in a relationship or disillusionment with someone is seen as a key element. It is like a reaction to the loss of a major element in a person’s life—be it a spouse, lover, job, health, or goal one is pursu-
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ing. The key question is why the act does not remain confined to a murder but also is followed by a suicide. Diverse dynamics are possible, such as not wanting the other person to survive and enjoy a life, the desire to punish, or the fantasy that they will both be happy and later reunited in some new sphere of existence. If an element of blame or faultfinding with others, or some component of society, is seen as responsible for the person’s misery, a type of mass killing may occur, such as in a violent outburst in public settings where persons unknown to the perpetrator are killed. Shootings in public places and school shootings are examples in which the perpetrator is either shot or commits suicide.
Specific Types of Murder-Suicide Disappointments in Relationships Spouse or lover murder-suicide represents the major category in terms of frequency, accounting for an estimated 50%–75% of all murder-suicides. When a murder results, it represents the point of no return in a love relationship that has gone awry. Some of these patients may have psychotic delusions operating that lead to the final act, but most patients experience deep jealousy and resentment that their once hopeful and happy relationship is not able to continue. The idea is the Othello syndrome: instead of allowing for the possibility that the other should live and have a happy future, the decision is, rather, “If I can’t live and be happy, neither will you.” Narcissistic entitlement is seen when the person believes that his or her own unhappiness entitles him or her to take another’s life. The killing may occur in an explosive and impulsive manner when the spouse or lover leaves or is about to do so. The perpetrator is then convinced that all hope for the relationship is gone. Yet why are men more likely than women to kill in this situation? The explanation given is that for the woman, murder in a spousal or lover relationship is connected to an abusive situation. Hence perpetrating a murder alone suffices without the need to kill herself. However, in one subtype, the children or the exspouse’s or ex-lover’s new partner may be killed as well.
Case Example 1 A middle-aged man discovers that his wife has developed a sexually intimate relationship with another woman. He first denies that this is possible, but when denial is no longer possible, he begins brooding and becomes deeply depressed. When he asks his wife about it, she first denies it, but after her return from a vacation with her female friend, she informs him that she wants to leave him to live with her friend and confirms that they are in love. For a few months, his wife and he continue
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to live together while arrangements are made for her to move out. On returning home from a holiday family gathering in a rural setting, he stops the car and tells his wife he has to get out to urinate. On returning to the car, he opens the trunk, takes out his shotgun, and shoots his wife. He then attempts suicide with the shotgun but cannot place it accurately, and he survives the shooting.
The emotional state in these individuals before the killing is that of being deeply shamed. It is as though they have been not only exposed but also destroyed. Hence, their life is over, and the life of the person or people who have done this to them also should be over. It is like a need for a completion—to end the story. This explanation is relevant to several of the mass murder-suicides that occur. An example is that at Jonestown, Guyana, where the Reverend James Jones’s psychotic thinking blurred his own self-concept into the extended family of 913 other people at the settlement he ran (Chidester 1988). Jones had had sexual relationships and fathered children with several women in “the family.” To kill himself first involved convincing others in the cult to commit suicide with him so that his act would feel complete; those who did not comply were murdered. Dependent personalities may show a variation of this type of despair (Malmquist 1996). The joint murder-suicide act in these situations is not only to destroy the person who has been the source of deep disappointment to him or her but also, it is hoped, to be reunited with that person. The dependency killings occur in the background of an overidealized relationship that has ended but without a realization of how distorted the relationship was. Thernstrom (1997) described the following murder-suicide by a student with dependent personality: Two female Harvard University students became roommates in an unplanned way. They were both immigrant students from different cultures, but their personalities were even more different. One was popular and outgoing, whereas the other was reticent and self-loathing. The brooding girl was proud and idealized who she had acquired as a roommate, but the other girl progressively ignored her in developing her own life. When the popular girl informed her roommate that she would not be rooming with her the next year, her roommate began pleading and attempted to cajole her not to leave her but to no avail. During final examination week, changes were noted in the brooding girl, who began to dress in a more provocative manner and seemed happy for a change. The culmination came when she stabbed her roommate 45 times one morning and then hung herself. At the beginning of the school year, she had written in her diary, “If I ever grow desperate enough to seek power and a fearful respect through killing, she would be the first one I would blow off.…You know what annoys me the
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most that situations would never reverse for me to be the strong and her to be the weak. She’ll live on tucked in the warmth and support of her family while I cry alone in the cold....The bad way out I see is suicide and the good way out killing, savoring their fear and [then] suicide. But you know what annoys me the most, I do nothing.”
Illness and Declining Health A second main type of homicide-suicide emerges when one or both persons in a committed relationship develop a serious illness or realize their health is rapidly declining. They will be left in a state of dependency because they will not be able to care for themselves. The perpetrator of the partner who is dying of an incurable disease or is becoming helpless may commit a mercy killing. However, the decision to murder also may be based on a practical factor; that is, their financial assets are dwindling, and living some extra time with pain and disability is not a benefit comparable to leaving something to loved ones. The person also may realize that his or her resources will not permit him or her to receive the care he or she had been receiving because long-term-care insurance is ending.
Case Example 2 A middle-aged man’s wife has developed multiple sclerosis. Over a period of years, she has had remissions and exacerbations, but she is now in a state of needing to be fed by him, and she is confined to a wheelchair. She has lost bowel and bladder control. She has always made clear to him that she never wanted to end up in a nursing home, but continuing to care for her at home has become impossible. Thoughts of helping her die would come and go, but after a few months, he concludes that he owes his wife a dignified ending rather than continuing in the state she is in. While she is in her wheelchair, he kisses her good-bye and, crying, strangles her with his belt while standing behind her. He then makes three unsuccessful attempts to hang himself, which leaves rope burns on his neck. Finally, he drives to an isolated country road with a gun and sits in a ditch for hours while putting the gun to his head, but he is not able to pull the trigger. He returns home and keeps his wife’s body in a freezer in the garage for several weeks until some relatives of his wife report that they are not able to contact anyone about her, which leads to an investigation. He is prosecuted and pleads guilty to seconddegree murder, receiving a mitigated sentence.
Suicide Pacts Suicide pacts are sometimes called double suicides and are seen as joint ventures. In contrast to the Romeo and Juliet scenario, it is customarily older couples with increased dependency needs who carry out the acts. These
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may be difficult to distinguish from a murder-suicide if outside confirmatory material is lacking. When both parties totally independently agree that, for diverse reasons, one is becoming too ill to be cared for and that they will both commit suicide, it would be viewed as a pact. However, if the party initiating the pact idea is more dominant or persuasive in the relationship, the issue can become blurred between a pact and a murder-suicide. The suicide pact of noted author Arthur Koestler (Darkness at Noon) and his third wife is an example (Maris et al. 2000). He was 77 years old and had Parkinson’s disease and leukemia while she, 55 years old, was his caregiver but was in good health. They both overdosed on barbiturates, and in her death note, she wrote, “I cannot face life without Arthur.”
Familicides Familicides are another variation of a homicide-suicide group. The goal of the perpetrator is to eliminate all members of the family who are present. However, in these cases, it is not a matter of seeking out someone, such as a sibling, who has left home. The victims are rather those family members who are at the scene, which suggests a degree of impulsivity. The motives may vary. In some cases, the person who is the prime source of financial support is no longer able to continue in that role. The perpetrator believes that the family needs to be relieved of an ensuing burden. Killing all the family members relieves them from a troubled future, so the perpetrator kills them and then commits suicide. In other cases, there may be a marital life with unresolved conflicts that continue. In the state of ongoing disturbances and depression, the solution dawns on a father, and occasionally a mother, to destroy the entire family and then commit suicide as the best solution for all of them in such an unhappy situation (Malmquist 1980). A variation is a depressed or psychotic adolescent who takes such action.
Infanticides and Pedicides Killings of a child younger than 1 year and of a child ages 1–17 years are actually separate types of killings but are often grouped under acts of “filicide.” Infanticide involves the complexities of postpartum conditions that arise in the puerperal period. These can vary from mild depressive states (“the blues”) to severe psychotic states with delusional content. Postpartum depressions may take on an altruistic theme to save the child from a miserable existence on earth and lead to the murder of the child and suicide by the mother. If the disorder is schizophrenia, the mother may have grandiose delusions and exaltations, sometimes of a religious nature, which result in a homicide-suicide of
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the child and mother because of the idea that they will be in Heaven together. The sad case of Andrea Yates, who drowned her five children while in a postpartum psychotic state, is an example of the homicidal behavior that can occur, although no suicide occurred in this case (O’Malley 2004). Women in the postnatal period ordinarily have a low suicide rate, but those with a postpartum illness, such as a psychotic depression or schizophrenia, in which a murder-suicide may occur, are in a high-risk group (Appleby et al. 1998). A host of diverse factors are usually involved and lead to the murder of a child and subsequent suicide. Precipitants can include psychosocial problems, isolation, immaturity, lack of an adequate social support system, earlier physical or sexual trauma, and a pervasive sense of hopelessness (Spinelli 2003).
Political Killings Political killings are perpetrated by cults or terrorist organizations and are a type of murder-suicide in which the victims are usually strangers, such as occurred in the September 11, 2001, attack on the World Trade Center in the United States. In most cases, the perpetrators are committed to dying, either in the course of the acts or by a direct suicide. These disgruntled individuals may externalize their inner states of discontent into a mass act of violence, or they may view themselves as carrying out some praiseworthy act to achieve political martyrdom. Thus, within their group, they may be viewed as heroes.
Murders in the Workplace Murders in the workplace are often connected to a disappointed and depressed employee or ex-employee who comes into his or her place of present or past employment, shoots others, and then commits suicide. Simon (1996) has listed several variations of workplace violence besides disgruntled employees: • Angry spouses or relatives may stalk employees at work. • Violence may occur during criminal acts such as robberies at a place of employment. • People who work in dangerous occupations such as law enforcement may experience violence. • Victims of acts of terrorism may be simply employees on site, such as at the World Trade Center or at the Alfred P. Murrah Federal Building in Oklahoma City, Oklahoma, during the bombing.
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Fortunately, many of these acts of violence in the workplace do not result in a murder-suicide. Similar acts have been noted in academic centers (besides high schools), post offices, health care facilities, and courthouses or lawyers’ offices. Displaced marital anger can lead to the shooting death of the spouse or former companion and whoever may be in the way. In one case, the shooting of a separated spouse occurred in his office and was followed by the spouse’s suicidal jump from the window in the office building. The killings are often part of a personal agenda arising from the combination of the perpetrator’s own specific social situation and psychopathology. Sometimes the goal is to kill a specific person and then others indiscriminately before committing suicide. Mullen (2004) refers to these types of killings as autogenic (self-generated) massacres. The people are seen as social isolates, often bullied in their childhoods, and they have not established themselves adequately in a work role. They often have paranoid and narcissistic traits. When they believe they have been rejected or encounter a disappointment, such as failing to obtain a promotion or not receiving an expected appointment, they decide to get their revenge and end it all (Copeland 1985). Some of the victims may be those who have failed them, but the act is often indiscriminate, and whoever is present gets killed. The final act by the perpetrator is a suicide by shooting himself or herself or a shoot-out with police in which the goal is to be killed. There are many overlaps between this type of mass murder-suicide by adults and the school shootings by adolescents. The clinical question always lurks as to the degree of depression mixed with a personality disorder in a psychologically wounded person. Many questions remain beyond this brief discussion that need to be addressed involving the assessment of people who are suicidal but who also may be homicidal. The diversity of types of murder-suicide is the key; clinicians must assess the degree of hurt and rejection, the pattern of externalizing, the person’s thoughts as mainly obsessional brooding or delusional, disturbances in attachments that lead the person to believe that he or she cannot go on in the absence of a particular person or attachment, past suicide attempts, stalking, and past homicidal levels of violence. Cult or terrorist acts are the most difficult in which to intervene because they are closely kept secrets and are not likely to be divulged by associates.
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❏ Key Points ■
Murder-suicide occurs in various contexts: situations of domestic violence with mass shootings, familicides, planned deaths of the elderly or those with a terminal illness, infanticidal acts, and mass killings as a response to personal disappointment or disillusionment.
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In all contexts, one must discern the degree of psychopathology, the situation, and possible diagnoses. Some of these individuals are psychotic, but many are not. The difficulty is obvious when so many of the perpetrators commit suicide.
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The central theme of all murder-suicides, despite their diviersity, is often the overvaluation of a relationship.
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The homicidal acts follow the end or threatened end of a relationship (in a marital or romantic context), the terminal illness of a loved one, the killing of an infant to shorten his or her supposed suffering on earth, or the narcissistic blow of a rejection or disappointment and the need to retaliate.
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The relevant theme running through many of these diverse situations is a disorder in the realm of attachments that has never been resolved. The vulnerability is reflected in difficulties in handling stress regulation and the lack of mental capacity to assess the consequences of causing innocent deaths. Because these persons are not able to perceive a remedy for their more immediate disorganized and insecure state, their solution is to end it all. The narcissistic blow and emerging depression are not seen as repairable. Although patients with borderline personality disorder seem especially prone to this “solution,” allowance must be made for some of these acts to be part of a delusional psychotic state. At another extreme are the mass killings carried out as part of a cult or terrorist group whose members view their acts as a service for the right cause and worthy to die for.
References Adinkrah M: Homicide-suicide in Fiji: offense patterns, situational factors, and sociocultural contexts. Suicide Life Threat Behav 33:65–73, 2003 Anderson M, Kaufman J, Simon TR, et al: School associated violent deaths in the United States, 1994–1999. JAMA 286:2695–2702, 2001 Appleby L, Mortensen PB, Faragher EB: Suicide and other causes of mortality after post-partum psychiatric admission. Br J Psychiatry 173:209–211, 1998 Barraclough B, Harris EC: Suicide preceded by murder: the epidemiology of homicide-suicide in England and Wales, 1988–1992. Psychol Med 32:577– 584, 2002
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Bourget D, Gagne P, Moamai U: Spousal homicide and suicide in Quebec. J Am Acad Psychiatry Law 28:179–183, 2000 Campanelli C, Gilson T: Murder-suicide in New Hampshire, 1995–2000. Am J Forensic Med Pathol 23:248–251, 2002 Canetto SS, Hollenshead JD: Older women and mercy killing. Omega 42:83–99, 2001 Cavan R: Suicide. Chicago, IL, University of Chicago Press, 1928 Chan CY, Beh SL, Broadburst RG: Homicide-suicide in Hong Kong, 1989–1998. Forensic Sci Int 140:261–267, 2004 Chidester D: Salvation and Suicide: An Interpretation of Jim Jones, the Peoples Temple, and Jonestown. Bloomington, IN, Indiana Univ Press, 1988 Cohen D: An update on homicide-suicide in older persons: 1995–2000. J Ment Health Aging 6:195–199, 2000 Cohen D, Llorente M, Eisdorfer C: Homicide-suicide in older persons. Am J Psychiatry 155:390–396, 1998 Coid J: The epidemiology of abnormal homicide and murder followed by suicide. Psychol Med 13:855–860, 1983 Cooper M, Eaves D: Suicide following homicide in the family. Violence Vict 11:99–112, 1996 Copeland AR: Dyadic death—revisited. J Forensic Sci 25:181–188, 1985 Felthous AR, Hempel A: Combined homicide-suicides: a review. J Forensic Sci 40:846–857, 1995 Haenel T, Elsasser PN: Double suicide and homicide in Switzerland. Crisis 21:122–125, 2000 Kivivuori J, Lehti M: Homicide followed by suicide in Finland: trend and social locus. Journal of Scandanavian Studies in Criminology and Crime Prevention 4:223–236, 2003 Lund LE, Smorodinsky S: Violent death among intimate partners: a comparison of homicide and homicide followed by suicide in California. Suicide Life Threat Behav 31:451–459, 2001 Malmquist CP: Psychiatric aspects of familicide. Bull Am Acad Psychiatry Law 8:298–304, 1980 Malmquist CP: Homicide: A Psychiatric Perspective. Washington, DC, American Psychiatric Press, 1996 Malphurs JE, Eisdorfer C, Cohen D: A comparison of antecedents of homicidesuicide and suicide in older married men. Am J Geriatr Psychiatry 9:49–57, 2001 Maris RW, Berman AL, Silverman MM: Comprehensive Textbook of Suicidology. New York, Guilford, 2000 Marzuk PM, Tardiff K, Hirsch CS: The epidemiology of murder-suicide. JAMA 267:3179–3183, 1992 Milroy CM: Reasons for homicide and suicide in episodes of dyadic death in Yorkshhie and Humberside. Med Sci Law 35:213–217, 1995 Mullen PE: The autogenic (self-generated) massacre. Behav Sci Law 22:311–323, 2004 Nock MK, Marzuk PM: Murder-suicide, in The Harvard Medical School Guide to Suicide Assessment and Intervention. Edited by Jacobs DG. San Francisco, CA, Jossey-Bass, 1999, pp 188–209
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O’Malley S: “Are You There Alone?” The Unspeakable Crime of Andrea Yates. New York, Simon & Schuster, 2004 Palmer S, Humphrey J: Criminal homicide followed by offender’s suicide. Suicide Life Threat Behav 10:106–118, 1980 Roberts AR: Murder-suicide, in Encyclopedia of Murder and Violent Crime. Edited by Hickey E. Thousand Oaks, CA, Sage, 2003, pp 324–326 Simon RI: Bad Men Do What Good Men Dream. Washington, DC, American Psychiatric Press, 1996 Spinelli MG (ed): Infanticide: Psychosocial and Legal Perspectives on Mothers Who Kill. Washington, DC, American Psychiatric Publishing, 2003 Stack S: Homicide followed by suicide: an analysis of Chicago data. Criminology 35:435–453, 1997 Thernstrom M: Halfway Heaven: Diary of a Harvard Murder. New York, Doubleday, 1997 West DJ: Murder Followed by Suicide. Cambridge, MA, Harvard University Press, 1966
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Legal Perspective on Suicide Assessment and Management Daniel W. Shuman, J.D.
We may have a process for passing judgment in negligence cases, but practically no law of negligence beyond the process itself. Leon Green, Judge and Jury 185 (1930)
If the occurrence of a patient suicide is an inevitability for most clinical psychiatrists (Simon 2002), then it is prudent for psychiatrists in a litigious society like ours to be concerned about the risk of a malpractice claim that the suicide could have been prevented if they had done their job properly. A psychiatrist can best reduce the malpractice risk from patient suicide in a straightforward manner—practice evidence-based psychiatry (Gray 2004; Gutheil 1992). This commonsense advice, positing a synchronous relation between clinical and legal strategies, is sensible for two reasons. First, clinically, the practice of evidence-based
Work on this chapter was supported by a summer research grant from the Southern Methodist University Dedman School of Law.
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psychiatry minimizes patient harm and maximizes the benefits of psychiatrist–patient interaction, reducing the risk of patient suicide attempts. Second, legally, when a patient commits or attempts suicide and malpractice litigation ensues, the determination of liability entails a critical comparison of what was done and what ought to have been done. No better articulation of what ought to be done exists than can be found in the definition of the practice of evidence-based medicine: “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” (Sackett et al. 1996, p. 71). The practice of evidence-based psychiatry is the best defense on the merits to a psychiatric malpractice claim. Having noted that the practice of evidence-based psychiatry is the best strategy to reduce the risk of a psychiatrist being found liable for malpractice following a patient suicide, it is also important to note that this chapter, authored by a law professor, is not a guide to the practice of psychiatry for suicide assessment and management; the other chapters of this book, authored by eminent psychiatrists, more appropriately address this subject. Rather, this chapter is a guide to the manner in which courts assess claims for malpractice arising out of patient suicide attempts. It is intended to demystify the legal process and to explain its relation to good clinical practice, which requires an examination of malpractice claims against psychiatrists arising out of patient suicides. Most malpractice claims against psychiatrists arising out of patient suicides are grounded in the law of negligence. The body of law that authorizes negligence claims consists of published judicial opinions (often augmented by statute) addressing deterrence of, and compensation for, inadvertently and/or unintentionally caused harm (Shuman 1993, 1994). Intentional tort claims for professional wrongdoing also exist (e.g., battery), but they present several pragmatic problems that often make them less appealing to plaintiffs. As contrasted with negligence claims, which require a showing of carelessly caused harm, intentional tort malpractice claims require proof of purposefully caused physician harm, an occurrence that is less likely as well as intuitively less believable to juries. In addition, most professional liability insurance policies exclude coverage for intentional conduct, potentially limiting the plaintiff’s ability to collect any monetary judgment. Thus, negligence claims dominate psychiatric malpractice litigation arising out of patient suicide. The prima facie case of negligence (i.e., minimally sufficient to be decided by the fact finder, usually a jury) consists of evidence from which a reasonable juror could find, by a preponderance of the evidence, a breach of a duty proximately causing harm. This definition is often reduced to four conjunctive elements: duty, breach, cause, and harm (Far-
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well v. Un 1990). All four of these elements must be present to constitute a prima case of negligence. The failure of any one is fatal to the plaintiff’s pursuit of a negligence claim and cannot be offset by compelling evidence of another element.
Duty A psychiatrist who takes on a patient owes that patient a legal duty to attend him or her and to avoid negligently harming that patient in treatment (Farrow v. Health Servs. Corp. 1979). But when does that duty arise? And, does a psychiatrist ever owe a duty to anyone other than his or her patients? This issue is best understood against the background of the common law principle that private citizens (even health care professionals) are under no legal duty to come to the aid of another in peril. If, however, a person voluntarily chooses to act for the benefit of another, that person is obligated to do so in a nonnegligent manner (Nally v. Grace Community Church 1988). Thus, a psychiatrist out for a weekend jog who, alone, comes across a man perched on a bridge, threatening to jump to his inevitable death or serious injury, is not legally obligated to interrupt her run to use her professional skills to attempt to talk the man off the bridge (or even dial 911 at no charge on her cell phone). Insofar as tort law is concerned, realizing the man’s peril, the psychiatrist may continue on her run with impunity (just as she may choose not to take on a new patient at the office without justification). If, for whatever reason, she chooses to assist the man on the bridge, or the new patient at the office, however, she takes on a duty to do so in a nonnegligent manner, or she may be subject to suit if harm consequentially results, without regard to payment for her services. (Some recent “Good Samaritan” statutes have raised the threshold for gratuitous rescuers to be held liable to gross negligence [e.g., New Mexico 2004]). Generally, a person who is, legally, a stranger to the psychiatrist– patient relationship (i.e., not a party to the relationship) is not entitled to bring a malpractice claim seeking damages for the result of a patient suicide, even if he or she consequentially experiences serious harm. For example, the best friend (Fred) of a patient (Pat) who took his life, which could have been prevented absent an elementary psychiatric blunder, is not entitled to bring a malpractice claim against his friend Pat’s psychiatrist for his (Fred’s) resulting emotional distress. The psychiatrist owes no legal duty to a patient’s best friend to treat the patient correctly. That duty is owed to the patient. The conjunctive element of duty requires that for the prototypical psychiatric malpractice claim, the psychiatrist owes a legal duty to the claimant, the person who attempts suicide or
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the estate of the person who commits suicide. (But see Mertz v. Temple Univ. Hosp. [1995] for a rare example of a third-party duty recognized in a suicide malpractice claim by children injured when a psychiatric patient committed suicide by blowing up the row house next to the children’s residence.) Tarasoff v. Regents of the University of California (1976), which recognized a psychotherapist’s duty to a nonpatient who was the object of the patient’s morbid obsession that was disclosed to the therapist, did not involve the issue of suicide risk assessment and has not been extended by case law to this setting. The law does not require any particular formality to create a psychiatrist–patient relationship with its consequential legal duties. Instead, the law’s determination of the existence of a duty follows from a pragmatic assessment of the substance of the relationship: [W]hen the professional services of a physician are accepted by another person for the purposes of medical or surgical treatment, the relation of physician and patient is created. The relation is a consensual one wherein the patient knowingly seeks the assistance of a physician and the physician knowingly accepts him as a patient. The relationship between a physician and patient may result from an express or implied contract, either general or special, and the rights and liabilities of the parties thereto are governed by the general law of contract, although the existence of the relation does not need to rest on any express contract between the physician and the person treated. However, the voluntary acceptance of the physician-patient relationship by the affected parties creates a prima facie presumption of a contractual relationship between them. A physician may accept a patient and thereby incur the consequent duties although his services are performed gratuitously or at the solicitation and on the guaranty of a third person. (Wilson v. Teng 2000, pp. 498–499)
Courts look to evidence of agreement to seek and to provide psychiatric services to ascertain the existence of a psychiatrist–patient relationship with its consequential duties (whose breach is discussed below). Once formed, however, the physician–patient relationship does not bind the parties indefinitely. A physician–patient relationship may be terminated by mutual agreement of the psychiatrist and patient, unilaterally by the patient, or unilaterally by the psychiatrist with adequate notice and assistance in securing the services of another psychiatrist. Unless or until that occurs, however, the psychiatrist’s legal duty to attend the patient remains extant. These principles governing the role of the psychiatrist and the patient in the formation and termination of the physician–patient relationship do not support attempts to limit the scope of professional duties
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during the relationship through the use of “no-suicide contracts” or “no-harm contracts.” Whatever the therapeutic implications of these documents may be, there is no cogent basis to conclude that they alter the psychiatrist’s legal duty to care for his or her patient as governed by the law of torts. Understanding why this is so requires a digression into tort and contract law. One important distinction between tort law and contract law is the approach to the ability of the parties to determine their rights and responsibilities. Contract law is deferential to the authority of the parties to define the terms of the relationship (e.g., Did the consumer demand and did the manufacturer agree to provide a vehicle that would protect the occupants in a rollover?); tort law is less deferential to the parties’ authority to define the terms of the relationship and more inclined to impose societal expectations on the parties (e.g., Would a reasonable manufacturer provide a vehicle that did not protect the occupants in a rollover?). Once the conduct of the parties gives rise to the existence of a psychiatrist–patient relationship, an attempt to bargain away society’s expectations regarding the standard of care enforced by tort law is less likely to be condoned (Mehlman 1990). A related duty issue involves a patient at risk for suicide who rejects the psychiatrist’s treatment recommendation (e.g., hospitalization) but who does not meet the legal threshold for involuntary hospitalization. Although a psychiatrist owes a legal duty to his or her outpatients and inpatients to render an acceptable level of professional care (Kockelman v. Segal 1998), courts have been reluctant to impose a duty on a psychiatrist to control a competent, noncommittable patient at risk who rejects a medically appropriate treatment plan (Paddock v. Chacko 1988). Thus, although a patient’s inpatient or outpatient status should not determine the existence of a duty, the substance of the duty owed may be affected by this status. Courts have considered the patient’s civil rights to limit the substance of the duty owed by a treating psychiatrist to an at-risk patient. Whether the element of duty, breach, or cause is used, courts have been less willing to impose liability in the case of a psychiatric outpatient who commits suicide than for an inpatient who does so (Lee v. Corregedore 1996; Tortuya v. United States 1994). Decisions regarding all of the conjunctive elements of negligence are not assigned to the same legal actors. The question of duty is generally regarded as a question of law for the judge to decide. Thus, questions of the therapist’s duty to a nonpatient third party, as, for example, in the well-known Tarasoff decision, as well as when or whether a duty arises to one who claims to be a patient, are decided by the judge. If the judge decides that no duty exists, any claim based on a breach of that alleged duty should be dismissed. If the duty issue is not raised (i.e., if it is
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waived) or if it is raised and resolved in favor of the plaintiff, the other elements of negligence (i.e., breach, causation, and harm) remain for the fact finder to decide.
Breach In our fault-based system of liability, the defendant’s behavior must be measured against the same uniform standard (King 1975). To determine whether the duty a psychiatrist owes to a patient has been breached, the law asks the fact finder to compare the psychiatrist’s behavior in the case before the court with the behavior of the proverbial reasonable psychiatrist. In so doing, the law seeks to measure whether this psychiatrist behaved as society expects a psychiatrist ought to behave under the circumstances. “Negligence of a physician who practices a specialty consists of a failure to exercise the degree of care and skill of the average qualified physician practicing that specialty, taking into account the advances in the profession and the resources available to the physician” (Stepakoff v. Kantar 1985, p. 1135). Although subject to some variation from state to state (see, e.g., Beno v. Secretary of Health and Human Servs. 1994, *4, “usual, customary and accepted practice”), the formulation of this test for professional expectations is largely consistent across medical specialties. In general, in the case of professional negligence claims, the courts defer to the profession’s specialized knowledge in setting the standard of care. In most cases, the custom of the profession (i.e., “the degree of care and skill of the average qualified physician practicing that specialty”) is regarded as the standard of care to which the defendant is held. Typically, the role of the fact finder is to ascertain and apply that standard of care by relying on evidence of customary practice presented by the parties (American Law Institute 2005). In our adversary system in which the parties are responsible for gathering and presenting evidence, absent authoritative evidence of a professional consensus, evidence of the standard of care is presented through the testimony of experts retained by the parties (Shuman 2001). This partisan expert testimony often differs descriptively regarding the practice customarily followed by psychiatrists, as well as compliance with that customary practice in the instant case. In some cases, this expert testimony will ascertain a well-established minority custom. In some states, compliance with well-established minority customs is admissible as proof that the standard of care was not breached, but in most states, no such exception to the role of majority custom in establishing the standard of care is recognized (Nunsuch v. United States 2001).
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Asking the fact finder to rely on the testimony of the experts retained by the parties may skew the decision-making process: retained experts’ opinions may not accurately represent the practices of the profession; subtle incentives may exist for retained experts to render an opinion that achieves a “just” outcome in a case; or not-so-subtle financial incentives may exist for retained experts to render an opinion that will dispose counsel to retain the expert. Ascertaining the standard of care for suicide assessment and management is accordingly well served by works like this treatise, which offers a detached review and analysis of professional practice outside the context of litigation of a particular claim. This work may not only raise “the degree of care and skill of the average qualified [psychiatrist]” but also offers testifying experts and the courts independent sources of information about customary practice regarding suicide assessment and management. A psychiatrist’s compliance with customary practice is, nevertheless, not always sufficient to avoid being found in breach of the standard of care. The classical explanation for the incomplete symmetry between professional custom and the standard of care is contained in a U.S. Supreme Court opinion authored by Justice Oliver Wendell Holmes Jr.: “What usually is done may be evidence of what ought to be done, but what ought to be done is fixed by a standard of reasonable prudence, whether it usually is complied with or not” (Texas and P. Ry. v. Behymer 1903, p. 470). Although courts in professional malpractice actions ordinarily seek only to ascertain what is customarily done as a proxy for what is reasonable (i.e., the optimal balance of risk and benefit), in a discrete minority of cases, courts have unilaterally attempted to protect society against unreasonably risky professional norms. The most widely cited instance of this judicial activism in a medical malpractice case is a decision of the Washington Supreme Court in Helling v. Carey (1974). The jury in Helling returned a defense verdict. On appeal, the Washington Supreme Court reversed and, without a remand for a retrial, concluded that an ophthalmologist’s failure to administer a noninvasive and inexpensive pressure test for glaucoma to an asymptomatic patient younger than 40 was negligent, notwithstanding the plaintiff’s and defendant’s experts’ testimony that it was not then the custom to do so. The appellate court reasoned that it was unreasonably risky for an ophthalmologist to fail to administer this test for all patients younger than 40, without the court’s considering the costs associated with false-positive test results or false-negative test results, health insurance coverage for the tests, or competing demands for health care dollars. Its reasoning rested on an opinion authored by Judge Learned Hand of the Second Circuit Court of Appeals, itself derivative of the
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Holmes opinion in Texas and P. Ry. v. Behymer (1903). Hand’s opinion in The T.J. Hooper (1932, p. 740) found the operator of an oceangoing tug whose cargo was lost in a storm at sea negligent in failing to use a radio to obtain weather forecasts, which had not then been adopted as an industry custom: In most cases reasonable prudence is in fact common prudence; but strictly it is never its measure; a whole calling may have unduly lagged in the adoption of new and available devices. It never may set its own tests, however persuasive be its usages. Courts must in the end say what is required; there are precautions so imperative that even their universal disregard will not excuse their omission.
Ironically, according to a post-Helling survey of ophthalmologists (Wiley 1982), unbeknownst to the Washington Supreme Court or the parties’ experts, the state high court’s opinion in Helling correctly reflected the customary practice regarding the administration of this test (i.e., it was customarily administered by ophthalmologists to asymptomatic patients younger than 40 before the Helling decision). A search of the reported case law found no instance of a court applying an independent judicial determination of the standard of care, rejecting customary professional norms, in the case of a psychiatric malpractice suicide claim. Thus, for now, Helling v. Carey remains a cautionary tale for psychiatrists. Nonetheless, Helling v. Carey and The T.J. Hooper stand as an imposing judicial reminder that professional customs must regularly be critically examined; compliance with professional customs, although generally sufficient to defeat the imposition of tort liability, provides no guarantees against liability. Indeed, this book offers a compelling critique of and the blueprint for a Helling challenge to customary psychiatric practice of suicide assessment and management. Given the state of the art of suicide risk assessment, however, it is rare for psychiatrists to be found liable simply for not accurately assessing the risk of suicide (Baerger 2001). As expressed by one New York court in the context of a negligent release claim: “When the claimed malpractice concerns the wrongful release of a patient, courts have refused to impose liability unless there was ‘something more’ than an error of judgment” (Bell v. New York City Health and Hosp. Corp. 1982, p. 281). Instead, following a patient suicide, psychiatrists are more likely to be found liable for having failed to engage in a timely, comprehensive risk assessment and consequential treatment planning process. Various attempts have been made to organize these failures into a taxonomy of psychiatric patient suicide malpractice claims:
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• Bongar (2002, pp. 52–61): “Failure to properly diagnose; Failure to take adequate protective measures; Early release of patient; Failure to commit; Liability of hospitals and managed care; Abandonment.” • Jobes and Berman (1993, p. 92): “(1) Failure to diagnose and safeguard (2) Failure to recognize patient’s suicidal tendencies and not taking precautionary measures to protect the patient (3) Failure to use proper care and treatment.” • Simon (2004, p. 2): “Failure to provide proper assessment and management in high volume patient settings; Failure to construct a comprehensive treatment plan; Failure to perform comprehensive risk assessment; Failure to obtain past treatment records; Failure to hospitalize; Failure to make a rational diagnosis based on the history and evaluation; Failure to record suicide risk assessment.” These taxonomies of failure may be useful to psychiatrists as a reminder of errors not to make, but given their negative orientation (e.g., do not abandon your patients), they do not communicate the state of the art of practice regarding suicide assessment and management. Inherent in the issues that are presented to the jury and reviewed by the courts in a medical malpractice case (e.g., “Did physician undertake mode or form of treatment that reasonable and prudent member of medical profession would not undertake under same or similar circumstances? Answer: Yes__ or No__”), standards drawn from these decisions inform psychiatrists what not to do, not what to do. Courts are only permitted to weigh in on the questions essential to the case before them—Was the defendant’s conduct negligent, and, if so, what harm did it cause?—not to offer an advisory opinion about how things might have been done better. The utility of noting such failings as a vehicle to comprehensively inform clinical practice is decidedly limited. The legal utility of these taxonomies is also limited. The cases on which these taxonomies are based do not establish comprehensive professional norms; rather, most simply find that the evidence regarding a particular expert’s testimony was sufficient to support the judgment in a specific case. Given the independence of malpractice decisions, they lack value as a guide for decision making in subsequent cases. Rejecting Justice Oliver Wendell Holmes Jr.’s suggestion that we crystallize standards that express the collective decision making in related cases (Holmes 1881/1946), a jury’s verdict in one negligence case (or an appellate court’s decision affirming it) is not admissible as evidence of negligence in another negligence case to establish the standard of care. Jury B asked to address a psychiatric suicide malpractice case identical to one just addressed by jury A last week may not be informed of jury
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A’s verdict; indeed, familiarity with case A might well disqualify a juror in case B. Each negligence case stands on its facts. The legal principles incorporated in the jury instructions that govern the standards to be applied are painted with broad brush strokes. In the end, with slight variation from state to state, the malpractice jury is given an instruction to the effect that “courts require…that physicians and surgeons exercise in diagnosis and treatment that reasonable degree of skill, knowledge, and care ordinarily possessed and exercised by members of the medical profession under similar circumstances” (Mann v. Cracchiolo 1985, p. 1143). Whether that degree of care has been met in the case at bar is not determined by the testimony of other experts in other cases, by another jury’s verdict based on that testimony, or its affirmation by the courts, but by the jury’s assessment of the evidence in the case before them. However, even when the psychiatric care was substandard, that, by itself, is not tortious.
Cause A common expression found in negligence case law is that “proof of negligence in the air” is not sufficient to satisfy the requirements of a prima facie case (The Chester Valley 1940, p. 594). This expression is intended to articulate the causal nexus the plaintiff is required to prove between the defendant’s wrongful conduct and the plaintiff’s injury. For moral and economic reasons, this causal requirement is intended to permit the defendant to be blamed for his or her behavior only when the professional negligence and the suicide are closely linked in a causal chain of events (Hart and Honoré 1985). This chain of causation requirement commonly demands that, for liability to attach, there must be a harmful result that would not have occurred “but for” the defendant’s negligence. If the defendant had behaved reasonably, would the harm still have occurred? If the harm would have occurred without regard to the defendant’s failure to meet professional norms, the defendant is not regarded as the cause of the harm. Thus, in a case in which a psychiatrist’s conduct did not meet professional norms, if a patient suicide would have occurred even if the psychiatrist’s conduct had complied with professional norms (e.g., because a warning to the family of the suicide risk posed and necessity to secure all firearms would not have discovered the weapon used by the patient to commit suicide, which he had hidden at another location months earlier), the causation requirement is not met, and a negligence claim should fail. Causation is an element of the prima facie case for negligence, which the court will scrutinize, if it is raised, before permit-
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ting the jury to consider the issue. Thus, for example, in Farwell v. Un (1990), the court of appeals affirmed the trial court’s dismissal of a professional liability claim following a suicide because even if the defendant’s care had been medically negligent, the passage of time and changes in the patient’s circumstances rendered the negligence legally insufficient to constitute a cause in fact of the suicide. The causation requirement does not, however, demand that the psychiatrist’s conduct be the sole cause of the suicide; rather, it need be only a “substantial factor” among several contributing causes of the suicide (Molchon v. Tyler 2001). By definition, a suicide (as contrasted with a homicide) requires that the patient played a causal role in his or her death or attempt. Some courts address the legal relevance of the patient’s causal role in a suicide as a matter of contributory negligence or even duty. Neither of these approaches adequately addresses society’s expectations for psychiatrists regarding the care of at-risk patients. Most courts analyze the implications of intervening forces with the concept of intervening and supervening cause. Whether the patient’s behavior is regarded as an intervening cause (which does not break the chain of causation and insulate the psychiatrist from liability) or is regarded as a supervening cause (which does break the chain of causation and insulate the psychiatrist from liability) turns on its foreseeability. Foreseeable intervening causes are not regarded as a supervening cause and are the responsibility of the defendant. Unforeseeable intervening causes are regarded as a supervening cause and are not the responsibility of the defendant. An opinion by Judge Posner of the Seventh Circuit Court of Appeals (Jutzi-Johnson v. United States 2001, pp. 755–756) explains how the courts apply these principles to causation for patient suicide: When failure to prevent a suicide is claimed to be negligent, the issue of foreseeability is analyzed under the rubric of “supervening cause” and the general rule is that the negligent actor is not liable for the victim’s decision to kill himself. The suicide is said to be a supervening cause of the victim’s loss of his life, breaking the chain of responsibility that would otherwise link the loss to the negligent act.…Of course this is just a conclusion, not reasoning; but it is a conclusion sustained by reasoning about the unforeseeability of most suicides and the role of foreseeability in determining tort liability.…But by the same token the doctrine of supervening cause is not applicable when the duty of care claimed to have been violated is precisely a duty to protect against ordinarily unforeseeable conduct. A risk unforeseeable to an ordinary person is foreseeable to a specialist who assumes a duty to prevent the risk from materializing. The duty is a recognition that the unforeseeable has become foreseeable to the relevant community. And so a hospital that fails to maintain
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a careful watch over patients known to be suicidal is not excused by the doctrine of supervening cause from liability for a suicide, .. . any more than a zoo can escape liability for allowing a tiger to escape and maul people on the ground that the tiger is the supervening cause of the mauling.
Some courts have addressed this same set of concerns holding the psychiatrist liable for causal consequences to which the patient has played a significant role by treating “sane” suicides as unforeseeable supervening causes and “insane” suicides as foreseeable intervening causes (Edwards v. Tardif 1997, pp. 1269–1270): This common law rule has been stated as follows: “If one is sane, or if the suicide is during a lucid interval, when one is in full command of all faculties, but life has become unendurable by reason of the injury, it is agreed in negligence cases that the voluntary choice of suicide is an abnormal thing, which supersedes the defendant’s liability.” . . . Conversely, suicide will not break the chain of causation if it was a foreseeable result of the defendant’s tortious act. In Wozniak v. Lipoff, .. .(1988), for example, the plaintiffs brought a medical malpractice action against a physician for negligence in the treatment of their decedent. The decedent had suffered from Graves’ disease, a hormonal disorder, and depression... .During his treatment of the decedent, the defendant prescribed sixty pills of the antidepressant Sinequan with three refills, on which the decedent overdosed. .. .After a jury verdict for the plaintiffs, the defendant appealed, claiming that the decedent’s death resulted from an intervening act other than his negligence....The court recognized that the jury heard evidence that suicide is always a possibility in treating a depressed patient and that the appropriate standard of care in treating a depressed patient is to prescribe the lowest feasible amount of medication.. .. Accordingly, the court concluded, “there was competent evidence from which a rational fact finder could find [the defendant] should have reasonably foreseen the danger of [the decedent] committing suicide by an overdose of Sinequan.”.. .Several other courts have concluded that Liability will be imposed on a physician when suicide was one of the foreseeable risks that made the physician’s antecedent conduct negligent. See, e.g., Meier v. Ross General Hospital . . . (1968) (“those charged with the care and treatment of a patient, who know of facts from which it might reasonably be concluded that a patient would be likely to harm himself in the absence of preclusive measures, must use reasonable care to prevent such harm”); Summit Bank v. Panos .. . (1991) (reversing summary judgment in favor of defendant because, “given [the decedent’s] history, and [the defendant’s] own testimony of his awareness of her emotional problems, there is a genuine issue of fact whether it was foreseeable that [the decedent] might abuse the drugs which he prescribed for her”); Fernandez v. Baruch. .. (1968) (“the con-
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trolling factor in determining whether there may be a recovery for a failure to prevent a suicide is whether the defendants reasonably should have anticipated the danger that the deceased would attempt to harm himself”); Champagne v. United States.. .(1994) (“if the patient’s act of suicide is a foreseeable result of the medical provider’s breach of duty to treat the patient, the patient’s act of suicide cannot be deemed a superseding cause of the patient’s death that breaks the chain of causation between the medical provider and the patient, which absolves the medical provider of liability”).
Another formulation of the attempt to impose proportional limitations on the consequences of negligently caused harm is the doctrine of proximate cause. Not all harmful consequences caused by a psychiatrist’s negligence are compensable; the law draws policy-based lines to prevent the consequences of a negligent act from extending indefinitely in time and space. There are many formulations, and there is much debate over proximate cause, but the approach that has the most currency is the “harm within the risk” test. To cabin the results of a tortious act proportionately, the “harm within the risk” approach to proximate cause limits negligence recovery to those consequences that are within the risk, the foreseeability of which rendered the conduct negligent (Vanderbeek v. Vernon Corp 2002). Why was this defendant’s conduct regarded as unreasonably risky, and is the consequence for which recovery is sought one of those unreasonable risks? For example, the foreseeable risk of failing to advise the family of a patient at high risk for suicide of this risk and to remove firearms from the home is that the patient may use the firearms to commit suicide. If, instead of a patient suicide, the presence of the unsecured firearms in the home results in the patient’s adolescent son accidentally killing an adolescent friend while playing with one of the firearms in the home, the psychiatrist’s negligence in failing to advise removal of firearms from the home would not be a proximate cause of the adolescent’s death, even though it may have been a substantial factor in its occurrence. The foreseeable risk that made the psychiatrist’s conduct negligent was that a patient at high risk for suicide might use the weapons to take his or her life. Removing the weapons from the home for the benefit of the patient would have averted the risk of adolescents playing with these weapons (“but for” the breach, the harm would not have occurred). However, because that was not the risk that rendered this conduct negligent, the psychiatrist’s failure to advise the family about the risk of suicide and firearm removal was not the proximate cause of the injury, and liability should not attach.
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Harm The requirement that the claimant suffer legally recognized harm as the result of the breach of a legally enforceable duty not only provides a measure for calculating the damages to which he or she may be entitled but also articulates a conjunctive element of the prima facie case of negligence. Absent legally recognized harm, the prima facie case of negligence fails. For example, driving under the influence of alcohol is a crime even if no one is injured, but if it only offends our sensibilities and does not result in legally recognized harm (e.g., broken bones or dented fenders), it is not tortious. Similarly, if a psychiatrist’s conduct falls below professional norms in the care provided a patient at high risk for suicide, but as a result of the actions of family and friends a suicide attempt is averted, the psychiatrist’s conduct is not tortious, even though it may subject the psychiatrist to professional discipline. There is little question about the presence of legally recognized harm in the case of a completed suicide. In the case of an unsuccessful suicide attempt, the hesitance of some jurisdictions to recognize claims for negligent infliction of emotional distress (Boyles v. Kerr 1993), standing alone without physical harm, may result in the failure to recognize malpractice claims for attempted suicide without demonstrable physical harm (Lourcey v. Estate of Scarlett 2004).
Conclusion Sifting through the small sliver of reported judicial decisions in cases in which psychiatrists were sued following a patient suicide, which were not settled because the parties could not agree as to the appropriate professional norms or damages, is an odd way to discern the standard of care for psychiatric suicide assessment and management. It relies on a skewed sample of cases. Most bad outcomes in physician–patient relationships do not result in tort claims. Of those bad outcomes that result in tort claims, most settle. And, most that do not settle are not appealed and do not produce reported decisions. This approach also assumes that the best way to guide professional practice is to inform psychiatrists, on a case-by-case basis, not widely publicized, years after their professional actions, whether their practices were reasonable. Particularly because courts begin (and usually end) their standard of care determination with professional customs, psychiatrists would do best to develop authoritative evidencebased standards for professional customs to reduce the risk of patient suicide and consequential risk of tort liability. But how can this knowledge of the practice of evidence-based psychiatry for suicide assessment and management be kept current and effectively communicated to psychiatrists?
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Only by effectively addressing the problem of refining evidencebased wisdom into practice guidelines (Gray 2004) can psychiatry offer to define and communicate these practice expectations comprehensively and authoritatively. This tactic has its own risks for psychiatrists; the failure to meet well-defined expectations holds obvious tort liability risks. However, in the absence of a willingness to clarify professional expectations, psychiatrists will continue to face clinical and legal uncertainties in suicide assessment and management.
❏ Key Points ■
The practice of evidence-based medicine and psychiatry is clinically and legally important in suicide assessment and management.
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Malpractice liability for negligence requires the plaintiff to prove that the breach of a legally recognized duty is the proximate cause of the harm complained of by the plaintiff.
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A psychiatrist owes a duty of care only to a person at risk for suicide whom the psychiatrist explicitly or implicitly accepts as a patient.
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The law does not impose a tort duty on a psychiatrist to cure a patient or to render care that is as good as the best psychiatrist would render; rather, in judging whether a psychiatrist acted reasonably under negligence law, the law typically demands compliance with customary professional practice.
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Courts retain the authority to impose a standard of care for suicide assessment and management that is more demanding than customary practice to protect against the failure of an entire profession, although this standard is rarely used.
References American Law Institute: Restatement (Third) of Torts: Liab. Physical Harm § 13 cmt. b (Proposed Final Draft No 1, April 6, 2005) Baerger DR: Risk management with the suicidal patient: lessons from the caselaw. Prof Psychol Res Pr 32:359–366, 2001 Bell v New York City Health and Hosp. Corp., 90 AD2d 270 (NY App Div 1982) Beno v Secretary of Health and Human Servs, 1994 U.S. Claims LEXIS 218 (Ct Cl 1994) Bongar B: The Suicidal Patient: Clinical and Legal Standards of Care, 2nd Edition. Washington, DC, American Psychological Association, 2002 Boyles v Kerr, 855 SW2d 593 (Tex 1993) Edwards v Tardif, 692 A2d 1266 (Conn 1997) Farrow v Health Servs Corp., 604 P2d 474 (Utah 1979) Farwell v Un, 902 F2d 282 (4th Cir 1990)
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Gray GE: Evidence-Based Psychiatry. Washington, DC, American Psychiatric Publishing, 2004 Gutheil TG: Suicide and suit: liability after self-destruction, in Suicide and Clinical Practice. Edited by Jacobs D. Washington, DC, American Psychiatric Press, 1992, pp 146–167 Hart HLA, Honoré T: Causation in the Law, 2nd Edition. Oxford, England, Clarendon Press, 1985 Helling v Carey, 519 P2d 981 (Wash 1974) Holmes OW: The Common Law (1881). Boston, MA, Little, Brown, 1946 Jobes DA, Berman AL: Suicide and malpractice liability: assessing and revising policies, procedures, and practice in outpatient settings. Prof Psychol Res Pr 24:91–99, 1993 Jutzi-Johnson v United States, 263 F3d 753 (7th Cir 2001) King JK: In search of a standard of care for the medical profession: the “accepted practice” formula. Vanderbilt Law Rev 28:1213–1276, 1975 Kockelman v Segal, 61 Cal App 4th 491 (Cal Ct App 1998) Lee v Corregedore, 925 P2d 324 (Haw 1996) Lourcey v Estate of Scarlett, 146 SW3d 48 (Tenn 2004) Mann v Cracchiolo, 694 P2d 1134 (Cal 1985) Mehlman MJ: Fiduciary contracting limitations on bargaining between patients and health care providers. U. PITT. L. REV. 51:365–417, 1990 Mertz v Temple Univ. Hosp., 29 Pa 467 (Pa CP 1995) Molchon v Tyler, 546 SE2d 691 (Va 2001) Nally v Grace Community Church, 763 P2d 948 (Cal 1988) New Mex Stat Ann § 24-10-3 (2004) Nunsuch v United States, 221 F Supp 2d 1027 (D Ariz 2001) Paddock v Chacko, 522 So2d 410 (Fla Dist Ct App 1988) Sackett DL, Rosenberg WM, Gray JA, et al: Evidence based medicine: what it is and what it isn’t. BMJ 312(7023):71–72, 1996 Shuman DW: The psychology of deterrence in tort law. Univ Kans Law Rev 42: 115–168, 1993 Shuman DW: The psychology of compensation in tort law. Univ Kans Law Rev 43:39–77, 1994 Shuman DW: Expertise in law, medicine, and health care. J Health Polit Policy Law 26:267–290, 2001 Simon RI: Suicide risk assessment: what is the standard of care? J Am Acad Psychiatry Law 30:340–344, 2002 Simon RI: Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management. Washington, DC, American Psychiatric Publishing, 2004 Stepakoff v Kantar, 473 NE2d 1131 (Mass 1985) Tarasoff v Regents of the University of California, 551 P2d 334 (Cal 1976) Texas and P. Ry. v Behymer, 189 US 468 (1903) The Chester Valley, 110 F2d 592 (5th Cir 1940) The T.J. Hooper, 60 F2d 737 (2d Cir 1932) Tortuya v United States, 1994 US Dist LEXIS 13178 (D Cal 1994) Vanderbeek v Vernon Corp., 50 P3d 866 (Colo 2002) Wiley J: The impact of judicial decisions on professional conduct: an empirical study. S. CAL. L. REV. 55:345–396, 1982 Wilson v Teng, 786 So2d 485 (Ala 2000)
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Patient Suicide and Litigation Charles L. Scott, M.D. Phillip J. Resnick, M.D.
Suicides account for nearly 30,000 deaths annually in the United States and are the eleventh leading cause of death (National Center for Health Statistics 2000; National Institute of Mental Health 2004). Studies indicate that during the course of his or her career, a psychiatrist has a 50% chance of losing a patient to suicide (Chemtob et al. 1988). In a review of malpractice claims against psychiatrists between 1980 and 1985, Robertson (1988) reported that lawsuits involving suicide represented the largest number of suits and yielded the largest financial settlements (Baerger 2001). In this chapter, we examine psychiatrists’ roles in two areas of litigation. In the first, we provide an overview of malpractice litigation when the psychiatrist is a defendant in a lawsuit. In the second section, we review retrospective psychiatric evaluations conducted to determine whether a person’s death was due to a suicide or resulted from other causes. In both situations, it is important that the psychiatrist be familiar with the legal principles that are relevant in approaching the referral issue. In the following case example, the psychiatrist received a formal legal complaint against him alleging psychiatric malpractice: Mr. A, a 44-year-old married man being treated in an outpatient psychiatric clinic for major depression and narcissistic personality disorder, has a history of suicide attempts that includes an attempted hanging
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while intoxicated when he was 33 years old. During the first week of that hospitalization, Mr. A denied having suicidal feelings and was taken off suicide precautions. Within 20 minutes of his change in status level, Mr. A attempted to hang himself with torn sheets. After 3 weeks of inpatient care, Mr. A was discharged and has been followed up as an outpatient on a weekly basis. At his last outpatient psychiatric appointment, Mr. A tells his psychiatrist that his wife informed him that morning that she was in love with a coworker. He is despondent and tearful. Mr. A denies any specific suicide plan but also refuses to answer questions related to current homicidal or suicidal thoughts. The psychiatrist learned that Mr. A had received a driving under the influence citation the prior week, and he smells alcohol on Mr. A’s breath during the interview. Mr. A refuses inpatient psychiatric admission, and the psychiatrist schedules a routine follow-up appointment for 4 weeks later. The following morning, the psychiatrist learns that Mr. A went home, shot and killed his wife, and then shot himself. The psychiatrist subsequently receives a formal legal complaint against him alleging psychiatric malpractice.
Suicide and Malpractice Litigation Legal Concepts Knowledge of general legal concepts assists the clinician in both providing mental health treatment and understanding medical-legal disputes that may arise when a patient dies. Tort law governs the legal resolution of complaints regarding medical treatment. A tort is a civil wrong. Tort law seeks to compensate financially individuals who have been injured or who have experienced losses because of the conduct of others. In cases involving suicide, the plaintiff is generally a surviving spouse or family member who seeks financial compensation for the loss of his or her loved one. Torts are typically divided into one of three categories: 1) strict liability, 2) intentional torts, and 3) negligence (Table 27–1). Strict liability imposes liability on defendants without requiring any proof of lack of due care, and this standard is not used in malpractice litigation involving suicide. The most common example of strict liability is harm caused to an individual by a product proven to be unreasonably dangerous and defective (Schubert 1996). Intentional torts involve actions when an individual either intends harm or knows that harm may result from his or her behavior (Schubert 1996). Examples of intentional torts that involve mental health care include assault (an attempt to inflict bodily injury), battery (touching without consent), false imprisonment, and violation of a person’s civil rights. Negligence occurs when a clinician’s behavior unintentionally causes an unreasonable risk of harm to another. This type of tort is typically used in
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TABLE 27–1. Types of torts Strict liability Intentional tort Negligence
Imposes liability without proof of lack of due care Individual intends harm or knows harm will result from his or her actions Individual’s behavior unintentionally causes an unreasonable risk of harm to another
a lawsuit against a clinician involving a suicide. Medical malpractice is based on the theory of negligence. The four elements required to establish medical negligence are commonly known as the four D’s. These include a dereliction of duty that directly causes damages (Table 27–2). A duty is most commonly established for a clinician when the patient seeks treatment, and treatment is provided. The provision of services does not require the patient’s presence and can even extend to assessment and treatment provided over the telephone. Dereliction of duty is usually the most difficult component of negligence for the plaintiff to establish. Dereliction of duty is divided into acts of commission (provision of substandard care) and acts of omission (failure to provide care). Acceptable care does not have to be perfect care but care provided by a reasonable practitioner. Medical malpractice is defined as “a doctor’s failure to exercise the degree of care and skill that a physician or surgeon of the same medical specialty would use under similar circumstances” (Garner 2004, p. 978). Two aspects of causation generally cited as establishing negligence include the foreseeability of the suicide and the clinician’s role in directly causing the harm. Damages are the amount of money the plaintiff is awarded in a lawsuit. Various types of damages may be awarded. Special damages are those actually caused by the injury and include payment for lost wages and medical bills. General damages are more subjective and provide financial compensation for the plaintiff’s pain and suffering, mental anguish, loss of future income due to injury, and loss of companionship. A third category of damages is referred to as exemplary or punitive damages. Punitive damages may be awarded when the defendant has been determined to have acted in a malicious or grossly reckless manner. Because punitive damages generally involve harm that is intentionally caused, they are rarely awarded in suicide malpractice cases. Table 27–2 summarizes the four key components necessary to establish a claim of medical negligence.
Treatment Settings and Malpractice Litigation The possibility of a patient committing suicide represents one of the greatest emotional and legal concerns of clinicians. This concern is realistic given that 10%–15% of patients with major psychiatric disorders
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TABLE 27–2. Four D’s of negligence Duty
Dereliction Directly causing Damages
Established when a professional treatment relationship exists between a clinician and a patient Deviations from minimally acceptable standards of care Relation between dereliction of duty and harm caused Amount of money awarded the plaintiff to compensate for harm caused
will die by suicide (Brent et al. 1988a). Lawsuits related to suicide usually involve one of three scenarios: 1) an inpatient suicide when the facility and its practitioners provide inadequate care or supervision; 2) a recently discharged patient who commits suicide; or 3) an outpatient who commits suicide (Knapp and VandeCreek 1983). Suicidality is the most common reason for inpatient psychiatric hospitalization (Friedman 1989). When a patient is admitted to the hospital because of thoughts of self-harm, the clinician is on notice that the patient is at an increased risk for suicidal behavior. Nearly one-third of inpatient suicides result in a lawsuit (Litman 1982). Malpractice actions often name the hospital in addition to the treating clinicians. For example, when hospital staff members are aware of the patient’s suicidal tendencies, the hospital assumes the duty to take reasonable steps to prevent the patient from inflicting harm (Robertson 1988). Common allegations of psychiatric malpractice following inpatient and outpatient suicides are outlined in Table 27–3 and Table 27–4, respectively. TABLE 27–3. Common allegations of negligence following inpatient suicides The treater(s) failed to Diagnose or foresee the suicide Control, supervise, or restrain Evaluate adequately suicidal intent Provide appropriate pharmacotherapy Provide adequate monitoring Gather an adequate history Remove potentially harmful items such as belts or shoelaces Provide a safe, secure environment Source.
Robertson 1988.
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TABLE 27–4. Common allegations of negligence following outpatient suicides The treater(s) failed to Evaluate properly the need for psychopharmacological intervention or provide suitable pharmacotherapy Implement hospitalization Maintain an appropriate clinician–patient relationship Obtain supervision and consultation Evaluate for suicide risk at intake and at management transitions Secure records of prior treatment or perform adequate history taking Conduct a mental status examination Diagnose a patient’s symptoms appropriately Establish a formal treatment plan Safeguard the outpatient environment Document adequately clinical judgments, rationales, and observations Source.
Packman et al. 2004.
Stages of Malpractice Litigation A malpractice case usually begins after a bad outcome coupled with the survivors’ bad feelings toward the clinician (Appelbaum and Gutheil 1991). Malpractice litigation goes through several steps before the case actually reaches trial. Laws governing the rules of civil procedure vary from state to state but typically have several components. The party believed to be injured first seeks legal advice to determine whether a basis exists for a malpractice claim. At this early stage, a plaintiff’s attorney often sends the medical records to a mental health expert to review the merits of the case. The attorney may provide a summary of the facts to the potential expert to see how he or she reacts before selecting a psychiatrist to review the records. A review by a mental health professional is important to determine whether potential negligence has occurred. Experts working with plaintiff’s counsel may be asked to identify deviations from the standard of care. Defense attorneys may seek help in defending any alleged deviations in care and in identifying critical areas to review as part of their deposition preparation. The reviewing expert on either side may be asked whether he or she believes that the hospital staff fell below the standard of care in addition to the care provided by the defendant physician. Some states require that 50%–75% of the expert’s time be spent in practice and teaching to be allowed to testify on standard of care in malpractice cases. Furthermore, experts should clarify with attorneys in-
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volved in cases outside of their home state if they are required to have a license in that state before giving expert testimony (Simon and Shuman 1999). Psychiatrists also should refer out those cases they are not qualified to do, such as a case involving complex psychopharmacology. If the plaintiff’s attorney decides to take the case, he or she then drafts a document known as the complaint. The complaint outlines specific claims of negligence, the form of relief sought (generally monetary), and the specific names of sued defendants. The complaint may be overly inclusive in both allegations of negligence and the number of parties sued. For an inpatient suicide, multiple defendants are likely. During the process of litigation, certain parties may eventually be dropped when evidence is insufficient to support a cause of action against them. Once the parties being sued are served with the complaint, they must provide a formal response, known as the answer, within a specified time. In the answer to the complaint, the responding party outlines his or her defense to each claim asserted and either admits or denies the claims as outlined in the plaintiff’s complaint. In certain situations, the response to the complaint involves a demurrer or a motion to dismiss for failure to state a cause of action. A demurrer is a written response to the complaint that requests dismissal because even if the facts as outlined in the complaint were true, no legal basis exists for the lawsuit. A judge holds a hearing to determine the validity of the demurrer and to decide if the case should be dismissed. If a demurrer is not granted, the next stage of litigation is known as discovery. The discovery phase involves an exchange of information so that each side has knowledge of the facts and anticipated testimony and is not surprised should the case proceed to trial. Information may be exchanged through a series of written documents known as interrogatories. Interrogatories are a set of written questions posed by one party to the other that require a written response (also termed answer to interrogatories) under oath within a specified time frame. Interrogatory questions commonly request detailed specifics about the suicide, care providers, and treatment provided. The discovery process can involve demands for production of documents such as nursing policies regarding suicide precautions or a mental health examination of a plaintiff alleging emotional damages. During the discovery stage of litigation, depositions of parties and potential witnesses are usually requested. Discovery depositions in suicide malpractice cases usually involve three phases: 1) depositions of the parties, treating health care professionals, and fact witnesses; 2) depositions of the various standard of care experts; and 3) depositions of the causation experts and damage experts. During a deposition, the testimony of a fact or expert witness is taken under oath before a court reporter, and a
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written transcript of this proceeding can be used to assist in trial preparation or to impeach the testimony of a witness during trial. After the discovery phase has concluded, either party may file a motion for summary judgment. A motion for summary judgment asserts that a trial is not necessary because there is no dispute as to any material fact issues in the case, and the law clearly favors judgment for the moving party. If the court grants summary judgment for the requesting party, the case ends at this point. If the case is not dismissed, an arbitration or settlement conference may be arranged to determine whether the parties can agree to a settlement and avoid the time and expense of a trial. Various factors that influence whether a case settles include an assessment of the defendant physician’s demeanor as caring or arrogant, the ability of the experts, the strength of the attorneys, the attitude of the particular judge, and the nature of the local jury pool. If the legal parties are unable to settle the case, litigation then proceeds to trial, at which the evidence is presented to the trier of fact. The trier of fact is either a judge or a jury and is responsible for determining the outcome of the litigation, known as the judgment. The types of damages resulting from the judgment are discussed earlier in this section.
Litigation and Retrospective Analysis of Suicidal Intent The psychiatrist’s evaluation of suicidal intent plays a pivotal role in various types of litigation surrounding an individual’s death. Whereas the actual cause of death may be clear (e.g., gunshot wound to the head or crush injury from a car accident), the mode of death examines the person’s intent to die. When assessing the mode of death, the examiner determines whether the death was from natural causes, an accident, a suicide, or a homicide (Ebert 1987). In 5%–20% of death cases reviewed by the medical examiner (coroner), the mode of death is unclear (Schneidman 1981). Common situations in which the cause of death is clear but the mode of death is not include autoerotic asphyxia, a fatal car accident, and death resulting from Russian roulette. Any one of these scenarios could result from suicidal intentions or from a tragic accident. When the circumstances surrounding a death are unclear, litigation may follow to answer such unresolved questions, especially if there are financial consequences. Multiple areas of potential litigation may follow a death from unclear reasons, and some of these are noted in Table 27–5 (Simon and Shuman 1999). Robins et al. (1959) conducted the first retrospective psychological study of suicides through their detailed analysis of 134 consecutive sui-
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TABLE 27–5. Areas of potential litigation following death from unclear reasons Life, health, or disability benefits from insurance policies that allow financial recovery for accidents but not suicides Homeowners’ policies that exclude coverage for intentionally violent acts Legal actions related to workers’ compensation benefits Malpractice actions alleging suicide Product liability claims Motor vehicle insurance claims Contested wills Awarding of military benefits to surviving family members Criminal prosecution when homicide by a third party rather than suicide of the decedent is alleged Determination of whether death from police intervention was “suicide by cop” Source.
Simon 1990.
cides that occurred during a 1-year period. This retrospective investigation of a victim’s mental state was further developed by the Suicide Prevention Center in Los Angeles, California, during the 1950s to assist coroners’ accuracy in the determination of death (Beskow et al. 1990; Curphey 1961; Jobes et al. 1986). The term psychological autopsy was coined by Schneidman (1981) to describe the method by which an evaluator conducts a retrospective review in equivocal deaths to determine whether the death involved suicidal intent. Three important legal components of intent are 1) that it is a state of mind, 2) about consequences of an act [or omission] and not about the act itself, and 3) it extends not only to having in mind a purpose [or desire] to bring about given consequences but also to having in mind a belief [or knowledge] that given consequences are substantially certain to result from the act. (Keeton et al. 1984)
More simply stated, suicidal intent involves a person’s understanding that an action he or she takes will result in his or her own death. Whereas suicidal intent involves an appreciation of the permanent consequences of the suicidal act, motive refers to the reasons that the person wants to die. Such reasons may include a desire to have insurance money cover a family debt in the face of overwhelming financial stress or the hope that suicide will provide an escape from personal problems or emotional pain. Retrospective reviews of suicidal intent and motive are potentially helpful in a variety of civil and criminal matters discussed in the following sections (Simon 2002).
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Role of Psychological Autopsies in Litigation Life Insurance Claims Many life insurance policies differentiate the extent of death benefits according to whether the death was due to natural or accidental causes rather than a suicide, as in the following example: Mrs. and Mr. B are enjoying their routine Sunday morning coffee and newspaper. Mr. B leaves the room to take his shower while Mrs. B begins tackling the weekly crossword puzzle. After 5 minutes, Mrs. B hears a loud shot from their bedroom and rushes to the room, where she discovers her husband lying dead on the floor. His .45-caliber revolver is in his right hand, and he has a gunshot wound to his head. Mr. B never communicated to her any suicidal thoughts, and she reports that he was not depressed. Mr. and Mrs. B each took out a life insurance policy 18 months ago that included an exclusion clause for any suicide that occurred within the first 2 years of the policy. The insurance company refuses to pay benefits to Mrs. B, stating that her husband’s death was a suicide, and she therefore is not entitled to the life insurance benefits. Mrs. B’s attorney contacts a psychiatrist to ask his assistance in conducting a “psychological autopsy” to offer an opinion about whether the decedent died by suicide.
When conducting an assessment of a deceased person’s suicidal intent, the evaluator should see the relevant insurance policy language. In particular, the psychiatrist should examine whether the policy governed by the relevant jurisdictional statute and case law distinguishes “sane” from “insane” suicides. In some jurisdictions, a person who commits a suicide but is assessed as insane is determined not to have intentionally committed the suicide; therefore, the beneficiaries have a right to the policy proceeds. One definition of an insane suicide was described more than 100 years ago in the U.S. Supreme Court case Mutual Life Insurance Company v. Terry (1873, p. 242). In this 1873 case, the Court wrote: If the death is caused by the voluntary act of the assured, he knowing and intending that his death shall be the result of his act, but when his reasoning faculties are so far impaired that he is not able to understand the moral character, the general nature, consequences and effect of the act he is about to commit, or when he is impelled thereto by an insane impulse, which he has not the power to resist, such death is not within the contemplation of the parties to the contract and the insurer is liable.
The following example illustrates a situation in which life insurance benefits may be granted if insane suicides are not specifically excluded from policy coverage:
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Mr. C, a psychotic man, shoots himself in the head with a revolver in the delusional belief that he is immortal and cannot be killed. Although Mr. C may have understood that he was pulling the trigger of a loaded weapon, if his delusional beliefs prevented him from understanding that he would die as a result of this gunshot wound, his death could be determined an insane suicide.
Some insurance companies have revised their policies to exclude specifically the recovery of benefits by suicide, whether sane or insane. In Bigelow v. Berkshire Life Insurance Company (1876), the Supreme Court upheld the exclusion of insane suicides from coverage under a particular life insurance policy, thereby preventing the distribution of life insurance benefits following a suicide, regardless of the mental state of the deceased.
Workers’ Compensation Claims Workers’ compensation awards monetary benefits when mental harms are determined to have been caused by a work-related injury. When an employee commits suicide following a work-related injury, can a family member seek workers’ compensation benefits? In this situation, a psychological autopsy may be useful in determining the relation, if any, between a work-related injury and a suspected suicide. In the 1984 Montana case Campbell v. Young Motor Co., the court allowed Dr. Walters, a psychologist who conducted a psychological autopsy, to testify whether a back injury Mr. Raymond Campbell sustained working as a car body repairman was a proximate cause of his suicide 5 years after the injury occurred. The trial court found that there was a causal connection between the injury and the suicide and commented as follows: Where can this Court find the bright line that distinguishes the act, the act premeditated by intellect from the act that is the result of the diseased mind? This Court must, and can only, discover this line by examining the pre-accident and post-accident conduct of the decedent, conduct which steps forward and speaks on his behalf, and the expert testimony of the psychologist who performed the psychological autopsy. (Campbell v. Young Motor Co. 1984)
In the subsequent 1992 Kansas case of Rodriguez v. Henkle Drilling and Supply Company, a deceased man’s wife sued for benefits, alleging that injuries her husband sustained while working on irrigation wells resulted in constant pain, decreased self-esteem, and depression that resulted in his suicide 2 years later. The employer presented findings from two psychological autopsies that indicated that the deceased had had difficulties with alcohol and drug use, prior suicidal threats, and marital problems.
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The experts conducting the psychological autopsy testified that workrelated injuries were not a significant cause of the man’s suicide. The trial court found that although a worker’s suicide does not automatically preclude compensation, the claimant failed to prove that her husband’s work injuries resulted in his suicide (Rodriguez v. Henkle Drilling and Supply Company 1992). In both of these workers’ compensation cases, the findings from the psychological autopsies were allowed into evidence to assist the court’s understanding of the relation between a work-related injury and the employee’s later suicide.
Inheritance Litigation A psychological autopsy may be helpful in determining whether an individual was sane or insane regarding his or her estate’s legal right to a potential inheritance following the individual’s commission of a homicidesuicide. In general, a perpetrator who takes a person’s life cannot inherit or profit from his or her crime. For example, if a son shoots his father because his father was about to alter his will to exclude his son, the son could not profit from his father’s death. Does this principle apply if a person commits a homicide and then takes his own life? Would the homicide victim’s assets be included in the deceased perpetrator’s estate if this perpetrator had been included in the victim’s will? In some states, the answer to this question requires a determination of whether the killer would have met the state’s legal test of criminal insanity at the time of the homicide. For example, in New York, if the evaluation finds that the deceased perpetrator would have met the criminal test for insanity, then the killer’s estate may profit from the victim’s estate (Goldstein 1986).
Criminal Cases The psychological autopsy also may provide useful information in the evaluation of defendants involved in the criminal justice system. Most commonly, a psychological autopsy may be requested from a defendant charged with homicide to support his or her defense that the death with which he or she is charged was actually a result of the victim’s suicide. In the case of United States v. St. Jean (1995), a husband charged with the premeditated murder of his wife argued that his wife’s death was as likely a result of a suicide as a homicide, and therefore reasonable doubt existed as to his guilt. To rebut this assertion, the prosecutor called an expert who had conducted a psychological autopsy of the victim and was prepared to testify that none of the factors normally associated with suicide was present. The defense challenged the admissibility of the psychological autopsy results, alleging that they were unreliable and that the evaluator
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was not an expert in suicidology. The court allowed the expert’s testimony, and the results of the psychological autopsy were deemed admissible on appeal (Biffl 1996; United States v. St. Jean 1995). Results from psychological autopsies also may be allowed in cases involving criminal child abuse. Jackson v. State (1989) is a frequently cited case in which a psychological autopsy examined the alleged relation between a mother’s alleged abusive behavior and her daughter’s subsequent suicide. In this case, a mother altered her 17-year-old daughter’s birth certificate so that she could work as a nude dancer in a nightclub. The teenager subsequently shot herself, and a psychiatrist was prepared to testify that the mother’s behavior was a substantial factor in the daughter’s suicide. Although the defense argued that psychological autopsies were not reliable and therefore not admissible, the court reasoned that the jury could determine the reliability of this testimony and allowed the psychological autopsy results into evidence. Dr. Douglas Jacobs, a psychiatrist specializing in suicidology, testified that the abusive relationship with the mother was a substantial contributing cause of the teenager’s suicide. The mother was found guilty of child abuse, and this verdict was challenged. A Florida appellate court held that the state had presented sufficient evidence to establish that psychological autopsies examining suicides had gained acceptance in the field of psychiatry and that the trial judge did not err in allowing the psychiatrist’s testimony (Jackson v. State 1989). In a subsequent Ohio case, a father was alleged to have repeatedly sexually abused his daughter. After she committed suicide, he was charged with nine counts of sexual battery and involuntary manslaughter. A psychological autopsy was conducted to determine if there was a connection between the father’s alleged sexual abuse and his daughter’s suicide. The father filed a motion to exclude the results of the psychological autopsy. Although the courts ultimately determined that the father could not be charged with involuntary manslaughter for his daughter’s suicide, they commented that the results of the psychological autopsy could be relevant to the charges of sexual abuse. The court also emphasized that the possible relation of the father’s sexual abuse to his daughter’s suicide could be considered as evidence during his sentencing phase (State v. Huber 1992).
Components of the Psychological Autopsy Schneidman (1981) recommended that forensic evaluators review 14 areas when conducting the psychological autopsy (Jacobs and Klein-Benheim 1995). Table 27–6 outlines important areas to review when conducting a psychological autopsy.
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TABLE 27–6. Areas to review for psychological autopsy Basic identifying information (e.g., age, gender, marital status, occupation) Specific details of the death Outline of the victim’s history to include previous suicide attempts Family psychiatric history (i.e., suicides and mood disorders) Victim’s personality and lifestyle characteristics Victim’s historical pattern of reaction to stress and emotional lability Recent stressors or anticipated conflicts Relation of alcohol and drugs to the victim’s lifestyle and death Quality of the victim’s interpersonal relationships Changes in the victim’s routine, schedule, and habits before death Information relating to the “lifeside” of the victim (i.e., successes and plans) Rating of lethality Reaction of informants to the victim’s death Assessment of suicidal intention Source.
Jacobs and Klein-Benheim 1995; Shneidman 1981.
To accomplish such an analysis, the evaluator examines two sources of information when conducting the psychological autopsy (Isometsa 2001). The first source involves extensive interviews of family members, friends, and other individuals close to the victim. Such interviews are considered the more important source of information (Hawton et al. 1998). The second source is a thorough review of collateral records. Collateral documents that should be considered for review include the victim’s psychiatric records, medical records, suicide notes, personal journals, computer hard drive, employment records, academic records (when indicated), and relevant legal documents such as the person’s will or new insurance polices; police reports; witness statements; accident reports; and autopsy reports. Although often admitted into evidence in a courtroom proceeding, psychological autopsies have been criticized for lacking basic psychometric test qualities such as reliability and validity. To address these concerns, the Centers for Disease Control and Prevention developed the Empirical Criteria for Determination of Suicide (ECDS). This instrument has 16 items that review a person’s mental state at the time of his or her death and has been shown to be 92% accurate in differentiating between a suicide and an accident. The 16 items included on this instrument are listed in Table 27–7 (Jobes et al. 1986; Simon 1998). The ECDS serves to supplement the evaluator’s clinical judgment and may provide useful data to submit to support opinions reached in the psychological autopsy (Simon 1998).
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TABLE 27–7. Suicide and mental state checklist 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.
Pathological evidence (autopsy) indicates self-inflicted death. Toxicological evidence indicates self-inflicted harm. Statements by witnesses indicate self-inflicted death. Investigatory evidence (e.g., police reports, photographs from scene) indicates self-inflicted death. Psychological evidence (observed behavior, lifestyle, personality) indicates self-inflicted death. States of the deceased indicate self-inflicted death. Evidence indicates that decedent recognized high potential lethality of means of death. Decedent had suicidal thoughts. Decedent had recent and sudden change in affect (emotions). Decedent had experienced serious depression or mental disorder. Decedent had made an expression of farewell, indicated desire to die, or acknowledged impending death. Decedent had made an expression of hopelessness. Decedent had experienced stressful events or significant losses (actual or threatened). Decedent had experienced general instability in immediate family. Decedent had recent interpersonal conflicts. Decedent had history of generally poor physical health.
Source.
Jobes et al. 1991; Simon 1998.
Conducting the Psychological Autopsy Surviving family members, friends, and colleagues may be reluctant to speak with an examiner following the victim’s death. Because the evaluator may have only one opportunity to interview a key informant, it is helpful to review carefully in advance the collateral documents when formulating interview questions. The evaluator should be sensitive to a variety of feelings that the person interviewed may experience. Such feelings range from extreme grief accompanied by guilt, sadness, or anger to suspicion and mistrust regarding the examiner’s role. In some circumstances, if the examiner determines that the cause of death was an intentional suicide, the individual being interviewed may endure a financial loss and therefore may have substantial reluctance to participate in the postmortem analysis. Such individuals also may have significant motivation to misrepresent information. Although some family members may be reluctant to discuss suicidal communications, a sudden death from suicide may be genuinely surprising to most family members. Research indicates that only one-third
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to one-half of all victims examined in a psychological autopsy had communicated explicit statements of suicidality to their family members or health care professionals during the months before their death (Barraclough et al. 1974; Isometsa et al. 1994; Robins 1959). Likewise, a clinician may not know that his or her patient was contemplating taking his or her own life. In a Finnish review of 100 suicides of persons who had met with a health care professional on the day of their suicide, only 21% had communicated their suicidal intent to their clinician (Isometsa 2001; Isometsa et al. 1995). When is the best time to conduct the interviews? Postmortem researchers of suicide have conducted interviews of informants ranging from a few weeks to 6 months after the victim’s death. Brent and colleagues (1988b) reported that when interviews were performed between 2 and 6 months after the suicide, no significant relation was found between the timing of the interview and the reporting of important diagnostic history and familial variables. However, studies also have found that survivors are more satisfied when interviews are conducted less than 10 weeks following the suicide rather than later (Runeson and Beskow 1991). Various approaches have been proposed for contacting informants to arrange the interview. Researchers have found that contacting informants by letter followed by a telephone call 1 week later resulted in a high acceptance rate, with 77% of the approached families agreeing to be interviewed (Brent et al. 1988b). In contrast, other researchers have achieved a low rejection rate by first contacting the survivors by telephone before sending a letter. By speaking directly with the informant during the initial contact, the evaluator is able to assess the reaction of the survivor (Beskow et al. 1990). When a letter is used to contact a close survivor, improved outcomes may be achieved through attempts to personalize the letter by referring to the deceased as “your son,” “wife,” “partner,” or other appropriate phrase (Cooper 1999). Procedures that require the informant to complete a personality inventory of the deceased in advance of the interview have generated negative reactions from interviewees and are not recommended (Beskow 1979). The evaluator must use caution in setting up the interview on potentially sensitive dates such as the victim’s birthday or the anniversary of his or her death. The examiner needs to be flexible and sensitive to the emotional needs of the interviewee. In a pilot study that examined factors increasing the acceptability of the interview, Cooper (1999) determined that asking questions surrounding the death during an early stage of the interview was recommended to alleviate anxiety as soon as possible. In addition, the use of the phrase “sudden death” instead of
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“suicide” was generally preferred, especially in those cases in which the informant did not believe the death was a result of suicide. The evaluator needs to anticipate the potential grief, guilt, or distress that an informant may experience during the interview. A refusal to participate during the first contact should be respected. The examiner may invite the individual to contact him or her when and if he or she is ready to do so. Although the investigator may discuss the factual circumstances of the death, information that has been concealed from relatives or close friends generally should not be disclosed (Beskow et al. 1990). In summary, the psychological autopsy is a delicate examination that balances the need to obtain sufficient relevant information with the requirement to treat both the survivors and the deceased person with dignity and respect.
❏ Key Points ■
The most common malpractice claims against psychiatrists are those that involve a patient’s suicide.
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To establish malpractice, the plaintiff must prove that a dereliction of duty directly resulted in damages.
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Psychological autopsies have been accepted into evidence in legal proceedings and can play a critical role in the outcome of both civil and criminal litigation.
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The psychological autopsy involves a combination of in-depth interviews with surviving family members and friends and an extensive review of collateral records.
References Appelbaum PS, Gutheil TG: Malpractice and other forms of liability, in Clinical Handbook of Psychiatry and the Law, 2nd Edition. Edited by Appelbaum PS, Gutheil TG. Baltimore, MD, Williams & Wilkins, 1991, pp 136–213 Baerger DR: Risk management with the suicidal patient: lessons from case law. Prof Psychol Res Pr 32:359–366, 2001 Barraclough BM, Bunch J, Nelson B, et al: A hundred cases of suicide: clinical aspects. Br J Psychiatry 125:355–373, 1974 Beskow J: Suicide and mental disorder in Swedish men. Acta Psychiatr Scand Suppl (277):1–138, 1979 Beskow J, Runeson B, Asgard U: Psychological autopsies: methods and ethics. Suicide Life Threat Behav 20:307–323, 1990 Biffl E: Psychological autopsies: do they belong in the courtroom? Am J Crim Law 123:24, 1996, pp 123-145 Bigelow v Berkshire Life Insurance Company, 93 US 284 (1876)
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Brent DA, Kupfer DJ, Bromet EJ, et al: The assessment and treatment of patients at risk for suicide, in American Psychiatric Press Review of Psychiatry, Vol 7. Edited by Frances AJ, Hales RE. Washington, DC, American Psychiatric Press, 1988a, pp 353–385 Brent D, Perper J, Kolko D, et al: The psychological autopsy: methodological considerations for the study of adolescent suicide. J Am Acad Child Adolesc Psychiatry 27:362–366, 1988b Campbell v Young Motor Co., 684 P2d 1101 (Mont 1984) Chemtob CM, Hamada RS, Bauer RS, et al: Patient suicide: frequency and impact on psychiatrists. Am J Psychiatry 145:224–228, 1998 Cooper J: Ethical issues and their practical application in a psychological autopsy study of suicide. J Clin Nurs 89:467–475, 1999 Curphey TJ: The role of the social scientist in the medicolegal certification of death from suicide, in The Cry for Help. Edited by Farberow NL, Shneidman ES. New York, McGraw-Hill, 1961, pp 110–117 Ebert BW: Guide to conducting a psychological autopsy. Prof Psychol Res Pr 18:52–53, 1987 Friedman RS: Hospital treatment of the suicidal patient, in Suicide: Understanding and Responding: Harvard Medical School Perspectives on Suicide. Edited by Jacobs DG, Brown HN. Madison, CT, International Universities Press, 1989, pp 379–402 Garner BA (ed): Black’s Law Dictionary, 8th Edition. St Paul, MN, West Publishing, 2004, p 978 Goldstein R: When it pays to be insane: three unusual legacies of insanity. Bull Am Acad Psychiatry Law 14:253–262, 1986 Hawton K, Appleby L, Platt S, et al: The psychological autopsy approach to studying suicide: a review of methodological issues. J Affect Disord 50:269– 276, 1998 Isometsa ET: Psychological autopsy studies—a review. Eur Psychiatry 16:379– 385, 2001 Isometsa ET, Henriksson MM, Sro HM, et al: Suicide in major depression. Am J Psychiatry 151:530–536, 1994 Isometsa ET, Heikkinen ME, Marttunen MJ, et al: The last appointment before suicide: is suicidal intent communicated? Am J Psychiatry 152:919–922, 1995 Jackson v State, 553 So2d 719, 720 (Fla Dist Ct App 1989) Jacobs D, Klein-Benheim M: The psychological autopsy: a useful tool for determining proximate causation in suicide cases. Bull Am Acad Psychiatry Law 23:165–182, 1995 Jobes DA, Berman AL, Josselson AR: The impact of psychological autopsies on medical examiner ’s determination of manner of death. J Forensic Sci 31:177–189, 1986 Keeton W, Dobbs D, Keeton R, et al: Prosser and Keeton on Torts, 5th Edition. St. Paul, MN, West Publishing, 1984, pp 33–66 Knapp S, VandeCreek L: Malpractice risks with suicidal patients. Psychotherapy: Theory, Research, and Practice 10:274–280, 1983 Litman RE: Hospitals suicides: lawsuits and standards. Suicide Life Threat Behav 12:212–220, 1982 Mutual Life Insurance Company v Terry, 15 Wall 21 LEd 236, 242 (1873)
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National Center for Health Statistics: Vital Statistics of the United States, Mortality. Washington, DC, U.S. Government Printing Office, 2000 National Institute of Mental Health: Suicide Facts and Statistics. Bethesda, MD, National Institute of Mental Health, 2004. Available at: http://www.nimh. nih.gov/suicideprevention/suifact.cfm. Accessed April 2, 2005. Packman WL, Pennuto TO, Bongar B, et al: Legal issues of professional negligence in suicide cases. Behav Sci Law 22:697–713, 2004 Robertson JD: Psychiatric Malpractice: Liability of Mental Health Professionals. New York, Wiley Law Publications, 1988 Robins E, Gassner S, Kayes J, et al: The communication of suicidal intent: a study of 134 consecutive cases of successful (completed) suicide. Am J Psychiatry 115:724–733, 1959 Rodriguez v Henkle Drilling and Supply Company, 828 P2d 1335 (Kan Ct App 1992) Runeson B, Beskow K: Reactions of survivors of suicide victims to interviews. Acta Psychiatr Scand 83:169–173, 1991 Schubert FA: Grilliot’s Introduction to Law and the Legal System, 6th Edition. Boston, MA, Houghton Mifflin, 1996, pp 537–541 Shneidman ES: The psychological autopsy. Suicide Life Threat Behav 11:325– 340, 1981 Simon RI: You only die once—but did you intend it? Psychiatric assessment of suicide intent in insurance litigation. Tort Insur Law J 25:650–662, 1990 Simon RI: Murder masquerading as suicide: postmortem assessment of suicide risk factors at the time of death. J Forensic Sci 43:1119–1123, 1998 Simon RI: Retrospective assessment of mental states in criminal and civil litigation: a clinical review, in Retrospective Assessment of Mental States in Litigation. Edited by Simon RI, Shuman DW. Washington, DC, American Psychiatric Publishing, 2002, pp 1–20 Simon RI, Shuman DW: Conducting forensic examinations on the road: are you practicing your profession without a license? J Am Acad Psychiatry Law 27:75–82, 1999 State v Huber, 597 NE2d 570 (Ohio C.P. 1992) United States v St. Jean, WL 106960, at 1 (A.F. Ct Crim App 1995)
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Clinically Based Risk Management of the Suicidal Patient Avoiding Malpractice Litigation Robert I. Simon, M.D.
Risk management is a reality of psychiatric practice, especially in the assessment and management of patients at risk for suicide. Risk management guidelines often recommend ideal or best practices, whereas the actual standard of care required of a psychiatrist is the skill and care “ordinarily provided,” or reasonable care. These standards can be confused by expert witnesses who testify in malpractice cases (Simon 2005). Moreover, suicide cases are challenging, multifaceted, and nuanced, making it difficult to provide precise assessment and management guidelines. Although most risk management guidelines commonly set forth best practices, much of clinical risk management is imbedded in the provision of sound clinical care and the use of common sense. Clinically based risk management is patient centered. It supports the treatment process and the therapeutic alliance (see Table 28–1). At a minimum, it follows the fundamental ethical principle in medicine of “first do no harm.” A working knowledge of the legal regulation of psychiatry enables the psychiatrist to manage clinical-legal issues more effectively. Clinically based risk management provides the psychiatrist 545
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TABLE 28–1. Elements of clinically based risk management Patient centered Clinically appropriate Supportive of treatment and the therapeutic alliance Working knowledge of legal regulation of psychiatry Clinical management of psychiatric-legal issues Wellness, not legal, agenda “First do no harm” ethic Source. Reprinted from Simon RI: Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management. Washington, DC, American Psychiatric Publishing, 2004. Used with permission.
with a significant measure of practice comfort that permits continued maintenance of the treatment role with patients at risk for suicide. Good clinical care provides the best risk management. For example, performing systematic suicide risk assessments that inform treatment and management interventions is good clinical care and, secondarily, sound clinically based risk management. Documentation of the risk assessments supports good patient care and substantiates clinical judgment (American Psychiatric Association 2002). In malpractice litigation, what is not recorded by a physician may be considered not to have been performed (Simon 2001). Good care of patients at suicidal risk requires the clinician’s full commitment to the patient’s evaluation, treatment, and management. This clinical imperative also holds true in collaborative treatment relationships with other mental health professionals. Risk management practices that are not clinically tempered and patient centered interfere with the patient’s treatment and undermine the therapeutic alliance. They are undertaken to avoid malpractice liability or to provide a legal defense against a malpractice claim. For example, an undue reliance on suicide prevention contracts (“no-harm contracts”) may be the result of the clinician’s attempt to reduce the anxiety associated with treating suicidal patients (Miller et al. 1998). Some erroneously believe that the suicide prevention contract legally binds the patient to refrain from self-harm. Suicide prevention contracts may falsely reassure the clinician, often preempting adequate suicide risk assessment and increasing the patient’s risk for suicide. Defensive psychiatry can be divided into preemptive and avoidant practices (Simon 1985). Preemptive defensive practices use procedures and treatments designed to prevent or limit liability; for example, unnecessarily hospitalizing a patient at risk for suicide who could be treated safely as an outpatient (Brown and Rayne 1989). Avoidant defensive prac-
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tices forgo necessary procedures or treatments for fear of being sued, even though the patient would likely benefit from these interventions. An example would be failing to involuntarily hospitalize a treatment-refusing, high-risk suicidal patient. Consulting with a colleague is good clinical practice when the clinician is confronted with complex diagnostic, treatment, and management issues. As a clinically based risk management technique, consultation supports and guides good clinical care by providing a “biopsy” of the standard of care. The clinician’s uncertainty, even anxiety, must be contained within reasonable limits to treat the patient’s condition effectively. The clinician should “never worry alone” (T.G. Gutheil, personal communication, December 2002). In certain cases, consulting with a risk manager or an attorney can be helpful. Clinically based risk management helps the psychiatrist avoid defensive practices that are harmful to both the patient and the clinician. The clinician must focus on providing good care while carrying sufficient malpractice insurance.
Suicide and Malpractice Litigation Unfortunately, clinical psychiatrists sometimes fall into one of three categories: 1) those who have had a patient commit suicide, 2) those who will have a patient commit suicide, and 3) those who will have more than one patient commit suicide. Patient suicide is an unavoidable occupational hazard of psychiatric practice that is accompanied by increased malpractice liability exposure. When a patient commits suicide, a lawsuit may follow. Patient suicides account for numerous malpractice suits filed against psychiatrists and the highest percentages of settlements and verdicts covered by professional liability insurers (American Psychiatric Association–Sponsored Professional Liability Insurance Program 2002). Professional Risk Management Services Inc. used data submitted from 1999 to 2003 to determine that suicide or attempted suicide accounted for 17% of all claims (Figure 28–1). Although the potential for malpractice suits remains high for psychiatrists who treat suicidal and violent patients, the plaintiff’s success rate in malpractice actions is only 2 or 3 out of every 10 litigated claims. Generally, malpractice claims against psychiatrists for a patient’s suicide are brought under the following theories of negligence: • Failure to diagnose the patient’s condition properly • Failure to assess suicide risk adequately • Failure to implement an appropriate treatment plan (use reasonable treatment interventions and safety precautions)
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Fen-phen Breach of confidentiality
Other Incorrect treatment
Unnecessary commitment
32%
Undue familiarity Improper supervision
Incorrect diagnosis
5% 9%
15% Adverse drug reaction
17% Suicide/attempted suicide
FIGURE 28–1. Most common malpractice claims against psychiatrists: United States, 1999–2003. Source. The Psychiatrist’s Program, the APA-Endorsed Psychiatrists’ Liability Insurance Program, 2004.
The Psychiatrist’s Purchasing Group workshop presented at the American Psychiatric Association (2002) annual meeting identified patient suicide as the most common insurance loss. The categories of claims involving suicide or attempted suicide were • Failure to provide proper assessment and management in highvolume patient settings. • Failure to construct a comprehensive treatment plan. • Failure to perform comprehensive suicide risk assessments. • Failure to record suicide risk assessments. • Failure to obtain past treatment records. • Failure to hospitalize. • Failure to make a rational diagnosis on the basis of the history and evaluation. Ordinarily, only the patient with whom the psychiatrist has established a doctor–patient relationship can file a malpractice claim. No duty is owed to any family members. Wrongful-death statutes, however, allow survivors to recover money damages for a death caused by another person’s wrongful act. The right to sue for wrongful death belongs to individuals who experience financial or other loss because of the patient’s death. Families may bring malpractice suits under the Federal Tort Claims Act (1946) if the individual who died was employed by the U.S. govern-
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ment and the government is accused of wrongdoing. This federal statute permits the government to be sued like any citizen in similar circumstances. It is an exception to the doctrine of sovereign immunity. Courts evaluate the psychiatrist’s assessment and management of the patient who attempts or commits suicide to determine the reasonableness of the suicide risk assessment process and whether the patient’s suicide attempt or suicide was foreseeable (Simon 2001). Foreseeability is a legal term of art rather than a scientific construct. It is a commonsense, probabilistic concept. There is, however, an imperfect fit between legal and medical terminology. Foreseeability is legally defined as the reasonable anticipation that harm or injury is likely to result from certain acts or omissions (Black 1999). The law does not require defendants to “foresee events which are merely possible but only those that are reasonably foreseeable” (Hairston v. Alexander Tank and Equip. Co. 1984). Foreseeability should not be confused with the predictability of suicide, for which no professional standard exists. Imminence of suicide is an illusion of short-term prediction. It is not synonymous with foreseeability (Simon, in press). Moreover, foreseeability is not the same as preventability. In hindsight, a suicide may have been preventable but not foreseeable at the time of the assessment. The assessment of suicide risk is determinable and, therefore, foreseeable. Reasonable clinical basis exists for assessing the patient’s suicide risk, but the prediction of suicide is not possible. Contemporaneous documentation of systematic suicide risk assessments provides the court with guidance. When adequate suicide risk assessments are not performed or documented, the court is less able to evaluate the clinical complexities and ambiguities that exist in the assessment, treatment, and management of patients at risk for suicide. The failure to perform an adequate suicide risk assessment is frequently alleged along with other claims of negligence. It is rarely the only complaint.
Basic Elements of Malpractice Psychiatric malpractice is medical malpractice. Malpractice lawsuits are civil actions that allege negligence, not intentional wrongdoing. A malpractice claim has four basic elements, sometimes referred to as the four D’s (see Table 28–2).
Duty of Care A legal duty of care derives from the existence of a doctor–patient relationship. Usually, a psychiatrist–patient relationship is created knowingly and voluntarily by both parties. No duty of care is owed to a patient un-
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TABLE 28–2. Basic elements of a malpractice claim DUTY of care (a doctor–patient relationship must exist) DEVIATION from the standard of care DAMAGE to the patient DIRECT damage caused by the deviation from the standard of care Source. Adapted from Simon RI: Concise Guide to Psychiatry and Law for the Clinician, 3rd Edition. Washington, DC, American Psychiatric Publishing, 2001. Used with permission.
less a psychiatrist–patient relationship exists. However, a psychiatrist– patient relationship may be established unwittingly (Simon 1992). Unless working in an emergency department or a similar setting where psychiatrists are legally obligated to treat all individuals who seek help, the psychiatrist owes no duty of care to a prospective patient. A court will determine whether a psychiatrist–patient relationship existed if a malpractice suit is brought. Several actions may be construed as creating a doctor–patient relationship (Table 28–3). On-line consultations may create a doctor–patient relationship with a duty of care. Individuals at risk for suicide should not have their conditions assessed or managed on-line. Face-to-face psychiatrist–patient interaction is necessary. Psychiatrists also may be vicariously liable for the negligence of others under their supervision or employ.
TABLE 28–3. Some actions by therapists that may create a doctor–patient relationship Providing online consultations Giving advice to prospective patients, friends, and neighbors Making psychological interpretations Writing a prescription or providing sample medications Supervising treatment by a nonmedical therapist Having a lengthy telephone conversation with a prospective patient Treating an unexamined patient by mail Giving a patient an appointment Telling walk-in patients that they will be seen Covering for a psychiatrist or other mental health professional Providing treatment during an evaluation Source. Adapted from Simon RI: Clinical Psychiatry and the Law, 2nd Edition. Washington, DC, American Psychiatric Press, 1992. Used with permission.
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Deviation From Standard of Care The standard of care, like the duty of care, is a legal concept. States define by statute the standard of care required of physicians. The precise definition of the standard of care varies from state to state. The specific statutory language is applied to the facts of a malpractice case to determine whether the physician’s treatment of the patient was negligent. For example, in Stepakoff v. Kantar (1985), the standard of care applied by the court in a suicide case was the “duty to exercise that degree of skill and care ordinarily employed in similar circumstances by other psychiatrists.” The court defined the duty of care as that of the “average psychiatrist.” Thus, an adequate suicide risk assessment will likely meet the standard of care in malpractice litigation. “Best practices” would exceed the “care ordinarily employed” by the “average psychiatrist” (Simon 2005). The standard of care is determined by expert testimony, practice guidelines, the psychiatric literature, hospital policies and procedures, and other authoritative sources. Managed care protocols and utilization review procedures are entrepreneurial based and are not necessarily clinically authoritative. Guidelines and policies are general concepts that must be applied to highly specific fact patterns of complex cases in litigation. The standard of care is not a fixed legal concept. Official practice guidelines are not static but evolve and change according to new developments in practice and science, requiring frequent updating. Studies show that no more than 90% of practice guidelines are valid after 3.6 years (Shekelle et al. 2001). At 5.8 years, half of such guidelines are outdated. Sponsoring organizations, such as the American Psychiatric Association (2003), in its “Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors,” issue disclaimers that practice guidelines do not represent the standard of care. The standard of care must be distinguished from the quality of care (Simon 1997). Quality of care refers to the adequacy of total care that the patient receives from the psychiatrist and other health care professionals and providers, including third-party payers. The quality of care is also influenced by the patient’s health care decisions and the allocation and availability of psychiatric services. The quality of care that is provided by the psychiatrist may be below, equal to, or even exceed the acceptable standard of psychiatric care. Generally, a psychiatrist who exercises the “skill and care ordinarily employed” by the “average psychiatrist” will not be held liable for any resulting injury (Stepakoff v. Kantar 1985). Mistakes alone are not a basis for liability if the standard of care is not breached. If the court finds that the psychiatrist did not deviate from the standard of care, then no basis
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for a malpractice claim exists. In psychiatry, the standard of care is broadly defined. For example, a depressed suicidal patient can receive a wider range of treatment than that provided by other specialists for patients with life-threatening illnesses (Hillard 2004). Although a lawsuit may follow a patient’s suicide, the suicide by itself does not establish that the psychiatrist was negligent. In Siebert v. Fink (2001), the court held that a clinician is not automatically liable when a patient commits suicide, provided that careful examination and assessment took place that directed the decision-making process. Experts for both the plaintiff (estate of deceased patient) and the defendant psychiatrist provide testimony regarding the standard of care. The “skill and care ordinarily employed” standard is undergoing change. Tort law generally allows physicians to set their own standard of care; for example, the practice of the “average physician” is the measure applied to negligence claims. Defendants in ordinary tort claims are expected to use reasonable care under the same or similar circumstances. Physicians, however, have needed only to conform their provision of care to the customs of their peers (Peters 2000). An increasing number of states are rejecting the “medical custom” standard in favor of the “reasonable, prudent physician” standard (Peters 2000). This standard goes beyond a statistical “head count.” For example, even if 99 out of 100 psychiatrists do not perform and document adequate suicide risk assessments, such omission constitutes negligent practice that is potentially harmful to patients. Courts have held that negligence cannot be excused simply because others practice the same kind of negligence (Simon 2002). Thus, actual practice must bear a relation to a reasonable, prudent standard of care.
Damage to the Patient Even if a deviation in the standard of care occurs, legal liability cannot be assessed when the patient is not harmed. The courts rely on the testimony of expert witnesses to determine the presence or absence of harm to the plaintiff. The determination of emotional injury can be difficult because psychiatric disorders or conditions often preexist. Also, the emotional injury claimed may be the result of the natural progression of the patient’s psychiatric disorder rather than the harm caused by the psychiatrist’s alleged negligence. Malpractice suits require plaintiffs to prove their allegations by a preponderance of the evidence. Preponderance of the evidence is defined as the weight of evidence (51% vs. 49%) for the plaintiff to prevail. The law, however, does not assign a percentage to the standard of proof.
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Because malpractice cases are determined by a preponderance of the evidence, the outcome of these suits is often difficult to predict. Defendants who perceive themselves to be vulnerable to substantial monetary awards may choose to settle for a given amount rather than risk open-ended liability.
Direct Damage Caused by Deviation From Standard of Care If a psychiatrist deviates from the standard of care in the diagnosis and treatment of a patient, no malpractice liability can be found unless the harm to the patient is the direct result of the deviation from the standard of care. In Paddock v. Chacko (1988/1989), a Florida appeals court concluded that the psychiatrist was not liable for the self-inflicted injuries of a patient he had seen only once. The patient had placed herself in her parents’ care and custody. The parents disregarded the psychiatrist’s recommendation that their daughter be hospitalized. The parents’ unwillingness to heed the psychiatrist’s recommendation represented a “superseding” factor that intervened between the patient’s injuries and the psychiatrist’s care.
Risk Management Suggestions • Fully commit to the overall care and treatment of the patient at risk for suicide. • Carefully document suicide risk assessments. Such documentation shows the provision of good clinical care and provides a sound legal defense in malpractice litigation. Defensible cases are settled or lost as the result of inadequate, altered, or absent documentation. • Do not unwittingly create a doctor–patient relationship. • Avoid online assessment and management of patients at risk for suicide. Face-to-face evaluation is clinically necessary. • Never worry alone. Consider obtaining consultation when confronted by complex, difficult problems in treatment and management of patients at risk for suicide. • Gain a working knowledge of the legal regulations of psychiatry, which will enable you to manage clinical-legal issues more effectively. • Remember that clinically based risk management is patient centered. It supports both the treatment process and the therapeutic alliance. At a minimum, risk management does not interfere with patient treatment.
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Suicide Risk Assessment Suicide risk assessment is often a complex, difficult, and challenging clinical task that informs treatment and management issues for patients at risk for suicide (Simon 2001). Assessment of suicide risk is a core competency that psychiatrists are expected to acquire (Scheiber et al. 2003). Suicide is a rare occurrence. No standard of care exists for the prediction of suicide (Pokorny 1983, 1993). Suicide is the result of many factors, including diagnostic (psychiatric and medical), psychodynamic, genetic, familial, occupational, environmental, social, cultural, existential, and chance factors, at any given point in time. Stressful life events also play a significant role in completed suicides (Heila et al. 1999). Attempts to predict who will commit suicide lead to false-positive and false-negative predictions. The national suicide rate in the general population for the year 2002 was 11.0 per 100,000 (Kochanek et al. 2004). The suicide rate or absolute risk of suicide for individuals with bipolar disorder is estimated to be 193 per 100,000, a relative risk 18 times greater than in the general population (Baldessarini et al. 2003). Thus, 99,807 patients with bipolar disorder do not commit suicide in a given year. On a statistical basis alone, the vast majority of bipolar patients do not commit suicide. Suicide is a low base rate event for all psychiatric disorders. The clinical challenge is to identify and treat those patients who are at significant risk for suicide at any given time (Jacobs et al. 1999). The standard of care requires psychiatrists to assess suicide risk adequately, when indicated. An adequate risk assessment systematically evaluates both risk and protective factors. Perfect assessments of suicide risk are not possible; exhaustive assessments are not necessary. Suicide risk assessment based on current research enables the clinician to make evidence-based treatment and safety management decisions.
Risk Management Suggestions for Suicide Assessment • The effective treatment and safety management of the suicidal patient require a full commitment of time and effort from the clinician. • Systematic suicide risk assessment informs the treatment and safety management of patients at risk for suicide. It is only secondarily, although importantly, a risk management technique. • Suicide risk assessment is a process, not an event. Psychiatric inpatients should have suicide risk assessments conducted at admission and discharge and at other important clinical decision points during
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the patient’s treatment. A similar risk assessment process can be applied to outpatient treatment. The uncertainty that clouds the treatment and safety management of the suicidal patient can be lessened by the process of systematic suicide risk assessment. Suicide prevention contracts do not supplant conducting systematic suicide risk assessments. Contemporaneous documentation of suicide risk assessments is essential to good clinical care and represents standard psychiatric practice. Systematic suicide risk assessment performed at the time of discharge informs the patient’s readiness for discharge and postdischarge planning. For inpatients at risk for suicide, obtain information of clinical importance from family members or others who know the patient regarding prior or current suicide threats, ideation, plan, or attempts. Whenever possible, do this with the patient’s permission. Just listening does not violate the patient’s confidentiality. During the treatment of outpatients at significant risk for suicide, it may become necessary to contact family members or others to facilitate hospitalization, mobilize support, and provide information of clinical importance to the clinician. Whenever possible, do this with the patient’s permission. Suicide risk assessment is the responsibility of the psychiatrist. Do not delegate it to others. Clinicians have a professional, ethical, and legal duty to provide adequate care to their patients, regardless of managed care protocols and other restrictions. Do not allow managed care limitations on patient care to heighten a patient’s risk for suicide. Consider personal factors that may potentially interfere with their care of the suicidal patient. Include a realistic self-appraisal regarding the number of suicidal patients a clinician can competently treat or treat at all.
Suicide Prevention Contracts The suicide prevention contract has achieved wide acceptance, although no studies have found that it is effective in preventing suicide (Stanford et al. 1994). Instead, these contracts often interfere with adequate suicide risk assessment. The suicide prevention contract goes by a variety of names, such as the “no-harm contract,” the “no-suicide contract,” and the “contract for safety.” It is used by psychiatrists and other mental health professionals in outpatient and inpatient settings and in hospital
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emergency departments. Suicide prevention contracts are now an integral part of nursing assessments (Egan 1997). With the advent of the managed care era, mental health professionals have come to rely on suicide prevention contracts to manage a patient’s risk for suicide (Simon 1999). In both outpatient and inpatient settings, most patients are treated briefly. The average length of stay for patients in acute-care psychiatric units and hospitals is often 5 days or less. The most frequent admissions are severely mentally ill patients who are at substantial risk for suicide. The admission requirements usually exceed substantive criteria for involuntary hospitalization. The therapeutic alliance often fails to develop in managed care settings because of limitations on treatment sessions and an increased reliance on medications. Empathic interaction, pivotal to the development of a therapeutic alliance, is difficult to maintain in managed care settings where a large volume of mentally ill patients are rapidly treated, stabilized, and discharged. Yet these settings are precisely where such contracts are heavily used. Suicide prevention measures that are not based on a therapeutic alliance are often unreliable. The therapeutic alliance is a dynamic, changeable interaction between the clinician and the patient that is influenced by the course of the patient’s illness and by situational and other factors. The therapeutic alliance that supports a patient’s safety during one session may dissipate before a next scheduled session because of an acute exacerbation of the illness. The status of the therapeutic alliance should be assessed regularly and documented. The absence or presence of a therapeutic alliance can be a key suicide risk or preventive factor. Health care decision-making capacity, the foundation of the patient’s ability to cooperate with a suicide prevention contract or plan, often varies with the patient’s clinical course. Mental capacity should be assessed regularly and documented. The existence and terms of agreement (including time limit) of the suicide prevention contract or plan also require documentation.
Risk Management Suggestions for Suicide Prevention Contracts • If used, the suicide prevention contract is an adjunct to the comprehensive psychiatric evaluation, to ongoing suicide risk assessment, and to safety management planning. • Do not use suicide prevention contracts in place of systematic suicide risk assessment. The contract establishes that the patient is a suicide risk but does not establish that suicide risk has been assessed.
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• Safety management is a process. Suicide prevention contracts are usually events. When suicide prevention contracts are used, reevaluate regularly with the patient, and document rationale for continued use. • Do not use a suicide prevention contract merely as a defensive risk management technique. • A suicide prevention contract is a clinical, not a legal, contract. It is a mutual understanding reached between the clinician and the patient regarding collaboration to prevent suicide. The trustworthiness of the arrangement is contingent on many variables. • Document indications for the use and the risks and benefits of the suicide prevention contract. • The process of safety management is determined by the clinical needs of the patient, not by the anxieties of the therapist or the clinical staff. • Suicide prevention contracts have little or no utility in emergency settings. • Train mental health professionals in the appropriate indications, applications, and limitations of suicide prevention contracts.
Outpatients Most patients at low to moderate risk for suicide, and even some patients at high suicide risk, are treated in outpatient settings. Many patients who were formerly treated as inpatients are now treated as outpatients, some after only a brief hospital stay. Heretofore, lawsuits against therapists for outpatient suicides have been relatively infrequent. Courts have reasoned that when an outpatient attempts or commits suicide, the therapist may not necessarily have breached a duty to protect the patient from self-harm because of the difficulty in controlling the patient (Bellah v. Greenson 1978; Speer v. United States 1981/1982). In Kockelman v. Segals (1998), however, a patient treated for depression as an outpatient committed suicide by taking an overdose of medications. The psychiatrist’s attorney moved to dismiss the case on the basis of a California law that did not impose a duty on a psychiatrist to prevent an outpatient from committing suicide. The appellate court held that a psychiatrist owes a duty of care to a patient who commits suicide, whether the patient is an outpatient or an inpatient. Insurance benefits for the treatment of outpatients are limited by managed care organizations. Severely ill inpatients are discharged to outpatient treatment after a brief hospitalization, some at significant risk for suicide. Therapists (“providers”) approved by managed care organizations receive patient referrals to provide outpatient psychotherapy.
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Patients who are at moderate to high risk for suicide require time-intensive psychotherapy. However, only a few sessions may be authorized. When the therapist simply abandons the patient after insurance coverage ends, the liability risk is high if the patient attempts or commits suicide. Summary discharge of patients when insurance benefits end is an invitation for lawsuits alleging negligent treatment and abandonment of the suicidal patient (Simon and Gutheil 2003). The therapist’s professional responsibility to the patient exists independently of managed care organization payments for treatment (Simon 1998b). The therapist’s duty of care to the patient is not defined or limited by managed care arrangements. In the managed care era, the outpatient therapist has increased malpractice liability exposure in the treatment of patients at risk for suicide (Table 28–4). Currently, outpatient psychiatrists are just as likely as inpatient psychiatrists are to be sued for malpractice for alleged negligent treatment of a patient who attempts or commits suicide (Bongar et al. 1998). Legal liability may be assessed against the psychiatrist for the failure to involuntarily hospitalize a patient at high risk for suicide who refuses voluntary hospitalization and attempts or commits suicide. TABLE 28–4. Malpractice liability for outpatient suicides: reducing the risk Evaluation Accurately diagnose the patient. Perform systematic suicide risk assessments. Obtain prior treatment records. Treatment Formulate, document, and implement a comprehensive, rational treatment plan. Continually assess the patient’s suicide risk. Consider hospitalizing, voluntarily or involuntarily, patients at high risk for suicide. Management Provide safety management (e.g., be available for emergencies; adjust frequency of visits). Communicate and enlist support of significant others during a patient’s suicide crisis. Source. Reprinted from Simon RI: Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management. Washington, DC, American Psychiatric Publishing, 2004. Used with permission.
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Partial hospitalization programs and intensive outpatient programs treat patients who are at heightened risk for suicide. Partial hospitalization programs ordinarily treat patients who have recently been discharged from inpatient treatment but continue to require transitional care to maintain stability, to provide safety, and to prevent rehospitalization. Some patients at high risk for suicide who do not adhere to follow-up treatment programs pose significant liability risk for therapists. Managed care has facilitated the popularity of partial hospitalization programs and intensive outpatient programs as variations of outpatient psychotherapy. Patients’ level of suicide risk and severity of mental illnesses are usually greater in partial hospitalization programs and intensive outpatient programs than in outpatient office settings. Worsening of a patient’s condition requires the careful assessment of the risk for suicide and for possible rehospitalization. Risk-benefit assessments regarding continued partial hospitalization program or intensive outpatient program treatment versus hospitalization should be carefully documented. If it is determined that the patient in a partial hospitalization program or intensive outpatient program needs to be hospitalized, the patient should be accompanied by a staff member to the emergency department or to the psychiatric unit for admission. Liability exposure exists for failure to hospitalize a patient who is decompensating, who is at high risk for suicide, or whose symptoms that led to the initial hospitalization are recurring. Coverage should exist for after-hours emergencies. The patient should be instructed in how to contact help in an emergency. After-hours coverage is usually provided by the patient’s outpatient therapist or psychiatrist or is made available through a local hospital emergency department.
Risk Management Suggestions for Outpatients • Conduct an initial screening for suicide risk with new patients. The presence of suicide risk factors alerts the clinician to conduct a systematic risk assessment. • An accurate diagnosis informs treatment and management of the suicidal patient. Perform and document a differential diagnosis. • Formulate a comprehensive, rational treatment and management plan before treatment is started. Document the initial treatment plan and any revisions in the patient’s record. • Avoid e-mail communication in the evaluation, treatment, and management of the patient at risk for suicide. • Suicide risk assessment is a process, not an event. Conduct systematic suicide risk assessments whenever significant changes occur in the condition, treatment, or management of the suicidal patient. Documentation of suicide risk assessment is essential.
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• For new patients, obtain records of prior treatments and make direct contact with former treaters, if possible. Records received deserve careful reading. • Before speaking with family members, obtain the patient’s permission. If the patient withholds permission, document the refusal and address it as a treatment issue. Merely listening to family members does not breach confidentiality. • Negative, even hostile, reactions can occur in the treatment of patients at risk for suicide. Identify countertransference reactions and constructively manage them so as not to interfere with the patient’s treatment. • Limiting the number of suicidal patients in current treatment may help avoid or mitigate exhaustion and negative feelings toward the patient. • Consider consultation with a colleague regarding assessment, treatment, and management of complex, difficult patients at risk for suicide. Consultation provides a “biopsy” of the standard of care. • Base the decision to hospitalize a patient at risk for suicide on systematic suicide risk assessment combined with a risk-benefit analysis of factors favoring continued outpatient treatment or hospitalization. • Use involuntary hospitalization as an emergency clinical intervention, not as a way to avoid malpractice liability or to provide a defense against a malpractice suit. Clinically based risk management places the patient’s treatment first. Unfounded fears of lawsuits may interfere with the psychiatrist’s clinical judgment. • Familiarize yourself with the state laws governing involuntary hospitalization. Knowledge of the legal requirements and the availability of community emergency mental health services facilitates involuntary hospitalization, especially in an emergency. • Standard measures to prevent patients from harming themselves may include enlisting family members and significant others to provide support during the time of a patient’s heightened suicide risk (e.g., facilitating removal and safe disarming of guns and other means of suicide, instructing family members to administer and monitor the patient’s medications). • When the decision is made to hospitalize a patient, the patient must go directly to the hospital, accompanied by a responsible escort. A detour may provide an opportunity for the patient to attempt/commit suicide. • Send a certified letter, return receipt requested, to a patient at risk for suicide who unilaterally terminates outpatient therapy, noting the unilateral termination; the need for continued treatment, if any; and the offer of assistance in finding another therapist. This procedure also applies to suicidal patients who do not continue treatment after the first appointment.
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Collaborative Treatment Assessment and management of patients at risk for suicide can be especially challenging in collaborative or split treatment arrangements. The hospital length of stay is very short for most psychiatric patients. Consequently, many patients at moderate to high risk for suicide with severe psychiatric conditions receive split treatment. Patients usually are referred by managed behavioral health organizations or primary care physicians to psychiatrists for medication management and to nonphysician therapists for psychotherapy. Managed behavioral health organizations usually authorize patients to see psychotherapists for more frequent and longer sessions than to see psychiatrists who prescribe medication. When the patient’s clinical condition deteriorates, he or she may be referred to a psychiatrist for consultation or medication management. The patient’s deterioration may be associated with an increased risk for suicide. The essence of collaborative treatment is effective communication. “We are in it together” is the operative phrase. Communication in split treatment is essential, whether the psychiatrist and the psychotherapist have low- or high-volume practices. Psychiatrists and psychotherapists with high-volume split treatment practices may not take the time or have the time to collaborate adequately. For example, a psychiatrist who sees 4 patients for medication management every hour, 8 hours per day for 5 days per week, logs 160 patient visits a week. The psychiatrist may have a patient base of more than 500 individuals. Assuming that the psychiatrist receives 20 patient calls a day from this large patient base, the psychiatrist will receive 140 telephone calls a week. Extremely busy high-volume medication management practices such as described are common. Will the psychiatrist find the time to collaborate? Collaboration takes time and effort. Adequate communication and collaboration between psychiatrist and psychotherapist is standard practice, especially for patients at risk for suicide. Communication between psychiatrist and psychotherapist is imperative to prevent the patient at risk for suicide from falling between the cracks of split treatment. When the psychiatrist and therapist work together in a clinic or similar arrangement, communication about the patient is more easily accomplished. However, if the psychiatrist’s and the therapist’s clinical schedules do not overlap, collaboration may fail to occur. When the psychiatrist and psychotherapist are unknown to each other, they often fail to communicate effectively about the suicidal patient. Split treatment presents unique clinical, ethical, legal, and administrative challenges for each clinician (Meyer and Simon 1999). Sederer et
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al. (1998) pointed out that collaborative relationships hold the greatest potential ambiguity for clinical duties and responsibilities. Appelbaum (1991) recommended that the responsibilities of the patient, the psychiatrist, and the nonmedical therapist should be clearly specified, preferably in a written agreement. The patient at risk for suicide must be suited for treatment and management in a split treatment arrangement. The patient’s diagnosis, severity of illness, and level of risk for suicide are all essential factors to consider for suitability when the patient is referred for split treatment. Suitability also applies to the relationship between the psychiatrist and the psychotherapist in split treatment. Some psychiatrists will not enter into a split treatment arrangement unless they know the psychotherapist personally and have a good sense of his or her clinical competence. Some psychiatrists meet quarterly or semiannually with psychotherapists, sometimes over breakfast or lunch. A psychiatrist and psychotherapist who do not know each other personally or who are unfamiliar with each other’s professional competence to conduct treatment should discuss their ability to treat the patient in split treatment. With severely mentally ill patients at moderate to high risk for suicide, the training and clinical experience of the psychiatrist and therapist should be determined before a split treatment relationship is initiated. Clinicians with limited training and experience may not be appropriate for such patients. Each clinician has the right to terminate an unworkable split-treatment relationship. Despite the best efforts to collaborate, teamwork may fail. Problems causing incompatibility may include diagnostic differences, irreconcilable theoretical and practice styles, and interfering transference and countertransference reactions to either the patient or the other clinician, or both. The clinician in an unworkable collaborative relationship should resign respectfully from treatment and give sufficient notice to allow the patient and the other clinician to make appropriate treatment arrangements. The patient’s best interest must guide the explanations that are given about termination. A patient’s risk for suicide may be increased by the perception of rejection or actual abandonment (Gutheil and Simon 2003). Split treatment artificially separates psychotherapy from medication management. Medication management is always accompanied by some psychotherapeutic interaction. The psychiatrist must not be only a drug dispenser. Empathic engagement of the patient as part of medication management encourages the development of a therapeutic alliance and increases the likelihood of medication adherence. The therapeutic alliance is an important protective factor against suicide (Simon 1998a).
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Risk Management Suggestions for Collaborative Treatment • Inquire about the psychotherapist’s training, clinical experience, licensure, and malpractice insurance coverage. Welcome the same questions from the psychotherapist. • Unless the psychiatrist intends to supervise a nonmedical therapist, the therapist and the patient must understand that the split treatment arrangement is not a supervisory relationship. In a supervisory relationship, the psychiatrist is responsible for monitoring and directing all aspects of the patient’s psychiatric treatment. • Effective communication and coordination between clinicians are essential in collaborative treatment, minimizing the risk of divergent clinical goals. • Do not prescribe potentially lethal amounts of medication to patients at moderate to high risk for suicide, despite managed care policies that encourage bulk purchase of medications. • Obtain consent from the patient for the psychiatrist and psychotherapist to communicate freely. • Demarcate clinical responsibilities between the psychiatrist and the psychotherapist to prevent harmful role confusion and misalignment between treaters and with the patient, possibly increasing the patient’s risk for suicide. • Document contacts between clinicians. • Each clinician should provide for routine and emergency availability of coverage during nights, weekends, and vacations. • Tell patients at risk for suicide which clinician to contact for routine calls and emergencies. Provide emergency telephone numbers to patients for each clinician. In an emergency, instruct the patient to contact the psychotherapist first. Direct questions about medications to the psychiatrist. • Prescribe medication and sign treatment plans only for patients personally examined or seen in consultation with the treatment team. • Do not be bound to collaborative treatment that does not conform to the professional standard of care. • The psychiatrist and psychotherapist have the right and obligation to terminate participation in an unworkable split treatment arrangement. Provide sufficient notice and treatment alternatives to the patient and to the other clinician.
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Inpatients The inpatient treatment of psychiatric patients has changed dramatically since the advent of managed care. The goal of psychiatric hospitalization is rapid stabilization of severely ill psychiatric patients through crisis intervention and safety management. Most psychiatric units are analogous to intensive care units, providing short-stay, acute care. Psychiatric patients who are suicidal, homicidal, or gravely disabled pass the strict precertification criteria for admission. Many of these patients have comorbid disorders, including substance abuse and substance use disorders (Simon 1998b). Patients at high risk for suicide may be prematurely discharged because cost-cutting policies have shortened the hospital length of stay. The average length of stay may be as short as 3–4 inpatient days. Close scrutiny by utilization reviewers allows for only brief hospitalization (Wickizer et al. 1996). The hospital administration may push for early discharge to keep patient length-of-stay statistics within predetermined goals. Premature discharge of severely ill patients at substantial suicide risk is a major clinical and liability problem for inpatient psychiatrists and hospitals. Early discharge planning begins at the patient’s admission. Rapid diagnosis and treatment decisions are essential. The psychiatrist must be able to work collaboratively with other mental health professionals on the treatment team to develop and implement a rational treatment plan. Inpatients come and go quickly. The psychiatrist has little time to develop a working alliance with patients. Some patients are too disturbed to provide a psychiatric history. Information should be obtained from other sources, such as family members or other individuals who know the patient. Current or previous therapists need to be contacted, with the patient’s permission. Records of the prior hospitalization should be obtained and read. A faxed copy of the discharge summary is typically the most information the psychiatrist can obtain quickly. In this hurly-burly inpatient environment, the systematic assessment of patients at risk for suicide is often neglected or overlooked. In its place, unfounded reliance is often placed on the suicide prevention contract. A suicide prevention contract with a patient places the clinician on notice that suicide is a concern and that an adequate assessment must be done. Systematic suicide risk assessment is essential because it informs and updates treatment planning and safety management. A suicide-proof psychiatric unit does not exist. Busch et al. (1993) reported that 5%–6% of the estimated 30,000 suicides a year in the United
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States occur in the hospital. Similar rates of inpatient suicides have been reported in the United Kingdom. Other studies have found that the suicide rate in the psychiatric hospital population is 1% of the total 30,000 admissions a year (Simon 1992). Inpatient suicides tend to occur shortly after admission and discharge and at change of staff (Qin and Nordentoft 2005). The clinical decision to hospitalize a patient is an indicator of suicide risk (Bostwick and Pankratz 2000). In general, courts hold psychiatrists accountable more often for inpatient than for outpatient suicides. A substantial number of inpatient suicides are litigated. The duty owed inpatients to prevent suicide attempts or suicide is higher than for outpatients (Macbeth et al. 1994). Courts reason that the opportunities to evaluate, observe, monitor, control, and anticipate a patient’s risk for suicide are greater on the psychiatric unit than in the therapist’s office. With the length of stay for patients in psychiatric hospitals drastically reduced, as noted earlier, a greater percentage of suicides occurs within a few days or months after discharge (Morgan and Stanton 1997). A malpractice suit filed against the psychiatrist claiming premature and negligent discharge of the patient is a distressingly common occurrence. Negligence in diagnostic evaluation, suicide risk assessment, and treatment, and failure to institute protective measures are other common claims in lawsuits filed against inpatient psychiatrists. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (2003) analyzed hospital-based suicides between 1996 and 2001 and identified the following environmental and practice deficiencies: nonbreakaway bars, rods, or safety rails; inadequate security; incomplete or inadequate suicide assessment methods; incomplete reassessment; incomplete orientation and training of staff or inadequate staffing levels; incomplete or infrequent patient observations; incomplete communication among caregivers or unavailable information; and inadequate care planning.
Risk Management Suggestions for Inpatients • Fully commit time and effort to the assessment, treatment, and management of the suicidal patient. • Perform a timely, complete psychiatric examination, including a careful mental status evaluation. • Formulate, document, and implement a comprehensive, rational treatment plan on admission, which is reviewed and updated as needed.
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• Conduct systematic suicide risk assessments at the patient’s admission and discharge and at other important clinical decision junctures. • Monitor and aggressively treat the patient’s acute suicide risk factors. • Mobilize protective factors. • When patients have threatened or attempted suicide, do not accept their denial of suicidal ideation, intent, or plan without further assessment. Be alert for other clinical correlates of suicide risk. • Adjust the patient’s safety precautions according to ongoing systematic suicide risk assessment. • Obtain prior records of treatment and/or speak with current or prior treaters. • Early discharge planning begins at the time of the patient’s admission. • Interview family members or significant others with the patient’s permission. If the patient refuses permission, the clinician may listen but not disclose patient information. • Psychiatrists need to work closely with the multidisciplinary team in assessing suicide risk, in conducting treatment, and in providing safety management. The team is present 24 hours a day, 7 days a week. • Designate a responsible family member or other person to remove and safely disarm guns, which could be used by the patient to commit suicide. Ask the responsible individual to call the clinician within a specified time to confirm that guns are removed from the home and are safely secured elsewhere. Feedback is essential because effective compliance with gun removal tends to be low. • Secure other lethal means for attempting or committing suicide. These may include knives, poisons, over-the-counter and prescription medications (e.g., analgesics), and car keys. A family member may need to dispense and monitor the patient’s medication. • Abide by hospital and psychiatric unit policy and procedures regarding the management of patients at risk for suicide. The standard of care is often reflected in official policies and procedures. • Contemporaneously document assessment, treatment, and safety management decisions. All documentation should legibly document all times and dates. If the patient attempts or commits suicide and litigation ensues, the plaintiff’s attorney may argue that what was not documented was not done. • Provide the patient autonomy and freedom of movement consistent with his or her treatment and safety needs. • At the time of contemplated discharge, carefully assess and document the risks and benefits of continued hospitalization. What remains unchanged or is different from the time of admission to the
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time of discharge regarding the patient’s mental condition and life situation? Can the patient be managed as an outpatient? Structure aftercare planning for maximal compliance by the patient. Do not discharge patients who are still on individualized suicide safety precautions. Observe the patient while off safety precautions before discharge. Determine whether family members or significant others are supportive or destabilizing to the patient. Especially in the latter instance, determine whether psychosocial interventions are available that could make a difference. Exaggerating the severity of the patient’s condition to qualify for managed care organization approval exposes the psychiatrist to increased liability risk when the patient is discharged early or prematurely. Educate patients and, if feasible, their families about mental disorders. Do not discharge patients from the hospital solely for financial reasons. Although the delivery of medical care has changed dramatically under managed care, provide competent care within the system. Prior to discharge, discuss with the patient whom to contact or where to go if an emergency arises after discharge. Provide telephone numbers. Attend inpatients each day of their hospitalization, including the day of discharge. A patient’s clinical condition can deteriorate rapidly as discharge approaches.
Emergency Psychiatric Services Patients at risk for suicide are frequently assessed and managed in emergency psychiatric services. Wingerson et al. (2001), in a study of 2,319 consecutive patients who visited a crisis triage unit, found that 30% had unipolar depression, 26% had psychosis, 20% had substance use disorder, 14% had bipolar disorder, 4% had adjustment disorder, 3% had anxiety disorder, and 2% had dementia. Dhossche (2000) found that 38% of psychiatric emergencies involved suicidal ideation or behavior. Ostamo and Lonnqvist (2001), in a 50-year follow-up study of patients treated in hospitals after suicide attempts, found an increase in mortality from suicide, homicide, and other causes. In the follow-up period, 16% of suicide attempters died, 40% by suicide. Many psychiatric patients who are evaluated in the emergency department of a hospital have more than one psychiatric disorder, substantially increasing the risk for suicide (Kessler et al. 1999). Standardized mortality ratios establish that virtually all psychiatric disorders have an
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associated risk for suicide (Harris and Barraclough 1997). Patients evaluated in emergency psychiatric services not only have an increased risk for suicide associated with their psychiatric disorders (necessary factors) but also experience stressful life circumstances (sufficient factors) that impart additional risk. The importance of stress factors in precipitating suicides is noted in several studies (Heikkinen et al. 1994; Maltsberger et al. 2003). Suicide attempts or completed suicides are invariably caused by the confluence of necessary and sufficient factors. Important goals of emergency psychiatric services include provision of rapid assessments to determine the appropriate setting for treatment and to provide stabilization and safety for patients. The basic types of emergency psychiatric services are the consultation model and the specialized psychiatric emergency services (Breslow 2002). In the consultation model, the psychiatrist consults with the emergency department staff. Some emergency departments have crisis counselors who initially evaluate psychiatric patients after they have been “medically cleared” by emergency department physicians. The on-call psychiatrist is usually consulted when an inpatient admission is contemplated or for other emergent matters. The proposed disposition of the patient is discussed with the psychiatrist. The psychiatrist may agree, disagree, or request additional information before making a final decision. When the emergency department physician, crisis counselor, or psychiatrist disagrees with the evaluation or disposition, the psychiatrist is usually required to come to the emergency department and examine the patient. The same situation applies when the emergency department physician calls the on-call psychiatrist in the absence of a crisis counselor arrangement. Emergency Medical Treatment and Active Labor Act (EMTALA) regulations were enacted to protect patients from dangerous transfers by requiring that they be stabilized first (Quinn et al. 2002). A suicidal patient would likely be considered stable for discharge or transfer when he or she is no longer assessed to be an imminent threat to self or others. Emergency department clinicians (including psychiatrists and crisis counselors) should be familiar with EMTALA requirements for appropriate transfer of patients generally, but especially for patients at risk for suicide.
Risk Management Suggestions for Emergency Psychiatric Services • Perform systematic suicide risk assessment on all psychiatric patients evaluated in the emergency department.
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• Suicide prevention contracts have little or no utility in emergency settings. • Individuals who come to the emergency department because of suspected suicidal behaviors may deny suicidal ideation, intent, or plan. Observe and assess other clinical correlates of suicide risk that do not rely on patient reporting. • Obtain patient information from collateral sources (e.g., family, partners, police, emergency department records of previous visits, current and former treaters). The individual may have told family members or significant others the full extent of suicidal intent or a plan. Obtaining collateral information is an important part of the suicide risk assessment process. • Routinely screen for drug and alcohol use in patients at risk for suicide. • Some patients at moderate or even high risk for suicide may be managed as outpatients, if sufficient protective factors against suicide are present. Construct a reasonable follow-up plan with the patient, including contact with treaters, if possible. • Assess the risk and benefits of hospitalization compared with the risks and benefits of discharge as part of the dispositional decisionmaking process. • Avoid reflexive inpatient admissions or discharges from the emergency department. Careful evaluation and systematic assessment of the patient at risk for suicide inform clinical decision making, especially for patients with “special agendas” (e.g., admission seekers or high-risk suicide deniers). • In emergencies, when treatment is necessary to save a life or to prevent imminent serious harm, the law “presumes” that consent would have been granted by the patient. • Secure the patient’s safety throughout the assessment process. Patients at high risk for suicide may injure themselves in the emergency department or may elope. Anticipate and institute preventive safety measures when indicated. • Knowledge of the mental health resources available in the community is necessary for psychiatrists who work in or consult with the emergency department. Patients discharged from the emergency department require follow-up instructions; when possible, schedule appointments for early evaluation and treatment. • Thoroughly document evaluations, clinical interventions, suicide risk assessments, risk-benefit determinations, and the decision-making process.
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• There is no such thing as a “VIP patient.” Carefully assess all patients at risk for suicide without exception. • Follow EMTALA mandates requiring appropriate screening examination, stabilization, and transfer or discharge of anyone seeking emergency services.
Suicide Aftermath After a patient’s death, the duty to maintain confidentiality of the patient’s record continues, unless a court decision or statute provides otherwise. Careful documentation and maintenance of confidentiality of the patient’s records provide a sound defense in malpractice litigation as well as in administrative and ethics proceedings. Suicide aftermath presents the clinician with conflicting tensions between maintaining patient confidentiality, providing support to the suicide survivors, and implementing risk management principles that limit liability exposure. T.G. Gutheil (personal communication, October 1989) recommends postsuicide family outreach by the clinician as crucial for the devastated family members following a suicide. This recommendation, which is based primarily on humanitarian concerns for survivors, has important risk management implications. Gutheil points out that “bad feelings” combined with a bad outcome often lead to litigation. The persons who lived with the patient before the suicide not only currently experience intense emotional pain but also shared it with the patient before death. Some lawsuits are filed because of the clinician’s refusal to express, in some way, feelings of condolence, sympathy, and regret for the patient’s death. In Massachusetts, an “apology statute” exists that renders various benevolent human expression such as condolences, regrets, and apologies “inadmissible as evidence of an admission of liability in a civil action” (Mass. Gen. Laws 1986). Slovenko (2002) noted that Texas and California enacted legislation similar to that in Massachusetts. The highest courts of Georgia and Vermont provided apology protection by judicial opinions in 1992. However, as Regehr and Gutheil (2002) noted, “[T]he current empirical evidence is insufficiently solid to support the proposition that apology by oppressors, perpetrators, and a defendant is a panacea leading to healing of trauma under all circumstances” (pp. 429–430). A fine line exists between a psychiatrist’s apology and the perception by others that fault is being admitted. Admissions of wrongdoing may void insurance coverage (Slovenko 2002). Moreover, another party may be found ultimately at fault in litigation, not the psychiatrist. A skillful lawyer may take feelings of genuine sympathy and turn them
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against the psychiatrist as an admission of fault. To say “I am sorry” is certainly the appropriate human response, but in a litigation context, it may backfire. The psychiatrist must be guided by good judgment, not by guilt-driven feelings. Attorneys advise psychiatrists in different ways about suicide aftercare. Following a bad outcome, many attorneys recommend that the case be sealed and no communication be established with the family. Some attorneys, however, encourage judicious communication with, consultation with, or even treatment of family members. The treatment of family members by the psychiatrist who treated the patient before his or her suicide is likely doomed from the start by insurmountable transference and countertransference reactions. The family should be referred for treatment. In meeting with family members, the psychiatrist should focus on addressing the feelings of family members rather than the specifics of the patient’s care. Suicide aftercare is similar to any other grief-related therapy or consultation. The value of such consultation in healing grief is important enough for clinicians to consider providing humanitarian support to the survivors of patient suicide. The clinician may justifiably worry that contact with survivors of suicide will increase the risk of a lawsuit. Outreach to survivors of patient suicides should not be undertaken primarily for risk management purposes. No easy answers exist for managing the complex and often conflicting tensions between suicide aftercare and risk management. Most practicing psychiatrists can expect that a patient suicide will occur during their years of practice. Psychiatrists’ reactions to a patient’s suicide often include shame, guilt, anger, avoidance behaviors, intrusive thoughts, questioning of their competency, and litigation fears (Gitlin 1999; Hendin et al. 2000; see also Chapter 24, “Psychiatrist Reactions to Patient Suicide,” this volume). The American Association of Suicidology’s Clinician Task Force makes several resources available to clinicians whose patients have committed suicide (see http://www. suicidology.org).
Risk Management Suggestions for the Aftermath of Suicide • The duty to maintain confidentiality of patient records follows the patient in death, unless provided otherwise by a specific court decision or statute. • The physician–patient privilege that protects confidentiality does not end with the patient’s death. It may be claimed by the deceased patient’s next of kin or a legal representative.
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• Obtain written authorization from the executor or administrator of the deceased patient’s estate before a copy of the medical record is released. • If the psychiatrist must disclose confidential information about a deceased patient, legal exposure may be minimized by providing only enough information about the matter at issue. • Follow standard procedures for correcting errors and misunderstandings. Accurately date postincident written statements. • Do not tamper with, delete, change, or destroy anything in the patient’s record after a suicide. • Retain patient records at least for the length of time that malpractice claims can be brought according to a state’s statute of limitations. Consider keeping patient records indefinitely for future treatment purposes and for administrative, licensure, or ethical proceedings that are not governed by the statute of limitations. • Consider consulting with an attorney before making any oral or written statements regarding a patient’s suicide or suicide attempt or before releasing patient records, unless it is to assist in the clinical care of a patient who has attempted suicide. • Consider the appropriateness of sending a condolence card or attending the deceased patient’s funeral on a case-by-case basis. Discuss with the grieving family his or her feelings about attending the patient’s funeral. Do not arrive at the funeral unannounced. • Suicide aftercare is a clinically based outreach effort to survivors of suicide, including clinicians who lose patients to suicide. No easy answers exist for handling the complexity of suicide aftercare and risk management. Case-by-case decisions are required. • After a patient’s suicide, immediately inform the professional liability insurance carrier.
❏ Key Points ■
Fully commit the time and effort necessary for the care and treatment of the patient at risk for suicide.
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Perform and contemporaneously document adequate suicide risk assessments.
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Obtain prior treatment records and information from significant others, if possible.
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Consider personal factors that can interfere with the care of the suicidal patient.
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Do not allow managed care limitation of payments to interfere with the provision of good clinical care.
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References American Psychiatric Association: Risk management issues in psychiatric practice. Workshop presented at the American Psychiatric Association Psychiatrist’s Purchasing Group, Inc, Component Workshop, 155th annual meeting of the American Psychiatric Association, Philadelphia, PA, May 18–23, 2002 American Psychiatric Association: Practice guideline for the assessment and treatment of patients with suicidal behaviors (published erratum appears in Am J Psychiatry 161:776, 2004). Am J Psychiatry 160 (11, suppl):1–60, 2003 American Psychiatric Association–Sponsored Professional Liability Insurance Program: Retaining and discarding psychiatric records. Rx for Risk 10:1, 6– 7, 2002 Appelbaum PS: General guidelines for psychiatrists who prescribe medication for patients treated by nonmedical psychotherapists. Hosp Community Psychiatry 42:281–282, 1991 Baldessarini RJ, Tondo L, Hennen J: Lithium treatments and suicide risk in major affective disorders: update and new findings. J Clin Psychiatry 64 (suppl 5):44–52, 2003 Bellah v Greenson, 81 Cal App 3d 614, 146 Cal Rptr 525 (1978) Black HC: Black’s Law Dictionary, 7th Edition. St Paul, MN, West Group, 1999 Bongar B, Maris RW, Berman AL, et al: Outpatient standards of care and the suicidal patient, in Risk Management With Suicide Patients. Edited by Bongar B, Berman AL, Maris FW, et al. New York, Guilford, 1998, pp 4–43 Bostwick JM, Pankratz VS: Affective disorders and suicide risk: a re-examination. Am J Psychiatry 157:1925–1932, 2000 Breslow RE: Structure and function of psychiatric emergency services, in Emergency Psychiatry. Edited by Allen MH. Washington, DC, American Psychiatric Publishing, 2002, pp 35–74 Brown J, Rayne JT: Some ethical considerations in defensive psychiatry: a case study. Am J Orthopsychiatry 59:534–541, 1989 Busch KA, Clark DC, Fawcett J, et al: Clinical features in inpatient suicide. Psychiatr Ann 23:256–262, 1993 Dhossche DM: Suicidal behavior in psychiatric emergency room patients. South Med J 93:310–314, 2000 Egan MP: Contracting for safety: a concept analysis. Crisis 18:17–23, 1997 Federal Tort Claims Act, 28 USCA § § 1346(b), 2674 (1946) Gitlin MJ: A psychiatrist’s reaction to a patient’s suicide. Am J Psychiatry 156:1630–1634, 1999 Gutheil TG, Simon RI: Abandonment of patients in split treatment. Harv Rev Psychiatry 11:175–179, 2003 Hairston v Alexander Tank and Equip Co, 310 NC 227, 234, 311 SE2d 559, 565 (1984) Harris CE, Barraclough B: Suicide as an outcome for mental disorders: a meta analysis. Br J Psychiatry 170:205–228, 1997 Heikkinen ME, Aro HM, Lonnqvist J: Recent life events, social support and suicide. Acta Psychiatr Scand Suppl 377:65–72, 1994 Heila H, Heikkinen ME, Isometsa ET, et al: Life events and completed suicide in schizophrenia: a comparison of suicide victims with and without schizophrenia. Schizophr Bull 25:519–531, 1999
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Hendin H, Lipschitz A, Maltsberger JT, et al: Therapists’ reactions to patients’ suicides. Am J Psychiatry 157:2022–2027, 2000 Hillard R: Malpractice: why do we worry so much? Current Psychiatry 3:3, September 2004 Jacobs DG, Brewer M, Klein-Benheim M: Suicide assessment: an overview and recommended protocol, in The Harvard Medical School Guide to Suicide Assessment and Intervention. Edited by Jacobs DJ. San Francisco, CA, Jossey-Bass, 1999, pp 2–39 Joint Commission on Accreditation of Healthcare Organizations: Hospital Accreditation Standards. Chicago, IL, Joint Commission on Accreditation of Healthcare Organizations, 2002, PE 1.7.1 Kessler RC, Borges G, Walters EE: Prevalence of and risk factors for lifetime suicide: suicide attempts in the National Comorbidity Study. Arch Gen Psychiatry 56:617–626, 1999 Kochanek KD, Murphy SL, Anderson RN, et al: Deaths: final data for 2002. Natl Vital Stat Rep 53(5):1–115, 2004 Kockelman v Segals, 61 Cal App 4th 491, 71 (Cal Rptr 2d 552 1998) Macbeth JE, Wheeler AM, Sithers J, et al: Legal and Risk Management Issues in the Practice of Psychiatry. Washington, DC, Psychiatrist’s Purchasing Group, 1994 Maltsberger JT, Hendin H, Haas AP, et al: Determination of precipitating events in the suicide of psychiatric patients. Suicide Life Threat Behav 33:111–119, 2003 Mass Gen Laws ch. 233, §23D (1986) Meyer DJ, Simon RI: Split treatment: clarity between psychiatrists and psychotherapists. Psychiatr Ann 29:241–245, 327–332, 1999 Miller MC, Jacobs DG, Gutheil TG: Talisman or taboo: the controversy of the suicide prevention contract. Harv Rev Psychiatry 6:78–87, 1998 Morgan HG, Stanton R: Suicide among psychiatric inpatients in a changing clinical scene. Br J Psychiatry 171:561–563, 1997 Ostamo A, Lonnqvist J: Excess mortality in suicide attempters. Soc Psychiatry Psychiatr Epidemiol 36:29–35, 2001 Paddock v Chacko, 522 So2d 410 (Fla Dist Ct App 1988), review denied, 553 So2d 168 (Fla 1989) Peters PG: The quiet demise of deference to custom: malpractice law at the millennium. Wash Lee Law Rev 57:163, 2000 Pokorny AD: Predictions of suicide in psychiatric patients: report of a prospective study. Arch Gen Psychiatry 40:249–257, 1983 Pokorny AD: Suicide prediction revisited. Suicide Life Threat Behav 23:1–10, 1993 Qin P, Nordentoft M: Suicide risk in relation to psychiatric hospitalization: evidence based on longitudinal registers. Arch Gen Psychiatry 62:427–432, 2005 Quinn DK, Geppert CMA, Maggiore WA: The Emergency Medical Treatment and Active Labor Act of 1985 and the practice of psychiatry. Psychiatr Serv 53:1301–1307, 2002 Regehr C, Gutheil TG: Apology, justice and trauma recovery. J Am Acad Psychiatry Law 30:425–429, 2002 Scheiber SC, Kramer TAM, Adamowski SE: Core Competencies for Psychiatric Practice. Washington, DC, American Psychiatric Publishing, 2003 Sederer LI, Ellison J, Keyes C: Guidelines for prescribing psychiatrists in consultative, collaborative and supervisory relationships. Psychiatr Serv 49:1197–1202, 1998
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Shekelle PG, Ortiz E, Rhodes S, et al: Validity of the Agency for Healthcare Research and Quality clinical practice guidelines: how quickly do guidelines become outdated? JAMA 286:1461–1467, 2001 Siebert v Fink, 280 AD2d 661, 720 NYS2d 564 (2d Dep’t 2001) Simon RI: Coping strategies for the “unduly” defensive psychiatrist. Int J Med Law 4:551–561, 1985 Simon RI: Clinical Psychiatry and the Law, 2nd Edition. Washington, DC, American Psychiatric Press, 1992 Simon RI: Discharging sicker, potentially violent psychiatric inpatients in the managed care era: standard of care and risk management. Psychiatr Ann 27:726– 733, 1997 Simon RI: Psychiatrists awake! Suicide risk assessments are all about a good night’s sleep. Psychiatr Ann 38:479–485, 1998a Simon RI: Psychiatrists’ duties in discharging sicker and potentially violent inpatients in the managed care era. Psychiatr Serv 49:62–67, 1998b Simon RI: The suicide prevention contract: clinical, legal and risk management issues. J Am Acad Psychiatry Law 27:445–450, 1999 Simon RI: Psychiatry and Law for Clinicians, 3rd Edition. Washington, DC, American Psychiatric Publishing, 2001 Simon RI: Suicide risk assessment: what is the standard of care? J Am Acad Psychiatry Law 30:340–344, 2002 Simon RI: Best practices or reasonable care? J Am Acad Psychiatry Law 33:8–11, 2005 Simon RI: Imminent suicide: the illusion of temporal prediction. Suicide Life Threat Behav (in press) Simon RI, Gutheil TG: Abandonment of patients in split treatment. Harv Rev Psychiatry 11:175–179, 2003 Slovenko R: Psychiatry in Law/Law in Psychiatry. New York, Brunner-Routledge, 2002 Speer v United States, 512 F Supp 670 (ND Tex 1981), aff’d, 675 F2d 100 (5th Cir 1982) Stanford EJ, Goetz RR, Bloom JD: The no harm contract in the emergency assessment of suicide risk. J Clin Psychiatry 55:344–348, 1994 Stepakoff v Kantar, 473 NE2d 1131, 1134 (Mass 1985) Wickizer TM, Lessler D, Travis KM: Controlling inpatient psychiatric utilization through managed care. Am J Psychiatry 153:339–345, 1996 Wingerson D, Russo J, Ries R, et al: Use of psychiatric emergency services and enrollment status in a public managed mental health plan. Psychiatr Serv 52:1494–1501, 2001
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A P P E N D I X
APA Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors Executive Summary of Recommendations Work Group on Suicidal Behaviors Douglas G. Jacobs, M.D., Chair Ross J. Baldessarini, M.D. Yeates Conwell, M.D. Jan A. Fawcett, M.D. Leslie Horton, M.D., Ph.D. Herbert Meltzer, M.D. Cynthia R. Pfeffer, M.D. Robert I. Simon, M.D. With commentary and case examples by Douglas G. Jacobs, M.D. and Margaret Brewer, R.N., M.B.A. Reprinted from American Psychiatric Association: “Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors: Part A: Assessment, Treatment, and Risk Management Recommendations.” American Journal of Psychiatry 160(suppl):1–60, 2003. Copyright 2003, American Psychiatric Association. Used with permission. Introductory comments and case examples have been added for purposes of this textbook appendix.
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In 2002 and 2003, under the auspices of the APA’s Steering Committee on Practice Guidelines, the Work Group on Suicidal Behaviors reviewed more than 17,000 publications and compiled relevant inclusions for the Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors. This important publication “represents a synthesis of current scientific knowledge and rational clinical practice on the assessment and treatment of adult patients with suicidal behaviors.” This appendix includes the entire Executive Summary from the practice guideline, a thoughtful summary of the guideline recommendations, with confidence factors ascribed to each recommendation, and relevant tables from elsewhere in the guideline. (Note that the numbering of tables included here has been altered for purposes of this appendix and does not necessarily correspond to the numbering of tables in the practice guideline.) This material has particular value in a book intended to help the practicing psychiatrist deal with the critical challenge of suicide assessment and intervention across the entire spectrum of psychiatric diagnoses. Also included in this appendix are some case examples intended to illustrate specific recommendations. Readers are urged to refer to the entire document (American Psychiatric Association 2004).
Executive Summary of Recommendations Definitions and General Principles Coding System Each recommendation is identified as falling into one of three categories of endorsement, indicated by a bracketed Roman numeral following the statement. The three categories represent varying levels of clinical confidence regarding the recommendation: [I] Recommended with substantial clinical confidence. [II] Recommended with moderate clinical confidence. [III] May be recommended on the basis of individual circumstances.
Definitions of Terms In this guideline, the following terms will be used: • Suicide—self-inflicted death with evidence (either explicit or implicit) that the person intended to die. • Suicide attempt—self-injurious behavior with a nonfatal outcome accompanied by evidence (either explicit or implicit) that the person intended to die.
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• Aborted suicide attempt—potentially self-injurious behavior with evidence (either explicit or implicit) that the person intended to die but stopped the attempt before physical damage occurred. • Suicidal ideation—thoughts of serving as the agent of one’s own death. Suicidal ideation may vary in seriousness depending on the specificity of suicide plans and the degree of suicidal intent. • Suicidal intent—subjective expectation and desire for a self-destructive act to end in death. • Lethality of suicidal behavior—objective danger to life associated with a suicide method or action. Note that lethality is distinct from and may not always coincide with an individual’s expectation of what is medically dangerous. • Deliberate self-harm—willful self-inflicting of painful, destructive, or injurious acts without intent to die. A detailed exposition of definitions relating to suicide has been provided by O’Carroll et al. (1996).
Suicide Assessment The psychiatric evaluation is the essential element of the suicide assessment process [I]. During the evaluation, the psychiatrist obtains information about the patient’s psychiatric and other medical history and current mental state (e.g., through direct questioning and observation about suicidal thinking and behavior as well as through collateral history, if indicated). This information enables the psychiatrist to 1) identify specific factors and features that may generally increase or decrease risk for suicide or other suicidal behaviors and that may serve as modifiable targets for both acute and ongoing interventions, 2) address the patient’s immediate safety and determine the most appropriate setting for treatment, and 3) develop a multiaxial differential diagnosis to further guide planning of treatment. The breadth and depth of the psychiatric evaluation aimed specifically at assessing suicide risk will vary with setting; ability or willingness of the patient to provide information; and availability of information from previous contacts with the patient or from other sources, including other mental health professionals, medical records, and family members. Although suicide assessment scales have been developed for research purposes, they lack the predictive validity necessary for use in routine clinical practice. Therefore, suicide assessment scales may be used as aids to suicide assessment but should not be used as predictive instruments or as substitutes for a thorough clinical evaluation [I]. Table A–1 presents important domains of a suicide assessment, including the patient’s current presentation, individual strengths and
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TABLE A–1.
Textbook of Suicide Assessment and Management Characteristics evaluated in the psychiatric assessment of patients with suicidal behavior
Current presentation of suicidality Suicidal or self-harming thoughts, plans, behaviors, and intent Specific methods considered for suicide, including their lethality and the patient’s expectation about lethality, as well as whether firearms are accessible Evidence of hopelessness, impulsiveness, anhedonia, panic attacks, or anxiety Reasons for living and plans for the future Alcohol or other substance use associated with the current presentation Thoughts, plans, or intentions of violence toward others Psychiatric illnesses Current signs and symptoms of psychiatric disorders with particular attention to mood disorders (primarily major depressive disorder or mixed episodes), schizophrenia, substance use disorders, anxiety disorders, and personality disorders (primarily borderline and antisocial personality disorders) Previous psychiatric diagnoses and treatments, including illness onset and course and psychiatric hospitalizations, as well as treatment for substance use disorders History Previous suicide attempts, aborted suicide attempts, or other self-harming behaviors Previous or current medical diagnoses and treatments, including surgeries or hospitalizations Family history of suicide or suicide attempts or a family history of mental illness, including substance abuse Psychosocial situation Acute psychosocial crises and chronic psychosocial stressors, which may include actual or perceived interpersonal losses, financial difficulties or changes in socioeconomic status, family discord, domestic violence, and past or current sexual or physical abuse or neglect Employment status, living situation (including whether or not there are infants or children in the home), and presence or absence of external supports Family constellation and quality of family relationships Cultural or religious beliefs about death or suicide Individual strengths and vulnerabilities Coping skills Personality traits Past responses to stress Capacity for reality testing Ability to tolerate psychological pain and satisfy psychological needs
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weaknesses, history, and psychosocial situation. Information may come from the patient directly or from other sources, including family members, friends, and others in the patient’s support network, such as community residence staff or members of the patient’s military command. Such individuals may be able to provide information about the patient’s current mental state, activities, and psychosocial crises and may also have observed behavior or been privy to communications from the patient that suggest suicidal ideation, plans, or intentions. Contact with such individuals may also provide opportunity for the psychiatrist to attempt to fortify the patient’s social support network. This goal often can be accomplished without the psychiatrist’s revealing private or confidential information about the patient. In clinical circumstances in which sharing information is important to maintain the safety of the patient or others, it is permissible and even critical to share such information without the patient’s consent [I].
Case Example 1 A 19-year-old single, white male has been referred to the student health clinic at a local college by his faculty advisor following a period of falling grades and attendance and a veiled suicide threat. He lives at home with his mother but says he has a conflicted relationship with her. His father committed suicide 9 years ago. He is sullen, with a depressed affect and only offers one word answers to questions. When asked why his advisor required this evaluation, he says, “I don’t know.” The advisor’s referral said the patient had expressed being unable to keep up with his work and said he was worthless and might as well give up, like his father did. The patient will not answer any of the psychiatrist’s questions about suicidal feelings or actions.
Discussion Since this young man is not offering much information and yet his advisor was obviously worried about him, more data are needed. The psychiatrist would do well to interview both the faculty advisor and, if possible, the patient’s mother. These people would likely provide much more relevant information than the patient is able to give. An adequate assessment is not possible without added information about the patient; therefore, more data must be gathered before an assessment is completed and a disposition is made. A conversation with the advisor, and probably the mother, should occur regardless of the patient’s wishes.
It is important to recognize that in many clinical situations not all of the information described in this section may be possible to obtain. It may be necessary to focus initially on those elements judged to be most relevant and to continue the evaluation during subsequent contacts with the patient.
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When communicating with the patient, it is important to remember that simply asking about suicidal ideation does not ensure that accurate or complete information will be received. Cultural or religious beliefs about death or suicide, for example, may influence a patient’s willingness to speak about suicide during the assessment process as well as the patient’s likelihood of acting on suicidal ideas. Consequently, the psychiatrist may wish to explore the patient’s cultural and religious beliefs, particularly as they relate to death and to suicide [II]. It is important for the psychiatrist to focus on the nature, frequency, depth, timing, and persistence of suicidal ideation [I]. If ideation is present, request more detail about the presence or absence of specific plans for suicide, including any steps taken to enact plans or prepare for death [I]. If other aspects of the clinical presentation seem inconsistent with an initial denial of suicidal thoughts, additional questioning of the patient may be indicated [II]. Where there is a history of suicide attempts, aborted attempts, or other self-harming behavior, it is important to obtain as much detail as possible about the timing, intent, method, and consequences of such behaviors [I]. It is also useful to determine the life context in which they occurred and whether they occurred in association with intoxication or chronic use of alcohol or other substances [II]. For individuals in previous or current psychiatric treatment, it is helpful to determine the strength and stability of the therapeutic relationship(s) [II]. If the patient reports a specific method for suicide, it is important for the psychiatrist to ascertain the patient’s expectation about its lethality, for if actual lethality exceeds what is expected, the patient’s risk for accidental suicide may be high even if intent is low [I] (Table A–2). In general, the psychiatrist should assign a higher level of risk to patients who have high degrees of suicidal intent or describe more detailed and specific suicide plans, particularly those involving violent and irreversible methods [I]. If the patient has access to a firearm, the psychiatrist is advised to discuss with and recommend to the patient or a significant other the importance of restricting access to, securing, or removing this and other weapons [I]. Documenting the suicide assessment is essential [I]. Typically, suicide assessment and its documentation occur after an initial evaluation or, for patients in ongoing treatment, when suicidal ideation or behaviors emerge or when there is significant worsening or dramatic and unanticipated improvement in the patient’s condition (Table A–3). For inpatients, reevaluation also typically occurs with changes in the level of precautions or observations, when passes are issued, and during evaluation for discharge. As with the level of detail of the suicide as-
Assessment and Treatment of Patients With Suicidal Behaviors TABLE A–2.
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Questions that may be helpful in inquiring about specific aspects of suicidal thoughts, plans, and behaviors
Begin with questions that address the patient’s feelings about living. Have you ever felt that life was not worth living? Did you ever wish you could go to sleep and just not wake up? Follow up with specific questions that ask about thoughts of death, self-harm, or suicide. Is death something you’ve thought about recently? Have things ever reached the point that you’ve thought of harming yourself? For individuals who have thoughts of self-harm or suicide When did you first notice such thoughts? What led up to the thoughts (e.g., interpersonal and psychosocial precipitants, including real or imagined losses; specific symptoms such as mood changes, anhedonia, hopelessness, anxiety, agitation, psychosis)? How often have those thoughts occurred (including frequency, obsessional quality, controllability)? How close have you come to acting on those thoughts? How likely do you think it is that you will act on them in the future? Have you ever started to harm (or kill) yourself but stopped before doing something (e.g., holding knife or gun to your body but stopping before acting, going to edge of bridge but not jumping)? What do you envision happening if you actually killed yourself (e.g., escape, reunion with significant other, rebirth, reactions of others)? Have you made a specific plan to harm or kill yourself? (If so, what does the plan include?) Do you have guns or other weapons available to you? Have you made any particular preparations (e.g., purchasing specific items, writing a note or a will, making financial arrangements, taking steps to avoid discovery, rehearsing the plan)? Have you spoken to anyone about your plans? How does the future look to you? What things would lead you to feel more (or less) hopeful about the future (e.g., treatment, reconciliation of relationship, resolution of stressors)? What things would make it more (or less) likely that you would try to kill yourself? What things in your life would lead you to want to escape from life or be dead? What things in your life make you want to go on living? If you began to have thoughts of harming or killing yourself again, what would you do?
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Textbook of Suicide Assessment and Management Questions that may be helpful in inquiring about specific aspects of suicidal thoughts, plans, and behaviors (continued)
For individuals who have attempted suicide or engaged in self-damaging action(s), parallel questions to those in the previous section can address the prior attempt(s). Additional questions can be asked in general terms or can refer to the specific method used and may include Can you describe what happened (e.g., circumstances, precipitants, view of future, use of alcohol or other substances, method, intent, seriousness of injury)? What thoughts were you having beforehand that led up to the attempt? What did you think would happen (e.g., going to sleep versus injury versus dying, getting a reaction out of a particular person)? Were other people present at the time? Did you seek help afterward yourself, or did someone get help for you? Had you planned to be discovered, or were you found accidentally? How did you feel afterward (e.g., relief versus regret at being alive)? Did you receive treatment afterward (e.g., medical versus psychiatric, emergency department versus inpatient versus outpatient)? Has your view of things changed, or is anything different for you since the attempt? Are there other times in the past when you’ve tried to harm (or kill) yourself? For individuals with repeated suicidal thoughts or attempts: About how often have you tried to harm (or kill) yourself? When was the most recent time? Can you describe your thoughts at the time that you were thinking most seriously about suicide? When was your most serious attempt at harming or killing yourself? What led up to it, and what happened afterward? For individuals with psychosis, ask specifically about hallucinations and delusions. Can you describe the voices (e.g., single versus multiple, male versus female, internal versus external, recognizable versus nonrecognizable)? What do the voices say (e.g., positive remarks versus negative remarks versus threats)? (If the remarks are commands, determine if they are for harmless versus harmful acts; ask for examples)? How do you cope with (or respond to) the voices? Have you ever done what the voices ask you to do? (What led you to obey the voices? If you tried to resist them, what made it difficult?) Have there been times when the voices told you to hurt or kill yourself? (How often? What happened?) Are you worried about having a serious illness or that your body is rotting? Are you concerned about your financial situation even when others tell you there’s nothing to worry about? Are there things that you’ve been feeling guilty about or blaming yourself for?
Assessment and Treatment of Patients With Suicidal Behaviors TABLE A–2.
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Questions that may be helpful in inquiring about specific aspects of suicidal thoughts, plans, and behaviors (continued)
Consider assessing the patient’s potential to harm others in addition to him- or herself. Are there others who you think may be responsible for what you’re experiencing (e.g., persecutory ideas, passivity experiences)? Are you having any thoughts of harming them? Are there other people you would want to die with you? Are there others who you think would be unable to go on without you?
TABLE A–3.
Circumstances in which a suicide assessment may be indicated clinically
Emergency department or crisis evaluation Intake evaluation (on either an inpatient or an outpatient basis) Before a change in observation status or treatment setting (e.g., discontinuation of one-to-one observation, discharge from inpatient setting) Abrupt change in clinical presentation (either precipitous worsening or sudden, dramatic improvement) Lack of improvement or gradual worsening despite treatment Anticipation or experience of a significant interpersonal loss or psychosocial stressor (e.g., divorce, financial loss, legal problems, personal shame or humiliation) Onset of a physical illness (particularly if life threatening, disfiguring, or associated with severe pain or loss of executive functioning)
sessment, the extent of documentation at each of these times varies with the clinical circumstances. Communications with other caregivers and with the family or significant others should also be documented [I]. When the patient or others have been given specific instructions about firearms or other weapons, this communication should also be noted in the record [I].
Case Example 2 A 59-year-old man is brought into the emergency department by his wife. He has threatened to shoot himself. The evaluating psychiatrist’s assessment is that the patient is suffering from an adjustment disorder following a demotion at work. He does not meet the criteria for a major depressive episode and has no history of psychiatric illness. Believing the patient can be safely managed at home until he is seen in an outpatient clinic tomorrow, the psychiatrist instructs the patient’s wife to have all the guns removed from the house before she takes him home. She replies that her husband is an avid hunter and target shooter and owns
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many guns, including handguns. She does not know how many guns are in the house. The patient is vague about where all of his guns are stored and tries to convince his wife and the psychiatrist that he won’t do anything so that there’s no need to worry about removing the guns. The psychiatrist feels increasingly uneasy with the proposed disposition, although the patient’s wife seems comfortable with it.
Discussion Even though the patient lacks diagnostic criteria for a major depressive disorder, the lethal nature of the threat and the complexity of the firearm issue indicate that an involuntary hold is necessary. The psychiatrist should clearly document in the record his instructions regarding firearms, as well as the patient’s and wife’s responses to the instructions.
Estimation of Suicide Risk Suicide and suicidal behaviors cause severe personal, social, and economic consequences. Despite the severity of these consequences, suicide and suicidal behaviors are statistically rare, even in populations at risk. For example, although suicidal ideation and attempts are associated with increased suicide risk, most individuals with suicidal thoughts or attempts will never die by suicide. It is estimated that attempts and ideation occur in approximately 0.7% and 5.6% of the general U.S. population per year, respectively (Crosby et al. 1999). In comparison, in the United States, the annual incidence of suicide in the general population is approximately 10.7 suicides for every 100,000 persons, or 0.0107% of the total population per year (Minino et al. 2002). This rarity of suicide, even in groups known to be at higher risk than the general population, contributes to the impossibility of predicting suicide. The statistical rarity of suicide also makes it impossible to predict on the basis of risk factors either alone or in combination. For the psychiatrist, knowing that a particular factor (e.g., major depressive disorder, hopelessness, substance use) increases a patient’s relative risk for suicide may affect the treatment plan, including determination of a treatment setting. At the same time, knowledge of risk factors will not permit the psychiatrist to predict when or if a specific patient will die by suicide. This does not mean that the psychiatrist should ignore risk factors or view suicidal patients as untreatable. On the contrary, an initial goal of the psychiatrist should be to estimate the patient’s risk through knowledgeable assessment of risk and protective factors (Tables A–4 and A–5), with a primary and ongoing goal of reducing suicide risk [I].
Assessment and Treatment of Patients With Suicidal Behaviors TABLE A–4.
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Factors associated with an increased risk for suicide
Suicidal thoughts/behaviors Suicidal ideas (current or previous) Suicide plans (current or previous) Suicide attempts (including aborted or interrupted attempts) Lethality of suicidal plans or attempts Suicidal intent Psychiatric diagnoses Major depressive disorder Bipolar disorder (primarily in depressive or mixed episodes) Schizophrenia Anorexia nervosa Alcohol use disorder Other substance use disorders Cluster B personality disorders (particularly borderline personality disorder) Comorbidity of Axis I and/or Axis II disorders Physical illnesses Diseases of the nervous system Multiple sclerosis Huntington’s disease Brain and spinal cord injury Seizure disorders Malignant neoplasms HIV/AIDS Peptic ulcer disease Chronic obstructive pulmonary disease, especially in men Chronic hemodialysis-treated renal failure Systemic lupus erythematosus Pain syndromes Functional impairment Psychosocial features Recent lack of social support (including living alone) Unemployment Drop in socioeconomic status Poor relationship with familya Domestic partner violenceb Recent stressful life event Childhood traumas Sexual abuse Physical abuse
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TABLE A–4.
Textbook of Suicide Assessment and Management Factors associated with an increased risk for suicide (continued)
Genetic and familial effects Family history of suicide (particularly in first-degree relatives) Family history of mental illness, including substance use disorders Psychological features Hopelessness Psychic paina Severe or unremitting anxiety Panic attacks Shame or humiliationa Psychological turmoila Decreased self-esteema Extreme narcissistic vulnerabilitya Behavioral features Impulsiveness Aggression, including violence against others Agitation Cognitive features Loss of executive functionb Thought constriction (tunnel vision) Polarized thinking Closed-mindedness Demographic features Male genderc Widowed, divorced, or single marital status, particularly for men Elderly age group (age group with greatest proportionate risk for suicide) Adolescent and young adult age groups (age groups with highest numbers of suicides) White race Gay, lesbian, or bisexual orientationb Additional features Access to firearms Substance intoxication (in the absence of a formal substance use disorder diagnosis) Unstable or poor therapeutic relationshipa aAssociation
with increased rate of suicide is based on clinical experience rather than formal research evidence. b Associated with increased rate of suicide attempts, but no evidence is available on suicide rates per se. cFor suicidal attempts, females have increased risk, compared with males.
Assessment and Treatment of Patients With Suicidal Behaviors TABLE A–5.
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Factors associated with protective effects for suicide
Children in the homea Sense of responsibility to familyb Pregnancy Religiosity Life satisfaction Reality testing abilityb Positive coping skillsb Positive problem-solving skillsb Positive social support Positive therapeutic relationshipb aExcept
among persons with postpartum psychosis or mood disorder. Association with decreased rate of suicide is based on clinical experience rather than formal research evidence.
b
Some factors may increase or decrease risk for suicide; others may be more relevant to risk for suicide attempts or other self-injurious behaviors, which are in turn associated with potential morbidity as well as increased suicide risk. In weighing risk and protective factors for an individual patient, consideration may be given to 1) the presence of psychiatric illness; 2) specific psychiatric symptoms such as hopelessness, anxiety, agitation, or intense suicidal ideation; 3) unique circumstances such as psychosocial stressors and availability of methods; and 4) other relevant clinical factors such as genetics and medical, psychological, or psychodynamic issues [I]. It is important to recognize that many of these factors are not simply present or absent but instead may vary in severity. Others, such as psychological or psychodynamic issues, may contribute to risk in some individuals but not in others or may be relevant only when they occur in combination with particular psychosocial stressors. Once factors are identified, the psychiatrist can determine if they are modifiable. Past history, family history, and demographic characteristics are examples of nonmodifiable factors. Financial difficulties or unemployment can also be difficult to modify, at least in the short term. While immutable factors are important to identify, they cannot be the focus of intervention. Rather, to decrease a patient’s suicide risk, the treatment should attempt to mitigate or strengthen those risk and protective factors that can be modified [I]. For example, the psychiatrist may attend to patient safety, address associated psychological or social problems and stressors, augment social support networks, and treat associated psychiatric disorders (such as mood disorders, psychotic disorders, substance use disorders, and personality disorders) or symptoms (such as severe anxiety, agitation, or insomnia).
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Psychiatric Management Psychiatric management consists of a broad array of therapeutic interventions that should be instituted for patients with suicidal thoughts, plans, or behaviors [I]. Psychiatric management includes determining a setting for treatment and supervision, attending to patient safety, and working to establish a cooperative and collaborative physician-patient relationship. For patients in ongoing treatment, psychiatric management also includes establishing and maintaining a therapeutic alliance; coordinating treatment provided by multiple clinicians; monitoring the patient’s progress and response to the treatment plan; and conducting ongoing assessments of the patient’s safety, psychiatric status, and level of functioning. Additionally, psychiatric management may include encouraging treatment adherence and providing education to the patient and, when indicated, family members and significant others. Patients with suicidal thoughts, plans, or behaviors should generally be treated in the setting that is least restrictive yet most likely to be safe and effective [I] (Table A–6). Treatment settings and conditions include a continuum of possible levels of care, from involuntary inpatient hospitalization through partial hospital and intensive outpatient programs to occasional ambulatory visits. Choice of specific treatment setting depends not only on the psychiatrist’s estimate of the patient’s current suicide risk and potential for dangerousness to others, but also on other aspects of the patient’s current status, including 1) medical and psychiatric comorbidity; 2) strength and availability of a psychosocial support network; and 3) ability to provide adequate self-care, give reliable feedback to the psychiatrist, and cooperate with treatment. In addition, the benefits of intensive interventions such as hospitalization must be weighed against their possible negative effects (e.g., disruption of employment, financial and other psychosocial stress, social stigma). For some individuals, self-injurious behaviors may occur on a recurring or even chronic basis. Although such behaviors may occur without evidence of suicidal intent, this may not always be the case. Even when individuals have had repeated contacts with the health care system, each act should be reassessed in the context of the current situation [I]. In treating suicidal patients, particularly those with severe or recurring suicidality or self-injurious behavior, the psychiatrist should be aware of his or her own emotions and reactions that may interfere with the patient’s care [I]. For difficult-to-treat patients, consultation or supervision from a colleague may help in affirming the appropriateness of the treatment plan, suggesting alternative therapeutic approaches, or monitoring and dealing with countertransference issues [I].
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Guidelines for selecting a treatment setting for patients at risk for suicide or suicidal behaviors
Admission generally indicated After a suicide attempt or aborted suicide attempt if Patient is psychotic Attempt was violent, near-lethal, or premeditated Precautions were taken to avoid rescue or discovery Persistent plan and/or intent is present Distress is increased or patient regrets surviving Patient is male, older than age 45 years, especially with new onset of psychiatric illness or suicidal thinking Patient has limited family and/or social support, including lack of stable living situation Current impulsive behavior, severe agitation, poor judgment, or refusal of help is evident Patient has change in mental status with a metabolic, toxic, infectious, or other etiology requiring further workup in a structured setting In the presence of suicidal ideation with Specific plan with high lethality High suicidal intent Admission may be necessary After a suicide attempt or aborted suicide attempt, except in circumstances for which admission is generally indicated In the presence of suicidal ideation with Psychosis Major psychiatric disorder Past attempts, particularly if medically serious Possibly contributing medical condition (e.g., acute neurological disorder, cancer, infection) Lack of response to or inability to cooperate with partial hospital or outpatient treatment Need for supervised setting for medication trial or ECT Need for skilled observation, clinical tests, or diagnostic assessments that require a structured setting Limited family and/or social support, including lack of stable living situation Lack of an ongoing clinician-patient relationship or lack of access to timely outpatient follow-up In the absence of suicide attempts or reported suicidal ideation/plan/intent but evidence from the psychiatric evaluation and/or history from others suggests a high level of suicide risk and a recent acute increase in risk
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Textbook of Suicide Assessment and Management Guidelines for selecting a treatment setting for patients at risk for suicide or suicidal behaviors (continued)
Release from emergency department with follow-up recommendations may be possible After a suicide attempt or in the presence of suicidal ideation/plan when Suicidality is a reaction to precipitating events (e.g., exam failure, relationship difficulties), particularly if the patient’s view of situation has changed since coming to emergency department Plan/method and intent have low lethality Patient has stable and supportive living situation Patient is able to cooperate with recommendations for follow-up, with treater contacted, if possible, if patient is currently in treatment Outpatient treatment may be more beneficial than hospitalization Patient has chronic suicidal ideation and/or self-injury without prior medically serious attempts, if a safe and supportive living situation is available and outpatient psychiatric care is ongoing
The suicide prevention contract, or “no-harm contract,” is commonly used in clinical practice but should not be considered as a substitute for a careful clinical assessment [I]. A patient’s willingness (or reluctance) to enter into an oral or a written suicide prevention contract should not be viewed as an absolute indicator of suitability for discharge (or hospitalization) [I]. In addition, such contracts are not recommended for use with patients who are agitated, psychotic, impulsive, or under the influence of an intoxicating substance [II]. Furthermore, since suicide prevention contracts are dependent on an established physician-patient relationship, they are not recommended for use in emergency settings or with newly admitted or unknown inpatients [II]. Despite best efforts at suicide assessment and treatment, suicides can and do occur in clinical practice. In fact, significant proportions of individuals who die by suicide have seen a physician within several months of death and may have received specific mental health treatment. Death of a patient by suicide will often have a significant effect on the treating psychiatrist and may result in increased stress and loss of professional self-esteem. When the suicide of a patient occurs, the psychiatrist may find it helpful to seek support from colleagues and obtain consultation or supervision to enable him or her to continue to treat other patients effectively and respond to the inquiries or mental health needs of survivors [II]. Consultation with an attorney or a risk manager may also be useful [II]. The psychiatrist should be aware that patient
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confidentiality extends beyond the patient’s death and that the usual provisions relating to medical records still apply. Any additional documentation included in the medical record after the patient’s death should be dated contemporaneously, not backdated, and previous entries should not be altered [I]. Depending on the circumstances, conversations with family members may be appropriate and can allay grief [II]. In the aftermath of a loved one’s suicide, family members themselves are more vulnerable to physical and psychological disorders and should be helped to obtain psychiatric intervention, although not necessarily by the same psychiatrist who treated the individual who died by suicide [II].
Case Example 3 On Monday morning following Thanksgiving weekend, a psychiatrist learns that one of her patients completed suicide the day before. She had seen the patient in an emergency session on Saturday and conducted a thorough suicide evaluation. The psychiatrist and the patient had considered hospitalization but determined he could be safe at home. The psychiatrist had been treating the patient for many years and felt confident in her assessment and in his truthfulness. She did not write a note at the time because she saw him in a satellite office and his chart was not readily available. The psychiatrist planned to document the session when she was in the office on Monday.
Discussion The psychiatrist should document the session and the suicide assessment completely but date the note with the contemporaneous date.
Specific Treatment Modalities In developing a plan of treatment that addresses suicidal thoughts or behaviors, the psychiatrist should consider the potential benefits of somatic therapies as well as the potential benefits of psychosocial interventions, including the psychotherapies [I]. Clinical experience indicates that many patients with suicidal thoughts, plans, or behaviors will benefit most from a combination of these treatments [II]. The psychiatrist should address the modifiable risk factors identified in the initial psychiatric evaluation and make ongoing assessments during the course of treatment [I]. In general, therapeutic approaches should target specific Axis I and Axis II psychiatric disorders; specific associated symptoms such as depression, agitation, anxiety, or insomnia; or the predominant psychodynamic or psychosocial stressor [I]. While the goal of pharmacologic treatment may be acute symptom relief, including acute
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relief of suicidality or acute treatment of a specific diagnosis, the treatment goals of psychosocial interventions may be broader and longer term, including achieving improvements in interpersonal relationships, coping skills, psychosocial functioning, and management of affects. Since treatment should be a collaborative process between the patient and clinician(s), the patient’s preferences are important to consider when developing an individual treatment plan [I].
Somatic Interventions Evidence for a lowering of suicide rates with antidepressant treatment is inconclusive. However, the documented efficacy of antidepressants in treating acute depressive episodes and their long-term benefit in patients with recurrent forms of severe anxiety or depressive disorders support their use in individuals with these disorders who are experiencing suicidal thoughts or behaviors [II]. It is advisable to select an antidepressant with a low risk of lethality on acute overdose, such as a selective serotonin reuptake inhibitor (SSRI) or other newer antidepressant, and to prescribe conservative quantities, especially for patients who are not well-known [I]. For patients with prominent insomnia, a sedating antidepressant or an adjunctive hypnotic agent can be considered [II]. Since antidepressant effects may not be observed for days to weeks after treatment has started, patients should be monitored closely early in treatment and educated about this probable delay in symptom relief [I]. To treat symptoms such as severe insomnia, agitation, panic attacks, or psychic anxiety, benzodiazepines may be indicated on a short-term basis [II], with long-acting agents often being preferred over short-acting agents [II]. The benefits of benzodiazepine treatment should be weighed against its occasional tendency to produce disinhibition and its potential for interactions with other sedatives, including alcohol [I]. Alternatively, other medications that may be used for their calming effects in highly anxious and agitated patients include trazodone, low doses of some second-generation antipsychotics, and some anticonvulsants such as gabapentin or divalproex [III]. If benzodiazepines are being discontinued after prolonged use, their doses should be reduced gradually and the patient monitored for increasing symptoms of anxiety, agitation, depression, or suicidality [II]. There is strong evidence that long-term maintenance treatment with lithium salts is associated with major reductions in the risk of both suicide and suicide attempts in patients with bipolar disorder, and there is
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moderate evidence for similar risk reductions in patients with recurrent major depressive disorder [I]. Specific anticonvulsants have been shown to be efficacious in treating episodes of mania (i.e., divalproex) or bipolar depression (i.e., lamotrigine), but there is no clear evidence that their use alters rates of suicide or suicidal behaviors [II]. Consequently, when deciding between lithium and other first-line agents for treatment of patients with bipolar disorder, the efficacy of lithium in decreasing suicidal behavior should be taken into consideration when weighing the benefits and risks of treatment with each medication. In addition, if lithium is prescribed, the potential toxicity of lithium in overdose should be taken into consideration when deciding on the quantity of lithium to give with each prescription [I]. Clozapine treatment is associated with significant decreases in rates of suicide attempts and perhaps suicide for individuals with schizophrenia and schizoaffective disorder. Thus, clozapine treatment should be given serious consideration for psychotic patients with frequent suicidal ideation, attempts, or both [I]. However, the benefits of clozapine treatment need to be weighed against the risk of adverse effects, including potentially fatal agranulocytosis and myocarditis, which has generally led clozapine to be reserved for use when psychotic symptoms have not responded to other antipsychotic medications. If treatment is indicated with an antipsychotic other than clozapine, the other secondgeneration antipsychotics (e.g., risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole) are preferred over the first-generation antipsychotic agents [I]. ECT has established efficacy in patients with severe depressive illness, with or without psychotic features. Since ECT is associated with a rapid and robust antidepressant response as well as a rapid diminution in associated suicidal thoughts, ECT may be recommended as a treatment for severe episodes of major depression that are accompanied by suicidal thoughts or behaviors [I]. Under certain clinical circumstances, ECT may also be used to treat suicidal patients with schizophrenia, schizoaffective disorder, or mixed or manic episodes of bipolar disorder [II]. Regardless of diagnosis, ECT is especially indicated for patients with catatonic features or for whom a delay in treatment response is considered life threatening [I]. ECT may also be indicated for suicidal individuals during pregnancy and for those who have already failed to tolerate or respond to trials of medication [II]. Since there is no evidence of a long-term reduction of suicide risk with ECT, continuation or maintenance treatment with pharmacotherapy or with ECT is recommended after an acute ECT course [I].
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Psychosocial Interventions Psychotherapies and other psychosocial interventions play an important role in the treatment of individuals with suicidal thoughts and behaviors [II]. A substantial body of evidence supports the efficacy of psychotherapy in the treatment of specific disorders, such as nonpsychotic major depressive disorder and borderline personality disorder, which are associated with increased suicide risk. For example, interpersonal psychotherapy and cognitive-behavioral therapy have been found to be effective in clinical trials for the treatment of depression. Therefore, psychotherapies such as interpersonal psychotherapy and cognitivebehavioral therapy may be considered appropriate treatments for suicidal behavior, particularly when it occurs in the context of depression [II]. In addition, cognitive-behavioral therapy may be used to decrease two important risk factors for suicide: hopelessness [II] and suicide attempts in depressed outpatients [III]. For patients with a diagnosis of borderline personality disorder, psychodynamic therapy and dialectical behavior therapy may be appropriate treatments for suicidal behaviors [II], because modest evidence has shown these therapies to be associated with decreased self-injurious behaviors, including suicide attempts. Although not targeted specifically to suicide or suicidal behaviors, other psychosocial treatments may also be helpful in reducing symptoms and improving functioning in individuals with psychotic disorders and in treating alcohol and other substance use disorders that are themselves associated with increased rates of suicide and suicidal behaviors [II]. For patients who have attempted suicide or engaged in self-harming behaviors without suicidal intent, specific psychosocial interventions such as rapid intervention; follow-up outreach; problemsolving therapy; brief psychological treatment; or family, couples, or group therapies may be useful despite limited evidence for their efficacy [III].
References American Psychiatric Association: Practice Guidelines for the Treatment of Psychiatric Disorders: Compendium 2004. Arlington, VA, American Psychiatric Association. 2004, pp 835–1027 [Individual practice guidelines available online at http://www.psychiatryonline.com] Crosby AE, Cheltenham MP, Sacks JJ: Incidence of suicidal ideation and behavior in the United States, 1994. Suicide Life Threat Behav 29:131–140, 1999 Minino AM, Arias E, Kochanek KD, et al: Deaths: Final Data for 2000. National Vital Statistics Reports, Vol 50, No 15 (DHHS Publication PHS 2002-1120). Hyattsville, Md, National Center for Health Statistics, 2002
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O’Carroll PW, Berman AL, Maris RW, et al: Beyond the Tower of Babel: a nomenclature for suicidology. Suicide Life Threat Behav 26:237–252, 1996
The American Psychiatric Association’s Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors offers thoughtful and useful additions to the psychiatrist’s clinical knowledge and practice. I believe the guideline makes it clear that there is no exact recipe for suicide assessment but rather suicide assessment is the ultimate clinical judgment based on a comprehensive psychiatric examination. Individual suicide cannot be predicted and in some situations cannot be prevented, but an individual’s suicide risk can be assessed and reduced with a variety of treatment options.
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Index Page numbers printed in boldface type refer to tables or figures.
Aboriginal groups, suicide rates in, 162 Aborted attempt, 21, 578 Abstinence, for substance-using patients, 359, 359 Abuse of alcohol. See Alcohol use/abuse childhood case example of, 229–231 litigation on, 538 of drugs. See Substance use/ abuse sexual, 95, 324, 538 ACA (American Correctional Association), 144 Acamprosate, 361 Access to care, for bipolar disorder, 284–285 Accidents, in substance-related disorders, 349 Accountability, of outpatient treatment team, 370 Acculturation of immigrants, 162–163 of Native Americans, 122–123 Active postvention model (APM), of survivors of suicide, 461–463, 462 Act of suicide, in psychodynamic psychiatry, 225, 226
Actuarial analysis, of suicide rate, 2 Addiction neurobiological factors of, 349–350 substance-related disorders vs., 348–349 suicide risk and, genetics of, 349–350 ADHD (attention-deficit/ hyperactivity disorder), 358 Adjustment disorders. See also Stress/stressors substance-related disorders and, 353 Administration as barrier, in split treatment, 245 interventions of, for staff safety, 150, 412 Admission, by patients. See Disclosure Admission assessments APA guidelines for, 404, 590, 591 case example of, 403 contraband search during, 432 emergency, 381–382, 433 of intoxicated patients, 405 for jails/prisons, 145, 145–146, 146 in managed care system, 406, 406, 426
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Admission assessments (continued) patient safety vs. freedom and, 424–425, 431, 433 systematic, 5, 8–9, 564 Adolescents, suicide in, 35–55 biological factors, 45 case examples of, 37–38 completed, aftermath of, 36, 50–51 confidentiality issues, 49 consent to treatment, 36, 48–49 death rate with, 35 demographics of, 35–37 differences from adults, 35, 36 environmental factors, 44 epidemiology of, 35–37 family factors, 43–44 gay, lesbian, bisexual, and transgender, 127–128 ideation in, 37, 41, 43 intent and in recent attempt, 39–41, 41 in reported ideation, 41–42 key points, 51 legal considerations, 48–51 personality disorders and, 329–330 pharmacotherapy for, 201 precipitants of, 44 prevention of, 43, 48–49 psychopathology of, 42–43 questionnaires and scales for, 39, 41, 45 rate of, 35–37 cultural perspectives of, 167–168 ethnicity correlations, 110–111 risk assessment for, 20, 38–39 risk factors for, 36, 37, 40 risk management considerations, 50–51 social factors, 43–44
stress factor, 43–44 substance-related disorders and, 357–358 suicide rate based on ethnicity, 110–111, 122, 163 treatment compliance and, 43 treatment of, 45–48, 46 protecting the patient, 45–46 protective factors enhancement, 48 risk assessment continuation, 46 risk factor amelioration, 46–48 Adults, suicide in differences from children/ adolescents, 35, 36, 50 malpractice cases, 35, 36, 50 personality disorders and, 329–330 rate of, 20 cultural perspectives of, 167–169 ethnicity correlations, 112 risk assessment for, 20 risk data on, 16, 20 Adversary system, legal system as, 516 Affective disorders. See also Mood disorders in children/adolescents, 42 in elderly, 63, 65 gendered differences in, 77, 128 lethality of attempts with, 280–281, 281 as panic disorder comorbidity, 315 severity of, in depressive disorders, 258–260, 260 suicide risk with, 16, 17, 285 African Americans suicide perspectives of, 116–118 HIV/AIDS and, 129 religion and, 125
Index suicide rate of, 109–112, 110 cultural competence and, 168, 169, 170 Aftercare plan. See also Outpatient treatment for completed suicide, 571 for discharges, 567. See also Discharge plan for follow-up. See Follow-up plan Aftermath, of completed suicide, 459–476. See also Suicide aftermath Against medical advice (AMA) discharge assessment for, 404–405 patient safety vs. freedom and, 433–434 Age. See also specific age group as psychiatrist distress predictor, 484–485, 485 suicide rate based on, 110, 110 cultural perspectives of, 167–169 ethnicity correlated to, 111–112 suicide risk with, 16, 20 in bipolar disorder, 282 gender differences in, 79, 81–82 in panic disorder, 315–316 Ageism, 72 Aggression in children/adolescents, 43 in depressive disorders, 257 gender differences of, 86, 88, 89, 90 psychodynamics of, 223 in stress-diathesis model, 331 in substance-related disorders, 347, 348, 351 suicide risk with, 20, 22 Agitation as outpatient crisis marker, 373–374
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suicide risk with, 15 Agoraphobia, 204–206 AIDS/HIV, 64, 128–130, 140 Akathisia, 239 inpatient treatment of, 409 Alaskan Natives cultural competence and, 162–163, 166, 168 suicide rate in, 109, 110, 111, 112 Alcoholics Anonymous, 361, 369 Alcoholism, 348–349 Alcohol use/abuse assessment during crisis, 449 as bipolar disorder comorbidity, 283, 285 as depressive disorder comorbidity, 257, 261 in elderly, 63, 65 emergency assessment of, 390, 395 gendered patterns of, 83–84, 85, 128 murder-suicide related to, 500 suicide rate with, 2, 596 ethnicity correlations, 110, 123 suicide risk with, 15, 16, 17, 20 factors associated with, 353–354, 354 psychiatric syndromes and, 352–353 Alienation, Minnesota Multiphasic Personality Inventory–2 of, 179, 180–182 Alprazolam, for acute depressive disorder, 268 Altruistic suicide, 170 AMA. See Against medical advice (AMA) American Correctional Association (ACA), 144 American Indians. See Native Americans
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American Psychiatric Association (APA) practice guidelines of, 577–597. See also Practice guidelines suicide prevention program, 144 Amisulpride, for bipolar disorder, 290 Amitriptyline, 209 Amoxapine, 209 Amphetamines schizophrenia and, 308 use/abuse of, suicide risk with, 356 Anding, George, 472 Anger murder-suicide related to, 501–502, 505–506 as psychiatrist reaction to suicide, 480, 482–483, 571 Anguish, as outpatient crisis marker, 372, 374 Anhedonia, 256, 372 Anniversary date, 466 Anomie, 163 Answer, in malpractice litigation, 532 Answer to interrogatories, 532 Anticonvulsants APA guidelines for, 594–595 for bipolar disorder, 289–290, 293 Antidepressants, 206–208 adverse effects with overdose, 209–210 APA guidelines for, 594 for bipolar disorder, 286–291, 288, 294 case examples of, 201–204, 265, 268 for children/adolescents, 47 for depressive disorder acute, 265–266, 268–269 chronic, 270 for elderly, 70 electroconvulsive therapy and, 200–201, 206
in inpatient treatment, 408–410 in outpatient treatment, 374 for short-term suicide risks, 15 for substance-using patients, 360–361 Antiepileptic mood stabilizers, 213–214 adverse effects of overdose, 210–211 for bipolar disorder, 289–290, 293 for substance-using patients, 360 Antipsychotics adverse effects with overdose, 211–212 for bipolar disorder, 290–291, 293 evidence-based use of, 454 first- vs. second-generation, 214 in inpatient treatment, 409 for personality disorders, 342 for schizophrenia, 306 use and efficacy of, 214–216 Antisocial personality disorder gender differences in, 98 suicidal behavior with, 334 suicide risk with, 21, 334 substance-related disorders and, 353 Anxiety clinical in outpatient treatment, 375–377 in split treatment, 245–246 in elderly, 67 gender differences of, 84 intense, as outpatient crisis marker, 372, 374 pharmacotherapy case example, 204–206 in psychiatrists, 546 as reaction to suicide, 477–479, 571 psychic, suicide risk with, 15
Index severity of criteria for, 259 in depressive disorders, 258–261, 260 Anxiety disorders. See also specific disorder APA treatment guidelines for, 594–595 suicide risk with, 313–327 factors associated with, 325, 325 generalized anxiety disorder, 15, 316–318 key points, 324–325 obsessive-compulsive disorder, 320–322 panic disorder, 15, 313–316 posttraumatic stress disorder, 322–324 social phobia, 318–320 substance-related disorders and, 352 Anxiolytic agents adverse effects with overdose, 212 in inpatient treatment, 408 for personality disorders, 341 use and efficacy of, 216 APA. See American Psychiatric Association (APA) APM (active postvention model), of survivors of suicide, 461–463, 462 Apology legislation on, 471–472, 570 in malpractice litigation, 470–471, 570–571 Arbitration, in malpractice litigation, 533 Aripiprazole, 212, 214, 216 for bipolar disorder, 290–291, 293 Arms-length safety precautions, 427–428 Arrests, as suicide prevention starting point, 146–147
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substance-related disorders and, 357 Artists, suicide rate of, 126–127 Asians/Asian Americans suicide perspectives of, 120–121, 167 suicide rate in, 109, 110, 111, 112 cultural competence and, 168, 169, 170 Assessment. See Suicide risk assessment Assimilation, cultural of immigrants, 162–163 of Native Americans, 122–123 Assisted suicide, gendered issues of, 101 Astronomical predictions, risk assessment vs., 14 Attachment theory, 221 Attempts. See Suicide attempts Attention-deficit/hyperactivity disorder (ADHD), 358 Auditory hallucinations inpatient treatment of, 409 suicide risk with, 17–18 Australia, immigrants from, 162–163 Autogenic massacres, 506 Autonomy, 88, 101, 413 patient safety vs. freedom and, 431–432, 566 Autopsy. See Psychological autopsy Avoidance behaviors, as psychiatrist reaction to suicide, 480, 480, 571 Axis II psychiatric disorders in children/adolescents, 42 as depressive disorder comorbidity, 257–259, 261 stress-diathesis model of, 331 suicide risk with, 25, 331, 335 Axis I psychiatric disorders in elderly, 63–64, 65 gender differences of, 84, 97, 98
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Axis I psychiatric disorders (continued) stress-diathesis model of, 331 suicide risk with, 21, 25, 237, 333 Bankruptcy, 167 Bathrooms, safety precautions for, 432 Baton Rouge Crisis Intervention Center, 461–462 Beck Depression Inventory (BDI), 177, 186–187 Beck Hopelessness Scale (BHS), 177, 186–187 Beck Suicide Intent Scale, 39, 41, 177, 187–188 Behavioral changes, as psychiatrist reaction to suicide, 480, 483–484, 571 effecting, 486, 487, 489 Behavioral therapy. See Cognitivebehavioral therapy Belief about intent, as lethal intent component, 39–41, 41 Benzodiazepines, 212, 216 for acute depressive disorder, 265, 269 APA guidelines for, 594 in inpatient treatment, 409 in outpatient treatment, 374 Bereavement. See Grief/grieving Best practices, 436, 473, 545 standard of care vs., 545, 551 BHS (Beck Hopelessness Scale), 177, 186–187 Bigelow V. Berkshire Life Insurance Company, 536 Bills/billing, in suicide aftermath, 466–467 Biological factors, of child/ adolescent suicide, 45 “Biopsy,” of standard of care, 547, 560
Bipolar disorder, 277–299 access to care for, 284–285 APA treatment guidelines for, 594–595 in children/adolescents, 42–43 comorbidities of, 277–278, 280, 283 impulsivity with, 283, 285–286 key points, 292, 294–295 mortality risk with, 277–278 prevalence of, 277–278 suicide rate with, 2, 278–279 suicide risk assessment for, 284 limitations of, 285 suicide risk with, 278–285 assessment of, 284–285 demographics of, 283 factors influencing, 18, 21, 282–284 illness duration effects, 282 illness severity effects, 279–280 lethality of attempts, 280–281, 281 sex differences in, 279, 280 statistics on, 278, 280 stressor effects, 283–284 substance-related disorders and, 352, 360 subtypes correlated to, 282–283 therapies for limiting, 285–292 treatment of, 285–292, 293–294 electroconvulsive therapy, 291 psychopharmacological, 285–291, 288 psychosocial interventions, 291–292 psychotherapy, 291 type I vs. type II, 277, 282 treatment differences, 287–288, 291 Birth date, 466
Index Bisexuality suicide rate related to, 127–128 suicide risk and, in children/ adolescents, 45 Black Americans. See African Americans Blame in child/adolescent suicide, 50–51 fear of, as psychiatrist reaction to suicide, 480, 481–482, 570–571 murder-suicide related to, 501 Blood glucose, emergency assessment of, 388 Body identification/viewing, by survivors of suicide, 469–471 Borderline personality disorder (BPD) APA treatment guidelines for, 596 gender differences in, 97–98 intrapsychic experience in, 333, 335 pharmacotherapy case example, 204–206 psychodynamic therapy case example, 227–229 suicidal behavior with management of, 331, 332 Self-Regulation Model of, 333, 337 stress-diathesis model of, 331–332 suicidal intent with, 330 suicide attempts with, 335 suicide rate with, 335 suicide risk with, 16, 21, 335 substance-related disorders and, 353 Boundary violations, case example of, 229–231 Brady Handgun Violence Prevention Act (1994), 72
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Breach, of duty as legal principle, 512, 516–520 from standard of care, 551–553 Breast implants, 94 Buddhism, 171 Bupropion, 209 Business cycle, suicide related to, 132 Buspirone, 212, 216 Campbell v. Young Motor Co., 536 Canadians, suicide perspectives of, 162–163, 166, 168 Cancer, 64 Cannabis use/abuse, suicide risk with, 356 Carbamazepine, 211, 213–214 for bipolar disorder, 289, 293 Cardiopulmonary resuscitation (CPR), for suicide attempt, in jails/prisons, 148–149 Care management services, for suicide prevention in elderly, 71–72 Car exhaust, murder-suicide by, 499 Case studies of borderline personality disorder, 204–206, 227–229 of boundary violations, 229–231 of child abuse, 229–231 of child/adolescent suicide, 37–38 of countertransference, 229–231 of cultural competence, 165, 170 of depression hopelessness, 268–269 hospitalization, 265–266 pharmacotherapy, 201–204, 265–266 of documentation, 593 of suicide in elderly, 57–59, 64, 66, 67 of electroconvulsive therapy, 201–206
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Case studies (continued) of emergency services, 383–387 of gender and suicide, 79–81 of generalized anxiety disorder, 316–317 of hospitalization, 411 admission assessment, 403 of jail/prison suicide, 142–143, 151 of malpractice litigation, 527–528 of murder-suicide, 501–502, 501–503 of obsessive-compulsive disorder, 320–321 of panic disorders, 313–314 of partial hospitalization, 411 of personality disorders, 336–338 of pharmacotherapy, 201–206, 240–241, 265 of posttraumatic stress disorder, 322–323 of psychiatric evaluation, 581 of psychodynamic psychiatry borderline personality disorder, 227–229 countertransference, 229–231 suicidality level, 225–229 of social phobia, 318–319 of split treatment, 240–241, 246–247 of substance-related disorders, 350–351 of suicidality level acute, 225–227, 229 chronic, 227–229 of suicide risk assessment, 3, 5–6 of suicide risk management in schizophrenia, 301–309 with substance abuse comorbidity, 306–309 of survivors of suicide, 466–472 Tikopia sociocultural context, 109 Catholics, suicide views of, 165, 171
Cause/causation direct in malpractice claims, 549–550, 550 in medical negligence, 529, 530 intervening vs. supervening, 521– 522 as legal principle, 512, 520–523 in standard of care deviation, 551–553 Center for Medicare and Medicaid Services (CMS), 430–431 Cerebrospinal fluid (CSF), 5-HIAA in, gender and, 86, 88 Champagne v. United States, 523 Change agents, clinicians as, 244 Charcoal-burning, as suicide method, 115–116 Chat rooms, for survivors of suicide support, 466 Checklists, for risk assessment, 2, 14, 15 Childhood abuse case example of, 229–231 litigation on, 538 sexual. See Sexual abuse Children, suicide in, 35–55 attempts for, 37, 39 intent and, 39–41, 41 biological factors, 45 completed, aftermath of, 36, 50–51 confidentiality issues, 49 consent to treatment, 36, 48–49 death rate with, 35 demographics of, 35–37 differences from adults, 35, 36 environmental factors, 44 epidemiology of, 35–37 family factors, 43–44 ideation in, 37, 43 intent in, 41–42
Index intent in recent attempt, 39–41, 41 intent in reported ideation, 41–42 key points, 51 legal considerations, 48–51 pharmacotherapy for, 201 precipitants of, 44 prevention of, 43, 48–49 psychopathology of, 42–43 questionnaires and scales for, 39, 41, 45 rate of, 35–37 risk assessment for, 20, 38–39 risk factors for, 36, 37, 40 risk management considerations, 50–51 social factors, 43–44 stress factor, 43–44 treatment compliance and, 43 treatment of, 45–48, 46 protecting the patient, 45–46 protective factors enhancement, 48 risk assessment continuation, 46 risk factor amelioration, 46–48 Chlorpromazine, 211, 214 for bipolar disorder, 293 Christianity, suicide views of, 165–166, 171 Chronic pain, as depressive disorder comorbidity, 257 Church attendance, 165–166 CISD (critical incident stress debriefing), 150, 412 Citalopram, 207, 209 Civil lawsuits. See Torts/tort law malpractice. See Malpractice litigation Civil procedure, for malpractice litigation, 531–533 Clinical data documentation of, 444–446 alterations of, 453, 572
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split treatment based on, 235–236, 244–245 in suicide risk assessment, 4, 24 dimensional parameters for, 24–25, 26 Clinical interview for depressive disorders, 262 case example of, 263–264 as face-to-face inquiry, 177, 183, 192–193 by multidisciplinary team, 191–192 Clinical judgment documentation of, 444–446 alterations of, 453, 572 mistrust in, after completed suicide, 467–468 for patient safety vs. freedom of movement, 423–425 in safe clinical practice, 447 in suicide risk assessment, 243–244 Clinical Manual for Assessment and Treatment of Suicidal Patients (Chiles and Strosahl), 441 Clinical plan documentation of, 51, 444–446 alterations of, 453, 572 evidence-based decisions for, 2–3, 446, 453–454 second-guessing, 453 Clinical practice barriers to, in split treatment, 245–246 clinician-patient relationship created by, 550, 550 customary and reasonable, 7, 50, 517, 521, 529 defensive, 546–547 experience in, as psychiatric distress predictor, 484–485, 485
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Clinical practice (continued) risk management for. See Risk management safe guidelines for, 444–452 competent clinical assessment, 444–445 crisis anticipation, 450–451 documentation alterations, 453, 572 documentation of plan, 444–445 emergency management, 447–450 evidence-based decisions, 2–3, 446, 453 informed consent as, 445–446 key points, 454 limitation of prevention measures, 446–447, 451 policy and procedure cautions, 447 suicidality reassessment over time, 446 suicide occurring despite, 452–454 uncertainty factor. See Clinical uncertainty Clinical record. See Documentation Clinical temperament, in split treatment, 243–244 Clinical uncertainty coping with, 423–439 factors influencing, 423–424 in inpatients, 426–434 key points, 437–438 in outpatients, 424–426 risk management for, 436–437 significant others and, 435–436 in split treatment, 245–246 suicide warnings and, 434–435 Clinician-patient relationship actions that create, 550, 550
evidence-based practice benefits for, 2, 446, 453, 511–513 intensity of, as psychiatrist distress predictor, 485, 485 legal duty regarding, 513–516 breach of, 516–520, 551 standard of care, 549–550, 550 as suicide protective factor, 24 Clinicians. See also Psychiatrists credentialing of, 243–244 disclosure of practice capacity, 243–244 reactions to patient suicide, 477–492, 571. See also Reactions safe practice guidelines for, 444–452. See also Clinical practice in split treatment, 235–236 case example of, 246–247 responsibilities of, 241–246 suicide aftermath role, 459–460. See also Survivors of suicide suicide risk related to, 22–23 as survivors, self-care for, 472–473, 473 women, suicide issues related to, 95–97 Clomipramine, 209 Clonazepam, for acute depressive disorder, 265, 269 case example of, 265–266 Close observation in hospitals, 427 in jails/prisons, 149 Clozapine, 212, 214–215 APA guidelines for, 595 for bipolar disorder, 290, 293 in inpatient treatment, 408 for schizophrenia, 306 for substance-using patients, 360
Index Cluster A personality disorders, 330, 331 suicidal behavior with, 333 Cluster B personality disorders, 330, 331 in children/adolescents, 42 gender differences in, 98 suicidal behavior with, 334–336 suicide risk with, 17, 21 substance-related disorders and, 353 Cluster C personality disorders, 330, 331 in children/adolescents, 42 suicidal behavior with, 333–334 CMS (Center for Medicare and Medicaid Services), 430–431 Cocaine use/abuse schizophrenia and, 308 suicide risk with, factors associated with, 355, 355 Cocainism, 348 Cognition deficits, with schizophrenia, 308–309 Cognitive-behavioral therapy APA guidelines for, 596 for children/adolescents, 46–47 for chronic depressive disorder, 271 in outpatient treatment, 370 for personality disorders, 340 for psychiatrist coping with suicide, 486, 487, 488–489 in split treatment, 236 for substance-using patients, 361 Collaborative treatment, 235–236, 241. See also Split treatment in outpatient setting, 370, 372, 425–426 risk management for, 561–563 shared responsibilities for, 244–246
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Collateral information/records emergency assessment of, 392–393 review of, 564, 566 for psychological autopsy, 539, 539 Command hallucinations, suicide risk with, 17–18 Commitment, to treatment. See Treatment compliance Communication in emergency assessment, 392–393 as lethal intent component, 39–41, 41 in outpatient treatment, 370, 372–372, 425 risk management for, 561–563 in split treatment, 245–246, 425–426 of suicidal ideation, 12, 19 for suicide prevention, in jails/ prisons, 145, 146–147 of suicide risk assessment, 585 therapeutic, cultural barriers to, 164 Comorbidity Axis I, 21, 25 of bipolar disorder, 277–278, 280, 283 of depressive disorders, 257–259, 261 emergency assessment of, 387–388, 393 gender differences in, 78, 84, 97, 98 of generalized anxiety disorder, 317–318 national survey on, 13 of panic disorder, 314–316 of personality disorders, 334 of posttraumatic stress disorder, 323–324
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Comorbidity (continued) of schizophrenia, 304–305 of social phobia, 319–320 in stress-diathesis model, 331–332 of substance-related disorders passive/unintentional, 348–349 psychiatric syndromes, 352–353 treatment of, 359, 360–361 suicide risk with, 15, 21 in elderly, 68 Compensation awards, for negligence, 512 Competence, 88 cultural, 159–176. See also Cultural competence professional in risk assessment, 22–23 in split treatment, 243–244 for treatment consent. See Consent to treatment Complaint, in malpractice litigation, 532 Completed suicide aftermath of, 459–476 active postvention model of, 461–463, 462 body identification/viewing, 469–471 case examples of, 466–472 in children/adolescents, 36, 50–51 clinician's role, 459–460 institutional response/barriers in, 460–461, 488 outreach to survivors, 463–473 risk management for, 570–572 safety interventions and, 452–453 self-care for clinicians, 472–473, 473
survivors in, 459–461 in alcohol users, 353–354, 354 bipolar disorder risk for, 277–278, 280 cultural perspectives of, 162–172 in elderly, 63, 71 gender differences in, 77–79, 81, 82, 83 behavioral perspectives of, 88–89 motivation and intent factor, 89–90 neurobiology of, 86, 88 in hospitals, 409, 565 in jails/prisons, 140–141 malpractice litigation and, 527–544. See also Malpractice litigation basic elements of, 549–550, 550 case example of, 527–528 claim trends, 272, 547–549, 548 common negligence allegations, 530, 530, 531 damage to patient, 552–553 deviation from standard of care, 551–552 direct damage from care deviations, 553 key points, 542 psychiatrist as defendant, 528–533 retrospective analysis of intent, 533–542 risk management for, 547–554 suggestions for, 553 mode of. See Suicide mode passive/unintentional, in substance-related disorders, 348–349 psychiatrist reactions to, 477–492, 571. See also Reactions significant dates and, 466
Index statistics on. See Suicide rate survivors of, grief counseling for, 452–453 Compliance/noncompliance. See Treatment compliance Concealment, as lethal intent component, 39–41, 41 Concentration, loss of, suicide risk with, 15 Condolence cards, 466, 572 Conduct disorder in children/adolescents, 42–43 substance-related disorders and, 358 Confidentiality for children/adolescents, 49 in outpatient treatment, 369 of risk assessment, 12–13 statutory waiver of, 13, 571 of suicide warnings, 434–435 Conflicts role, in split treatment, 245–246, 249 unconscious, 221–222 Confrontation, in outpatient treatment, 371 Confucianism, 171 Consent for confidential information disclosure, 13, 392 informed, 445–446 for weapon removal, in elderly, 69 Consent to treatment in children/adolescents, 36, 48–49 for hospitalization, 49 in outpatient setting, 368–369 Consequences of Suicidal Behavior Questionnaire, 443 Consortial murder, 99–100 Constant observation, in jails/ prisons, 149
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Constructive behaviors, for psychiatrist coping with suicide, 486, 487, 489–490 Consultations/consultants APA guidelines for, 592–593 in emergency services, 382 for hospitalization, 406, 407 in outpatient treatment, 370, 372 Contagion effects, of suicide, in children/adolescents, 43–44 Continuum of services, 402 Contraband, search for on admission, 432, 564 Contract law, tort law vs., 515 Control issues, in outpatient treatment, 375–376 Coping style of elderly, 69, 169 gender differences in, 93–94 of psychiatrists, 478–479 with patient suicide, 486–480, 487 substance-related disorders and, 353 of survivors of suicide, 459–460, 462–464 Correctional institutions. See Jails; Prisons Correctional officers inmate suicide prevention role, 146–147 suicide prevention training for, 144–145, 145 Correspondence, in suicide aftermath, 466–467, 572 Cosmetic surgery, 94 Co-twin control method, for research, 127–128 Countertransference negative, in risk assessment, 22 in psychodynamic psychiatry case example of, 229–231
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Countertransference (continued) in psychodynamic psychiatry (continued) monitoring of, 225, 226, 590 pitfalls with, 224–225 CPR (cardiopulmonary resuscitation), for suicide attempt, in jails/prisons, 148–149 Credentialing, of clinicians, 243–244 Criminal(s) incarceration of. See Jails; Prisons suicide viewed as, 171 Criminal litigation, psychological autopsy for, 534, 537–538 Crises, suicidal. See Suicidal crises Crisis Card, 451 Crisis counselors, 381 Crisis lines, for survivors of suicide, 465 Critical incident stress debriefing (CISD), 150, 412 CSF (cerebrospinal fluid), 5-HIAA in, gender and, 86, 88 Cults, murder-suicide and, 502, 505–506 Cultural competence, in risk assessment, 159–176 acculturation and, 162–163 age factor, 167–169 case examples of, 165, 170 definition of, 160 economic factors, 166–167 ethnicity and, 160, 169–170 family support and, 166–167 immigration and, 162–163 interpersonal factors, 166–167 key points, 171–172 marital status and, 166–167, 170 religion and, 165–166 terminology for, 159–160 therapeutic alliance for, 163–164
variables of, 160–161 Cultural sanctions as protective factor, 23–24, 171 for women, 91–94 for suicide, 108, 170, 171 Culture definition of, 159–160 as suicide factor, 107–137. See also Sociocultural context Customary practice, as clinician duty, 7, 50, 517, 521, 523, 529 deviation from, 551–552 direct damage from deviation of, 552–553 Cutting with personality disorders, 331 as suicide method, 37, 87 suicide risk with, 13, 21 in children/adolescents, 39 in hospitals, 413 Cyclothymia, 277 Damages in malpractice claims, 549–550, 550 for medical negligence, 512, 529, 530 from standard of care deviation, 551–553 direct, 553 Danger, confidential information disclosure based on, 12–13 Darkness at Noon (Koestler), 504 Data clinical. See Clinical data demographic. See Demographic factors Dates, significant, for survivors of suicide, 466 Day programs, for outpatient treatment, 369 DBT. See Dialectical behavior therapy (DBT)
Index Death mode of. See Suicide mode from suicide. See Completed suicide Death date, 466 Death ideation (DI), in elderly, 60, 61–62, 63, 71 Death rate in jails/prisons, 140–141 from suicide. See Suicide rate Death registries, linkage studies to physical illness registries, 64 Debriefing, critical incident stress, 150, 412 Defendant, in malpractice litigation, 531–533, 572 Defensive practices, no-suicide contract as, 546–547 Dehydration, 349 Delegation, of risk assessment, 12 Delirium, suicide risk with, 64 Delusions, 16, 372 Dementia, suicide risk with, 64 Demographic factors of suicide, 107–137 with bipolar disorder, 283 egocentrism vs., 108 ethnicity and, 116–123. See also Ethnicity gay, lesbian, bisexual, and transgender individuals, 127–128 gender differences, 79, 81–82 HIV/AIDS and, 64, 128–130 international perspectives, 112–116. See also International rates key points, 132–133 occupation and, 125–127 paradox of, 107–108 rate data on, 109–112, 110
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religion and, 124–125 socioeconomic change and, 130–132 Tikopia case study, 109 unemployment and, 130–132 in suicide risk assessment, 5, 16–17, 24. See also specific factor DeMontiney v. Desert Manor Convalescent Center, 522 Demoralization in elderly, 64, 66 with hospitalization, 394 Demurrer, in malpractice litigation, 532 Denial by patients, of suicidal ideation, 12, 262 as psychiatrist reaction to suicide, 480, 480, 486, 571 Dentists, suicide rate of, 125–126 Dependency gender differences in, 88, 90, 92 murder-suicide related to, 501–503 Depersonalization, as psychiatrist reaction to suicide, 480, 480, 571 Depositions, in malpractice litigation, 532–533 Depression/depressive disorders, 255–275 acute high risk for, 256, 258–259 chronic risk vs., 257 management of, 264–270 APA treatment guidelines for, 594–596 Beck Inventory for, 177, 186–187 chronic high risk for, 256–258 acute risk vs., 257 management of, 270–272 comorbidities of, 257, 261 severity risk and, 257–259
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Depression/depressive disorders (continued) in elderly, 66, 70, 71 electroconvulsive therapy case example, 201–204 ethnicity and, 116–123 gender differences of, 84, 94 Hamilton Rating Scale for, 270 history of illness and, 261 hopelessness in, 256–257, 262–263 case example of, 268–269 management of, 267–268 hospitalization for, 265–266 key points, 272–273 literature review, 255–256 major. See Major depressive disorder meta-analysis of trends, 255–256 Minnesota Multiphasic Personality Inventory–2 of, 179, 180–182 murder-suicide related to, 499–501, 504 pharmacotherapy case examples, 201–204, 265–266 postpartum, 98–99, 100 murder-suicide related to, 504–505 “postpsychotic,” 304–305, 307–308 protective factors for, 267 as psychiatrist reaction to suicide, 479 psychotic vs. nonpsychotic, 16 schizophrenia and assessment issues with, 305, 307–308 as comorbidity, 304–305 sleep disorders and, 256, 269, 372 social phobia and, 319–320 suicidal ideation and, 261–263 case example of, 263–264
suicidality at worst period, 261 suicide plan and, 261–263 case example of, 263–264 suicide prevention failure and, 272 suicide risk assessment in, 256–261 anxiety severity, 258–261, 260 chronic vs. acute, 257 current clinical state, 256–259 risk severity, 256–259 suicidal tendencies, 260–261, 262 timing of, 260–261 suicide risk management acute high, 264–270 chronic high, 270–272 substance-related disorders and, 352, 360–361 treatment-refractory, 286 unipolar, bipolar disorder vs., 282–283, 288 Dereliction of duty damage caused by, 552–553 in medical negligence, 529, 530, 551–553 Desipramine, 209, 360 Despair murder-suicide related to, 501–502 as outpatient crisis marker, 372 Desperation, as outpatient crisis marker, 372–374 Detoxification, safe, for substanceusing patients, 359, 359 Deviation, from standard of care in malpractice claims, 549–550, 550 in medical negligence, 529, 530, 551–553 DI (death ideation), in elderly, 60, 61–62, 63, 71
Index Diagnostic evaluation. See Psychiatric evaluation Dialectical behavior therapy (DBT) APA guidelines for, 596 in inpatient treatment, 410 in outpatient treatment, 370–371 for personality disorders, 339–340 for substance-using patients, 361 Dignity, personal, 88, 101, 413 , 430 Direct cause in malpractice claims, 549–550, 550 in medical negligence, 529, 530 in standard of care deviation, 551–553 Disability Eastman case study, 57–59, 64, 66, 67 in elderly, 64, 66, 69, 71 murder-suicide related to, 503–504 suicide as cause of, internationally, 112, 113 Disappointment, murder-suicide related to, 500–501, 506 case example of, 501–502 Disbelief, as psychiatrist reaction to suicide, 480, 480 Discharge assessments importance of, 402 for against medical advice, 404–405, 433 planned, 405, 405–406 premature, 426, 433–434, 564 systematic, 6, 10–11, 564, 582 Discharge plan for children/adolescents, 45–46 guidelines for, 405, 405–406, 564 Discipline problems, in children/ adolescents, 42 Disclosure by clinicians
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of practice capacity, 243–244 of suicide warnings, 434–435 of treatment limitations, 468 by patient elderly, 69 during emergency assessment, 392–393 split treatment and, 238, 248 of suicidal ideation, 12, 19 of risk cultural views of, 164 ethics of, 12–13 Discovery, in malpractice litigation, 532–533 Discussions, clinical. See also Collaborative treatment in split treatment, 245 Disillusionment, murder-suicide related to, 500–501 case example of, 501–502 political, 505–506 Disruptive behaviors substance-related disorders and, 357–358 suicide risk with, 20, 22 Dissociation, as outpatient crisis marker, 372 Distress, as psychiatrist reaction to suicide, 478–479, 571 predictors of, 484–486, 485 Disulfiram, 361 Divalproex sodium APA guidelines for, 594 for bipolar disorder, 293 for personality disorders, 341 Divorce, suicide risk with, 17 in children/adolescents, 43 Doctors. See Physicians; Psychiatrists Documentation alterations after the fact, 453, 572 APA guidelines for, 593 case example of, 593
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Documentation (continued) collateral emergency assessment of, 392–393 review of, for psychological autopsy, 539, 539 of emergency interventions, 395–396 obtaining copy after suicide, 572 of risk assessment, 9, 11–12 APA guidelines for, 582, 585 for children/adolescents, 51 sample note for, 24, 25 of treatment plan, 51, 444–445 Domestic violence, murder-suicide connected to, 495, 496 clinical factors of, 500–501 difficulties in assessing, 496–497 epidemiological perspectives of, 497–500 Do no harm negligence and, 512–513, 524 as safety principle, 442–443, 443 Dopamine D 2 receptor, psychosis and, 306 Dopamine-norepinephrine reuptake inhibitors, 209 use and efficacy of, 206–208 “Double-suicide,” 498, 503 Doxepin, 209 Dreams, as psychiatrist reaction to suicide, 479 Drowning, as suicide method, 86–87 Drug abuse. See Substance use/ abuse Drug therapy. See Pharmacotherapy Dual diagnoses, in substance-using patients, 352–353
treatment of, 359, 360–361 Duloxetine, 209 Duration of illness. See Illness duration Durkheim, Emile, 77, 83, 107, 165–166 Duty of care, 549–551, 550 dereliction of in malpractice claims, 549–550, 550 in medical negligence, 529, 530 as legal principle, 512, 513–516 breach of, 512, 516–520, 551 damage with deviation from, 551–553 to patient vs. family, 548 to remove firearms, 434, 523 Dysphoria, with dopamine D2 receptor antagonism, 306 Dysphoric-irritable states, 282–283, 286 Dysthymia, 279 Eastern cultures, risk assessment views in, 162, 164, 166, 171 Eastman, George, 57–59, 63, 64, 66, 67 Eating disorders, as panic disorder comorbidity, 315 ECA (Epidemiologic Catchment Area) study, 314, 353, 355 ECDS (Empirical Criteria for Determination of Suicide), 539, 540 Economic factors, suicide related to, 130–132 cultural perspectives of, 166–167 ECT. See Electroconvulsive therapy (ECT)
Index Educational programs for suicide prevention in elderly, 72 for hospitalization pharmacotherapy, 409–410 psychoeducational therapy, 410 staff training, 411–412 for jail/prison staff, 144–145, 145 for substance-related disorders, 361 Egocentric personality, 108 Egocentric societies, 108 Ego psychology, 221, 223–224 Elderly, suicide in, 57–76 assessment of, 69 attempts for, 60, 63 completed, 63, 71 Eastman case study, 57–59 epidemiology of, 59–60, 63 ideation in, 60, 61–62, 63 depression and, 66, 71 detection of, 68 key points, 73–74 lethality of method, 63, 69, 70 management of, 68–72 aggressive intervention for, 69 risk-based preventive approaches to, 70–72 murder-suicide in, 495, 496 clinical factors of, 500–501 difficulties in assessing, 496–497 epidemiological perspectives of, 497–500 personality traits and, 67–68 physical illness factor, 64, 66 prevention of, 20, 70–72, 71 indicated approaches for, 70–71 selective approaches for, 71–72 universal approaches for, 72
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psychiatric illness correlates, 63–64, 65, 69 “psychological autopsy” studies of, 63–64, 65, 67 rate of, 20, 59–60, 60 cultural perspectives of, 167–169 ethnicity correlations, 112 risk factors for, 59–68, 63, 67 social support factors, 66–67, 69 prevention role, 70–72 stress factor, 66–67 substance-related disorders and, 358 treatment compliance and, 70–71 Electroconvulsive therapy (ECT), 199–220 antidepressants and, 200–201, 206 APA guidelines for, 595 for bipolar disorder, 291, 293 case examples of, 201–206 importance of, 200–201 indications for, 199–220 in inpatient treatment, 409 key points, 217–218 long-term impact of, 200–201, 402 multidisciplinary approach to, 200 pharmacotherapy vs., 206–216, 209–212 short-term effects of, 216–217 Elopement, 415–416 E-mail in split treatment, 245 for survivors of suicide support, 466 Emergencies confidential information disclosure based on, 13 response to in hospitals, 409 in jails/prisons, 148–149 safe practices for, 447–450
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Emergency Medical Treatment and Active Labor Act (EMTALA), patient transfer regulations, 388, 396, 568 Emergency services, 381–400 case example of, 383–387 consultative model of, 382 key points, 396–398 patient safety principles for, 447–450 psychiatric assessment for additional history and examination, 389 alcohol and substance use, 390, 395 collateral information, 392–393 follow-up outpatient treatment, 395 hospitalization decision, 393–395 intervention recommendations, 395–396 medical status, 387–388 models of, 381–382 patient safety, 388–389 psychiatric history, 391–392 psychosocial factors, 390–391 recommended, documentation of, 395–396 release from, APA guidelines for, 590, 591 risk management for, 567–570 state-specific legal criteria for, 395 suicide risk assessment and, 381–382 transfer to another facility regulations, 388, 396, 568 variability across facilities, 381–382 Emotional pain of completed suicide, 452–453 loss-related. See Loss
in personality disorders, 335, 337 Emotions gender differences in, 88–89, 92 of psychiatrist, 590 with patient suicide, 477–491 self-examination instruments for, 443 Empathy, 92 Empirical Criteria for Determination of Suicide (ECDS), 539, 540 Employability. See Functionality Employees, murder-suicide by, 505–506 EMTALA (Emergency Medical Treatment and Active Labor Act), patient transfer regulations, 388, 396, 568 Entitlement, narcissistic, 501 Entrapment, 372 Environmental factors of child/adolescent suicide, 44 of suicide in elderly, 69 of hospital safety, 413 Epidemiologic Catchment Area (ECA) study, 314, 353, 355 Epidemiology, of inpatient treatment, 402–403 Escitalopram, 207, 209 Escort staff, in hospitals, 408, 416 Estimation, of suicide risk, APA guidelines for, 586–589, 587–588 “Ethic of care,” 93 Ethics first do no harm, 442–443, 443 gender differences in, 93 of risk disclosure, 12–13 in split treatment, 243–244, 248–249 of suicide warnings, 434–435
Index Ethnicity. See also specific ethnicity assisted suicide and, 101 definition of, 160 suicide rate based on, 109–112, 110 HIV/AIDS and, 64, 128–130 suicide risk with, 16–17 in America, 116–123 in children/adolescents, 37 as cultural factor, 160, 169–170 in elderly, 60, 60 gender differences in, 79, 82, 84, 101 Euthanasia, gendered issues of, 101 Evidence, preponderance of, 552–553 Evidence-based treatment, 2–3 for malpractice risk reduction, 511–512 as safe practice, 446, 453–454 Exemplary damages, in medical negligence, 529 Experiences clinical practice, as psychiatrist distress predictor, 484–485, 485 personal sharing of, for psychiatrist coping with suicide, 490 Expert opinions, 531–532 as legal testimony, 517, 520 on standard of care, 545, 551–552 Exposure, to suicide, child/ adolescent suicide and, 43–44 Extrapyramidal symptoms, of psychotropic drugs, 239 Fact finder, legal role of, 516–517 Failure(s), suicide risk with, 11–12, 167, 272 Falls, as suicide method, 86–87 Familial transmission, of suicide risk, 17
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Familicides, 504 Family interviews, for psychological autopsy, 539, 539 conducting, 540–542 Family relationships in child/adolescent suicide, 43–44 in suicide in elderly, 66–67, 71 emergency assessment of, 390–391 of psychiatrists, in aftermath of suicide, 478–479 substance-related disorders and, 357–358 in suicide aftermath, 459–460. See also Survivors of suicide supervision issues with, 435–436 Family support, as suicide protective factor in children/adolescents, 43, 48–49 cultural perspectives of, 166–167, 168 ethnicity and, 121 in outpatient treatment, 369 patient safety vs. freedom and, 435–436 religiosity influence on, 165–166 Fantasies interpersonal, in psychodynamic psychiatry, 225, 226 as psychiatrist reaction to suicide, 479 Fantasy of suicide, in psychodynamic psychiatry, 225, 226 Farwell v. Un, 521 FAST (Firestone Assessment for SelfDestructive Thoughts), 188–189 Fatal Flaws (Yudofsky), 206 Fatalism, 488 Fathers, murder-suicide by, 100 Faultfinding. See Blame
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FDA (Food and Drug Administration), U.S., antidepressant warning, 47 Fear of blame, as psychiatrist reaction to suicide, 480, 481–482, 570–571 Federal Tort Claims Act (1946), 548–549 Feelings, as psychiatrist reaction to suicide, 479–480 conflicting, 480, 484 Fernandez v. Baruch, 523 Filicide-suicide, 100, 504–505 Financial issues in aftermath of suicide, 460–461, 467 split treatment based on, 235–236, 239–240 Financial stress in children/adolescents, 44 cultural perspectives of, 167 in elderly, 66, 69 gender differences in, 81, 82 murder-suicide related to, 503 Firearms discharge plan consideration of, 406 legislative restriction of, 72 in murder-suicide, 499 as suicide method in children/adolescents, 37, 42, 44, 48–49 duty to remove, 434, 523 in elderly, 63, 68, 69, 72 ethnicity correlations, 110–111 gender differences in, 84–85, 86–87, 100 in rural vs. urban areas, 116 Firestone Assessment for SelfDestructive Thoughts (FAST), 188–189
First aid, for suicide attempt, in jails/ prisons, 148–149 First do no harm, 442–443, 443 Firth, R., 109 Fluoxetine, 207, 209 for children/adolescents, 47 for personality disorders, 341 Flupenthixol, 342 Fluphenazine, 211, 214 Fluvoxamine, 207, 209 Follow-up plan APA guidelines for, 590, 591 for children/adolescents, 45–46 for elderly, 69 for emergency services, 395 for jail/prison suicides, 150 for survivors of suicide, 463–466 Food and Drug Administration (FDA), U.S., antidepressant warning, 47 Forensics. See Psychological autopsy Foreseeability, reasonable preventability vs., 549 of risk, 7, 50, 517, 521, 523, 529 Freedom of movement autonomy factor, 431–432, 566 clinically based risk management and, 436–437, 437 for inpatients, 426–434 key points, 437–438 for outpatients, 424–426 patient safety vs., 423–439 professional judgments of, 423–425 significant others and, 435–436 suicide warnings and, 434–435 Functionality Eastman case study, 57–59, 64, 66, 67 in elderly, 64, 66, 69, 71 emergency assessment of, 387–388, 393–395
Index gender differences in, 81–82, 83, 101 with obsessive-compulsive disorder, 321–322 with schizophrenia, 304, 308–309 of survivors of suicide, 463–464 Funerals, attendance of clinician at, 572 Gabapentin, APA guidelines for, 594 GAD. See Generalized anxiety disorder (GAD) Gamma-hydroxybutyrate use/ abuse, suicide risk with, 356 Gay, lesbian, bisexual, and transgender (GLBT) youth, 127–128 Gay individuals children/adolescents as, suicide risk in, 45, 127 suicide rate of, 127–128 Gender, suicide and, 77–105 age factor, 79, 81–82 attempts data, 78, 98 case examples of, 79–81 completed, 77–79, 81, 82, 83 behavioral perspectives of, 88–89 motivation and intent factor, 89–90 neurobiology of, 86, 88 demographic risk factors of, 79, 81–82 epidemiological studies of, 77–78, 93 help-seeking behaviors, 88–89, 90 historical social factors, 83 HIV/AIDS and, 128–130 ideation differences, 83, 86, 88 issues related to, 94–101 assisted suicide, 101 childhood sexual abuse, 95
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murder-suicide, 99–100 personality disorders, 97–98 pregnancy and postpartum period, 98–99, 100 women physicians, 95–97, 486 key points, 101–102 lethality of method, 84–86, 86–87 motivation and intent, 89–90 neurobiology differences, 86, 88 in panic disorder, 315 paradox in, 78–79, 82 explanations for, 82–90 personality factor, 88, 90–92 plans/planning differences, 83, 86, 88 posttraumatic stress disorder trends, 323–324 protective factors in women, 90–94 as psychiatrist distress predictor, 485, 486 race factor, 79, 82 rate data, 77, 97 ethnicity correlations, 110–112, 117 occupation correlations, 95–96, 126 risk associations, 16–17, 19, 20, 94 with bipolar disorder, 279, 280 in children/adolescents, 36–37, 39 socially constructed role and, 82–83 substance abuse/dependence patterns, 83–84, 85 substance-related disorders and, 358 “Gender paradox of suicidal behavior,” 78–79, 82 standard explanations for, 82–90 General damages, in medical negligence, 529
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Generalized anxiety disorder (GAD) case example of, 316–317 depression comorbidity with, STAR*D trial of, 317–318 suicide risk with, 15, 317–318 Genetics, of suicide risk, 17 addiction similarities, 349–350 in children/adolescents, 45 Geriatric assessment clinic, 71 Geriatric population. See Elderly “Gestures,” of suicide, 90, 98 GLBT (gay, lesbian, bisexual, and transgender) youth, 45, 127–128 Glucose level, emergency assessment of, 388 Good Samaritan statutes, 513 Graphic flow sheets, for inpatient observations, 414 Grief counseling active postvention model of, 461–463, 462 for survivors, 452–453 Grief/grieving in elderly, 66 as psychiatrist reaction to suicide, 480, 481–482 in suicide aftermath, 36, 50, 459 after initial period, 463–473 during initial period, 463–466 psychological autopsy consideration of, 540–542 Gross v. Allen, 434 Group therapy, in outpatient treatment, 369 Guilt, as reaction to suicide, 542 by psychiatrist, 480, 481–482, 486, 571 Guns. See Firearms Hallucinations auditory inpatient treatment of, 409
suicide risk with, 17–18 suicide risk with, 17 Hallucinogens use/abuse, suicide risk with, 356 Haloperidol, 211, 214 for schizophrenia, 306 Hamilton Rating Scale for Depression, 270 Handcuffs, 148 Handguns, regulation of, 72 Haney, Adam, 470–471 Hanging in hospitals, 413 in murder-suicide, 499 as suicide method, 37, 86–87 Harm as legal principle, 513, 524 strategies for prevention of, 442–443, 443 Hatred, psychodynamic therapy and, 224–225 Health mental. See Mental status examination physical. See Physical health Health Care Financing Administration (HCFA), 430 Health care services. See Mental health care Health insurance for hospitalization, 265 involuntary, 375, 423 lack of, murder-suicide related to, 503 managed model of. See Managed care split treatment and, 236, 239–240 Hearings, in malpractice litigation, 532 Heaven, 505 Helling v. Carey, 517–518
Index Help-seeking behaviors, gender differences in, 88–89, 90 Hemlock Society, 499 5-HIAA (5-hydroxyindoleacetic acid), gender and, 86, 88 Hinduism, 124–125, 170 Hispanic Americans suicide perspectives of, 118–120 suicide rate in, 109, 111, 112 cultural competence and, 168, 171 History of illness. See Illness duration History taking, during emergency assessment, 389 Histrionic personality disorder, 334, 342 HIV/AIDS, 64, 128–130, 140 Holidays, in aftermath of suicide, 466 Holmes, Oliver Wendell, Jr., 517–519 Homicide rate Brady Act impact on, 72 rural vs. urban, 116 Homicide-suicide, 99–100, 499, 506. See also Murder-suicide litigation on, 537 Homosexuality suicide rate related to, 127–128 suicide risk and, in children/ adolescents, 45 Hong Kong, posttransition, suicide rate in, 115–116 Hope, maintaining realistic, 267–268 Hopelessness Beck Scale for, 177, 186–187 in children/adolescents, 43, 47 depressive disorders and, 256–257, 262–263 case example of, 268–269 management of, 267–268 in elderly, 64
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murder-suicide related to, 500–501, 505 as outpatient crisis marker, 372 suicide risk with, 16, 19, 20, 23 with bipolar disorder, 283 with schizophrenia, 304 Hospitalization, 401–419 for acute depressive disorder, 265 case example of, 265–266 admission assessments case example, 403 contraband search during, 432 emergency, 381–382, 393, 433, 449 guidelines for, 404, 590, 591 medical necessity in, 406, 406–407 patient safety vs. freedom during, 424–425, 431, 433 systematic, 5, 8–9, 564 APA guidelines for, 404, 590, 591 case example of, 411 consent for, 49 consultations for, 406, 407 continuum of services with, 402 dialectical behavior therapy with, 410 discharge assessments importance of, 402 for against medical advice, 404–405, 433 planned, 405, 405–406 premature, 426, 433–434 systematic, 6, 10–11, 564, 582 of elderly, 69 electroconvulsive therapy for, 409 elopement from, 415–416 emergency, 381, 393–395, 433, 449 epidemiology of, 402–403 forces influencing, 401–402 graphic flow sheets for, 414 insurance coverage for, 265
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Hospitalization (continued) interpersonal interaction during, 408 involuntary, 401, 425, 558 for children/adolescents, 49 insurance coverage for, 375, 423 key points, 417 length of stay averages, 401–402, 426, 564 in managed care systems, 406, 406, 426 mental status changes during, 408–410 necessity for, severity threshold for, 51 negligence allegations related to, 530, 530 observation levels during, 407–408, 414–415 occupational health issues with, 412 organizational and system issues of, 412–416 outpatient treatment vs., 367, 375 patient control of, 375–376 partial. See Partial hospitalization patient safety vs. freedom during, 426–434 for personality disorders, 338, 339 pharmacotherapy for, 408–409 education on, 409–410 as psychiatrist distress predictor, 485, 485–486 psychoeducational therapy for, 410 psychotherapy goals during, 410 risk management for, 564–567 safety contracts vs., 394 safety policies for, 412–415 second opinions for, 406, 407 self-efficacy reduction with, 451
staff shift changes and, 414 staff training and education for, 411–412 state-specific legal criteria for, 395 statistical trends, 401–402 suicidal crisis response, 409 supervision levels during, 407 for survivors of suicide, 467–468 therapeutic pass and, 415–416 transfer to another facility, 388, 396 treatment and interventions with, 407–411 voluntary, 558 Hostility in elderly, 67 with schizophrenia, 309 Housing, in jails/prisons, for suicide prevention, 145, 146–148 Huntington's disease, 64 Husbands, murder-suicide by, 99–100 5-Hydroxyindoleacetic acid (5-HIAA), gender and, 86, 88 Hyperthermia, 349 Hypnotics use/abuse, suicide risk with, 356–357 Hypochondriasis, in elderly, 67 Hypoglycemia, emergency assessment of, 388 Hypomania Minnesota Multiphasic Personality Inventory–2 of, 179, 180–182 suicide rate with, 2 suicide risk with, 16, 17, 282–283 Ideal practices, 545 Idiomatic phrases, in risk assessment, 23
Index Illness mental. See Psychiatric disorders; specific illness physical. See Physical illness/ disorders Illness duration, risk based on in bipolar disorder, 282 in depressive disorders, 261 in schizophrenia, 309 Illness severity, risk based on in affective disorders, 258–260, 260 in bipolar disorder, 279–280 in depressive disorders, 257–259 hospitalization and, 51 in suicidal ideation, 41–42 Imipramine, 209 Imitation, of suicide, in children/ adolescents, 43–44 Immigrants, acculturation of, 162–163 Imminence, of suicide confidential information disclosure based on, 13 patient safety vs. freedom and, 429–430 risk assessment for, 22, 549 Impact of Event Scale, 478 Impulsivity with bipolar disorder, 283, 285–286 in depressive disorders, 257 Minnesota Multiphasic Personality Inventory–2 of, 179, 180–182 in personality disorders, 335 psychodynamic therapy and, 224 in stress-diathesis model, 331 in substance-related disorders, 347, 348, 351, 357–358 suicide risk with, 21, 22 in children/adolescents, 43–45 Impunity, 513
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Incarceration. See Jails; Prisons Incompetence. See Competence Independence, rigid, in elderly, 67 Indicated interventions, for suicide prevention, in elderly, 70–71, 71 Indigenous populations, suicide rates in, 162–163. See also specific group Individual factors, in suicide risk assessment, 4, 24 Individualism, 122–123 insufficient, 170 Industrialization, 168 Infanticidal murder-suicide, 495, 496 clinical factors of, 500–501 difficulties in assessing, 496–497 epidemiological perspectives of, 497–500 Infanticide, 100 Infidelity, murder-suicide related to, 501–502 Informed consent, 445–446 Inhalant use/abuse, suicide risk with, 355–356 Inheritance litigation, 534, 537 Initial reactions, psychiatrist, to patient suicide, 480, 480, 571 Inmates. See Jails; Prisons Inpatients, safety vs. freedom of, 426–434 autonomy rationale in, 431–432 factors influencing, 426–427 imminent suicide and, 429–430 in intensive care unit, 430 observation levels and, 427–429 outpatients vs., 424–426 policies and procedures for, 432–433 premature discharge and, 426, 433–434 restraint and, 430–431 seclusion and, 430–431
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Inpatient treatment. See Hospitalization Insane suicide, sane vs., 535 Insomnia in depressive disorders, 256, 269 global, suicide risk with, 15 Institutional response, to completed suicide, 460–461, 488 Insurance malpractice. See Malpractice insurance for mental health. See Health insurance Intake screening. See also Admission assessments for suicide prevention, in jails/ prisons, 145, 145–146, 146 Intensity of involvement, as psychiatrist distress predictor, 485, 485 Intentional tort, 528, 529 Intentional wrongdoing, 549 Interest, loss of, suicide risk with, 15 Internal object relations theory, 221, 223–224 International rates of murder-suicide, 497–500 of suicide, 112–116 America, 116, 162–163 China, 114–115 cultural factors, 160–161 disabilities related to, 112, 113 Hong Kong, posttransition, 115–116 Russia, 113, 114 Internet resources, for survivors of suicide, 466 Interpersonal fantasies, in psychodynamic psychiatry, 225, 226 Interpersonal interaction, during hospitalization, 408, 416
Interpersonal relationships in child/adolescent suicide, 42, 43 cultural perspectives of, 166–167 in suicide in elderly, 66–67 gender differences in, 83, 89, 92 murder-suicide and, 495–509 specific dynamics of, 501–506 patient safety vs. freedom and, 435–436 of psychiatrists, in aftermath of suicide, 478–479 as suicide protective factor, 23–24 in children/adolescents, 43 in suicide risk assessment, 5, 24 Interpersonal therapy (IPT) APA guidelines for, 596 in outpatient treatment, 370–371 Interrogatories answer to, 532 in malpractice litigation, 532 Intervening cause, 521–522 Interventions during hospitalization, 407–411 for jail/prison suicides, 145, 149 Interviews patient. See Clinical interview for psychological autopsy, 539, 539–542 Intoxicated patients, admission assessment of, 405 Intrapsychic experience, in borderline personality disorder, 333, 335–336 Involuntary hospitalization, 401, 425, 558 for children/adolescents, 49 insurance coverage for, 375, 423 Involvement intensity of, as psychiatrist distress predictor, 485, 485 therapeutic, as suicide protective factor, 24
Index IPT. See Interpersonal therapy (IPT) Isolation decreasing, for psychiatrist coping with suicide, 486–488, 487 murder-suicide related to, 498, 505–506 social in elderly, 67, 71 in immigrants, 163 of survivors of suicide, 466 Jackson v. State, 538 Jails, suicide prevention in, 139–155 case examples of, 142–143, 151 children/adolescents and, 44 communication for, 146–147 comprehensive policy for, 144, 145 death rate related to, 140–141 definitions, 139 follow-up for, 150 housing for, 146–148 intake screening for, 145–146, 146 interventions for, 149 key points, 152–153 levels of supervision for, 148–149 mortality review for, 150, 150 negative attitudes impact on, 143–144 ongoing assessment for, 145–146, 146 population statistics, 139 programming for, 143–151 psychiatric disorders prevalence, 140, 141 reporting for, 149–150 staff training for, 144–145 substance-related disorders and, 357 suicide rate and, 140 victim characteristics, 141, 141–142
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Jews, suicide views of, 125, 165 Johnson v. United States, 432 Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 413, 416, 430–431, 565 Jones, James, 502 Jonestown, Guyana, 502 Judgment, in malpractice litigation, 533 Judicial decisions hearings for, 532 on negligence, 515, 517–519, 521 Jury, instructions for, 519–520 Kamikaze missions, 170 Ketamine use/abuse, suicide risk with, 356 Kockelman v. Segals, 557 Koss-Butcher Critical Item Set— Revised, of MMPI-2, 179 Lamotrigine, 211, 214 for bipolar disorder, 289, 293 Language skills, in risk assessment, 22–23 Latinos suicide perspectives of, 118–120 HIV/AIDS and, 129 suicide rate in, 109, 111, 112 Lawsuits civil. See also Torts/tort law common reasons for, 444, 444 malpractice. See Malpractice litigation Laypersons, suicide risk assessment by, 11 Learning disabilities, in children/ adolescents, 42, 358 Legal perspectives, 511–526 in aftermath of suicide, 460–461, 467 apology as, 470–472
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Legal perspectives (continued) breach of duty as, 512, 516–520 from standard of care, 551–553 cause/causation as, 512, 520–523 duty as, 512, 513–516 of care, 549–550, 550 of expert testimony, 517, 520 harm as, 513, 524 of hospitalization, 401–402 key points, 524–525 of malpractice risks, 511–513. See also Malpractice litigation negligence as, 7, 512–513 of taxonomies of malpractice cases, 518–519 of treatment for children/adolescents, 36, 48–51 for depressive disorders, 272 Legal problems, of children/ adolescents, 42 Length of stay, for hospitalization, 401–402, 426, 564 Lesbians, suicide rate of, 127–128 Lethality of suicidal behavior affective disorders and, 280–281, 281 assessing intent for, 39, 41 bipolar disorder and, 280–281, 281 definition of, 21, 579 gender differences in, 84–86, 86, 87 motivation and intent factor, 89–90 increased, in elderly, 63, 69, 70 legislative restriction of, 72 misjudgment of, by children/ adolescents, 39–40 passive/unintentional, in substance-related disorders, 349 psychiatric evaluation of, 582, 583–585
Level of consciousness, emergency assessment of, 387–388 Liability of psychiatrists, 512–513, 520, 523, 551, 570. See also Legal perspectives in outpatient treatment, 558, 558–559 strict, 528, 529 Licensure, professional, split treatment and, 242–243 Life events, negative for children/adolescents, 43–44 for elderly, 66–67 for psychiatrists, 477–478 in psychodynamic psychiatry, 225, 226 suicide as. See Completed suicide; Survivors of suicide (SOS) suicide risk with, 16, 21 Life insurance claims, litigation and, 534, 535–536 Life span, suicide rate based on ethnicity, 112 Life transitions, in elderly, 66 Linehan Reasons for Living Inventory (LRFL), 189 Lithium salts adverse effects of overdose, 210 for anguish, 374 APA guidelines for, 594–595 for bipolar disorder, 287–289, 288, 293 for depressive disorder acute, 268–269 chronic, 270–271 evidence-based use of, 454 in inpatient treatment, 408 for personality disorders, 341 for substance-using patients, 360 use and efficacy of, 208, 213
Index Litigation civil. See also Torts/tort law common reasons for, 444, 444 on patient suicide, 527–544. See also Malpractice litigation Living, reasons for. See Meaning in life Local Outreach to Suicide Survivors (LOSS), 461–463, 469 Los Angeles Suicide Prevention Center scale, 185 Loss of concentration, 15 of control, 88, 101 of interest, 15 murder-suicide related to, 500–501 of pleasure, 15 of reasons for living. See Meaning in life suicide risk with, 15, 20, 23, 107 in children/adolescents, 42, 44 cultural perspectives of, 167 gender differences in, 92–94 of support groups, in outpatient treatment, 371–372 of trust, after completed suicide, 467–468 Love triangles, murder-suicide related to, 501–502 Loxapine, 211, 214 LRFL (Linehan Reasons for Living Inventory), 189 Major depressive disorder (MDD) APA treatment guidelines for, 594–596 in children/adolescents, 42–43, 45, 49 in elderly, 63, 65, 169 gender differences in, 77–78 suicide rate with, 2
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suicide risk with, 2, 13, 15, 16, 20, 21, 22, 23 in bipolar disorder, 282–283, 288 generalized anxiety disorder and, 317–318 treatment of, STAR*D trial of, 317 “Male depressive syndrome,” 94 Male-female relationships, cultural perspectives of, 167 Malignant neoplasms, 64 Malpractice insurance disclosure of coverage, 243 response to completed suicide, 460–461 risk management with, 50, 452, 512. See also Risk management clinically based, 545–575 suicide claim statistics, 547–549, 548 Malpractice litigation apologies and, 470–471 case example of, 527–528 civil lawsuits vs., 444, 444 clinical uncertainty and, 423–424, 425 defense practice based on, 546–547 evidence for, 552–553 key points, 542 legal aspects of, 511–513. See also Legal perspectives legal concepts for, 528–529, 529 liability factors, 512–513, 520, 523, 551, 570 in outpatient treatment, 558, 558–559 prevalence of, 527 professional judgment factors, 423–425, 447 psychiatrist as defendant, 528–533
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Malpractice litigation (continued) risk assessment adequacy standards and, 7 risk management for, 50–51, 452, 511–512 clinically based, 547–554, 548 safety precautions and, 423, 432 stages of, 531–533 suicidal intent and, retrospective analysis of, 533–542. See also Psychological autopsy suicide and, 527, 547–554 basic elements of, 549–550, 550 claim trends, 272, 547–549, 548 damage to patient, 552–553 deviation from standard of care, 551–552 direct damage from care deviations, 553 suggestions for, 553 for suicide prevention failure, 272 on suicide risk assessment, taxonomy of, 518–519 treatment settings and, 529–530 common inpatient allegations, 530, 530 common outpatient allegations, 530, 531 Managed care hospital admissions with, 406, 406, 426 treatment influences by outpatient, 557–559 risk management suggestions for, 559–560, 572 Mania, 277, 282 Manic-depression, 282–283, 287–288 Manipulativeness, 92 MAOIs. See Monoamine oxidase inhibitors (MAOIs) Marginality, sociocultural, 163
Marital status murder-suicide and, 99–100 suicide risk with, 16–17 cultural factors, 166–167, 170 gender differences in, 81, 82 Marketing, in suicide aftermath, 467 Martyrdom, murder-suicide and, 502, 505 Mass killings, 501–502 MDD. See Major depressive disorder (MDD) Meaning in life in elderly, 66, 69 inventories for, 189 questionnaires for, 443 self-report on, 23 loss of, suicide risk with, 15, 20, 23 Meanings, unconscious, 222 Medical disorders. See Physical illness/disorders Medical malpractice. See Malpractice litigation Medical necessity, for hospitalization, 406, 406–407 severity threshold of, 51 Medical personnel, inmate suicide prevention role, 146–147 Medical status, emergency assessment of, 387–388 Medication history, emergency assessment of, 389 Medications in psychotherapy. See Pharmacotherapy as restraint, 430–431 Memories, as psychiatrist reaction to suicide, 479 Memos, clinical, in split treatment, 245 Mental capacity, for treatment consent. See Consent to treatment
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Index Mental health care access to, for bipolar disorder, 284–285 continuum of services for, 402 gender-based utilization of, 88–89 stigma of, 72, 88 for survivors of suicide after initial period, 463–473 clinicians as, 473, 473 during initial period, 461–463, 462 uncertainty in. See Clinical uncertainty Mental health personnel inmate suicide prevention role, 146–147 in split treatment, 235–236 case example of, 246–247 responsibilities of, 241–246 Mental health trainees, split treatment and, 242–243 Mental illness. See Psychiatric disorders; specific illness Mentalization therapy, 229 in outpatient treatment, 371 Mental retardation, 237 Mental status examination for inpatient treatment, 408–410, 429 for outpatient treatment, 368–369, 372–373 for risk assessment, 9, 11, 13, 16 dimensional parameters for, 24–25, 26 by significant others, 435–436 Mentoring, 489–490 Mercy killings, 499, 503 Mertz v. Temple University Hospital, 514 Mexican Americans. See Hispanic Americans Michigan Alcohol Screening Test, 349
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Micronesia, suicide rate in, 168 Minnesota Multiphasic Personality Inventory–2 (MMPI-2) clinical scales of, 179, 180–182 content scales of, 179, 182–183, 183 critical items of, 179, 182–183, 183 utilization of, 177–179 Mirtazapine, 209 Moclobemide, 210 Mode of death. See Suicide mode Monoamine oxidase inhibitors (MAOIs) adverse effects with overdose, 210 use and efficacy of, 206, 208 Mood disorders. See also Affective disorders antidepressants for, 287, 294 assessment during crisis, 449 in elderly, 64, 65, 66 lethality of attempts with, 280–281, 281 as panic disorder comorbidity, 316 suicide rate with, 2 suicide risk with, 21, 285 demographics of, 283 substance-related disorders and, 352 Mood stabilizers adverse effects with overdose, 210–211 for anguish, 374 antiepileptic, 213–214 adverse effects of overdose, 210–211 for bipolar disorder, 289–290, 293 for substance-using patients, 360 for depressive disorder acute, 268–269 chronic, 270–271
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Mood stabilizers (continued) in inpatient treatment, 408–409 for personality disorders, 341 use and efficacy of, 208, 213–214 Moral-based stance, on suicide, 442–443, 443 Moral obligations, cultural attitudes on, 108, 170–171 Morbidity, passive/unintentional, in substance-related disorders, 348–349 Mortality rate in jails/prisons, 140–141 in substance-related disorders passive/unintentional, 348–349 prevention efforts for, 361 from suicide. See Completed suicide Mortality review for inpatient suicides, 416 for jail/prison suicides, 150, 150 Mothers, murder-suicide by, 100 Motion for summary judgment, 533 Motivation suicidal intent and, gender differences in, 89–90 unconscious, 222 Motive, for suicide, 534 Multidisciplinary team/services, 566 for suicide prevention in elderly, 71–72 inmate suicide prevention role, 146–147 for pharmacotherapy, 200 for schizophrenia, 309 as Suicide Assessment Team, 191–192 Multiple sclerosis, 64 Multisystemic therapy, for children/ adolescents, 48
Murderous impulse, psychodynamic therapy and, 224 Murder-suicide, 495–509 case examples of, 501–503 classification of, 495, 496 clinical factors of, 500–501 cult-related, 502, 505–506 depression and, 499–501, 504–505 difficulties in assessing, 496–497 domestic, 495, 496 in elderly, 495, 496 epidemiological perspectives of, 497–500 familicides in, 504 filicides, 100, 504–505 gendered issues of, 99–100 illness and declining health in, 503 infanticidal, 495, 496, 504–505 interpersonal disappointments in, 501–503 key points, 507 mental illness–related, 495, 496 pedicides in, 504–505 political, 505 specific types of, 501–506 suicide pacts in, 503–504 terrorism, 505–506 in the workplace, 505–506 Muslims, 125 Mutual Life Insurance Company v. Terry, 535 Naltrexone, 361 Narcissistic entitlement, 501 Narcissistic personality disorder psychodynamic therapy and, 224 suicidal behavior with, 334–335 Narcotics Anonymous, 361 National Center on Institutions and Alternatives (NCIA), 140
Index National Commission on Correctional Health Care (NCCHC), 144 National Comorbidity Survey, 13, 315, 352 National Mortality Followback Survey (1993), 84, 89 National populations, suicide rates in, 162–163. See also specific group National Strategy for Suicide Prevention (Office of the Surgeon General), 57 Native Americans suicide perspectives in, 121–123 suicide rate in, 109, 110, 111, 112 cultural competence and, 163, 169–170 NCCHC (National Commission on Correctional Health Care), 144 NCIA (National Center on Institutions and Alternatives), 140 Necessity. See Medical necessity Nefazodone, 209 Negative attitudes cultural, 160–161 on jail/prison suicide prevention, 143–144 Negative countertransference, in risk assessment, 22 Negative life events in children/adolescents, 43–44 in elderly, 66–67 in psychodynamic psychiatry, 225, 226 suicide risk with, 16, 21 Negligence breach of duty element, 512, 516–520 damage caused by, 52–553 cause element of, 512, 520–523
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clinically based risk management for, 545–575. See also Risk management duty element of, 512, 513–516 clinical basis of, 548–520, 550 harm element of, 513, 524 legal aspects of, 7, 512 medical, four D’s of, 529, 530 prima facie case of, 512–513, 520 as tort concept, 528–529, 529, 548–549 Negotiation, in outpatient treatment, 368, 375–376 Neoplasms, malignant, 64 Neurobiology of psychosis, 306 of suicide pathogenesis addiction similarities, 349–350 in children/adolescents, 45, 47 in elderly, 68, 70 gender differences in, 86, 88 Neuroleptics, for schizophrenia, 306 Neuroticism, in elderly, 67 New Zealand, immigrants from, 162–163 Nicotine use/abuse, suicide risk with, 356 Nihilism, 489 911 crisis line, 465 No-harm contract. See No-suicide contract Noncompliance/compliance. See Treatment compliance Nondisclosure. See Disclosure Nonfatal suicide. See also Suicide attempts gender differences in, 86–87, 89–90, 91 Nortriptyline, 209 No-suicide contract, 11 APA guidelines for, 592 in bipolar disorder, 291–292
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No-suicide contract (continued) for children/adolescents, 46 as defensive practice, 546–547 in depressive disorders, 262 legal duty regarding, 515 limitations of, 446–447, 451 in outpatient treatment, 368, 373 risk management for, 555–557 safety concerns with, 451–452 No Time to Say Goodbye (Fine), 465 Nursing shift changes, 414 Object relations theory, 221, 223–224 Observation levels in hospitals patient safety vs. freedom and, 427–429 for suicide prevention, 407–408, 414–415 in jails/prisons, for suicide prevention, 145, 148–149 Obsessive-compulsive disorder (OCD) case example of, 320–321 suicide risk with, 321–322 Obsessiveness, in elderly, 67 Occupation murder-suicide related to, 505–506 suicide rates based on, 95–96, 125–126 Occupational health issues, in hospitals, 412 OCD. See Obsessive-compulsive disorder (OCD) Olanzapine, 212, 214–216 for acute depressive disorder, 265 for bipolar disorder, 290–291, 293 for personality disorders, 342 for schizophrenia, 306 Omens, finding, as psychiatrist reaction to suicide, 480, 483–484
On-call staff, for hospitals, 414–415 One-to-one safety precautions, 427–429 “Open-door” policy, 432 Openness to Experience (OTE), 67–68 Opiate antagonists, for personality disorders, 341–342 Opioid use/abuse, suicide risk with, 354–355 Organic mental disorders, as depressive disorder comorbidity, 257–259 Organizational issues, in hospitals, 412–416 OTE (Openness to Experience), 67–68 Othello syndrome, 501 Outpatients risk management suggestions for, 559–560 safety vs. freedom of, 424–426 inpatients vs., 424–425 suicide by, 557–560, 558, 558 insurance influences on, 557–559 malpractice liability for, 558, 558 Outpatient treatment, 367–379 APA guidelines for, 590, 591 beginning, 370–371 case examples of, 374–377 for children/adolescents, 46 commitment to, 368, 371, 377 communication principle, 370, 372–373 confidentiality in, 369 consent for, 368–369 continuum of services with, 402 planning for, 405–406 in emergency services, 395 frequency of, 371
Index hospitalization vs., 367, 375 assessment for, 424–425 patient control of, 375–376 key points, 377–378 levels of care, 405, 405 mental state as guide for, 368–369, 372–373 negligence allegations related to, 530, 531 negotiation dynamics in, 368, 375–376 no-suicide contracts and, 368, 373 patient safety vs. freedom in, 424–426 pharmacotherapy for, 374–375 problems and difficulties with, 373–374 as psychiatrist distress predictor, 485, 485–486 risk management for, 557–561 split treatment in, 425–426 substance abuse and, 374 suicidal crises in, 369, 371–372, 375 suicidal intent and, 372–373 suicide risk assessment for, 368–369 support resources for, 369 loss of, 371–372 therapeutic alliance for, 367–368 tracking and monitoring, 371–373, 373 treatment team for, 369–370 Outreach services for suicide prevention in elderly, 71–72 to survivors of suicide active postvention model of, 461–463, 462 after initial period, 463–473 clinician's role, 459–461 during initial period, 461–463, 462
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Overdose, with substance-related disorders, 349 Oxcarbazepine, 211, 214 Pacific Islanders suicide perspectives of, 120–121, 167 suicide rate in, 109, 110, 111, 112 cultural competence and, 168, 169 Paddock v. Chacko, 553 Pain chronic, as depressive disorder comorbidity, 257 Eastman case study, 57–59, 64 emotional of completed suicide, 88–89, 92 loss-related. See Loss in personality disorders, 335, 337 gender differences in, 93 murder-suicide related to, 503–504 psychic, in depressive disorders, 257, 259–260 Pakistan, 171 Panic disorder/attacks APA treatment guidelines for, 594 case example of, 313–314 as depressive disorder comorbidity, 257, 261, 269 pharmacotherapy case example, 204–206 suicide risk with, 15, 314–316 Parasuicide, 331, 358 Parent-child conflict, child/ adolescent suicide and, 43–44 Parents, murder-suicide by, 100 Paroxetine, 207, 209 Partial hospitalization advantages of, 411 case example of, 411
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Partial hospitalization (continued) continuum of services with, 402 managed care influence on, 559 for outpatient treatment, 369, 559 for personality disorders, 339 risk management suggestions for, 559–560 Passive aggressiveness, 90 Passive suicidality, 349 with substance-related disorders, 348–349 Passivity, 488 cultural practice of, 92, 164 Patient disclosure elderly trends, 69 during emergency assessment, 392–393 split treatment and, 238, 248 of suicidal ideation, 12, 19 Patient interviews. See Clinical interview Patient safety for children/adolescents, 45–46, 46 clinically based risk management and, 436–437, 437 contracts for. See Safety contracts for elderly, 69 during emergency evaluation, 388–389 freedom of movement vs., 423–439 in hospitals, 412–416 for inpatients, 426–434 interventions for, 441–455. See also Safety interventions key points, 437–438 for outpatients, 424–426 professional judgments of, 423–425 significant others and, 435–436 with substance use, 358–359, 359 during detoxification, 359 suicide warnings and, 434–435
Pedicide, 100, 504–505 Peer pressure/support, in aftermath of suicide, 460–461, 472, 473 Perfectionism, psychodynamics of, 223 Perpetrators, in murder-suicide, 500–501 Perphenazine, 211, 214 Personality disorders, 329–346. See also specific disorder APA treatment guidelines for, 596 case examples of, 336–338 in children/adolescents, 42 as depressive disorder comorbidity, 261 DSM-IV-TR classification of, 330, 331 in elderly, 67–68, 69 gendered issues of, 97–98 hospitalization for, 338 key points, 342–343 as panic disorder comorbidity, 315–316 prevalence of, 329 among youth, 329–330 self-injurious behavior with, 330–331, 333, 335, 338 tested treatments for, 339–342 self-mutilation with, 331 substance abuse and, 334, 361 suicidal ideation with, 338 suicidal intent with, 330 suicide attempts with, 330, 335 suicide rate with, 329–330, 335 suicide risk assessment in, 338 suicide risk with, 16–17, 20–21 Cluster A, 333 Cluster B, 334–336 Cluster C, 333–334 substance-related disorders and, 352–353
Index treatment of, 339–342 cognitive therapy, 340 dialectical behavior therapy, 339–340 pharmacotherapy, 340–342 psychoanalytic/psychodynamic therapy, 339 Personality traits egocentric vs. sociocentric, 108 in elderly, 67–68 gender differences in, 88, 90–92, 97 murder-suicide related to, 501–502 personality disorders and, 331, 335 as psychiatrist distress predictor, 485, 486 as split treatment obstacle, 238, 247 valid measures of, 67 Personnel policies, for hospitals, 412, 414–415 Pervasiveness, of suicidal ideation, 41–42 Pessimism Beck Inventory for, 177, 186–187 Minnesota Multiphasic Personality Inventory–2 of, 182–183, 183 Pharmacotherapy, 199–220. See also specific classification or drug antidepressants, 206–208 adverse effects with overdose, 209–210 antipsychotics, 214–216 adverse effects with overdose, 211–212 anxiolytics, 216 adverse effects with overdose, 212
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for bipolar disorder, 286–291, 288, 293–294 case examples of, 201–206 for children/adolescents, 46–47, 201 for depressive disorder acute, 265–266, 268–269 chronic, 270–271 electroconvulsive therapy vs., 216–217 evidence-based practice of, 453–454 gender differences in, 89 importance of, 200–201 indications for, 199–200 in inpatient treatment, 408–409 education on, 409–410 key points, 217–218 limitations of, 446–447 long-term impact of, 200–201, 402 mood stabilizers, 208, 213–214 adverse effects with overdose, 210–211 multidisciplinary approach to, 200 in outpatient treatment, 374–375 for patient safety, 389 for personality disorders, 340–342 risk management for, 561–563 for short-term suicide risks, 15 in split treatment, 236, 239–240 case example of, 240–241 shared/separate responsibilities for, 241–243, 246–247 Phencyclidine use/abuse, suicide risk with, 356 Phenelzine, 210 Philosophical approach, to psychiatrist coping with suicide, 486, 487, 488–489 Phinney v. Vinson, 471
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Physical health. See also Functionality declining, murder-suicide related to, 503 emergency assessment of, 387–388 Physical illness/disorders as bipolar disorder comorbidity, 277, 292 as depressive disorder comorbidity, 257 in elderly, 64, 66, 69 emergency assessment of, 387–388 gender differences in, 81–82, 83 murder-suicide related to, 503 standardized mortality ratio of, 19 with substance-related disorders, 349 Physical illness registries, linkage studies to death registries, 64 Physician-patient relationship. See Clinician-patient relationship Physicians, suicide rate of, gender differences in, 95–97, 126 Pimozide, 211, 214 Plaintiff in malpractice litigation, 528, 531–532 proof requirements for, 552–553 Plan/planning. See Suicide plan Pleasure, loss of, suicide risk with, 15 Poisoning, as suicide method, 37, 86– 87 Pokorny, A.D., 178 Police officers, suicide rate of, 125–126
Policies and procedures for patient safety freedom of movement vs., 432–433 in hospitals, 412–415 in jails, 144, 145 for personnel, in hospitals, 412, 414–415 safe clinical practices and, 447 Political killings, 505 Politics, suicide related to, 132 Population(s) indigenous, suicide rates in, 162–163 jail, suicide prevention in, 139 national, suicide rates in, 162–163 risk assessment for, 20–23 special, substance-related disorders in, 357–358 Posey, Allen, 470–471 Postpartum depression murder-suicide related to, 504–505 suicide related to, 98–99, 100 “Postpsychotic” depression, 304–305, 307–380 Posttraumatic stress disorder (PTSD), 43 case example of, 322–323 as depressive disorder comorbidity, 257 as psychiatrist reaction to suicide, 479 suicide risk with, 323–324 Postvention, 462 Postvention model, active, of survivors of suicide, 461–463, 462 Power struggles, in outpatient treatment, 375–377 Practice guidelines, of APA, 577–597 coding system for, 578
Index for consultations, 592–593 for documentation, 592 for emergency services, 590, 592 for hospitalization, 590, 591 for “no-harm contract,” 592 for outpatient treatment, 590, 592 for psychiatric management, 590–593, 591–592 for psychosocial interventions, 596 for somatic interventions, 594–595 for specific treatment modalities, 593–596 for suicide assessment, 579–586, 580, 583–585 for suicide risk estimation, 586–589, 587–589 term definitions, 578–579 Precipitants, of suicide in children/adolescents, 44 gender differences in, 82 in psychodynamic psychiatry, 225, 226 Prediction, of suicide risk, 453 APA guidelines for, 586–589, 587– 588 Prediction scales, for suicide risk. See also specific scale Beck, 39, 41, 177, 186–187 in children/adolescents, 39, 41, 45 limitations of, 7, 178, 185–186 psychological tests vs., 2, 16, 177–178. See also Psychological tests/testing self-administered, 2 standardized, 1–2 Pregnancy, suicide related to, 98–99, 100 Premature discharge patient safety vs. freedom and, 433–434 risk assessment for, 426, 564
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Preparation, as lethal intent component, 39–41, 41 Preponderance of the evidence, 552–553 Prevention, of suicide. See also Protective factors in depressive disorders with acute high risk, 264–270 with chronic high risk, 270–272 failure of, 272 in elderly, 20, 70–72, 71 indicated approaches for, 70–71 selective approaches for, 71–72 universal approaches for, 72 foreseeability vs., 549 in hospitals levels of supervision for, 407 mortality review for, 416 organizational and system issues, 412–416 staff training for, 411–412 in jails/prisons, 139–155 case examples of, 142–143, 151 communication for, 146–147 comprehensive policy for, 144, 145 death rate related to, 140–141 definitions, 139 follow-up for, 150 housing for, 146–148 intake screening for, 145–146, 146 interventions for, 149 key points, 152–153 levels of supervision for, 148–149 mortality review for, 150, 150 negative attitudes impact on, 143–144 ongoing assessment for, 145–146, 146
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Prevention, of suicide (continued) in jails/prisons (continued) population statistics, 139 programming for, 143–151 psychiatric disorders prevalence, 140, 141 reporting for, 149–150 staff training for, 144–145 suicide rate and, 140 victim characteristics, 141, 141–142 limitations of, 446–447, 451 psychological testing for, 177–194. See also Psychological tests/ testing risk management for, 555–557 in substance-related disorders, 361 Prevention of Suicide in Primary Care Elderly:Collaborative Trial (PROSPECT), 70 Prima facie case, of negligence, 512–513, 520 Primary care, for suicide prevention, 20 in elderly, 70–71 Primum non nocere, 442 Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry (APA), 435 Prisons, suicide prevention in, 139–155 case examples of, 142–143, 151 children/adolescents and, 44 communication for, 146–147 comprehensive policy for, 144, 145 death rate related to, 140–141 definitions, 139 follow-up for, 150 housing for, 146–148 intake screening for, 145–146, 146
interventions for, 149 key points, 152–153 levels of supervision for, 148–149 mortality review for, 150, 150 negative attitudes impact on, 143–144 ongoing assessment for, 145–146, 146 population statistics, 139 programming for, 143–151 psychiatric disorders prevalence, 140, 141 reporting for, 149–150 staff training for, 144–145 substance-related disorders and, 357 suicide rate and, 140 victim characteristics, 141, 141–142 Problem solving poor, in children/adolescents, 43 suicidal behavior reframed for, 450 Procedures. See Policies and procedures Prodromal risk factors, 16, 23 Professional activities, for psychiatrist coping with suicide, 487, 489–490 Professional competence in aftermath of suicide, 460–461 in risk assessment, 22–23 in split treatment, 243–244 Professional judgment. See Clinical judgment Professional licensure, split treatment and, 242–243 Professional Risk Management Services, 547 Professional training. See also Staff training in split treatment, 243–244
Index Professions/professionals, suicide rates of, 95–96, 125–126 PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial), 70 Protection of patient, as treatment component. See also Patient safety for children/adolescents, 45–46, 46 for elderly, 69 Protective factors, for suicide, 23–24. See also Prevention APA list of, 586, 589 in children/adolescents, 43–44 enhancement of, 46, 48 in depressive disorders, 267 immigrants loss of, 163 religion/religiosity as, 23–24, 165–166 variability of, 24 in women, 90–94, 97 Protestants, suicide views of, 165 Protocol, suicide, during crisis, 450, 450–451 Provider networks, split treatment and, 236 “Psychache,” 259 Psychiatric disorders. See also specific disorder in children/adolescents, 42–43, 45, 49 in elderly, 63–64, 65, 69 emergency assessment of, 391–392 in inmates, 140, 141 Minnesota Multiphasic Personality Inventory–2 of, 179, 180–183, 182–184 murder-suicide related to, 495, 496 clinical factors of, 500–501 difficulties in assessing, 496–497
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epidemiological perspectives of, 497–500 risk factor profile for, 16, 23 standardized mortality ratio of, 18–19, 19 suicide risk and, 280 suicide risk with, 16, 17 personality disorders and, 333, 335–336 substance-related disorders and, 352–353, 360 in women physicians, 95–97 Psychiatric evaluation in emergency services, 381–382 additional history and examination, 389 alcohol and substance use, 390, 395 collateral information, 392–393 follow-up outpatient treatment, 395 hospitalization decision, 393–395 intervention recommendations, 395–396 medical status, 387–388 models of, 381–382 patient safety, 388–389 psychiatric history, 391–392 psychosocial factors, 390–391 for suicide assessment, 9, 11, 13, 579–581, 580 case example of, 581 dimensional parameters for, 24–25, 26 documentation of, 582, 585 indications for, 582, 585 specific questions for, 582, 583–585 for treatment, of elderly, 69
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Psychiatric malpractice. See Malpractice litigation Psychiatric management APA guidelines for, 590–593 case example of, 593 guidelines for selecting, 590, 591– 592 Psychiatrist-patient relationship. See Clinician-patient relationship Psychiatrists. See also Clinicians emotions of, 590 practice capacity of, disclosure of, 243–244 reactions to patient suicide, 477–492 coping style, 478–479, 486–490, 487 distress predictors, 484–486, 485 general, 478–479 importance of understanding, 477–478, 571 initial, 480, 480 key points, 490–491 second-phase, 480, 481–484 specific, 479–484, 480 risk management for, with children/adolescents, 50–51 in split treatment, 235–236 case example of, 246–247 responsibilities of, 241–246 risk management for, 561–563 suicide rate of, 127 suicide risk related to, 22–23 women severe distress reactions of, 486 suicide rate of, 95–97, 126 Psychiatrist's Purchasing Group, 548 Psychiatry, psychodynamic, 221–233. See also Psychodynamic psychiatry Psychic pain, in depressive disorders, 257, 259–260
Psychoanalytic psychotherapy, in outpatient treatment, 371 Psychodynamic psychiatry, 221–233 conceptual model of, 221 countertransference in case example of, 229–231 monitoring of, 225, 226 pitfalls of, 224–225 efficacy of, 222 key points, 232–233 literature review on, 222–225 principles of, 222 in split treatment, 236 suicidality case examples of, 225–229 acute, 225–227, 229 chronic, 227–229 theme patterns in, 223–224 theoretical models of, 221–222 treatment modalities for, 222 treatment steps for, 225–232, 226 Psychoeducational therapy, in inpatient treatment, 410 Psychological activators, of suicide, 248 Psychological autopsy, 453 components to review, 538–539, 539 checklist for, 539, 540 conducting, 540–542 of elderly, 63–64, 65, 67 key points, 542 litigation and, 534 of criminal cases, 537–538 of inheritances, 537 of life insurance claims, 535–536 of motive vs. intent, 533–534 unclear reasons in, 533, 534 of workers' compensation claims, 536–537 psychiatrist coping and, 488 survivor benefits from, 464–465
Index Psychological tests/testing Beck Depression Inventory, 177, 186–187 Beck Hopelessness Scale, 177, 186–187 Beck Suicide Intent scale, 39, 41, 177, 187–188 clinical inquiry as, 177, 183, 192–193 false positives with, 185 Firestone Assessment for SelfDestructive Thoughts, 188–189 Linehan Reasons for Living Inventory, 189 Los Angeles Suicide Prevention Center scale, 185 Minnesota Multiphasic Personality Inventory–2, 177–179, 180–182, 182 risk assessment overview, 2, 16, 177–178 Risk Estimator for Suicide, 190–191 Rorschach Inkblot Test, 177, 184–185 Scale for Suicide Ideation, 39, 41, 187–188 Suicide Assessment Battery, 191–192 Suicide Probability Scale, 189–190 Thematic Apperception Test (TAT), 177, 188 Psychologists, in split treatment, 236 Psychometric tests, in psychological autopsy, 539, 539 Psychopathology. See Psychiatric disorders Psychopharmacologist, in outpatient treatment team, 369–370 Psychopharmacology. See Pharmacotherapy
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Psychosis dopamine D2 receptor and, 306 in elderly, 65 inpatient treatment of, 409, 449 postpartum, 98–99, 100 suicide risk with, 16, 304 treatment considerations for, 309 Psychosocial interventions APA guidelines for, 596 for bipolar disorder, 291–292, 294 for children/adolescents, 48 Psychosocial relations emergency assessment of, 390–391 gender differences in, 91–94 with obsessive-compulsive disorder, 321–322 posttraumatic stress disorder and, 324 Psychostimulants, schizophrenia and, 308–309 Psychotherapist in outpatient treatment team, 369–370 anxiety and control issues, 375–377 in split treatment, risk management for, 561–563 Psychotherapy APA guidelines for, 596 for bipolar disorder, 291 for children/adolescents, 47–48 dynamically informed, 221–222. See also Psychodynamic psychiatry in inpatient treatment, 410 limitations of, 446–447 psychoanalytic, in outpatient treatment, 371 in split treatment, 236 Psychotropic drugs. See Pharmacotherapy
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PTSD. See Posttraumatic stress disorder (PTSD) Public health services, for suicide prevention in elderly, 72 Punitive damages, in medical negligence, 529 Quality of care, standard of care vs., 551 Questionnaires, for self-examination, 443 Quetiapine, 212, 214, 216 for acute depressive disorder, 265 for anguish, 374 for bipolar disorder, 290, 293 Race. See also specific race assisted suicide and, 101 definition of, 160 suicide rate based on, 109–112, 110 HIV/AIDS and, 64, 128–130 suicide risk with, 16–17 in America, 116–123 in children/adolescents, 37 as cultural factor, 160, 169–170 in elderly, 60, 60 gender differences in, 79, 82, 84 Rage, as outpatient crisis marker, 372 Rape. See Sexual abuse “Rational suicide,” 114 Reactions, psychiatrists', to patient suicide, 477–492 coping style, 478–479, 486–490, 487 distress predictors, 484–486, 485 general, 478–479 importance of understanding, 477–478, 571 initial, 480, 480 key points, 490–491 second-phase, 480, 481–484
specific, 479–484, 480 Reasonable care, 545, 552 Reasonableness, of suicide risk assessment, 7, 549. See also Foreseeability Reasons for living. See Meaning in life Reasons for Living Inventory, 443 Linehan, 189 Reassessment, of suicide risk in depressive disorders, 258 over time, 446 in split treatment, 238–239 Reciprocity, 92 Referrals for inmates, 146 for survivors of suicide, 464–466 Rehabilitation programs, for outpatient treatment, 369 Rehearsals, for suicide, 18–19, 248 Reimbursements. See Health insurance Rejection, of treatment. See Treatment compliance Relapse prevention, for substancerelated disorders, 361 Relatedness to others, gender differences in, 91–94 Reliability of psychological autopsy, 539, 539 of suicide risk assessment, 1, 12, 23 Relief, as psychiatrist reaction to suicide, 480, 483 Religion/religiosity, suicide and, 124–125 aftermath response of, 461 cultural influences, 165–166, 169, 171 as protective factor, 23–24, 43 “Remedies,” apology as, 472
Index Reparative behaviors, for psychiatrist coping with suicide, 486, 487, 489–490 Reports/reporting on jail/prison suicides, 145, 149–150 on sentinel events, 413 Resentment Minnesota Multiphasic Personality Inventory–2 of, 179, 180–182 psychodynamic therapy and, 224–225 Responsibility in child/adolescent suicide, 50–51 gender differences in, 92–93 of outpatient treatment team, 370, 558 rights and, in contract vs. tort law, 515 Restraints, 430 for patient safety, 148, 389, 408 freedom of movement vs., 430–431 Retirement, 66 Retrospective analysis, of suicidal intent. See also Psychological autopsy for litigation, 533–542 “Revolving door” patient, 434 Rhabdomyolysis, 349 Rights and responsibilities, in contract vs. tort law, 515 Risk assessment. See Suicide risk assessment Risk Estimator for Suicide, 190–191 Risk factor profile, 16, 23 Risk factors. See Suicide risk factors Risk management clinically based, 545–575 collaborative treatment and, 561–563
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elements of, 436–437, 437, 546 for emergency psychiatric services, 567–570 importance of, 545–547 for inpatients, 564–567 key points, 572 malpractice litigation and, 50–51, 452, 511–512, 547–553, 548 for outpatients, 557–560, 558 as patient centered, 545–546 suicide aftermath and, 570–572 suicide prevention contracts and, 555–557 suicide risk assessment and, 554–555 for hospitals, 413 for psychiatrist in child/adolescent care, 50–51 clinically based, 545–575 codification cautions, 447 legal strategies for, 511–513 for suicide. See Suicide risk management Risperidone, 212, 214, 216 for bipolar disorder, 290, 293 for personality disorders, 342 Rodriguez v. Henkle Drilling and Supply Company, 536–537 Role conflicts, in split treatment, 245–246, 249 Romance cultural perspectives of, 167 murder-suicide related to, 501–502 Root cause analysis, 413, 416 Rorschach Comprehensive System, 184 Rorschach Inkblot Test, 177, 184–185 Rural area suicides, urban areas vs., 116, 168
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Russia immigrants from, 162 suicide rate in, 113, 114 Sadism, psychodynamic therapy and, 224–225 SADS (Schedule for Affective Disorders and Schizophrenia), 258–259, 262 SADS-C (Schedule for Affective Disorders Schizophrenia, Change Version), 259, 260 Safety, of patient. See Patient safety Safety contracts in bipolar disorder, 291–292 as defensive practice, 546–547 in depressive disorders, 262 hospitalization vs., 394 limitations of, 446–447, 451 risk management for, 555–557 safety concerns with, 451–452 for suicide prevention, 11, 46, 69 Safety interventions, 441–455 for clinical practice, 444–452 first do no harm, 442–443, 443 significance of, 441 Sanctions cultural, as protective factor, 23–24, 171 for women, 91–94 social/religious, for suicide, 108, 170, 171 Sane suicide, insane vs., 535 Scale for Suicide Ideation (SSI), 39, 41, 187–188 Schedule for Affective Disorders and Schizophrenia (SADS), 258–259, 262 Schedule for Affective Disorders and Schizophrenia, Change Version (SADS-C), 259, 260
Schizophrenia, 301–311 in children/adolescents, 42 depression and assessment issues with, 305, 307–308 as comorbidity, 304–305 functionality with, 304, 308–309 inpatient treatment of, 409 key points, 309–310 neurobiology of, 306 substance abuse comorbidity with, 306–309 suicidality management with, 301–309 chronic case example, 306–309 newly diagnosed case example, 302–306 suicide risk with, 16, 304 treatment considerations for, 309 School shootings, 500, 506 S-CON (Suicide Constellation), of Rorschach index, 184 Screening during emergency assessment, 389 intake, in jails/prisons, 145, 145–146, 146 for substance-related disorders, 349 in youth, 361 Screening instruments, for suicide risk self-administered, 2 standardized, 1–2 Seclusion, 430 for patient safety, 389, 408 freedom of movement vs., 430–431 shy, in elderly, 67, 71 Second opinions, for hospitalization, 406, 407 Second-phase reactions, psychiatrist, to patient suicide, 480, 481–484
Index Security issues, in hospitals, 413 Sedative-hypnotics use/abuse, suicide risk with, 356–357 Seizure disorders, 64 Selective interventions, for suicide prevention, in elderly, 71, 71–72 Selective serotonin reuptake inhibitors (SSRIs) adverse effects with overdose, 209 APA guidelines for, 594 for bipolar disorder, 287 for children/adolescents, 47 for personality disorders, 341 for social phobia, 320 use and efficacy of, 206–208 Self-condemnation, in personality disorders, 333, 335–336 Self-defeating behavior, confronting, 371 Self-defense, 100 Self-doubt, as psychiatrist reaction to suicide, 486, 571 Self-efficacy, hospitalization impact on, 451 Self-esteem, cultural perspectives of, 167 Self-examination, instruments for, 443 Self-generated massacres, 506 Self-harm. See Self-injurious behavior Self-hate, as outpatient crisis marker, 372 Self-injurious behavior, deliberate definition of, 330, 379 disclosure of, by elderly, 69 emergency assessment of, 393–395. See also Emergencies by inpatients, 413–414, 416 nonsuicidal, 39 with personality disorders, 330–331, 333, 335, 338 tested treatments for, 339–342
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psychiatric evaluation of, 582, 583–585 threats of, confidential information disclosure based on, 13 unintentional, with substancerelated disorders, 348–349 warnings of, 434–435 Self-mutilation with personality disorders, 331 as suicide method, 37, 87 suicide risk with, 13, 21 in children/adolescents, 39 in hospitals, 413 Self psychology, 221, 224 Self-Regulation Model, of suicidal behavior, 333, 337 Self-Report Reasons for Living Inventory, 23 Self-worth, personality disorders and, 333, 335–336 Senesac v. Associates in Obstetrics and Gynecology, 471 Senior citizens. See Elderly Sentinel events, 413 Separation issues, child/adolescent suicide and, 44 Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial, 317–318 Serotonin dysregulation of in children/adolescents, 45, 47 in elderly, 68, 70 gender differences in, 86, 88 modulators of for bipolar disorder, 287 use and efficacy of, 206–208 Serotonin-norepinephrine reuptake inhibitors (SNRIs) adverse effects with overdose, 209 use and efficacy of, 206–208
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Sertraline, 207, 209 for personality disorders, 341 Settlement conference, in malpractice litigation, 533 Severity of illness. See Illness severity Sex, in suicide risk. See Gender Sexual abuse childhood, gendered issues of, 95 in females, posttraumatic stress disorder in, 324 litigation on, 538 Sexual orientation, suicide risk and, 127–128 in children/adolescents, 45 HIV/AIDS correlations, 128–130 Sexual relationships, murder-suicide related to, 501–502 Shame, as psychiatrist reaction to suicide, 480, 481–482, 486, 571 “Shame suicides,” 22 Sharing, as psychiatrist coping with suicide, 490 Shift changes, in hospitals, 414 Shock, as psychiatrist reaction to suicide, 480, 480 SI. See Suicidal ideation (SI) Siebert v. Fink, 552 Significant dates, for survivors of suicide, 466 Significant others interviews of, for psychological autopsy, 539, 539 conducting, 540–542 patient safety vs. freedom and, 435–436 SIS (Suicide Intent Scale), Beck's, 39, 41, 177, 187–188 Situational factors, in suicide risk assessment, 5, 24 Slang expressions, in risk assessment, 23
Sleep disorders depressive disorders and, 256, 269, 372 as psychiatrist reaction to suicide, 479 Slovenko, Ralph, 471 SMR. See Standardized mortality ratio (SMR) SNRIs. See Serotonin-norepinephrine reuptake inhibitors (SNRIs) Social factors of hospitalization, 401–402 in suicide, 107–137. See also Sociocultural context Social isolation in elderly, 67, 71 in immigrants, 163 Social phobia case example of, 318–319 suicide risk with, 319–320 Social role stereotypes gender expectations in, 82–83 as protective factor for women, 90–94, 97 Social services, for suicide prevention in elderly, 71–72 Social skills deficit, in children/ adolescents, 43, 47 Social support bipolar disorder and, 284 cultural perspectives of, 166–167, 169–170 suicide in elderly and, 66–67, 69 prevention role, 70–72 emergency assessment of, 390–391, 393 for outpatient treatment, 368–369 loss of, 371–372 PTSD and, 324 religion as, 124–125 as suicide protective factor, 23–24 in children/adolescents, 43, 49 gender differences in, 91–94
Index Sociocentric personality, 108 Sociocentric societies, 108 Sociocultural context, of suicide, 107–137 egocentrism vs., 108 ethnicity and, 116–123, 160–161 gay, lesbian, bisexual, and transgender individuals, 127–128 HIV/AIDS and, 64, 128–130 immigration and acculturation in, 162–163 international perspectives, 112–116 key points, 132–133 occupation and, 125–127 paradox of, 107–108 religion and, 124–125 socioeconomic change and, 130–132 Tikopia case study, 109 unemployment and, 130–132 Socioeconomic status change in, suicide related to, 130–132 child/adolescent suicide and, 44 of elderly, 66, 69 gender differences in, 82 Somatic interventions, APA guidelines for, 594–595 SOS. See Survivors of suicide (SOS) South Africa, immigrants from, 162 Special damages, in medical negligence, 529 Specialness, conflicting feelings of, as psychiatrist reaction to suicide, 480, 484 Spinal cord injury, 64 Spirituality. See Religion/religiosity Split treatment, 235–251 clinical assessment in, 237–241
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goals of, 237 for medications, 239–241 of risk, 237–239 clinical factors supporting, 235–236 description of, 235 financial advantages of, 235–236 key points, 249–250 leaving a team, 248–249 modalities included in, 236 for outpatients, 425–426 patient disclosure in, 238, 248 patient selection for, 237–239 personality traits and, 238, 247 professional disclosure in, 243–244 psychiatrists' responsibilities in, 241–247 case example of, 246–247 clinical temperament and, 243–244 for collaboration, 214, 235–236, 244–246 for communication, 245–246 competence assessment, 243–244 for data incorporation, 244–245 for medications, 241–242 for mental health trainees, 242–243 training assessment, 243–244 psychotropic drugs in, 236, 239–240 case example of, 240–241 shared/separate responsibilities for, 241–243, 246–247 reassessment frequency in, 238–239 risk management for, 561–563 role conflicts in, 245–246, 249
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Split treatment (continued) suicide risk assessment in, 237–239, 247–248 transference in, 242 Spousal murder, 99–100 SPS (Suicide Probability Scale), 189–190 SSI (Scale for Suicide Ideation), 39, 41, 187–188 SSRIs. See Selective serotonin reuptake inhibitors (SSRIs) Staffing issues, in hospitals, 414–415 Staff training, on suicide prevention in hospitals, 411–412 in jails/prisons, 144–145, 145 Stalking, 505 Standardized mortality ratio (SMR), of psychiatric disorders, 18–19, 19 suicide risk and, 280 Standard of care best practices vs., 545, 551 “biopsy” of, 547, 560 as clinician duty, 7, 50, 517, 521, 523, 529 codification cautions, 447 deviation from, 551–552 damage caused by, 552–553 direct damage caused by, 553 quality of care vs., 551 for risk assessment, 1–2, 7, 14 state-based definition of, 551 STAR*D (Sequenced Treatment Alternatives to Relieve Depression) trial, 317–318 Startle response, as psychiatrist reaction to suicide, 479 Statutory waiver, of confidential information, 13 Stepakoff v. Kantar, 7, 551
Stimulant use/abuse, suicide risk with, 356 Strangulation. See Hanging(s) Stress-diathesis model, of suicidal behavior, 331–332 Stress/stressors suicide risk with, 16, 21 in bipolar disorder, 283–285 in children/adolescents, 43–44 cultural shaping of, 108 in elderly, 66–67 occupation correlations, 126–127 in psychodynamic psychiatry, 225, 226 split treatment considerations, 244, 248 substance-related disorders and, 353 in survivors of suicide, 459–460, 462–464 Strict liability, 528, 529 Stroke, 64 Subspecialties, in split treatment, 236 Substance-related disorders, 341–364. See also specific substance addiction vs., 348–349 genetic similarities of, 349–350 in alcohol users, 353–354, 354 in amphetamine users, 356 in cannabis users, 356 case examples of, 350–351 clinical management of, 358 abstinence, 359–360 approaches to, 347–348, 358, 596 for comorbidities, 360–361 detoxification, 359 essential components, 358, 359 relapse prevention, 361 safety in, 358–359
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Index clinical states included in, 348 in cocaine users, 355, 355 comorbidities of passive/unintentional, 348–349 psychiatric disorders, 352–353 treatment of, 359, 360–361 in gamma-hydroxybutyrate users, 356 in hallucinogen users, 356 impulsivity and aggression in, 347, 348, 351, 357–358 in inhalant users, 355–356 in ketamine users, 356 key points, 361–362 neurobiological factors of, 349–350 in nicotine users, 356 in opioid users, 354–355 in phencyclidine users, 356 in sedative-hypnotic users, 356–357 in stimulant users, 356 suicidal intent with, 348–349 suicide risk assessment for, 357–358 general issues of, 357 for special populations, 357–358 suicide risk with, 347, 348. See also Substance use/abuse factors contributing to, 351, 351 general issues of, 352 psychiatric syndromes and, 352–353 substances of abuse and, 353–357, 354, 355 Substance use/abuse as bipolar disorder comorbidity, 278, 283, 285 in children/adolescents, 42–43
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as depressive disorder comorbidity, 257, 261 disorders related to. See Substance-related disorders in elderly, 63, 65 emergency assessment of, 390, 395 gendered patterns of, 83–84, 84, 128 murder-suicide related to, 500 outpatient treatment consideration of, 374 as panic disorder comorbidity, 315–316 suicide rate with, 2 ethnicity correlations, 110, 117, 123 suicide risk with, 16, 17, 20, 21, 347 in personality disorders, 334 psychiatric syndromes and, 352–353 in schizophrenia, 306–309 terminology for, 348 “Sudden death,” 541 Suffocation in murder-suicide, 499 as suicide method, 37, 86–87 Suicidal behavior consequences of, questionnaires for, 443 cultural factors, 159–161 estimation of. See also Suicide risk assessment APA guidelines for, 586–589, 587–588 gender paradox of, 78–79, 82 management of evidence-based, 2–3, 446 professional recommendations for, 2–3 in personality disorders, 330–336
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Suicidal behavior (continued) psychiatric evaluation of, 582, 583–585 reassessment over time, 446 reframed as problem solving, 450 Self-Regulation Model of, 333, 337 stress-diathesis model of, 331–332 Suicidal crises anticipation of, 450–451 confidential information disclosure based on, 13 in inpatients, 429–430 in outpatients, 369, 371–372, 375 response to in hospitals, 409 in jails/prisons, 148–149 safe practices for, 447–450 safe management of protocols for, 450, 450–451 risk assessment in, 447–450, 450 suicide risk with, 16 Suicidal gestures, as risk factor, 21 Suicidal ideation (SI), 579 absence of, risk based on, 12 in anxiety disorders, 313, 324–325 assessment scale for, 39, 41, 187–188 in bipolar disorder, 284 in children/adolescents, 37, 43 intent in, 41–42 in depressive disorders, 261–263 case example of, 263–264 in elderly, 60, 61–62, 63 depression and, 66, 71 detection of, 68 ethnicity and, 116–123 gender differences in, 83, 86, 88 HIV/AIDS and, 130 as key risk factor, 13, 16, 19 Minnesota Multiphasic Personality Inventory–2 for, 179, 180–183, 182
in outpatient setting, 372 passive vs. active, 13 patients' admitting rate, 12 with personality disorders, 338 pervasiveness dimension of, 41–42 in posttraumatic stress disorder, 323–324 psychiatric evaluation of, 582, 583–585 psychodynamic approach to, 225, 226 religion and, 124–125 safe management of, 448–449 severity dimension of, 41–42 Suicidal intent assessment scale for, 39, 41, 177, 187–188 in children/adolescents recent attempt and, 39–41, 41 suicidal ideation and, 41–42 definition of, 21, 579 in elderly, 63, 69 legal components of, 534 litigation and retrospective analysis of, 533–542 unclear reasons in, 533, 534 motivation and, gender differences in, 89–90 outpatient treatment and, 372–373 with personality disorders, 330 as risk factor, 16, 21 substance-related disorders and, 348–349 Suicidality assessment of. See Suicide risk assessment in depressive disorders, 261 hospitalization indications for, 530 interventions for. See Suicide risk management
Index passive, with substance-related disorders, 348–349 in psychodynamic psychiatry, 225, 226 acute example, 225–227, 229 chronic example, 227–229 as risk. See Suicide risk factors “Suicidal patient,” 1 Suicidal tendencies, in depressive disorders, 260–261, 262 Suicidal thinking. See Suicidal ideation Suicidal threats, as risk factor, 21 Suicide act of, in psychodynamic psychiatry, 225, 226 aftermath of, 459–476. See also Suicide aftermath age and, 16, 20. See also Age altruistic, 170 assessment for. See Suicide risk assessment assisted, 101 completed. See Completed suicide definition of, 330, 578 fantasy of, in psychodynamic psychiatry, 225, 226 gender and, 77–105. See also Gender gendered issues in, 94–101 childhood sexual abuse, 95 murder-suicide, 99–100 personality disorders, 97–98 pregnancy and postpartum period, 98–99, 100 women physicians, 95–97 imminent confidential information disclosure based on, 13 patient safety vs. freedom and, 429–430 risk assessment for, 22, 549
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insane vs. sane, 535 intent for. See Suicidal intent methods of. See Suicide mode motive for, 534 murder combined with, 495–509. See also Murder-suicide nonfatal. See also Suicide attempts gender differences in, 86–87, 89–91 occurring in your practice, 452–454 protective factors against, 23–24 in children/adolescents, 43 psychiatrist reactions to, 477–492 psychological activators of, 248 as rare event, 1 “rational,” 114 risk factors for. See Suicide risk factors “shame,” 22 socially/religiously sanctioned, 108, 170, 171 Suicide (Durkheim), 77, 107, 165 Suicide aftermath, 459–476 active postvention model of, 461–463, 462 body identification/viewing, 469–471 case examples of, 466–472 in children/adolescents, 36, 50–51 clinician's role, 459–460 institutional response/barriers in, 460–461, 488 outreach to survivors, 463–473 risk management for, 570–572 safety interventions and, 452–453 self-care for clinicians, 472–473, 473 survivors in, 459–461. See also Survivors of suicide (SOS) Suicide Assessment Battery, 191–192
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Suicide Assessment Team comprehensive, 191–192 multidisciplinary, 191 Suicide attempts aborted, 21, 578 in alcohol users, 353–354, 354 with anxiety disorders, 313, 324–325 in children/adolescents, 37, 39 intent and, 39–41, 41 completed. See Completed suicide definition of, 330, 578 in elderly, 60, 63 gender differences in, 78, 86–87, 89–90, 91, 98 incomplete. See Nonfatal suicide in jails and prisons, 141 national data on, 20 with personality disorders, 330, 335 tested treatments for, 339–342 with posttraumatic stress disorder, 323–324 psychiatric evaluation of, 582, 583–585 response to, in jails/prisons, 148–149 standardized mortality ratio of, 18–19 suicide risk with, 16, 17 Suicide Constellation (S-CON), of Rorschach index, 184 Suicide Intent Scale (SIS), Beck's, 39, 41, 177, 187–188 Suicide mode charcoal-burning as, 115–116 firearms as. See Firearms lethality of. See Lethality of suicidal behavior litigation and, 533–534 in murder-suicide, 499 Suicide pacts, 503–504
Suicide plan in bipolar disorder, 284 in children/adolescents, 39 in depressive disorders, 261–263 case example of, 263–264 in elderly, 63 gender differences in, 83, 86, 88 as lethal intent component, 39–41, 41 psychiatric evaluation of, 582, 583–585 with schizophrenia, 308–309 Suicide precautions, 427. See also Observation levels standard vs. close, 427–429, 431 Suicide prevention contract for. See No-suicide contract; Safety contracts in elderly, 20 Suicide prevention program, 143–144, 145. See also Prevention Suicide Probability Scale (SPS), 189–190 Suicide protocol, during crisis, 450, 450–451 Suicide rate with bipolar disorder, 2, 278–279 in children/adolescents, 35–37 demographic data on, 109–112, 110 in elderly, 20, 59–60, 60 gender differences in, 77, 97 ethnicity correlations, 110–112, 117 occupation correlations, 95–96, 126 international, 112–116 America, rural, 116 China, 114–115 cultural factors, 160–161 disabilities related to, 112, 113 Hong Kong, posttransition, 115–116 Russia, 113, 114
Index in jails/prisons, 140 national, 2, 527 in personality disorders, 329–330, 335 with personality disorders, 329–330, 335 of professions/professionals, 95–96 Suicide rehearsals, 18–19, 248 Suicide risk assessment, 1–31 APA guidelines for, 586–589, 587–588 for bipolar disorder, 284 limitations of, 285 case example of, 3, 5–6 categories of, 4–5, 24 checklist for, 2, 14, 15 in children/adolescents, 20, 38–39 continuing during treatment, 46, 46 clinical competence for, 444–445 confidentiality of, 12–13 cultural competence in, 159–176 acculturation and, 162–163 age factor, 167–169 case examples of, 165, 170 definition of, 160 economic factors, 166–167 ethnicity and, 160, 169–170 family support and, 166–167 immigration and, 162–163 interpersonal factors, 166–167 key points, 171–172 marital status and, 166–167, 170 religion and, 165–166 terminology for, 159–160 therapeutic alliance for, 163– 164 variables of, 160–161 in depressive disorders, 256–261 anxiety severity, 258–261, 260
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chronic vs. acute, 257 current clinical state, 256–259 risk severity, 256–259 suicidal tendencies, 260–261, 262 timing of, 260–261 dimensional parameters in, 24–25, 26 for discharges. See Discharge assessments documentation of, 9, 11–12, 444–446 alterations of, 453, 572 sample note for, 24, 25 emergency services and, 381–382 ethics of disclosure of, 12–13 evidence-based consensus on, 2–3 failure to perform, 11–12 foreseeability factor, 7, 50, 517, 521, 523, 529, 549 for inpatient treatment. See Admission assessments key points, 25–27 malpractice claims on, taxonomy of, 518–519 methodology for, 23–25, 25 Minnesota Multiphasic Personality Inventory–2 for, 177–179, 180–182 ongoing, in jails/prisons, 145, 145–146, 146 for outpatient treatment, 368–369 patient response in, 12 for personality disorders, 338 population-based, 20–23, 139, 162–163, 357–358 professional recommendations for, 2–3 psychiatric examination for, 9, 11, 13, 579–581, 580 case example of, 581
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Suicide risk assessment (continued) psychiatric examination for (continued) dimensional parameters for, 24–25, 26 documentation of, 582, 585 indications for, 582, 585 specific questions for, 582, 583–585 psychological testing in, 2, 16, 177–178 purpose of, 1, 11 reasonableness of, 7, 549 reassessment indications, 238–239, 258, 446 reliability of, 1, 12, 23 risk factors review, 1–2, 14–20 risk management for, 554–555 skills and judgment competency for, 243–244 in split treatment, 237–239, 247–248 stand-alone forms for, 23 standard of care for, 1–2, 7, 14 for substance-related disorders, 357–358 general issues of, 357 for special populations, 357–358 during suicidal crisis, 447–450, 450 suicidal ideation and, 12–13, 16, 19 for survivors of suicide, 460, 464 systematic, 2, 7, 9, 11–13, 564 on admission, 5, 8–9 conceptual model of, 4–5, 23–24 for discharge, 6, 10–11, 402, 582 weather forecasting analogy, 14 Suicide risk factors, 14–20 in anxiety disorders, 313–327 factors associated with, 325, 325
generalized anxiety disorder, 15, 316–318 key points, 324–325 obsessive-compulsive disorder, 320–322 panic disorder, 15, 313–316 posttraumatic stress disorder, 322–324 social phobia, 318–320 assessment based on, 1–2, 13, 14 in bipolar disorder, 278–285 assessment of, 284–285 demographics of, 283 illness duration effects, 282 illness severity effects, 279–280 lethality of attempts, 280–281, 281 miscellaneous, 18, 21, 282–284 sex differences in, 279, 280 statistics on, 278, 280 stressor effects, 283–284 subtypes correlated to, 282–283 therapies for limiting, 285–292 in children/adolescents, 36, 37, 40 amelioration of, 46, 46–48 dementia and delirium as, 64 demographic, 16–17 in elderly, 59–68, 63, 67 family history and, 17 gender associations, 16–17, 19, 20, 77–79, 94 in children/adolescents, 36–37, 39 genetic and familial transmission of, 17 hierarchy of, 23 increased, APA list of, 586–589, 587–588 long-term, 15–16
Index with personality disorders, 16–17, 20–21 Cluster A, 333 Cluster B, 334–336 Cluster C, 333–334 prodromal, 16 profile of, 16, 23 in schizophrenia, 16, 304 short-term, 14–15 substance use/abuse and, 16, 17, 20, 21, 347, 348 actual substances used, 353–357, 354, 355 general issues of, 352 influences on, 351, 351 in personality disorders, 334 psychiatric syndromes and, 352–353 in schizophrenia, 306–309 treatment timing and, 15 Suicide risk management. See also Prevention assessment overview, 2, 16, 177–178 clinically based, 545–575 collaborative treatment and, 561–563 for emergency psychiatric services, 567–570 importance of, 545–547 for inpatients, 564–567 key points, 572 legal elements of, 436–437, 437, 546 malpractice litigation and, 547–553, 548 for outpatients, 557–560, 558 risk assessment and, 554–555 suicide aftermath and, 570–572 suicide prevention contracts and, 555–557
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depression/depressive disorders acute high, 264–270 chronic high, 270–272 malpractice litigation and, 50–51, 452, 511–512 clinical perspectives of, 547–553, 548 with schizophrenia, 301–309 chronic case example, 306–309 newly diagnosed case example, 302–306 substance abuse comorbidity and, 306–309 tools and scales for, 177–194. See also Psychological tests/ testing Suicide warnings, patient safety vs. freedom and, 434–435 Summaries, in malpractice litigation, 531 Summary judgment, motion for, 533 Summit Bank v. Panos, 522–523 Supervening cause, 521–522 Supervision in hospitals patient safety vs. freedom and, 426–427 for suicide prevention, 407 in jails/prisons, for suicide prevention, 145, 148–149 by significant others, 435–436 in split treatment, 242–243 Support groups/systems interviews of, for psychological autopsy, 539, 539 conducting, 540–542 for outpatient treatment, 369 loss of, 371–372 social. See Social support Survivors of suicide (SOS), 459–476 active postvention model of, 461–463, 462
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Survivors of suicide (continued) case examples of, 466–472 in children/adolescents, 36, 50–51 clinicians as, self-care for, 472–473, 473 clinician's role, 459–460 coping mechanisms of, 459–461 institutional response/barriers to, 460–461, 488 interviews of, for psychological autopsy, 539, 539 conducting, 540–542 outreach to after initial period, 463–473 during initial period, 461–463 referrals for, 464–466 safety interventions and, 452–453 Suttee, 124 Systematic assessment, of suicide risk, 2, 7, 9, 11–13, 564 on admission, 5, 8–9 conceptual model of, 4–5, 23–24 for discharge, 6, 10–11, 402, 582 Systemic lupus erythematosus, 64 Systems issues, in hospitals, 412–416 Tarasoff v. Regents of the University of California, 434, 514, 515 TAT (Thematic Apperception Test), 177, 188 Taxonomy, of malpractice claims, on suicide risk assessment, 518–519 TCAs. See Tricyclic/tetracyclic antidepressants (TCAs) Team leader, for outpatient treatment, 370 Telehelp/Telecheck service, 71–72 Temperament, clinical, in split treatment, 243–244 Terrorism, 505–506
Tetracyclic antidepressants. See Tricyclic/tetracyclic antidepressants (TCAs) Texas and P.Ry. v. Behymer, 518 Thematic Apperception Test (TAT), 177, 188 Therapeutic alliance actions that create, 550, 550 clinically based risk management for, 545–575. See also Risk management for cultural competence, 163–164 legal duty regarding, 549–550, 550. See also Duty for outpatient treatment, 367–368 commitment to, 368, 371, 377 in psychodynamic psychiatry, 225, 226 schizophrenia challenges for, 309 as suicide protective factor, 24 for children/adolescents, 46 Therapeutic pass, in inpatient treatment, 415–416 Thioridazine, 211, 214 Thiothixene, 211, 214 Third parties, duty to, 434, 548 Third-party payers, split treatment and, 236, 239–240 Threats, of self-harm, confidential information disclosure based on, 13 Tikopia, sociocultural case study, 109 The T.J. Hooper decision, 518 Torts/tort law common litigation reasons, 444, 444 contract law vs., 515 duty principle in, 515, 548–549, 549 intentional, 528 legal concepts of, 520, 528–529 types of, 528, 529 Toxicology data, gender differences in, 84
Index Traditionalism, 163 Training collegial, in split treatment, 243–244 of staff in hospitals, 411–412 in jails/prisons, 144–145, 145 Transfer, to another facility, 388, 396 Transference in psychodynamic psychiatry, 225, 226 in split treatment, 242 Transference-based psychotherapy, in outpatient treatment, 371 Transgender individuals, suicide rate of, 127–128 Tranylcypromine, 210 Trauma stress disorder from. See Posttraumatic stress disorder (PTSD) in substance-related disorders, 349 Trazodone, 209, 594 Treatment compliance in children/adolescents, 43 in elderly, 70–71 negligence and, 515 in outpatient setting, 368, 371, 377 split treatment and, 239 Treatment/management consent to in children/adolescents, 36, 48–49 for hospitalization, 49 in outpatient setting, 368–369 documentation of, 51, 444–446 alterations of, 453, 572 in elderly, 68–72 emergency services in, 381–400 evidence-based consensus on, 2–3 as safe practice, 446, 453–454 during hospitalization, 407–411
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limitations of disclosure of, 468 in psychodynamic psychiatry, 225, 226 professional recommendations for, 2–3 rejection of. See Treatment compliance split, 235–251. See also Split treatment suicide risk related to, 22–23 of survivors of suicide, 467–469 expectations for, 468–469 trust issues with, 467–468 timing of, 15 Treatment setting inpatient, 401–419. See also Hospitalization malpractice litigation and, 529–530 common inpatient allegations, 530, 530 common outpatient allegations, 530, 531 outpatient, 46, 367–379. See also Outpatient treatment partial hospitalization, 339, 401–419, 559 as psychiatrist distress predictor, 485, 485–486 Treatment team, in outpatient setting, 369–370, 377 Trial, in malpractice litigation, 533 Tricyclic/tetracyclic antidepressants (TCAs) adverse effects with overdose, 209 use and efficacy of, 206, 208 Trier of fact, in malpractice litigation, 533 Trifluoperazine, 211, 214 Triggers, of suicidal behavior, 331–332
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Trust, loss of, after completed suicide, 467–468 211 crisis line, 465–466 Uncertainty. See Clinical uncertainty Unconscious conflict/meanings, 221–222 Unemployment, suicide related to, 130–132 cultural perspectives of, 167, 168 Unintentional injury, with substancerelated disorders, 348–349 United States v. St. Jean, 537–538 Universal interventions, for suicide prevention, in elderly, 71, 72 Urbanization, 116, 168 Validity, of psychological autopsy, 539, 539 Valproate/valproic acid, 210, 213–214 for bipolar disorder, 289 Value-based stance, on suicide, 442–443, 443 Venlafaxine, 209, 268 Veterans, male, posttraumatic stress disorder in, 323 Violence gender differences of, 86, 88 murder-suicide related to, 505–506 substance-related disorders and, 347, 348, 351–352 Vital signs, emergency assessment of, 387–388 Vocational ability. See Functionality Voice mail, in split treatment, 245 Vulnerability, social, of men, 91–94 Ward supervision, 428–429 Weapons. See Firearms Weather forecasting analogy, of risk assessment, 14
Web sites, for survivors of suicide, 466 Western cultures, risk assessment views in, 162–164, 166–167, 168, 171 Western Pacific Island, sociocultural case study, 109 White Americans, suicide rate in, 110, 110–112 Withdrawal syndromes admission assessment of, 405 emergency assessment of, 387–388 Wives, murder-suicide by, 99–100 Women physicians severe distress reactions of, 486 suicide rate of, 95–97, 126 Workers' compensation claims, litigation and, 534, 536–537 Workplace/setting murder-suicide in, 505–506 as psychiatrist distress predictor, 485, 485–486 World War II, 170 Wozniak v. Lipoff, 522 Writing, as psychiatrist coping with suicide, 490 Wrongful-death statutes, 548 Yates, Andrea, 505 Youth. See also Adolescents; Children gay, lesbian, bisexual, and transgender, 127–128 risk assessment for, 20 suicide rate based on ethnicity, 110–111, 122, 163 suicide risk data on, 16, 20, 167 Youth Risk Behavioral Surveillance (YRBS) study, 37 Ziprasidone, 212, 214, 216 for bipolar disorder, 290, 293 Zone observation, 428
