0
1

Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors

DOI: 10.1176/appi.books.9780890423363.56008
+

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.

 

Originally published in November 2003. A guideline watch, summarizing significant developments in the scientific literature since publication of this guideline, may be available.

+

Guide to Using This Practice Guideline

Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors consists of three parts (Parts A, B, and C) and many sections, not all of which will be equally useful for all readers. The following guide is designed to help readers find the sections that will be most useful to them.

Part A, "Assessment, Treatment, and Risk Management Recommendations," is published as a supplement to the American Journal of Psychiatry and contains the general and specific recommendations for the assessment and treatment of patients with suicidal behaviors. Section I summarizes the key recommendations of the guideline and codes each recommendation according to the degree of clinical confidence with which the recommendation is made. Section II discusses the assessment of the patient, including a consideration of factors influencing suicide risk. Section III discusses psychiatric management, Section IV discusses specific treatment modalities, and Section V addresses documentation and risk management issues.

Part B, "Background Information and Review of Available Evidence," and Part C, "Future Research Needs," are not included in the American Journal of Psychiatry supplement but are provided with Part A in the complete guideline, which is available in print format from American Psychiatric Publishing, Inc., and online through the American Psychiatric Association (http://www.psych.org). Part B provides an overview of suicide, including general information on its natural history, course, and epidemiology. It also provides a structured review and synthesis of the evidence that underlies the recommendations made in Part A. Part C draws from the previous sections and summarizes areas for which more research data are needed to guide clinical decisions.

+

Development Process

This practice guideline was developed under the auspices of the Steering Committee on Practice Guidelines. The development process is detailed in the document "APA Guideline Development Process," which is available from the APA Department of Quality Improvement and Psychiatric Services. Key features of this process include the following:

  • A comprehensive literature review

  • Development of evidence tables

  • Initial drafting of the guideline by a work group that included psychiatrists with clinical and research expertise in suicide and suicidality

  • Production of multiple revised drafts with widespread review; six organizations and more than 60 individuals submitted significant comments

  • Approval by the APA Assembly and Board of Trustees

  • Planned revisions at regular intervals

Relevant literature was identified through a computerized search of PubMed for the period from 1966 to 2002. Keywords used were "suicides,""suicide,""attempted suicide,""attempted suicides,""parasuicide,""parasuicides,""self-harm,""self-harming,""suicide, attempted,""suicidal attempt," and "suicidal attempts." A total of 34,851 citations were found. After limiting these references to literature published in English that included abstracts, 17,589 articles were screened by using title and abstract information. Additional, less formal literature searches were conducted by APA staff and individual members of the work group on suicidal behaviors through the use of PubMed, PsycINFO, and Social Sciences Citation Index. Sources of funding were not considered when reviewing the literature.

This document represents a synthesis of current scientific knowledge and rational clinical practice on the assessment and treatment of adult patients with suicidal behaviors. It strives to be as free as possible of bias toward any theoretical approach to treatment. In order for the reader to appreciate the evidence base behind the guideline recommendations and the weight that should be given to each recommendation, the summary of treatment recommendations is keyed according to the level of confidence with which each recommendation is made. Each rating of clinical confidence considers the strength of the available evidence and is based on the best available data. When evidence is limited, the level of confidence also incorporates clinical consensus with regard to a particular clinical decision. In the listing of cited references, each reference is followed by a letter code in brackets that indicates the nature of the supporting evidence.

+

Part A: Assessment, Treatment, and Risk Management Recommendations

+

I. Executive Summary of Recommendations

+

A. Definitions and General Principles

+
1. 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.

+
2. 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.

  • 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. (1).

+

B. 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 1 presents important domains of a suicide assessment, including the patient's current presentation, individual strengths and 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].

+
Table Reference Number
Table 1. Characteristics Evaluated in the Psychiatric Assessment of Patients With Suicidal Behavior

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.

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]. 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. 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 assessment, 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].

+

C. 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 (2). 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 (3). 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, with a primary and ongoing goal of reducing suicide risk [I].

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).

+

D. 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]. 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].

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 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].

+

E. 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 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].

+
1. 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 their occasional tendency to produce disinhibition and their 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 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 second-generation 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].

+
2. 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 behavior therapy have been found to be effective in clinical trials for the treatment of depression. Therefore, psychotherapies such as interpersonal psychotherapy and cognitive behavior therapy may be considered appropriate treatments for suicidal behavior, particularly when it occurs in the context of depression [II]. In addition, cognitive behavior 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; problem-solving therapy; brief psychological treatment; or family, couples, or group therapies may be useful despite limited evidence for their efficacy [III].

+

II. Assessment of Patients With Suicidal Behaviors

+

A. Overview

The assessment of the suicidal patient is an ongoing process that comprises many interconnected elements (Table 1). In addition, there are a number of points during patients' evaluation and treatment at which a suicide assessment may be indicated (Table 2).

+
Table Reference Number
Table 2. Circumstances in Which a Suicide Assessment May Be Indicated Clinically

The ability of the psychiatrist to connect with the patient, establish rapport, and demonstrate empathy is an important ingredient of the assessment process. For suicidal patients who are followed on an ongoing basis, the doctor-patient relationship will provide the base from which risk and protective factors continue to be identified and from which therapeutic interventions, such as psychotherapies and pharmacotherapies, are offered.

At the core of the suicide assessment, the psychiatric evaluation will provide information about the patient's history, current circumstances, and mental state and will include direct questioning about suicidal thinking and behaviors. This evaluation, in turn, will enable the psychiatrist to identify specific factors and features that may increase or decrease the potential risk for suicide or other suicidal behaviors. These factors and features may include developmental, biomedical, psychopathologic, psychodynamic, and psychosocial aspects of the patient's current presentation and history, all of which may serve as modifiable targets for both acute and ongoing interventions. Such information will also be important in addressing the patient's immediate safety, determining the most appropriate setting for treatment, and developing a multiaxial differential diagnosis that will further guide the planning of treatment.

Although the approach to the suicidal patient is common to all individuals regardless of diagnosis or clinical presentation, the breadth and depth of the psychiatric evaluation will vary with the setting of the assessment; the ability or willingness of the patient to provide information; and the availability of information from previous contacts with the patient or from other sources, including other mental health professionals, medical records, and family members. Since the approach to assessment does vary to some degree in the assessment of suicidal children and adolescents, the psychiatrist who evaluates youths may wish to review the American Academy of Child and Adolescent Psychiatry's Practice Parameter for the Assessment and Treatment of Children and Adolescents With Suicidal Behavior (4). In some circumstances, the urgency of the situation or the presence of substance intoxication may necessitate making a decision to facilitate patient safety (e.g., instituting hospitalization or one-to-one observation) before all relevant information has been obtained. Furthermore, when working with a team of other professionals, the psychiatrist may not obtain all information him- or herself but will need to provide leadership for the assessment process so that necessary information is obtained and integrated into a final assessment. Since the patient may minimize the severity or even the existence of his or her difficulties, other individuals may be valuable resources for the psychiatrist in providing information about the patient's current mental state, activities, and psychosocial crises. Such individuals may include the patient's family members and friends but may also include other physicians, other medical or mental health professionals, teachers or other school personnel, members of the patient's military command, and staff from supervised housing programs or other settings where the patient resides.

+

B. Conduct a Thorough Psychiatric Evaluation

The psychiatric evaluation is the core element of the suicide risk assessment. This section provides an overview of the key aspects of the psychiatric evaluation as they relate to the assessment of patients with suicidal behaviors. Although the factors that are associated with an increased or decreased risk of suicide differ from the factors associated with an increased or decreased risk of suicide attempts, it is important to identify factors modulating the risk of any suicidal behaviors. Additional details on specific risk factors that should be identified during the assessment are discussed in Sections II.E, "Estimate Suicide Risk", and III.H, "Reassess Safety and Suicide Risk". For further discussion of other aspects of the psychiatric evaluation, the psychiatrist is referred to the American Psychiatric Association's Practice Guideline for Psychiatric Evaluation of Adults (5) (included in this volume). Additional information on details of the suicide assessment process is reviewed elsewhere (6, 7).

+
1. Identify specific psychiatric signs and symptoms

It is important to identify specific psychiatric signs and symptoms that are correlated with an increased risk of suicide or other suicidal behaviors. Symptoms that have been associated with suicide attempts or with suicide include aggression, violence toward others, impulsiveness, hopelessness, and agitation. Psychic anxiety, which has been defined as subjective feelings of anxiety, fearfulness, or apprehension whether or not focused on specific concerns, has also been associated with an increased risk of suicide, as have anhedonia, global insomnia, and panic attacks. In addition, identifying other psychiatric signs and symptoms (e.g., psychosis, depression) will aid in determining whether the patient has a psychiatric syndrome that should also be a focus of treatment.

+
2. Assess past suicidal behavior, including intent of self-injurious acts

A history of past suicide attempts is one of the most significant risk factors for suicide, and this risk may be increased by more serious, more frequent, or more recent attempts. Therefore, it is important for the psychiatrist to inquire about past suicide attempts and self-destructive behaviors, including specific questioning about aborted suicide attempts. Examples of the latter would include putting a gun to one's head but not firing it, driving to a bridge but not jumping, or creating a noose but not using it. For each attempt or aborted attempt, the psychiatrist should try to obtain details about the precipitants, timing, intent, and consequences as well as the attempt's medical severity. The patient's consumption of alcohol and drugs before the attempt should also be ascertained, since intoxication can facilitate impulsive suicide attempts but can also be a component of a more serious suicide plan. In understanding the issues that culminated in the suicide attempt, interpersonal aspects of the attempt should also be delineated. Examples might include the dynamic or interpersonal issues leading up to the attempt, significant persons present at the time of the attempt, persons to whom the attempt was communicated, and how the attempt was averted. It is also important to determine the patient's thoughts about the attempt, such as his or her own perception of the chosen method's lethality, ambivalence toward living, visualization of death, degree of premeditation, persistence of suicidal ideation, and reaction to the attempt. It is also helpful to inquire about past risk-taking behaviors such as unsafe sexual practices and reckless driving.

+
3. Review past treatment history and treatment relationships

A review of the patient's treatment history is another crucial element of the suicide risk assessment. A thorough treatment history can serve as a systematic method for gaining information on comorbid diagnoses, prior hospitalizations, suicidal ideation, or previous suicide attempts. Obtaining a history of medical treatment can help in identifying medically serious suicide attempts as well as in identifying past or current medical diagnoses that may be associated with augmented suicide risk.

Many patients who are being assessed for suicidality will already be in treatment, either with other psychiatrists or mental health professionals or with primary care physicians or medical specialists. Contacts with such caregivers can provide a great deal of relevant information and help in determining a setting and/or plan for treatment. With patients who are currently in treatment, it is also important to gauge the strength and stability of the therapeutic relationships, because a positive therapeutic alliance has been suggested to be protective against suicidal behaviors. On the other hand, a patient with a suicide attempt or suicidal ideation who does not have a reliable therapeutic alliance may represent an increased risk for suicide, which would need to be addressed accordingly.

+
4. Identify family history of suicide, mental illness, and dysfunction

Identifying family history is particularly important during the psychiatric evaluation. The psychiatrist should specifically inquire about the presence of suicide and suicide attempts as well as a family history of any psychiatric hospitalizations or mental illness, including substance use disorders. When suicides have occurred in first-degree relatives, it is often helpful to learn more about the circumstances, including the patient's involvement and the patient's and relative's ages at the time of the suicide.

The patient's childhood and current family milieu are also relevant, since many aspects of family dysfunction may be linked to self-destructive behaviors. Such factors include a history of family conflict or separation, parental legal trouble, family substance use, domestic violence, and physical and/or sexual abuse.

+
5. Identify current psychosocial situation and nature of crisis

An assessment of the patient's current psychosocial situation is important to detect acute psychosocial crises or chronic psychosocial stressors that may augment suicide risk (e.g., financial or legal difficulties; interpersonal conflicts or losses; stressors in gay, lesbian, or bisexual youths; housing problems; job loss; educational failure). Other significant precipitants may include perceived losses or recent or impending humiliation. An understanding of the patient's psychosocial situation is also essential in helping the patient to mobilize external supports, which can have a protective influence on suicide risk.

+
6. Appreciate psychological strengths and vulnerabilities of the individual patient

In estimating suicide risk and formulating a treatment plan, the clinician needs to appreciate the strengths and vulnerabilities of the individual patient. Particular strengths and vulnerabilities may include such factors as coping skills, personality traits, thinking style, and developmental and psychological needs. For example, in addition to serving as state-dependent symptoms, hopelessness, aggression, and impulsivity may also constitute traits, greater degrees of which may be associated with an increased risk for suicidal behaviors. Increased suicide risk has also been seen in individuals who exhibit thought constriction or polarized (either-or) thinking as well in individuals with closed-mindedness (i.e., a narrowed scope and intensity of interests). Perfectionism with excessively high self-expectation is another factor that has been noted in clinical practice to be a possible contributor to suicide risk. In weighing the strengths and vulnerabilities of the individual patient, it is also helpful to determine the patient's tendency to engage in risk-taking behaviors as well as the patient's past responses to stress, including the capacity for reality testing and the ability to tolerate rejection, subjective loneliness, or psychological pain when his or her unique psychological needs are not met.

+

C. Specifically Inquire About Suicidal Thoughts, Plans, and Behaviors

In general, the more an individual has thought about suicide, has made specific plans for suicide, and intends to act on those plans, the greater will be his or her risk. Thus, as part of the suicide assessment it is essential to inquire specifically about the patient's suicidal thoughts, plans, behaviors, and intent. Although such questions will often flow naturally from discussion of the patient's current situation, this will not invariably be true. The exact wording of questions and the extent of questioning will also differ with the clinical situation. Examples of issues that the psychiatrist may wish to address in this portion of the suicide assessment are given in Table 3.

+
Table Reference Number
Table 3. Questions That May Be Helpful in Inquiring About Specific Aspects of Suicidal Thoughts, Plans, and Behaviors 
+
1. Elicit the presence or absence of suicidal ideation

Inquiring about suicidal ideation is an essential component of the suicide assessment. Although some fear that raising the topic of suicide will "plant" the issue in the patient's mind, this is not the case. In fact, broaching the issue of suicidal ideation may be a relief for the suicidal patient by opening an avenue for discussion and giving him or her an opportunity to feel understood.

In asking about suicidal ideas, it is often helpful to begin with questions that address the patient's feelings about living, such as, "How does life seem to you at this point?" or "Have you ever felt that life was not worth living?" or "Did you ever wish you could go to sleep and just not wake up?" If the patient's response reflects dissatisfaction with life or a desire to escape it, this response can lead naturally into more specific questions about whether the patient has had thoughts of death or suicide. When such thoughts are elicited, it is important to focus on the nature, frequency, extent, and timing of them and to understand the interpersonal, situational, and symptomatic context in which they are occurring.

Even if the patient initially denies thoughts of death or suicide, the psychiatrist should consider asking additional questions. Examples might include asking about plans for the future or about recent acts or thoughts of self-harm. Regardless of the approach to the interview, not all individuals will report having suicidal ideas even when such thoughts are present. Thus, depending on the clinical circumstances, it may be important for the psychiatrist to speak with family members or friends to determine whether they have observed behavior (e.g., recent purchase of a gun) or have been privy to thoughts that suggest suicidal ideation (see Section V.C, "Communication With Significant Others"). In addition, patients who are initially interviewed when they are intoxicated with alcohol or other substances should be reassessed for suicidality once the intoxication has resolved.

+
2. Elicit the presence or absence of a suicide plan

If suicidal ideation is present, the psychiatrist will next probe for more detailed information about specific plans for suicide and any steps that have been taken toward enacting those plans. Although some suicidal acts can occur impulsively with little or no planning, more detailed plans are generally associated with a greater suicide risk. Violent and irreversible methods, such as firearms, jumping, and motor vehicle accidents, require particular attention. However, the patient's belief about the lethality of the method may be as important as the actual lethality of the method itself.

If the patient does not report a plan, the psychiatrist can ask whether there are certain conditions under which the patient would consider suicide (e.g., divorce, going to jail, housing loss) or whether it is likely that such a plan will be formed or acted on in the near future. If the patient reports that he or she is unlikely to act on the suicidal thoughts, the psychiatrist should determine what factors are contributing to that expectation, as such questioning can identify protective factors.

Whether or not a plan is present, if a patient has acknowledged suicidal ideation, there should be a specific inquiry about the presence or absence of a firearm in the home or workplace. It is also helpful to ask whether there have been recent changes in access to firearms or other weapons, including recent purchases or altered arrangements for storage. 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. Such discussions should be documented in the medical record, including any instructions that have been given to the patient and significant others about firearms or other weapons.

+
3. Assess the degree of suicidality, including suicidal intent and lethality of plan

Regardless of whether the patient has developed a suicide plan, the patient's level of suicidal intent should be explored. Suicidal intent reflects the intensity of a patient's wish to die and can be assessed by determining the patient's motivation for suicide as well as the seriousness and extent of his or her aim to die, including any associated behaviors or planning for suicide. If the patient has developed a suicide plan, it is important to assess its lethality. The lethality of the plan can be ascertained through questions about the method, the patient's knowledge and skill concerning its use, and the absence of intervening persons or protective circumstances. In general, the greater and clearer the intent, the higher the risk for suicide will be. Thus, even a patient with a low-lethality suicide plan or attempt may be at high risk in the future if intentions are strong and the patient believes that the chosen method will be fatal. At the same time, a patient with low suicidal intent may still die from suicide by erroneously believing that a particular method is not lethal.

+
4. Understand the relevance and limitations of suicide assessment scales

Although a number of suicide assessment scales have been developed for use in research and are described more fully in Part B of the guideline, their clinical utility is limited. Self-report rating scales may sometimes assist in opening communication with the patient about particular feelings or experiences. In addition, the content of suicide rating scales, such as the Scale for Suicide Ideation (8) and the Suicide Intent Scale (9), may be helpful to psychiatrists in developing a thorough line of questioning about suicide and suicidal behaviors. However, existing suicide assessment scales suffer from high false positive and false negative rates and have very low positive predictive values (10). As a result, such rating scales cannot substitute for thoughtful and clinically appropriate evaluation and are not recommended for clinical estimations of suicide risk.

+

D. Establish a Multiaxial Diagnosis

In conceptualizing suicide risk, it is important for the psychiatrist to develop a multiaxial differential diagnosis over the course of the psychiatric evaluation. Studies have shown that more than 90% of individuals who die by suicide satisfy the criteria for one or more psychiatric disorders. Thus, the psychiatrist should determine whether a patient has a primary axis I or axis II diagnosis. Suicide and other suicidal behaviors are also more likely to occur in individuals with more than one psychiatric diagnosis. As a result, it is important to note other current or past axis I or axis II diagnoses, including those that may currently be in remission.

Identification of physical illness (axis III) is essential since such diagnoses may also be associated with an increased risk of suicide as well as with an increased risk of other suicidal behaviors. For some individuals, this increase in risk may result from increased rates of comorbid psychiatric illness or from the direct physiological effects of physical illness or its treatment. Physical illnesses may also be a source of social and/or psychological stress, which in turn may augment risk.

Also crucial in determining suicide risk is the recognition of psychosocial stressors (axis IV), which may be either acute or chronic. Certain stressors, such as sudden unemployment, interpersonal loss, social isolation, and dysfunctional relationships, can increase the likelihood of suicide attempts as well as increase the risk of suicide. At the same time, it is important to note that life events have different meanings for different individuals. Thus, in determining whether a particular stressor may confer risk for suicidal behavior, it is necessary to consider the perceived importance and meaning of the life event for the individual patient.

As the final component of the multiaxial diagnosis, the patient's baseline and current levels of functioning are important to assess (axis V). Also, the clinician should assess the relative change in the patient's level of functioning and the patient's view of and feelings about his or her functioning. Although suicidal ideation and/or suicide attempts are reflected in the Global Assessment of Functioning (GAF) scoring recommendations, it should be noted that there is no agreed-on correlation between a GAF score and level of suicide risk.

+

E. Estimate Suicide Risk

The goal of the suicide risk assessment is to identify factors that may increase or decrease a patient's level of suicide risk, to estimate an overall level of suicide risk, and to develop a treatment plan that addresses patient safety and modifiable contributors to suicide risk. The assessment is comprehensive in scope, integrating knowledge of the patient's specific risk factors; clinical history, including psychopathological development; and interaction with the clinician. The estimation of suicide risk, at the culmination of the suicide assessment, is the quintessential clinical judgment, since no study has identified one specific risk factor or set of risk factors as specifically predictive of suicide or other suicidal behavior.

Table 4 provides a list of factors that have been associated with increased suicide risk, and Table 5 lists factors that have been associated with protective effects. While risk factors are typically additive (i.e., the patient's level of risk increases with the number of risk factors), they may also interact in a synergistic fashion. For example, the combined risk associated with comorbid depression and physical illness may be greater than the sum of the risk associated with each in isolation. At the same time, certain risk factors, such as a recent suicide attempt (especially one of high lethality), access to a firearm, and the presence of a suicide note, should be considered serious in and of themselves, regardless of whether other risk factors are present.

+
Table Reference Number
Table 4. Factors Associated With an Increased Risk for Suicide 
+
Table Reference Number
Table 5. Factors Associated With Protective Effects for Suicide

The effect on suicide risk of some risk factors, such as particular life events or psychological strengths and vulnerabilities, will vary on an individual basis. Risk factors must also be assessed in context, as certain risk factors are more applicable to particular diagnostic groups, while others carry more general risk. Finally, it should be kept in mind that, because of the low rate of suicide in the population, only a small fraction of individuals with a particular risk factor will die from suicide.

Risk factors for suicide attempts, which overlap with but are not identical to risk factors for suicide, will also be identified in the assessment process. These factors should also be addressed in the treatment planning process, since suicide attempts themselves are associated with morbidity in addition to the added risk that they confer for suicide.

+
1. Demographic factors

In epidemiologic studies, a number of demographic factors have been associated with increased rates of suicide. However, these demographic characteristics apply to a very broad population of people and cannot be considered alone. Instead, such demographic parameters must be considered within the context of other interacting factors that may influence individual risk.

+
a) Age

Suicide rates differ dramatically by age. In addition, age-related psychosocial stressors and family or developmental issues may influence suicide risk. The age of the patient can also be of relevance to psychiatric diagnosis, since specific disorders vary in their typical ages of onset.

Between age 10 and 24 years, suicide rates in the general population of the United States rise sharply to approximately 13 per 100,000 in the 20- to 24-year-old age group before essentially plateauing through midlife. After age 70, rates again rise to a high of almost 20 per 100,000 in those over age 80 (Figure 1). These overall figures can be misleading, however, since the age distribution of suicide rates varies as a function of gender as well as with race and ethnicity. For example, among male African Americans and American Indians/Alaska Natives, suicide rates rise dramatically during adolescence, peak in young adulthood, and then fall through mid- and later life. Thus, in adolescence and young adulthood, the suicide rates of African American men are comparable with those of white men, although overall, African American males are half as likely to die from suicide as white males. While suicide rates in many age groups have remained relatively stable over the last 50 years, the rate among adolescents and young adults has increased dramatically, and the rate among the elderly has decreased. Among the 14- to 25-year-old age group, suicide is now the third leading cause of death, with rates that are triple those in the 1950s (12).

+
+
Figure 1. Number and Rate of Deaths by Suicide in Males and Females in the United States in 2000, by Age Groupa
aIncludes deaths by suicide injury (ICD-10 codes X60–X84, Y87.0). From the Web-Based Injury Statistics Query and Reporting System, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (11).

Suicide rates are higher in older adults than at any other point in the life course. In 2000 in the United States there were approximately 5,300 suicides among individuals over age 65, a rate of 15.3 per 100,000. Whereas older adults made up 12.6% of the population, they accounted for 18.1% of suicides. In addition, the high suicide rate in those over age 65 is largely a reflection of the high suicide rate in white men, which reaches almost 60 per 100,000 by age 85. While rates in Asian men also increase after age 65 and rates in Asian women increase dramatically after age 80, the rate for all other women is generally flat in late life.

Thoughts of death are also more common in older than in younger adults, but paradoxically, as people age they are less likely to endorse suicidal ideation per se (13). Attempted suicide is also less frequent among persons in later life than among younger age groups (14). Whereas the ratio of attempted suicides to suicides in adolescents may be as high as 200:1, there are as few as one to four attempts for each suicide in later life (15). However, the self-destructive acts that do occur in older people are more lethal. This greater lethality is a function of several factors, including reduced physical resilience (greater physical illness burden), greater social isolation (diminished likelihood of rescue), and a greater determination to die (15). Suicidal elders give fewer warnings to others of their plans, use more violent and potentially deadly methods, and apply those methods with greater planning and resolve (15, 16). Therefore, compared with a suicide attempt in a younger person, a suicide attempt in an older person confers a higher level of future suicide risk.

+
b) Gender

In virtually all countries that report suicide statistics to the World Health Organization, suicide risk increases with age in both sexes, and rates for men in older adulthood are generally higher than those for women (17). One exception is China, where the suicide rate of women is much greater than that of men (18). In the United States, death by suicide is more frequent in men than in women, with the suicide rate in males approximately four times that in females (Figure 1). In the psychiatric population, these gender differences are also present but are less prominent. In terms of murder-suicide, the male predominance is more pronounced, with identified typologies including young men with prominent sexual jealousy and elderly men with ailing spouses (19, 20). From age 65 on, there are progressive increases in suicide rates for white men and for Asian men as well as for men overall. With the exception of high suicide rates in Asian women over age 80, women in the United States are at highest risk in midlife (11).

A number of factors may contribute to these gender differences in suicide risk (21). Men who are depressed are more likely to have comorbid alcohol and/or substance abuse problems than women, which places the men at higher risk. Men are also less likely to seek and accept help or treatment. Women, meanwhile, have factors that protect them against suicide. In addition to their lower rates of alcohol and substance abuse, women are less impulsive, more socially embedded, and more willing to seek help. Among African American women, rates of suicide are remarkably low, a fact that has been attributed to the protective factors of religion and extended kin networks (22). At the same time, women have higher rates of depression (23) and respond to unemployment with greater and longer-lasting increases in suicide rates than do men (24).

Overall, for women in the general population, pregnancy is a time of significantly reduced suicide risk (25). Women with young children in the home are also less likely to kill themselves (26). Nonetheless, women with a history of depression or suicide attempts are at greater risk for poor outcomes postpartum. Although suicide is most likely to occur in the first month after delivery, risk continues throughout the postpartum period. Teenagers, women of lower socioeconomic status, and women hospitalized with postpartum psychiatric disorders may be at particularly increased risk postpartum (27, 28).

Women tend to choose less lethal suicide methods than men do (e.g., overdose or wrist cutting versus firearms or hanging). Such differences may in part account for the reversal in the gender ratio for suicide attempters, with women being reported to attempt suicide three times as often as men (29). This female predominance among suicide attempters varies with age, however, and in older adults the ratio of women to men among suicide attempters approaches 1:1 (11, 30). Rates of suicidal ideation and attempts are also increased in individuals with borderline personality disorder and in those with a history of domestic violence or physical and/or sexual abuse, all of which are more common among women (31–36). In addition, the likelihood of suicide attempts may vary with the phase of the menstrual cycle (37, 38).

+
c) Race, ethnicity, and culture

Variations in suicide rates across racial and ethnic groups have been mentioned earlier in the discussion of the influences of age and gender on suicide risk. Overall, however, in the United States, age-adjusted rates for suicide in whites and in non-Hispanic Native Americans are approximately double those observed in Hispanics, non-Hispanic African Americans, and Asian-Pacific Islanders (12.1 and 13.6 per 100,000 versus 6.1, 5.8, and 6.0 per 100,000, respectively) (11). For immigrant groups, in general, suicide rates tend to mirror the rates in the country of origin and converge toward the rate in the host country over time (39–41).

In the United States, racial and ethnic differences are also seen in the rates of suicide across the lifespan, with the highest suicide rates occurring in those over age 65 among non-Hispanic whites, Hispanics, and Asian-Pacific Islanders (11). In contrast, among Native Americans and African Americans, the highest suicide rates occur during adolescence and young adulthood (11). Such figures may be deceptive, however, since each of these groups exhibits a striking degree of heterogeneity that is rarely addressed in compilations of suicide rates.

Racial and ethnic differences in culture, religious beliefs, and societal position may influence not only the actual rates of suicide but also the views of death and suicide held by members of a particular group. For some groups, suicide can be considered a traditionally accepted way of dealing with shame, distress, and/or physical illness (42). In addition, cultural values about conveying suicidal ideas may differ; in some cultures, for example, suicidal ideation may be considered a disgraceful or private matter that should be denied. Cultural differences, particularly in immigrants and in Native Americans and Alaska Natives, may generate acculturative stresses that in turn may contribute to suicidality (43, 44). Thus, knowledge of and sensitivity to common contributors to suicide in different racial and ethnic groups as well as cultural 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.

+
d) Marital status

Suicide risk also varies with marital status, with the suicide rate of single persons being twice that of those who are married. Divorced, separated, or widowed individuals have rates four to five times higher than married individuals (45, 46). Variations in suicide rates with marital status may reflect differing rates of baseline psychiatric illness but may also be associated with psychological or health variations. The presence of another person in the household may also serve as a protective factor by decreasing social isolation, engendering a sense of responsibility toward others, and increasing the likelihood of discovery after a suicide attempt. For women, the presence of children in the home may provide an additional protective effect (26, 47). It is also important to note that although married adults have lower rates of suicide overall, young married couples may have increased risk, and the presence of a high-conflict or violent marriage can be a precipitant rather than a protective factor for suicide.

+
e) Sexual orientation

Although no studies have examined rates of suicide among gay, lesbian, and bisexual individuals, available evidence suggests that they may have an increased risk for suicidal behaviors. Many recent studies involving diverse sample populations and research methods have consistently found that gay, lesbian, and bisexual youths have a higher risk of suicide attempts than matched heterosexual comparison groups (48–53). The female-to-male ratio for reported suicide attempts in the general population is reversed in lesbian and gay youths, with more males than females attempting suicide (48). While some risk factors leading to suicide, such as psychiatric and substance use disorders, are shared by both gay, lesbian, and bisexual youths and heterosexual youths, others are unique to being gay, lesbian, or bisexual (e.g., disclosure of sexual orientation to friends and family, experience of homophobia and harassment, and gender nonconformity). Aggressive treatment of psychiatric and substance use disorders, open and nonjudgmental support, and promotion of healthy psychosocial adjustment may help to decrease the risk for suicide in gay, lesbian, and bisexual youths and adults.

+
f) Occupation

Occupational groups differ in a number of factors contributing to suicide risk. These factors include demographics (e.g., race, gender, socioeconomic class, marital status), occupational stress (54, 55), psychiatric morbidity (56), and occupationally associated opportunities for suicide (56, 57). Physicians have been consistently found to be at higher risk for suicide than persons in other occupations including professionals (57, 58). After basic demographic correlates of suicide across 32 occupations were controlled, risk was found to be highest among dentists and physicians (with multivariate logistic regression odds ratios of 5.43 and 2.31, respectively) and was also increased among nurses, social workers, artists, mathematicians, and scientists (54). Although evidence is more varied, farmers may be at somewhat higher risk, whereas risk in police officers generally does not appear to differ from that of age- and sex-matched comparison subjects (54, 57).

+
2. Major psychiatric syndromes

The presence of a psychiatric disorder is probably the most significant risk factor for suicide. Psychological autopsy studies have consistently shown that more than 90% of persons who die from suicide satisfy the criteria for one or more psychiatric disorders (59, 60). The psychological autopsy method involves a retrospective investigation of the deceased person, within several months of death, and uses psychological information gathered from personal documents; police, medical, and coroner records; and interviews with family members, friends, co-workers, school associates, and health care providers to classify equivocal deaths or establish diagnoses that were likely present at the time of suicide (61–63).

In addition to there being high rates of psychiatric disorder among persons who die by suicide, almost all psychiatric disorders with the exception of mental retardation have been shown to increase suicide risk as measured by standardized mortality ratios (SMRs) (64) (Table 6). An SMR reflects the relative mortality from suicide in individuals with a particular risk factor, compared with the general population. Thus, the SMR will be equal to 1.0 when the number of observed suicide deaths is equivalent to the number of expected deaths by suicide in an age- and sex-matched group in the general population. Values of the SMR for suicide that are greater than 1.0 indicate an increased risk of suicide, whereas values less than 1.0 indicate a decreased risk (i.e., a protective effect). It is also important to note that SMRs do not correspond precisely to the incidence or prevalence of suicide and may vary in their reliability depending on the number of suicides in the sample, the time period of the study, and the representativeness of the study population. Thus, SMRs should be viewed as estimates of relative risk and not as reflections of absolute risk for individuals with a particular disorder. It is equally necessary to appreciate distinctions in risk across disorders and variations in risk at differing points in the illness course in the effort to differentiate high-risk patients within an overall at-risk population identified in terms of standardized mortality.

+
Table Reference Number
Table 6. Risk of Suicide in Persons With Previous Suicide Attempts and Psychiatric Disordersa
+
a) Mood disorders

Study after study has confirmed that the presence of a major mood disorder is a significant risk factor for suicide. Not surprisingly, mood disorders, primarily in depressive phases, are the diagnoses most often found in suicide deaths (59, 65–67). Although most suicides in individuals with bipolar disorder occur during depressive episodes, mixed episodes are also associated with increased risk (68–70). Suicidal ideation and attempts are also more common during mixed episodes than in mania (71).

When viewed from the standpoint of lifetime risk, mood disorders are associated with an increased risk of mortality that has been estimated to range from a 12-fold increase in risk with dysthymia to a 20-fold increase in risk with major depression (64). Lifetime suicide risk in bipolar disorder has generally been found to be similar to that in unipolar major depression (69, 72). However, several longitudinal studies of patients followed after an index hospitalization have demonstrated suicide risks in patients with major depressive disorder that are greater than those in patients with either bipolar I disorder or bipolar II disorder (73–75).

Particularly for younger patients, suicides are more likely to occur early in the course of illness (68, 73, 75, 76). Nonetheless, risk persists throughout life in major depressive disorder as well as in bipolar disorder (73, 74). Suicide risk also increases in a graduated fashion with illness severity as reflected by the level of required treatment. Lifetime suicide rates in psychiatric outpatients ranged from 0.7% for those without an affective disorder to 2.2% for those with affective disorders, whereas lifetime suicide rates for individuals requiring hospitalization ranged from 4% for those whose admission for depression was not prompted by suicidal behavior or risk to 8.6% for those whose admission was the result of suicidality (77). Illness severity may also be an indicator of risk for suicide attempts (75, 78).

Among patients with mood disorders, lifetime risk also depends on the presence of other psychiatric symptoms or behaviors, some of which are modifiable with treatment. For example, patients with mood disorders who died by suicide within 1 year of initial evaluation were more likely to have panic attacks, severe psychic anxiety, diminished concentration, global insomnia, moderate alcohol abuse, and severe loss of pleasure or interest in activities (79). At later time points, hopelessness has been associated with increased suicide risk in mood disorder patients (78, 79). Suicidal ideation and a history of suicide attempts also augment risk (74, 79). Comorbid anxiety, alcohol use, and substance use are common in patients with mood disorders and may also increase the risk of suicide and suicide attempts (see Sections II.E.2.f, "Alcohol Use Disorders" and II.E.2.g, "Other Substance Use Disorders"). Although a greater risk for suicide or suicidal behaviors among patients with psychotic mood disorders has been seen in some studies (80–83), this relationship has not been found in other studies (84–88).

+
b) Schizophrenia

Compared to the risk in the general population, the risk of suicide in patients with schizophrenia is estimated to be about 8.5-fold higher (64), with even greater increments in risk in patients who have been hospitalized (89). Although earlier research suggested a 10%–15% lifetime risk of suicide among patients with schizophrenia (90–93), such estimates were likely inflated by biases in the patient populations and length of follow-up. More recent estimates suggest a lifetime risk of suicide in schizophrenia of about 4% (94).

Suicide may occur more frequently during the early years of the illness, with the time immediately after hospital discharge being a period of heightened risk (83, 89, 90, 95–98). However, risk continues throughout life (99, 100) and appears to be increased in those with a chronic illness course (83, 89, 101), multiple psychiatric hospitalizations (89, 95), or a previous suicide attempt (89, 90, 95, 100). Other consistently identified factors that confer an increased risk of suicide in patients with schizophrenia include male sex (83, 89, 90, 95, 102, 103), younger age (<30 years) (83, 90, 102), and social isolation (97, 104).

In individuals with schizophrenia or schizoaffective disorder, psychotic symptoms are often present at the time of a suicide attempt or suicide (105–107). However, command hallucinations seem to account for a relatively small percentage of suicides, and there is limited evidence on whether they increase suicide risk. Nonetheless, they may act as a precipitant to a suicide attempt or to suicide in some individuals (106, 108) (see Section II.E.3.c, "Command Hallucinations"). Suicide in patients with schizophrenia may be more likely to occur during periods of improvement after relapse or during periods of depressed mood (83, 89, 90, 95, 100, 109–111), including what has been termed postpsychotic depression (112, 113). Also, patients with schizoaffective disorder appear to be at greater risk for suicide than those with schizophrenia (114).

Suicide risk may paradoxically be increased in those who have insight into the implications of having a schizophrenic illness, particularly if this insight is coupled with a feeling of hopelessness. Suicide risk is also increased in those who recognize a loss of previous abilities and are pessimistic about the benefits of treatment in restoring those abilities (93, 101, 115). This pattern is consistent with the increased risk of suicide observed in individuals with schizophrenia who had a history of good premorbid and intellectual functioning (83, 89, 103) as well as with the decreased risk of suicide in patients with prominent negative symptoms (83, 89, 103, 116).

Suicidal ideation and suicide attempts are common among individuals with schizophrenia and need to be identified and addressed in the assessment process. In series of hospitalized or longitudinally followed patients with schizophrenia, 40%–53% reported having suicidal ideation at some point in their lives and 23%–55% reported prior suicide attempts (80, 93, 108, 117). For individuals with schizoaffective disorder, these figures are likely to be even higher (80). Patients often reported that suicide attempts were precipitated by depression, stressors, or psychotic symptoms (108). In addition, suicide attempts among individuals with schizophrenia or schizoaffective disorder were often medically serious and associated with a high degree of intent (108), both of which would confer greater future risk for suicide.

+
c) Anxiety disorders

Although studies of lifetime suicide risk in anxiety disorders are more limited than for mood disorders, evidence suggests anxiety disorders are associated with a six- to 10-fold increase in suicide risk (64, 118, 119). Among persons who die from suicide, rates of anxiety disorders appear to be lower than rates of mood disorders, with one psychological autopsy study identifying an anxiety disorder in only 11% of persons who died from suicide (120). However, the prevalence of anxiety disorders may be underestimated because of the masking of anxiety by affective disorders and by alcohol use (121).

Of the anxiety disorders, panic disorder has been studied in the most detail. In psychological autopsy studies, panic disorder is present in about 1% of persons who die from suicide (120), whereas other studies of panic disorder show an SMR for suicide that is about 10 times that of the general population (64). As with anxiety disorders in general, comorbid depression, alcohol use, or axis II disorders are often present in individuals with panic disorder who die by suicide (122, 123).

Suicidal ideation and suicide attempts are common in individuals with anxiety disorders, but their rates vary with the patient population and with the presence of comorbid diagnoses. In panic disorder, for example, reported rates of prior suicide attempts range from 0% to 42% (124–129). In other anxiety disorders, the relative risks of suicidal ideation and suicide attempts also appear to be increased (118, 130). In addition, in patients with major depression, the presence of a comorbid anxiety disorder appears to increase the risk of suicidal ideation or suicide attempts (131, 132). Less clear, however, is whether anxiety disorders are associated with an increased risk for suicide and other suicidal behaviors in the absence of comorbid diagnoses (130, 132–136) or whether the observed increases in risk can be accounted for solely on the basis of comorbid disorders (127, 137). Nonetheless, suicide risk may be diminished by identifying masked anxiety symptoms and anxiety disorders that are misdiagnosed as medical illness as well as by explicitly assessing and treating comorbid psychiatric diagnoses in individuals with anxiety disorders.

+
d) Eating disorders

Eating disorders, particularly anorexia nervosa, are a likely risk factor for suicide as well as being associated with an increased risk of mortality in general (64, 138, 139). Exact risk is difficult to determine, however, as data on rates of suicide in eating disorders may be subject to underreporting bias (140). Suicide attempts are also common, particularly in individuals with bingeing and purging behaviors and in those with comorbid mood disorders, aggression, or impulsivity (141, 142). Conversely, suicide attempters may have increased rates of abnormal eating behaviors (142). The role of comorbid diagnoses in increasing the risk of suicidal behaviors remains to be delineated. It is also not clear whether the self-imposed morbidity and mortality associated with severe caloric restriction or bingeing and purging should be viewed as a self-injurious or suicidal behavior. Regardless, clinicians conducting a suicide risk assessment should be attentive to the presence of eating disorders and especially the co-occurrence of eating disorders with behaviors or symptoms such as deliberate self-harm or depression.

+
e) Attention deficit hyperactivity disorder

The relationship between attention deficit hyperactivity disorder (ADHD) and suicidal behavior is unclear, with some studies indicating an association between the diagnosis of ADHD and suicide attempts or completions (143, 144) and other studies indicating no such connection (145, 146). However, individuals with ADHD, combined type, may be at greater risk than those with ADHD, inattentive type, perhaps because of an increased level of impulsivity in the combined type of the disorder (144). In addition, the presence of ADHD may increase suicide risk through comorbidity with conduct disorder, substance abuse, and/or depressive disorder (143).

+
f) Alcohol use disorders

Alcoholism is associated with an increased risk for suicide, with suicide mortality rates for alcoholics that are approximately six times those of the general population (64, 94). In fact, abuse of substances including alcohol may be the second most frequent psychiatric precursor to suicide (147). Although suicide rates among alcoholics are higher in Europe and older literature indicated a lifetime risk for suicide in the 11%–15% range, recent literature suggests the lifetime risk of suicide among alcoholics in the United States is as low as 3.4% (148). In addition, in psychological autopsy studies, alcohol abuse or dependence is present in 25%–50% of those who died by suicide (59, 149–151).

Several factors, including recent or impending interpersonal losses and comorbid psychiatric disorders, have been specifically linked to suicide in alcoholic individuals. The loss or disruption of a close interpersonal relationship or the threatened loss of such a relationship may be both a consequence of alcohol-related behavior and a precipitant to suicide (110, 152–154). Suicide is also more likely to occur among alcoholics who suffer from depressive episodes than in persons with major depression or alcoholism alone. In addition, studies have found major depressive episodes in half to three-fourths of alcoholics who die by suicide (67, 120, 149, 152, 155–157). As a result, psychiatrists should systematically rule out the presence of a comorbid depressive disorder and not simply assume that depressive symptoms result from alcohol use or its psychosocial consequences.

Whereas full-time employment appears to be a protective factor in alcoholics, factors that increase suicide risk include communications of suicidal intent, prior suicide attempts, continued or heavier drinking, recent unemployment, living alone, poor social support, legal and financial difficulties, serious medical illness, other psychiatric disorders, personality disturbance, and other substance use (64, 149, 152, 154, 156, 158, 159). In terms of gender, alcoholic men are more likely to die by suicide, but female alcoholics appear to have a greater standardized mortality due to suicide than men (64), indicating an increased risk of suicide in alcoholics regardless of gender. While the likelihood of a suicidal outcome increases with the total number of risk factors (149, 160), not all of these factors suggest an immediate risk. In fact, in contrast to suicide in depressed and schizophrenic patients, suicide in alcoholics appears to be a relatively late sequela of the disease (161), with communications of suicidal intent usually being of several years' duration and health, economic, and social functioning showing a gradual deterioration (149).

In addition to being associated with an increased risk of suicide, alcohol use disorders are associated with a greater likelihood of suicide attempts (162, 163). For suicide attempts among alcoholics, greater rates are associated with female sex, younger age, lower economic status, early onset of heavy drinking and alcohol-related problems, consumption of greater amounts of alcohol when drinking, and having a first- or second-degree relative who abused alcohol (164–167). The risk of suicide attempts among alcoholics is also increased by the presence of a comorbid psychiatric diagnosis, particularly major depression, other substance use disorders, antisocial personality disorder, or an anxiety disorder (165–171).

Thus, individuals with alcohol use disorders are at increased risk for suicide attempts as well as for suicide. Family histories of alcoholism and comorbid psychiatric disorders, particularly mood disorders and other substance use disorders, are frequent in alcoholics who die by suicide and who attempt suicide. Interpersonal loss and other adverse life events are commonly noted to precede suicide in alcoholics. These factors may act as precipitants, or, conversely, alcohol use disorders may have a deteriorating effect on the lives of alcoholics and culminate in suicide. Together, however, these findings suggest the need to identify and address comorbid psychiatric diagnoses, family history, and psychosocial factors, including recent interpersonal losses, as part of the suicide assessment of persons with alcohol use disorders.

+
g) Other substance use disorders

Although the role of alcoholism in suicide has been widely studied and recognized, abuse of other substances is also associated with increased rates of suicide (172). Substance use disorders are particularly common among adolescents and young adults who die by suicide (110, 145, 173, 174). In fact, it has been suggested that the spread of substance abuse may have contributed to the two- to fourfold increase in youth suicide since 1970 (147). For many individuals, substance abuse and alcoholism are co-occurring, making it difficult to distinguish the contributions of each to rates of suicide (153, 172, 173). In addition, other comorbid psychiatric disorders, particularly mood disorders and personality disorders, may add to the risk of suicide in patients with substance use disorders (145, 173–175).

Substance use disorders also seem to make an independent contribution to the likelihood of making a suicide attempt (176, 177). In addition, a history of suicide attempts is common among individuals with substance use disorders (31, 178–180). Even after other factors, including comorbid psychiatric disorders and demographic characteristics, are controlled, it is the number of substances used, rather than the type of substance, that appears to be important (176). As with suicide in individuals with alcohol use disorders, the loss of a significant personal relationship is a common precipitant for a suicide attempt (179). Suicide attempts are also more likely in individuals with substance abuse who also have higher childhood trauma scores for emotional neglect (180, 181). Moreover, a substance use disorder may complicate mood disorders (182), increasing susceptibility to treatment resistance, increasing psychological impairment, and contributing to an elevated risk for suicide attempts. Thus, it is important to identify patterns of substance use during the psychiatric evaluation and to note comorbid psychiatric diagnoses or psychosocial factors that may also affect the likelihood of suicidal behaviors among individuals with substance use disorders.

+
h) Personality disorders

Diagnoses of personality disorders have been associated with an increased risk for suicide, with estimated lifetime rates of suicide ranging from 3% to 9% (183–185). Compared with the general population, individuals with personality disorders have an estimated risk for suicide that is about seven times greater (64). Specific increases in suicide risk have been associated with borderline and antisocial personality disorders, with possible increases in risk associated with avoidant and schizoid personality disorders (186). Psychological autopsy studies have shown personality disorders to be present in approximately one-third of those who die by suicide (174, 183, 186, 187). Among psychiatric outpatients, personality disorders are present in about one-half of patients who die by suicide (78, 188).

In individuals with personality disorders, suicide risk may also be increased by a number of other factors, including unemployment, financial difficulty, family discord, and other interpersonal conflicts or loss (189, 190). In individuals with borderline personality disorder, in particular, impulsivity may also increase suicide risk (185).

Although comorbid diagnoses do not account for the full increase in suicide risk with personality disorders (184, 185), comorbid diagnoses are frequent and augment suicide risk. In fact, for individuals with personality disorders, concurrent depressive symptoms or substance use disorders are seen in nearly all individuals who die by suicide (187).

Among individuals who attempt suicide, diagnoses of personality disorders are also common, with overall rates of about 40% (31, 177, 184). Individuals with personality disorders tend to attempt suicide more often than individuals with other diagnoses (191–193), with 40%–90% of individuals with personality disorders making a suicide attempt during their lifetime (184). Comorbid psychiatric diagnoses, including mood disorders and substance use disorders, are quite prevalent among suicide attempters with personality disorders and independently contribute to risk (131, 184, 191, 192, 194, 195). Impulsivity has also been shown to increase the risk of suicide attempts in some (196, 197) but not all studies (191). Rates of suicide attempts in those with personality disorder may also vary with treatment setting, with greater risk in individuals who are receiving acute inpatient treatment (198).

Of personality disorder diagnoses, borderline personality disorder and antisocial personality disorder confer an added risk of suicide attempts (31, 177, 191, 193). In individuals with borderline personality disorder, there is some evidence of increased risk being associated with the number and severity of symptoms (195). Among female suicide attempters, rates of borderline personality disorder are higher than among male suicide attempters (199, 200). These findings suggest that personality disorders, particularly borderline personality disorder and antisocial personality disorder, should be identified and addressed as part of the suicide assessment process.

+
i) Comorbidity

As discussed in preceding sections, comorbid psychiatric diagnoses (most commonly, major depression, borderline and antisocial personality disorders, and alcohol and other substance use disorders) increase suicide risk and are often present in individuals who die by suicide (13, 59, 120, 174, 201). Comorbid medical diagnoses may also increase suicide risk, as will be discussed in Section II.E.5, "Physical Illness". In general, the greater the number of comorbid diagnoses that are present, the greater will be the increase in risk. Furthermore, even in the absence of a formal comorbid diagnosis, suicide is more likely to occur when there are high levels of additional psychiatric symptoms (67, 185, 202–204).

In patients with a mood disorder, either bipolar disorder or major depression, the risk of suicide is particularly increased in the presence of comorbid alcohol or substance use (68, 205–207), with some studies suggesting that males are at additional risk (68, 205). Comorbid alcohol use may also increase suicide risk in patients with schizophrenia (107). In addition, suicide in schizophrenia may be more likely to occur during periods of depression (83, 90, 109–113). In anxiety disorders and particularly in panic disorder, individuals who die by suicide often have experienced comorbid depression, alcohol use, or axis II disorders (122, 123). Similarly, when suicide occurs in individuals with eating disorders, it is often associated with a comorbid mood disorder or substance use disorder (138).

For individuals with alcohol use disorders, major depression is found in half to three-fourths of individuals who die by suicide (67, 120, 149, 152, 155–157), and alcoholics who suffer from depressive episodes are more likely to die from suicide than persons with major depression or alcoholism alone. Serious medical illness and other psychiatric disorders, including personality disturbance and other substance use disorders, also increase suicide risk in alcoholics (64, 149, 152, 154, 156, 158, 159). For many individuals, substance abuse and alcoholism are co-occurring, making it difficult to distinguish the contributions of each to rates of suicide (153, 172, 173, 208). Furthermore, it appears to be the number of substances used, rather than the specific substance, that determines risk (176).

Individuals who die by suicide and who abuse or are dependent on substances other than alcohol are typically adolescents or young adults. Comorbid mood disorders are commonly seen in both males and females (66, 145, 204). In addition, borderline personality disorder is relatively frequent in females with substance use disorders (175), whereas young males with substance use disorders who die by suicide more commonly have comorbid antisocial personality disorder (120, 159, 173, 204). The presence of ADHD may increase suicide risk through comorbidity with conduct disorder, substance abuse, and/or depressive disorder (143). For individuals with personality disorders, concurrent depressive symptoms or substance use disorders augment suicide risk (184, 185, 209, 210) and are seen in nearly all suicides (187).

Comorbid diagnoses are also essential to identify and address because of their role in increasing the risk of suicide attempts (199). Furthermore, the likelihood of a suicide attempt appears to increase with an increasing number of comorbid diagnoses (166, 176, 177, 211). In addition, the number and severity of symptoms may play a role in increasing risk, regardless of whether the full criteria for a separate diagnosis are met. The specific comorbid disorders that augment the risk of suicide attempts are similar to those that are commonly seen to augment the risk of suicide and include comorbid depression (129, 131, 193, 195, 197, 211), alcohol and other substance use disorders (31, 129, 167, 168, 170, 180, 182, 191, 199, 211–214), anxiety disorders (127, 130–135, 137, 211, 215), and personality disorders (184, 191), particularly borderline personality disorder (31, 195, 200) and antisocial personality disorder (165, 204, 216). Thus, given the evidence that comorbidity increases the risks for suicide and for suicide attempts, the suicide risk assessment should give strong consideration to all current and previous psychiatric diagnoses.

+
3. Specific psychiatric symptoms
+
a) Anxiety

Anxiety appears to increase the risk for suicide (79, 217, 218). Specifically implicated has been severe psychic anxiety consisting of subjective feelings of fearfulness or apprehension, whether or not the feelings are focused on specific concerns. Clinical observation suggests that anxious patients may be more inclined to act on suicidal impulses than individuals whose depressive symptoms include psychomotor slowing. Studies of suicide in patients with affective disorders have shown that those who died by suicide within the first year after contact were more likely to have severe psychic anxiety or panic attacks (79, 219). In an inpatient sample, severe anxiety, agitation, or both were found in four-fifths of patients in the week preceding suicide (218). Similar associations of anxiety with suicide attempts have been noted in some (212) but not all (220) studies. Since severe anxiety does seem to increase suicide risk, at least in some subgroups of patients, anxiety should be viewed as an often hidden but potentially modifiable risk factor for suicide (109). Once identified, symptoms of anxiety can be addressed with psychotherapeutic approaches and can also respond rapidly to aggressive short-term treatment with benzodiazepines, second-generation antipsychotic medications, and possibly anticonvulsant medications.

+
b) Hopelessness

Hopelessness is well established as a psychological dimension that is associated with increased suicide risk (10, 78, 79, 217, 221–223). Hopelessness may vary in degree from having a negative expectation for the future to being devoid of hope and despairing for the future. In general, patients with high levels of hopelessness have an increased risk for future suicide (78, 221–225). However, among patients with alcohol use disorders, the presence of hopelessness may not confer additional risk (226, 227). For patients with depression, hopelessness has been suggested to be the factor that explains why some patients choose suicide, whereas others do not (222). Hopelessness also contributes to an increased likelihood of suicidal ideation (192, 228) and suicide attempts (197, 212, 229–231) as well as an increased level of suicidal intent (197, 232, 233).

Hopelessness often occurs in concert with depression as a "state-dependent" characteristic, but some individuals experience hopelessness on a primary and more enduring basis (221). High baseline levels of hopelessness have also been associated with an increased likelihood of suicidal behaviors (234). However, patients experiencing similar levels of depression may have differing levels of hopelessness (222), and this difference, in turn, may affect their likelihood of developing suicidal thoughts (228). Whatever the source or conceptualization of hopelessness, interventions that reduce hopelessness may be able to reduce the potential for suicide (10, 222, 235–237).

+
c) Command hallucinations

Command hallucinations, which order patients to carry out tasks or actions, can occur in individuals with psychotic disorders, primarily schizophrenia (238). Evidence for the association of command hallucinations with suicide is extremely limited (102, 239). The presence of auditory command hallucinations in inpatients does not appear to increase the likelihood of assaultiveness or of suicidal ideation or behavior over that associated with auditory hallucinations alone (240). Furthermore, in patients who do experience auditory command hallucinations, reported rates of compliance with commands vary widely from 40% to 84% (106, 241–244). Variables that have been associated with a propensity to obey command hallucinations include being able to identify the hallucinatory voice, having more severe psychotic disturbance, having a less dangerous command, and experiencing the commands for the first time or outside of a hospital environment (241, 242, 245). Thus, at least for some individuals, suicidal behaviors can occur in response to hallucinated commands, and individuals with prior suicide attempts may be particularly susceptible (106). Consequently, in the psychiatric evaluation, it is important to identify auditory command hallucinations, assess them in the context of other clinical features, and address them as part of the treatment planning process.

+
d) Impulsiveness and aggression

Impulsivity, hostility, and aggression may act individually or together to increase suicide risk. For example, many studies provide moderately strong evidence for the roles of impulsivity and hostility-related affects and behavior in suicide across diagnostic groups (89, 217, 246–248). Multiple other studies have also demonstrated increased levels of impulsivity and aggression in individuals with a history of attempted suicide (31, 193, 197, 212, 220, 249–252). Many patients with borderline personality disorder exhibit self-mutilating behaviors, and, overall, such behaviors are associated with increased impulsivity (251). However, for many self-mutilating patients, these behaviors are premeditated rather than impulsive (253). Consequently, self-mutilatory behaviors alone should not be regarded as an indicator of high impulsivity. Moreover, measures of aggression and impulsivity are not highly correlated (253), making aggression a poor marker of impulsivity as well. Thus, impulsivity, hostility, aggression, and self-mutilating behaviors should be considered independently in the psychiatric evaluation as well as in estimating suicide risk.

+
4. Other aspects of psychiatric history
+
a) Alcohol intoxication

In addition to the increased suicide risk conferred by alcohol abuse or dependence, intoxication itself appears to play a role in alcoholic as well as nonalcoholic populations (254). Autopsies have found alcohol to be present in 20%–50% of all persons who die by suicide (121, 255). Those who consume alcohol before suicide are more likely to have experienced a recent breakup of an interpersonal relationship but less likely to have sought help before death (255). They are also more likely to have chosen a firearm as a suicide method (151, 256, 257). Alcohol intoxication at the time of suicide may also be more common in younger individuals (154, 255, 258), in men (121, 255), and in individuals without any lifetime history of psychiatric treatment (154). Among suicide attempters who later died by suicide, alcohol appeared to contribute to death in more than a third (259). In addition, a study of the interaction of employment and weekly patterns of suicide emphasizes the role of intoxication in suicides and indicates that employment may be a stabilizing factor that curbs heavy drinking during the work week (260), thereby decreasing rates of suicide. Consequently, in some subsets of patients, alcohol consumption appears to contribute to the decision to die by suicide (255).

Alcohol use is also a common prelude to suicide attempts (258). Some estimates show that more than 50% of individuals have used alcohol just before their suicide attempt. Among alcoholics, heavier drinking adds to risk (64, 149, 165). Suicide attempts that involve alcohol are more likely to be impulsive (258). Indeed, the majority of acutely intoxicated alcoholics either did not remember the reason for their attempt or had done it on a sudden impulse (258). Thus, alcohol consumption may make intervention more difficult by simultaneously limiting the communication of intent (255, 261), increasing impulsivity, decreasing inhibition, and impairing judgment (262).

Alcohol use in conjunction with attempted suicide is more common in men than in women (258), although among younger attempters, females may be more likely than males to consume alcohol (258). Alcohol use in conjunction with a suicide attempt has also been associated with repeated suicide attempts and future suicide (263). In some individuals, intentionally drinking to overcome ambivalence about suicide may signify serious suicidal intent. Thus, since intoxication is a risk factor for suicide attempts as well as for suicide, the clinician should inquire about a patient's drinking habits and consider the effect of alcohol intoxication when estimating suicide risk.

+
b) Past suicide attempts

Individuals who have made a suicide attempt constitute a distinct but overlapping population with those who die by suicide. As with individuals who die by suicide, a high preponderance of suicide attempters have one or more axis I or II diagnoses, with major depression and alcohol dependence observed most commonly for axis I and borderline personality disorder observed most commonly for axis II (199, 200, 264). However, suicide attempts are about 10–20 times more prevalent than suicide (265), with lifetime prevalence ranging from 0.7% to 6% per 100,000 in a random sample of U.S. adults (2). Although a substantial percentage of individuals will die on their initial suicide attempt (266), a past suicide attempt is one of the major risk factors for future suicide attempts (164, 267) and for future suicide (64, 78, 79, 266, 268–271).

After a suicide attempt, there can be significant mortality from both natural and unnatural causes (259, 272). A suicide attempt by any method is associated with a 38-fold increase in suicide risk, a rate that is higher than that associated with any psychiatric disorder (64). Depending on the length of the follow-up, from 6% to 27.5% of those who attempt suicide will ultimately die by suicide (64, 273), and similar results have been suggested for acts of deliberate self-harm (274). Some studies have found that suicide risk appears to be particularly high during the first year after a suicide attempt (259, 275). An additional increase in risk may be associated with aborted suicide attempts (276, 277) or repeated suicide attempts (64, 259, 263, 272, 274, 278). Thus, the increase in suicide mortality subsequent to attempted suicide emphasizes the need for aftercare planning in this heterogeneous population.

In the context of a suicide attempt, a number of other factors are associated with increases in suicide risk. For example, risk is augmented by medical and psychiatric comorbidity, particularly comorbid depression, alcohol abuse, or a long-standing medical illness (64). Low levels of social cohesion may also increase risk (64). Risk of later suicide in males, particularly younger males, appears to be two to four times greater than that in females after a suicide attempt (275). In addition, serious suicide attempts are associated with a higher risk of eventual suicide, as are having high intent (164), taking measures to avoid discovery, and using more lethal methods that resulted in physical injuries (263).

Given this increased likelihood of additional suicide attempts and suicide deaths after a suicide attempt or aborted suicide attempt, psychiatric evaluation should be incorporated into emergency medical assessments of suicide attempters (279) and the importance of follow-up should be emphasized (2, 280).

+
c) History of childhood physical and/or sexual abuse

A history of childhood abuse has been associated with increased rates of suicidal behaviors in multiple studies. Rates of suicide in individuals with a history of childhood abuse have not been widely studied, but available evidence suggests that suicide rates are increased at least 10-fold in those with a history of childhood abuse (36). In addition, a number of studies have demonstrated that individuals with a history of childhood abuse have an increased risk of suicide attempts (230, 281–283), suggesting that risk of later suicide will also be increased. Rates of suicide attempts are increased in individuals who report experiencing childhood physical abuse (196, 250, 284–290) as well as in individuals who report experiencing childhood sexual abuse (33, 35, 36, 164, 196, 250, 284, 285, 288–294). Rates of suicidal ideation are similarly increased in individuals with a childhood history of abuse (284).

Since many traumatized individuals have experienced both sexual and physical abuse during childhood, it is often difficult to establish the specific contributions of each form of abuse to the risk of suicide and other suicidal behaviors. In addition, the duration and severity of childhood abuse vary across individuals and can also influence risk. It appears, however, that the risk of suicide attempts is greater in individuals who have experienced both physical and sexual abuse in childhood (288) and that greater levels of risk are associated with increasing abuse severity (285, 286, 291).

Childhood trauma can also be associated with increased self-injurious behaviors, including self-cutting and self-mutilation, without associated suicidal intent. Sexual abuse may be a particular risk factor for such behaviors, which can often become repetitive (164). Indeed, deliberate self-harm is common in patients with posttraumatic stress disorder and other traumatic disorders and serves to reduce internal tension and provide nonverbal communication about their self-hate and intense distress (295). As a result, inquiring about the motivations of self-injurious behavior may help to inform estimates of suicide risk.

Gender may also influence the risk of suicidal behaviors in those with a history of childhood abuse. This influence, in part, relates to differences in the prevalence of childhood abuse between men and women, with rates of childhood physical abuse being higher in men and rates of childhood sexual abuse being higher in women (288). However, in individuals who have a history of childhood sexual abuse, the risk of a suicide attempt may be greater in men than in women (33).

Given the significant rates of childhood physical and/or sexual abuse, particularly among psychiatric patient populations (35, 284, 288, 292), and the increased risk for suicidal behaviors that such abuse confers, it important to assess for a history of physical abuse and sexual abuse as part of the psychiatric evaluation. In addition, the duration and severity of childhood abuse should be determined, as these factors will also influence risk.

+
d) History of domestic partner violence

Domestic partner violence has been associated with increased rates of suicide attempts and suicidal ideation; however, there is no information about its effects on risk for suicide per se. The risk for suicide attempts in individuals who have experienced recent domestic partner violence has been estimated to be four- to eightfold greater than the risk for individuals without such experiences (34, 296–300). Conversely, among women presenting with suicide attempts, there is a severalfold increase in their risk for experiencing domestic partner violence (230, 301).

Although much more commonly experienced by women, domestic partner violence is also experienced by men and can increase their risk for suicide attempts (302). Men with a history of domestic violence toward their partners may also be at increased risk for suicide (303). Furthermore, domestic violence in the home may increase the risk for suicide attempts among children who are witnesses to such violence (281).

Given the clear increase in risk for suicide attempts in individuals experiencing domestic partner violence and the likely association of suicide attempts with an increased risk for suicide, it is important to specifically ask about domestic partner violence as a part of the suicide assessment. Such inquiry may also help to identify individuals in addition to the identified patient who may be at increased risk for suicidal behaviors.

+
e) Treatment history

Multiple studies have shown that greater treatment intensity is associated with greater rates of eventual suicide (64, 77, 198). Although hospitalization generally occurs because a patient has a more severe illness and is deemed to be at increased risk for suicide, for some patients, hospitalization could conceivably result in increased distress and thus an increase in suicide risk. Thus, as a general rule, a past history of treatment, including a past history of hospitalization, should be viewed as a marker that alerts the clinician to increased suicide risk.

Temporally, the risk for suicide appears to be greatest after changes in treatment setting or intensity (304), with recently admitted and recently discharged inpatients showing increased risk (64, 72, 91, 95, 305–308). This increase in rates of suicide after hospital discharge is seen across diagnostic categories and has been observed in individuals with major depressive disorder, bipolar disorder, schizophrenia, and borderline personality disorder. Rates decline with time since discharge but may remain high for as long as several years (91, 306, 309). Similar findings are seen with suicide attempts, which are also more frequent in the period after hospitalization (267, 305, 308). These observations suggest a need for close follow-up during the period immediately after discharge.

+
f) Illness course and severity

In some psychiatric disorders, suicide risk is greater at certain points in the illness or episode course. For example, in the course of major depressive disorder, suicidality tends to occur early, often before a diagnosis has been made or treatment has begun (304, 310–312). In patients with major depressive disorder (73, 313), as well as in those with bipolar disorder (73, 74, 305) or schizophrenia (83), suicide has been noted to be more likely during the first few episodes, early in the illness (314, 315). After a suicide attempt, the risk for suicide is also greatest initially, with most suicides occurring in the first year after the attempt (275). Although risks of suicide and suicide attempts later in the illness course are less than they are earlier on, these risks remain greater than those for the general population (74, 100, 316–318). These findings highlight the need for early identification of these disorders and for therapeutic approaches that will treat the illness while simultaneously promoting longer-term treatment adherence.

Risk may also vary with severity of symptoms. For example, higher levels of depression have been associated with increased risk of suicide in at least one study (319), whereas greater numbers of symptoms of borderline personality disorder have been associated with an increased risk for suicide attempts (195). In addition, higher levels of suicidal ideation and subjective hopelessness also increase risk for suicide (78) and suicide attempts (31). In contrast, higher levels of negative symptoms have been associated with decreased suicide risk in individuals with schizophrenia (320). It is also important to recognize that other factors such as age will modulate the effects of symptom severity on risk. With older adults, for example, milder symptoms may be associated with greater risk than moderate symptoms in younger adults (207, 321). Consequently, clinicians should consider the severity of a patient's illness and psychiatric symptoms in the context of other patient-specific factors when assessing suicide risk.

+
5. Physical illness

Identification of medical illness (axis III) is also an essential part of the assessment process. Such diagnoses will need to be considered in developing a plan of treatment, and they may influence suicide risk in several ways. First, specific medical disorders may themselves be associated with an increased risk for suicide. Alternatively, the physiological effects of illness or its treatment may lead to the development of psychiatric syndromes such as depression, which may also increase suicide risk. Physical illnesses are also a source of social and/or psychological stress, which in turn augments risk. Physical illnesses such as hepatitis C or sexually transmitted diseases may signal an increased likelihood of impulsive behaviors or comorbid substance use disorders that may in turn be associated with greater risk for suicidal behaviors. Finally, when physical illness is present, psychiatric signs and symptoms may be ascribed to comorbid medical conditions, delaying recognition and treatment of the psychiatric disorder.

Data from clinical cohort and record linkage studies indicate clearly that medical illness is associated with increased likelihood of suicide (Table 7). Not surprisingly, disorders of the nervous system are associated with an elevated risk for suicide. The association between seizure disorders and increased suicide risk is particularly strong and consistently observed (64, 322–328). Presumably because of its close association with impulsivity, mood disorders, and psychosis, temporal lobe epilepsy is associated with increased risk in most (322, 327, 328) but not all (325) studies. Suicide attempts are also more common among individuals with epilepsy (329–331). Other neurological disorders that are associated with increased risk for suicide include multiple sclerosis, Huntington's disease, and brain and spinal cord injury (25, 323, 332–334).

+
Table Reference Number
Table 7. Risk of Suicide in Persons With Physical Disordersa

Other medical disorders that have also been associated with an increased risk for suicide include HIV/AIDS (25, 335, 336), malignancies (especially of the head and neck) (25, 333, 337, 338), peptic ulcer disease (25), systemic lupus erythematosus (25), chronic hemodialysis-treated renal failure (339), heart disease (337), and, in men, chronic obstructive pulmonary disease and prostate disease (337). In contrast, studies have not demonstrated increased suicide risk in patients with amyotrophic lateral sclerosis (ALS), blindness, cerebrovascular disease, hypertension, rheumatoid arthritis, or diabetes mellitus (25, 337).

Beyond the physical illness itself, functional impairments (321, 333, 338), pain (340–342), disfigurement, increased dependence on others, and decreases in sight (333) and hearing increase suicide risk. Furthermore, in many instances, the risk for suicide associated with a medical disorder is mediated by psychiatric symptoms or illness (321, 342, 343). Indeed, suicidality is rarely seen in individuals with serious physical illness in the absence of clinically significant mood disturbance. Finally, the risk for suicide or suicide attempts may also be affected by characteristics of the individual patient, including gender, coping style, availability of social supports, presence of psychosocial stressors, previous history of suicidal behaviors, and the image and meaning to the individual of the illness itself.

+
6. Family history

In individuals with a history of suicide among relatives, the risk of suicidal behaviors is increased, apparently through genetic as well as environmental effects. An increased relative risk for suicide or suicide attempts in close relatives of suicidal subjects has been demonstrated repeatedly (31, 82, 202, 214, 312, 344–364). Overall, it appears that the risk of suicidal behaviors among family members of suicidal individuals is about 4.5 times that observed in relatives of nonsuicidal subjects (365–368; R. Baldessarini, personal communication, 2002). Furthermore, this increase in the risk of suicidal behaviors among family members seems, at least in part, to be independent of genetic contributions from comorbid psychiatric diagnoses (355, 361, 367, 368).

Twin studies also provide strong support for the role of a specific genetic factor for suicidal behaviors (365, 368, 369), since there is substantially higher concordance of suicide and suicide attempts in identical twins, compared with fraternal twin pairs (370–375). Adoption studies substantiate the genetic aspect of suicide risk in that there is a greater risk of suicidal behavior among biologic than among adopted relatives of individuals with suicidal behavior or depression (376–378).

Despite the fact that family, twin, and adoption methods provide highly suggestive evidence of heritable factors in risk of suicide as well as some evidence for nonlethal suicidal behavior, the mode of transmission of this genetic risk remains obscure. Thus far, molecular genetic approaches have not yielded consistent or unambiguous evidence of a specific genetic basis for suicide risk (16). In addition, genetic associations with suicide risk may be confounded by the heritability of other factors such as mood disorders or substance use disorder that are also associated with increased risk for suicidal behaviors.

+
7. Psychosocial factors
+
a) Employment

Unemployment has long been associated with increased rates of suicide (379, 380). In recent case-control and longitudinal studies, higher rates of unemployment have been consistently noted in suicide attempters (78, 149, 361, 381–383) and in persons who died by suicide (24, 190, 384, 385). Compared with individuals in control groups, unemployed persons have a two- to fourfold greater risk for suicide. Risk is particularly elevated in those under age 45 and in the years closest to job loss, with even greater and longer-lasting effects noted in women (24). Parallel increases in rates of suicide and suicide attempts are also seen in socioeconomically deprived geographical areas, which have larger numbers of unemployed people (386).

For many individuals, unemployment occurs concomitantly with other factors that affect the risk of suicidal behaviors. For example, with job loss, financial and marital difficulties may increase. Alternatively, factors such as psychiatric illness (380) or adverse childhood experiences (361) may affect rates of suicidal behaviors but also influence the likelihood of gaining and maintaining employment. Thus, while unemployment appears to be associated with some independent increase in risk, a substantial fraction of the increase in risk for suicidal behaviors among unemployed persons can be accounted for by co-occurring factors (361, 381, 384, 385).

Among individuals with alcohol use disorders, particularly those under age 45, unemployment is one of a number of stressors that is a common precipitant to suicide (149, 382, 387). Even in those without substance use disorders, unemployment may result in increased drinking, which in turn may precipitate self-destructive behavior (154). Conversely, in those with substance use disorders, full-time employment protects against suicidal behaviors, a finding that may in part relate to decreases in use of alcohol or other substances during the work week (260). Thus, unemployment may serve as a risk factor for suicide, whereas employment may have protective effects on suicide risks.

+
b) Religious beliefs

The likelihood of suicide may also vary with religious beliefs as well as with the extent of involvement in religious activities. In general, individuals are less likely to act on suicidal thoughts when they have a strong religious faith and believe that suicide is morally wrong or sinful. Similar findings of low suicide rates are found in cultures with strong religious beliefs that the body is sacred and not to be damaged intentionally. In the United States, Catholics have the lowest rate of suicide, followed by Jews, then Protestants (388). Among other religious groups, Islamic tradition has consistently regarded suicide as morally wrong, and some Islamic countries have legal sanctions for attempted suicide (389, 390). In some countries, suicide rates among Muslims appear to be greater than those among Hindus (391, 392), although suicide rates across countries do not appear to vary with the proportion of Muslims in the population (393).

Additional evidence suggests that it is the strength of the religious beliefs and not the specific religion per se that alters suicide rates (43, 394–398). In the African American community, for example, religion is viewed as a source of social solidarity and hope (22). Religious involvement may also help to buffer acculturative stress, which is associated with depression and suicidal ideation (43). The religious belief system itself and the practice of spiritual techniques may also decrease suicide risk by acting as a coping mechanism and providing a source of hope and purpose.

Although protective effects can be afforded by religious beliefs, this is not invariably the case. For example, suicide may be more likely to occur among cultures in which death by suicide is a traditionally accepted way of dealing with distress or in religions that deemphasize the boundaries between the living and the dead. Particularly for adolescents, belief in an afterlife may lead to suicide in an effort to rejoin a deceased loved one. Thus, it is important to gain an understanding of the specific religious beliefs and religious involvement of individuals and also to inquire how these religious beliefs relate to thoughts and conceptions of suicide.

+
c) Psychosocial support

The presence of a social support system is another factor that may reduce suicide risk (399, 400). Consequently, communicating with members of the patient's support network may be important in assessing and helping to strengthen social supports (see Section V.C, "Communication With Significant Others"). Although social supports typically include family members or friends, individuals may also receive support from other sources. For example, those in the military and those who belong to religious, community, or self-help organizations may receive support through these affiliations.

In addition to determining whether a support system is present, the clinician should assess the patient's perception of available social supports. Individuals who report having more friends and less subjective loneliness are less likely to have suicidal ideation or engage in suicidal behaviors (401). By the same token, if other social supports are not available, living alone may increase suicide risk (149, 385, 402), although this is not invariably true (343, 403, 404). Family discord, other relationship problems, and social isolation may also increase risk (403, 405, 406). Risk of suicidal behaviors may also increase when an individual rightly or wrongly fears that an interpersonal loss will occur (149). Thus, in estimating suicide risk, the clinician should assess the patient's support network as well as his or her perception of available social supports.

+
d) Reasons for living, including children in the home

An additional protective factor against suicidal behaviors is the ability to cite reasons for living (231, 407), which reflects the patient's degree of optimism about life. A sense of responsibility to family, particularly children, is a commonly cited reason for living that makes suicide a less viable option to escape from pain. The presence of children in the home as well as the number of children appear to decrease the risk for suicide in women (26, 47). Although less well-studied, a smaller effect on suicide potential may also be present in men who have children under age 18 within the home (408). Thus, knowledge of the patient's specific reasons for living, including information about whether there are children in the home, can help inform estimates of suicide risk.

+
e) Individual psychological strengths and vulnerabilities

Estimates of suicide risk should also incorporate an assessment of the patient's strengths and vulnerabilities as an individual. For example, healthy and well-developed coping skills may buffer stressful life events, decreasing the likelihood of suicidal actions (409). Conversely, lifelong patterns of problematic coping skills are common among those who die by suicide (410). Such factors may be particularly important in patients with substance use or personality disorders, for whom heightened suicide risk may be associated with life stressors or interpersonal loss.

In addition to the diagnosis of categorical axis II disorders, as discussed elsewhere, dimensional and trait approaches to personality can also inform estimates of suicide risk. Although the positive correlation value of individual personality traits with suicide is low, increased suicide risk may be associated with antisocial traits (411) as well as with hostility, helplessness/dependency, and social disengagement/self-consciousness (246).

Extensive clinical literature and clinical consensus support the role of psychodynamics in assessing a patient's risk for suicidal behavior (409, 410, 412–419). Suicide may have multiple motivations such as anger turned inward or a wish of death toward others that is redirected toward the self. Other motivations include revenge, reunion, or rebirth. Another key psychodynamic concept is the interpretation of suicide as rooted in a triad of motivations: the wish to die, the wish to kill, and the wish to be killed (415). Other clinicians have conceptualized these motivations as escape (the wish to die), anger or revenge (the wish to kill), and guilt (the wish to be killed). The presence of one or several of these motivations can inform the psychiatrist about a patient's suicide risk.

Object relations theories offer important concepts for psychodynamic formulations of suicide. Suicidal behavior has been associated with poor object relations, the inability to maintain a stable, accurate, and emotionally balanced memory of the people in one's life (413). In some cases the wish to destroy the lives of the survivors is a powerful motivator (415, 420). For other individuals, a sadistic internal object is so tormenting that the only possible outcome is to submit to the tormentor through suicide (416, 417).

Other important psychodynamic concepts for the clinician to assess are shame, worthlessness, and impaired self-esteem. Early disturbance in parent-child relationships through failure of empathy or traumatic loss can result in an increased vulnerability to later injuries of self-esteem. These patients are vulnerable to narcissistic injuries, which can trigger psychic pain or uncontrollable negative affects. In these situations some patients may experience thoughts of death as peaceful, believing that their personal reality is emotionally intolerable and that it is possible to end pain by stopping consciousness.

Suicidal individuals are often ambivalent about making a suicidal action. As a result, suicide is less likely if an individual sees alternative strategies to address psychological pain (410). However, certain traits and cognitive styles limit this ability to recognize other options. For example, thought constriction and polarized, all-or-nothing thinking are characterized by rigid thinking and an inability to consider different options and may increase the likelihood of suicide (410, 421–423). Individuals who are high in neuroticism and low in "openness to experience" (affectively blunted and preferring the familiar, practical, and concrete) may also be at greater risk for suicide (424). Perfectionism with excessively high self-expectation is another factor that has been noted in clinical practice to be a possible contributor to suicide risk (425). As already discussed, pessimism and hopelessness may also act in a trait-dependent fashion and further influence individual risk.

In estimating suicide risk it is therefore important for the clinician to appreciate the contributions of patients' individual traits, early or traumatic history, ability to manage affects including psychological pain, past response to stress, current object relations, and ability to use external resources during crises. Identifying these issues may help the psychiatrist in assessing suicide risk. In addition, gaining an empathic understanding of the patient's unique motivations for suicide in the context of past experiences will aid in developing rapport as well as in formulating and implementing a psychotherapeutic plan to reduce suicide risk (410, 412, 421, 426).

+
8. Degree of suicidality
+
a) Presence, extent, and persistence of suicidal ideation

Suicidal ideation is an important determinant of risk because it precedes suicide. Moreover, suicidal ideation is common, with an estimated annual incidence of 5.6% (2) and estimated lifetime prevalence of 13.5% (427). Since the majority of individuals with suicidal ideation will not die by suicide, the clinician should consider factors that may increase risk among individuals with suicidal ideation. Although current suicidal ideation increases suicide risk (78, 79), death from suicide is even more strongly correlated with the worst previous suicidal ideation (273, 428). Thus, during the suicide assessment, it is important to determine the presence, magnitude, and persistence of current as well as past suicidal ideation.

In addition to reporting suicidal ideation per se, patients may report thoughts of death that may be nonspecific ("life is not worth living") or specific ("I wish I were dead"). These reports should also be assessed through further questioning since they may serve as a prelude to later development of suicidal ideas or may reflect a sense of pessimism and hopelessness about the future (see Section II.E.3.b, "Hopelessness"). At the same time, individuals with suicidal ideation will often deny such ideas even when asked directly (218, 429–431). Given these associations of suicide with suicidal ideation, the presence of suicidal ideation indicates a need for aggressive intervention. At the same time, since as many as a quarter of suicide attempts occur impulsively (432), the absence of suicidal ideation does not eliminate risk for suicidal behaviors.

+
b) Presence of a suicide plan and availability of a method

Determining whether or not the patient has developed a suicide plan is a key part of assessing suicide risk. For many patients, the formation of a suicide plan precedes a suicidal act, typically within 1 year of the onset of suicidal ideation (427). A suicide plan entails more than simply a reference to a particular method of harm and includes at least several of the following elements: timing, availability of method, setting, and actions made in furtherance of the plan (procuring a method, "scoping out" the setting, rehearsing the plan in any way). The more detailed and specific the suicide plan, the greater will be the level of risk. Plans that use lethal methods or are formulated to avoid detection are particularly indicative of high risk (433). Access to suicide methods, particularly lethal methods, also increases suicide risk. Even in the absence of a specific suicide plan, impulsive actions may end in suicide if lethal methods are readily accessible. Thus, it is important to determine access to methods for any patient who is at risk for suicide or displays suicidal ideation.

In the United States, geographic variations in rates of firearm suicide parallel variations in the rates of gun ownership (434). Although individuals may opt for a different suicide method when a particular method is otherwise unavailable, studies show some decreases in overall suicide rates with restrictions in access to lethal suicide methods (e.g., domestic gas and paracetamol) (435–437). Men are most likely to use firearms in suicidal acts, but other specific populations at increased risk of using firearms include African Americans, elderly persons, and married women. In adolescents and possibly in other age groups, the presence of firearms may be an independent risk factor for suicide (438). Consequently, 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.

In addition to addressing access to firearms, clinicians should recognize the potential lethality of other suicide methods to which the patient may have access. As with restrictions for firearms, it is important for the psychiatrist to work with the patient, family members, and other social support persons in restricting the patient's access to potentially lethal suicide methods, particularly during periods of enhanced risk. Removal of such methods from a patient's presence does not remove the risk for suicide, but it removes the potential for the patient to impulsively gain access to the means with which to carry out a suicidal wish.

+
c) Lethality and intent of self-destructive behavior

Suicidal intent refers to the patient's subjective expectation and desire to die as a result of a self-inflicted injury. This expectation may or may not correspond to the lethality of an attempt, which represents the medical likelihood that death will result from use of a given method. For example, some patients may make a nonlethal attempt with the intention of being saved and getting help, whereas others may make a nonlethal attempt, thinking it will kill them. From the standpoint of suicide risk assessment, the strength of the patient's intent to die and his or her subjective belief about the lethality of a method are more relevant than the objective lethality of the chosen method (439, 440). The presence of a suicide note also indicates intensification of a suicidal idea and/or plan and generally signifies premeditation and greater suicidal intent. Regardless of whether the patient has attempted suicide or is displaying suicidal ideation, the clinician should assess the timing and content of any suicide note and discuss its meaning with the patient. The more specifically a note refers to actual suicide or steps to be taken after death, the greater the associated increase in suicidal intent and risk. Factors separating suicide attempters who go on to make future fatal versus nonfatal attempts include an initial attempt with high intent (164, 441), having taken measures to avoid discovery (224), and having used more lethal methods that resulted in physical injuries (263), all of which indicate a greater degree of suicidal intent. Consequently, suicidal intent should be assessed in any patient with suicidal ideation. In addition, for any patient who has made a prior suicide attempt, the level of intent at the time of the suicide attempt should be determined.

+

F. Additional Considerations When Evaluating Patients in Specific Treatment Settings

+
1. Inpatient settings

Patients are often admitted to an inpatient unit in the midst of an acute suicidal crisis with either overt suicidal behavior or intense suicidal ideation. Even when a patient who is not in an acute suicidal crisis is admitted, the symptoms and disorders that typically lead to psychiatric hospitalization are associated with an increased suicide risk. There do not appear to be specific risk factors that are unique to the inpatient setting, with about half of inpatient suicides in a recent study involving individuals with prior suicide attempts and about half occurring in individuals with psychosis (218). Inpatient suicides also cannot be predicted by the reason for hospitalization, since fewer than half of the patients who die by suicide in the hospital were admitted with suicidal ideation and only a quarter were admitted after a suicide attempt. However, extreme agitation or anxiety (218) or a rapidly fluctuating course (442) is common before suicide. Thus, it is important to conduct a suicide risk assessment, as discussed earlier, when individuals are admitted for inpatient treatment, when changes in observation status or treatment setting occur, when there are significant changes in the patient's clinical condition, or when acute psychosocial stressors come to light in the course of the hospitalization. For patients with repeated hospitalizations for suicidality, each suicidal crisis must be treated as new with each admission and assessed accordingly.

+
2. Outpatient settings

An initial evaluation of a patient in an office-based setting should be comprehensive and include a suicide assessment. The intensity and depth of the suicide assessment will depend on the patient's clinical presentation. In following outpatients over time, the psychiatrist should be aware that suicidality may wax and wane in the course of treatment. Sudden changes in clinical status, which may include worsening or precipitous and unexpected improvements in reported symptoms, require that suicidality be reconsidered. Furthermore, risk may also be increased by the lack of a reliable therapeutic alliance, by the patient's unwillingness to engage in psychotherapy or adhere to medication treatment, or by inadequate family or social supports. Again, however, the frequency, intensity, and depth of the suicide assessment will depend on the patient's clinical state, past history, and other factors, including individual strengths, vulnerabilities, and stressors that will simultaneously influence risk. These factors will also be important in judging when family members or other significant support persons may need to be contacted.

+
3. Emergency settings

Regardless of the patient's presenting problem, the suicide assessment is an integral part of the psychiatric evaluation in an emergency setting. As in the inpatient setting, substantial numbers of individuals present to emergency settings with suicidal ideation or after having made a suicide attempt (443–447). Even when suicidality is not a part of the initial presentation, the majority of individuals seen in emergency psychiatric settings have diagnoses that are associated with an increased risk of suicide (268, 269, 271, 275, 448).

As the suicide assessment proceeds, the psychiatrist should be alert for previously unrecognized symptoms of trauma or toxicity resulting from ingestions. Ambivalence is a key element in individuals presenting with suicidality, and individuals may simultaneously seek help yet withhold information about recent ingestions (449) or self-induced trauma. Thus, in addition to initially assessing the patient's vital signs, the psychiatrist should investigate any changes in the patient's physical condition or level of consciousness that may develop during the course of the evaluation. For patients who are administered medications in the emergency area or who have concomitant alcohol or substance use, serial monitoring of vital signs is important to detect adverse events or signs of substance withdrawal.

Simultaneous presentation with intoxication and suicidality is common in emergency settings (444, 450–454) and requires some modification in the assessment process. Depending on the severity of the intoxication, medical intervention may be needed before psychiatric assessment begins. Also, it is often necessary to maintain the patient in a safe setting until the intoxication resolves and a thorough suicide assessment can be done. In this regard, some institutions find it helpful to quantify the level of intoxication (with serum alcohol levels or breath alcohol measurements), since some individuals may not show physical symptoms of intoxication despite substantially elevated blood alcohol concentrations (455). At some facilities, short-term observation beds are available in the emergency area or elsewhere for monitoring and serial assessments of intoxicated individuals who present with suicidality. At other facilities, such observation may need to be carried out in a more typical medical or psychiatric inpatient setting.

Although obtaining collateral information is useful with all suicidal individuals, in the emergency setting such information is particularly important to obtain from involved family members, from those who live with the patient, and from professionals who are currently treating the patient. Patients in emergency settings may not always share all of the potentially relevant aspects of their recent symptoms and their past psychiatric history, including treatment adherence. In addition, most psychiatrists who evaluate patients in emergency settings do not have the benefit of knowing and working with the patient on a longitudinal basis. Corroboration of history is particularly important when aspects of the clinical picture do not correspond to other aspects of the patient's history or mental state. Examples include patients who deny suicidal ideas and request discharge yet who made a highly lethal suicide attempt with clear suicidal intent or those who request admission on the basis of command hallucinations while seeming relaxed and jovial and without appearing to respond to internal stimuli.

The process by which the patient arrived at the emergency department can provide helpful information about his or her insight into having an illness or needing treatment. Typically, individuals who are self-referred have greater insight than those who are brought to the hospital by police or who reluctantly arrive with family members. For individuals who are brought to the emergency department by police (or as a result of a legally defined process such as an emergency petition), it is particularly important to address the reasons for the referral in estimating suicide risk.

+
4. Long-term care facilities

When evaluating patients in long-term care facilities, psychiatrists and staff should be aware of the varied forms that suicidality may take in such settings. In particular, it is important to recognize that indirect self-destructive acts are found among both men and women with chronic medical conditions (456–459) and are a common manifestation of suicide in institutional settings (460). Despite these occurrences, suicide rates in long-term care facilities are generally lower than expected (460, 461), perhaps as a result of greater supervision and residents' limited access to potentially lethal means and physical inability to carry out the act as well as underreporting or misattribution of self-destructive behaviors to accident or natural death (66).

Risk factors for suicide and other self-destructive behaviors are similar to those assessed in other settings of care. For example, 90% or more of randomly sampled residents of long-term care facilities have been shown to have a diagnosable psychiatric illness (462, 463), with the prevalence of depression in nursing homes estimated to range from 15% to 50% (66). Physical illness, functional impairment, and pain are associated with increased risk for suicide and are ubiquitous factors in long-term care facilities. Hopelessness (228) and personality styles that impede adaptation to a dependent role in the institutional setting also play a role (464).

When treating individuals in long-term care facilities, the psychiatrist should be mindful of the need for follow-up assessments, even when initial evaluation does not show evidence of depression or increased risk for suicide or other self-injurious behaviors. To facilitate early intervention, safety and suicide risk should be reassessed with significant changes in behavior, psychiatric symptoms, medical status, and/or level of functional disability. Psychiatrists can also play a critical role in educating long-term care providers about risk factors and warning signs for suicide in residents under their care.

+
5. Jail and correctional facilities

In jails, prisons, and other correctional facilities, most initial mental health assessments are not done by psychiatrists (465, 466); however, psychiatrists are often asked to perform urgent suicide assessments for individuals identified as being at risk. The actual rates of suicide in jails and in prisons are somewhat controversial, and reported rates depend on the method by which they are calculated (467). The U.S. Department of Justice Bureau of Justice Statistics reported that the rate of suicide per 100,000 prison inmates was 14 during 1999, compared with 55 per 100,000 jail inmates (468). However, reported rates are generally based on the average daily census of the facility. Since jails are local facilities used for the confinement of persons awaiting trial and those convicted of minor crimes, whereas prisons are usually under state control and are used to confine persons serving sentences for serious crimes, jails have a much more rapid turnover of detainees than prisons. This turnover results in a higher reported rate of suicides per 100,000 incarcerated persons in jails relative to prisons, since annual jail admissions are more than 20 times the average daily jail census, whereas the annual number of persons admitted to prisons nationwide is about 50% of the average daily prison census. Reported suicide rates in jails are also elevated relative to those in prisons because the majority of suicides in jail occur during the first 24 hours of incarceration (469, 470).

The importance of identification and assessment of individuals at increased risk for suicide is underscored by the fact that suicide is one of the leading causes of death in correctional settings. For example, from July 1, 1998, to June 30, 1999, natural causes other than AIDS barely led suicide as the leading cause of death in jails. Between 1995 and 1999, suicide was the third leading cause of death in prisons, after natural causes other than AIDS and deaths due to AIDS (468). In relative terms, suicides among youths in juvenile detention and correctional facilities are about four times more frequent, suicide rates for men in jails are about nine to 15 times greater, and the suicide rate in prisons is about one-and-a-half times greater than the suicide rate in the general population (471).

Factors that increase risk in other populations are very prevalent and contribute to increased risk in correctional populations (472, 473). Persons who die by suicide in jails have been consistently shown to be young, white, single, intoxicated individuals with a history of substance abuse (470, 474–476). Suicide in correctional facilities generally occurs by hanging, with bed clothing most commonly used (470, 474, 476–478). It is not clear whether first-time nonviolent offenders (474, 476) or violent offenders (473, 477) are at greater risk. Most (473, 474, 476, 479) but not all (480) investigators have reported that isolation may increase suicide in correctional facilities and should be avoided. While inmates may become suicidal anytime during their incarceration, there are times when the risks of suicidal behavior may be heightened. Experience has shown that suicidal behaviors increase immediately on entry into the facility, after new legal complications with the inmate's case (e.g., denial of parole), after inmates receive bad news about loved ones at home, or after sexual assault or other trauma (471).

There is little doubt that successful implementation of suicide prevention programs results in a significantly decreased suicide rate in correctional facilities (469, 481–483). Consequently, the standards of the National Commission on Correctional Health Care (NCCHC) require jails and prisons to have a written policy and defined procedures for identifying and responding to suicidal inmates, including procedures for training, identification, monitoring, referral, evaluation, housing, communication, intervention, notification, reporting, review, and critical incident stress debriefing (484, 485). Other useful resources include a widely used instrument for suicide screening (486) and the detailed discussions of specific approaches to suicidal detainees that are provided in a later NCCHC publication (487).

+

III. Psychiatric Management

Psychiatric management consists of a broad array of interventions and approaches that should be instituted by psychiatrists for all patients with suicidal behaviors. Psychiatric management serves as the framework by which the patient and psychiatrist will collaborate in the ongoing processes of assessing and monitoring the patient's clinical status, choosing among specific treatments, and coordinating the various treatment components. Psychiatric management includes establishing and maintaining a therapeutic alliance; attending to the patient's safety; and determining the patient's psychiatric status, level of functioning, and clinical needs to arrive at a plan and setting for treatment. For individuals with suicidal behaviors, such treatment planning will encompass interventions targeted to suicidality per se as well as therapeutic approaches designed to address psychosocial or interpersonal difficulties and any axis I and axis II disorders that may be present. Once a plan of treatment has been established with the patient, additional goals of psychiatric management include facilitating treatment adherence and providing education to patients and, when indicated, family members and significant others.

+

A. Establish and Maintain a Therapeutic Alliance

Beginning with the initial encounter with the patient, the psychiatrist should attempt to build trust, establish mutual respect, and develop a therapeutic relationship with the patient. Suicidal ideation and behaviors can be explored and addressed within the context of this cooperative doctor-patient relationship, with the ultimate goal of reducing suicide risk. This relationship also provides a context in which additional psychiatric symptoms or syndromes can be evaluated and treated. At the same time, the psychiatrist should recognize that an individual who is determined to die may not be motivated to develop a cooperative doctor-patient relationship and indeed may view the psychiatrist as an adversary. Appreciating the patient's relationship to and with significant others can help inform the clinician about the patient's potential to form a strong therapeutic relationship. In addition, the therapeutic alliance can be enhanced by paying careful attention to the concerns of patients and their family members as well as their wishes for treatment. Empathy (488, 489) and understanding of the suicidal individual (488–491) are also important in establishing a therapeutic psychiatrist-patient relationship, helping the patient feel emotionally supported, and increasing the patient's sense of possible choices other than suicide (492). In this manner, a positive and cooperative psychotherapeutic relationship can be an invaluable and even life-sustaining force for suicidal patients.

In caring for potentially suicidal patients, the psychiatrist will need to manage the often competing goals of encouraging the patient's independence yet simultaneously addressing safety. In addition, the psychiatrist should be aware of his or her own emotions and reactions to the suicidal patient that may influence the patient's care (488). Psychiatrists should acknowledge the unique place that they may hold in a patient's life, often seeming to be the only source of stability or consistency. At the same time, the clinician must guard against falling into the role of constant savior (490, 491). Suicidal patients may wish to be taken care of unconditionally (493, 494) or alternatively, to assign others the responsibility for keeping them alive (490). Therapists who are drawn into the role of savior with suicidal patients often operate on the conscious or unconscious assumption that they can provide the love and concern that others have not, thus magically transforming the patient's wish to die into a desire to live (420, 490). Under such circumstances, or if the therapist uses defensive reaction formation to deny hostile feelings toward the patient, the therapist may go to great lengths to assure the patient that he or she has only positive feelings about the patient and will do whatever is necessary to save the patient's life. In the worst-case scenario, this need to demonstrate one's caring may contribute to boundary crossings or outright boundary violations (495). Also, by producing false or unrealistic hopes, the psychiatrist may ultimately disappoint the patient by not fulfilling those expectations. Thus, the psychiatrist must remember that taking responsibility for a patient's care is not the same as taking responsibility for a patient's life.

Suicidal patients can also activate a clinician's own latent emotions about death and suicide, leading to a number of defensive responses on the part of the clinician (426). On one hand, there is a potential to develop countertransference hate and anger at suicidal patients (496) that may be manifested by rejecting behavior on the part of the clinician (488). At the other extreme, the clinician may avoid patients who bring up his or her own anxieties surrounding suicide (426, 490). Clinicians may also overestimate the patient's capabilities, creating unrealistic and overwhelming expectations for the patient. Conversely, they may become enveloped by the patient's sense of hopelessness and despair and become discouraged about the progress of treatment and the patient's capacity to improve (488). Thus, management of the therapeutic alliance should include an awareness of transference and countertransference issues, regardless of the theoretical approach used for psychotherapy and regardless of whether these issues are directly addressed in treatment. In this regard, the use of consultation with a senior colleague with experience and some expertise in the management of suicidal patients may be helpful. It is also important to keep in mind that the course and conduct of treatment may be influenced by gender and cultural differences between patients and therapists as well as by cultural differences between patients and other aspects of the care delivery system.

+

B. Attend to the Patient's Safety

Although it is impossible to prevent all self-injurious actions including actual suicide, it is critically important to attend to the patient's safety and work to minimize self-endangering behaviors throughout the evaluation and treatment process. The preceding sections have discussed an orderly process for assessing the patient, estimating suicide risk, and then instituting interventions to target that risk. In actual practice, however, some interventions may be needed to address the patient's safety while the initial evaluation proceeds. For example, in emergency or inpatient settings, specific interventions may include ordering observation of the patient on a one-to-one basis or by continuous closed-circuit television monitoring, removing potentially hazardous items from the patient's room, and securing the patient's belongings (since purses and backpacks may contain weapons, cigarette lighters or matches, and medications or other potentially toxic substances). If restraints are indicated, continuous observation is also recommended (497, 498). Some institutions screen patients for potentially dangerous items by searching patients or scanning them with metal detectors (499). In addition, some institutions have policies prohibiting any guns in emergency areas, since police or security officers' weapons may be taken by suicidal patients. In other circumstances, such as with agitated, uncooperative, intoxicated, or medically ill patients, significant time may elapse before it will be possible to complete a full psychiatric evaluation, including a suicide assessment. Under such conditions, the psychiatrist will need to use the information that is available to make a clinical judgment, with steps being taken to enhance the patient's safety in the interim.

+

C. Determine a Treatment Setting

Treatment settings include a continuum of possible levels of care, from involuntary hospitalizations to partial hospital and intensive outpatient programs to more typical ambulatory settings. In general, patients should be treated in the setting that is least restrictive yet most likely to prove safe and effective. In addition, the optimal treatment setting and the patient's ability to benefit from a different level of care should be reevaluated on an ongoing basis throughout the course of treatment.

The choice of an appropriate site of treatment will generally occur after the psychiatrist evaluates the patient's clinical condition, including specific psychiatric disorder(s) and symptoms (e.g., hopelessness, impulsiveness, anxiety), symptom severity, level of functioning, available support system, and activities that give the patient a reason to live. The psychiatrist should also consider whether or not the current suicidality is related to an interpersonal crisis such as a recent separation, loss of a loved one, or other trauma. The estimate of suicide risk will obviously be an important component of the choice of treatment setting, and the potential for dangerousness to others should also be taken into consideration. Under some clinical circumstances, a decision for hospitalization may need to be made on the basis of high potential dangerousness to self or others, even if additional history is unavailable or if the patient is unable to cooperate with the psychiatric evaluation (e.g., in the presence of extreme agitation, psychosis, or catatonia). At the same time, 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, persistent societal stigma). Other aspects to be incorporated into the determination of a treatment setting include the patient's ability to provide adequate self-care, understand the risks and benefits of various treatment approaches, understand what to do in a crisis (e.g., contact family members or other support persons, contact the psychiatrist, seek emergency care), give reliable feedback to the psychiatrist, and cooperate with treatment planning and implementation. Consequently, choice of a specific treatment setting will not depend entirely on the estimate of suicide risk but rather will rely on the balance between these various elements. An overview of factors to consider in determining a setting for treatment is provided in Table 8.

+
Table Reference Number
Table 8. Guidelines for Selecting a Treatment Setting for Patients at Risk for Suicide or Suicidal Behaviors

Hospitalization should always be viewed as a possible intervention and should be considered whenever the patient's safety is in question. Hospitalization, by itself, is not a treatment. Rather, it is a treatment setting that may facilitate the evaluation and treatment of a suicidal person. In addition, inpatient settings can implement approaches such as constant observation, seclusion, or physical or pharmacological restraint that may restrict an individual's ability to act on suicidal impulses. Although such interventions may delay suicide and permit initiation of treatment approaches, there is no empirical evidence that these methods reduce the incidence of suicide in the long term (77, 500, 501). In addition, hospitals must balance requirements for security against the patient's need to prepare to return to independent living in the community. Since patients cannot be continuously observed or restrained, they can and do die by suicide while hospitalized. In fact, it is estimated that approximately 1,500 inpatient suicides occur in the United States each year, with about a third of these occurring while patients are on one-to-one observation or every-15-minute checks (218).

Although no guidelines regarding hospitalization decisions can be absolute, inpatient care is usually indicated for individuals who are considered to pose a serious threat of harm to themselves or others. Other indications for hospitalization include factors based on illness (e.g., symptom severity, violent or uncontrollable behavior) and those based on the intensity of services needed (e.g., a need for continuous skilled observation; complicated medication trials, particularly for an elderly or a medically fragile patient; ECT; clinical tests or diagnostic evaluation that cannot be performed on an outpatient basis). Severely ill individuals may require hospitalization if they cannot be maintained safely in a less restrictive environment or if they lack adequate structure and social support outside of a hospital setting. More intensive treatment will also be called for whenever there is a new, acute presentation that is not part of a repetitive pattern. Additionally, those patients who have complicating psychiatric or general medical conditions or who have not responded adequately to outpatient treatment may need to be hospitalized. Inpatient care may also be necessary at lower levels of suicide risk in geographic areas where partial hospital or intensive outpatient programs are not readily accessible. If the clinician is not the patient's regular health care provider, does not have an ongoing relationship with the patient, or otherwise does not know the patient well and does not have access to the patient's history or medical records, hospitalization may be necessary until further data can be collected. More intensive treatment may also be necessary even for patients with lesser degrees of suicidality if the patient lacks a strong psychosocial support system, is unable to gain timely access to outpatient care, has limited insight into the need for treatment, or is unable to adhere to recommendations for ambulatory follow-up.

The hospital length of stay should similarly be determined by the ability of the patient to receive the needed care safely in a less intensive environment. In addition, before the patient is transitioned to a less restrictive setting, the patient's condition should show evidence of being improved and more stable both in the estimated level of suicide risk and in the symptoms of any associated psychiatric disorders.

Less intensive treatment may be more appropriate if suicidal ideation or attempts are part of a chronic, repetitive cycle and the patient is aware of the chronicity. For such patients, suicidal ideation may be a characteristic response to disappointment or a way to cope with psychological distress. If the patient has a history of suicidal ideation without suicidal intent and an ongoing doctor-patient relationship, the benefits of continued treatment outside the hospital may outweigh the possible detrimental effects of hospitalization even in the presence of serious psychiatric symptoms.

When considering hospitalization, the risk of suicide is not the only factor to take into account. Patients may feel humiliated or frightened in the hospital rather than experience a sense of emotional relief. Hospitalization can also be associated with realistic life stressors, including the social and financial burdens of having received inpatient treatment. For some patients, treatment in a restrictive setting such as an inpatient unit may foster dependency and a regressive, vicious cycle of intensifying suicidal thoughts requiring ever more restrictive care. Such individuals, most notably those with personality disorders, suffer chronic morbidity if they are never supportively challenged to bear painful feelings. In addition, some patients may gain positive reinforcement from hospitalization and repeatedly harm themselves with the goal of regaining admission. Psychiatric hospitalization may also arouse unrealistic expectations in patients, family members, therapists, and medical and nursing staff members. Often, a plea for hospitalization comes from a sense of exasperation on the part of an individual involved with the patient's situation. When hospital treatment does not meet these unrealistic expectations, the associated disillusionment may contribute to hopelessness and have a negative effect on future therapeutic relationships. The inpatient admission process itself may also cause the patient to mistrust mental health professionals, particularly when hospitalization occurs on an involuntary basis. Thus, the clinician's key responsibility is to weigh the risks and benefits of hospitalization before and during admission (especially around decisions related to therapeutic passes and privilege levels) and ultimately when contemplating discharge (502). Moreover, a person's right to privacy and self-determination (which includes the right to be treated in the least restrictive environment) must be balanced against the issue of potential dangerousness to self or others.

If hospitalization is indicated, the psychiatrist must next decide whether it should occur on a voluntary or involuntary basis. This decision will also depend on multiple factors, including the estimated level of risk to the patient and others, the patient's level of insight and willingness to seek care, and the legal criteria for involuntary hospitalization in that jurisdiction. In general, patients at imminent risk for suicide will satisfy the criteria for involuntary hospitalization; however, the specific commitment criteria vary from state to state (503), and in some states, willingness to enter a hospital voluntarily may preclude involuntary admission. To that end, psychiatrists should be familiar with their specific state statutes regarding involuntary hospitalization.

Patients who are not assessed to be at imminent risk for suicide and who do not require inpatient treatment for other reasons may be suitable for treatment on an outpatient basis. Outpatient treatment may vary in its intensity from infrequent office visits for stable patients to more frequent office visits (up to several times per week) to intensive outpatient or partial hospital treatment. Either of the latter settings may function as a "step-down" from inpatient treatment or as a "step-up" from outpatient therapy, if once- or twice-a-week therapy is insufficient to maintain the patient's stabilization. For patients at significant risk for suicide in these treatment programs, a member of the treatment team must be available to respond to emergencies by telephone, beeper, or other means of contact. In military settings, "unit watch" protocols may be activated to look after the patient between treatment sessions. For patients who continue to be followed by an outside therapist or psychiatrist while in a partial hospital or intensive outpatient treatment program, regular communication among treating professionals is important. Communication with significant others is also helpful, and appropriate supervision and supports should be available and may include a plan for continued after-hours monitoring. If such supervision is not possible, a higher level of care (i.e., inpatient admission) may be needed to maintain the patient's safety even at lower levels of suicide risk. Worsening of a patient's condition, with a concomitant increase in the risk of suicide, requires the careful assessment of the patient's risk for suicide and possible hospitalization. Discharge planning should include appropriate continuing treatment to maintain stability gains and to continue monitoring of suicide risk.

Under some circumstances, individuals who are not currently engaged in outpatient treatment may be referred for care after a suicide attempt or emergency department visit in which suicidality was at issue. Since adherence is often a problem when individuals are referred for outpatient follow-up from emergency departments (448, 504), it may be helpful to discuss the referral with the patient during the course of the interview and if possible arrange a specific appointment time (505–507). When determining a treatment setting in emergency situations, it is also important to consider the potential effects of countertransference and lack of knowledge about suicidality on clinical decision making, since individuals who present with suicidal ideas or attempts may engender a broad range of countertherapeutic reactions in medical professionals, including antipathy, anger, helplessness, and indifference (445, 450, 508–510).

+

D. Develop a Plan of Treatment

Individuals with suicidal thoughts, plans, or behaviors may benefit from a variety of treatments. If the patient is at risk for suicide, a plan that integrates a range of biological and psychosocial therapies may increase the likelihood of a successful outcome. Choosing among possible treatments requires knowledge of the potential beneficial and adverse effects of each option along with information about the patient's preferences. In addition, treatment decisions should be continually reassessed as new information becomes available, the patient's clinical status changes, or both. For patients in ongoing treatment, this may mean that existing treatment plans will require modification as suicidal ideas or behaviors emerge or wane. Thus, treatment planning is an iterative process in which the psychiatrist works with the patient to implement and modify treatments over time, depending on the patient's responses and preferences. Depending on the clinical circumstances, it may be important for the treatment planning process to include family members or other significant supports (e.g., military unit personnel, community residence or adult home providers, case management staff). More detail on the specific therapeutic approaches discussed subsequently can be found in APA practice guidelines that discuss treatment of specific psychiatric disorders (all included in this volume), including major depressive disorder (511), bipolar disorder (512), schizophrenia (513), panic disorder (514), and borderline personality disorder (515).

Psychiatrists should be cautioned against developing a treatment plan in which the stated goal is to "eliminate" suicide risk; this is impossible to do for the reasons already discussed. Instead, the goals of treatment should include a comprehensive approach to treatment with the major focus directed at reducing risk. Since individuals with suicidal behaviors often have axis I and axis II disorders, reducing risk frequently involves treating an associated psychiatric illness. Given the high rates of comorbid alcohol and substance use among individuals with suicidal behaviors, it is particularly important to address substance use disorders in the treatment plan (516). Medical disorders and treatments for those disorders will also need to be considered in developing a plan of treatment for the patient with suicidal behaviors.

In the early stages of treatment, more intense follow-up may be needed to provide support for the patient as well as to monitor and rapidly institute treatment for relevant symptoms such as anxiety, insomnia, or hopelessness. In addition, it is during the early stages of illness that denial of symptoms and lack of insight into the need for treatment are likely to be most prominent, and, therefore, specific education and supportive psychotherapy are required to target these issues. Appreciating the patient's past responses to stress, vulnerability to life-threatening affects, available external resources, death fantasies, and capacity for reality testing may help the clinician to weigh the strengths and vulnerabilities of the individual patient (412) and may aid in the planning of treatment. For patients treated in ambulatory settings, it is also important for the psychiatrist to review with the patient guidelines for managing exacerbations of suicidal tendencies or other symptoms that may occur between scheduled sessions and could contribute to increased suicide risk.

+

E. Coordinate Care and Collaborate With Other Clinicians

Providing optimal treatment for patients with suicidal behaviors frequently involves a multidisciplinary treatment team that includes several mental health professionals. While ongoing coordination of the overall treatment plan is generally easier to implement in inpatient or partial hospital settings as opposed to less integrated ambulatory settings, useful strategies for coordination in any treatment setting include clear role definitions, regular communication among team members, and advance planning for management of crises. It is also helpful to clarify with the patient that a number of individuals will be involved in his or her care and to outline the specific roles of each. In this regard, it is important for patients to understand that treatment team members assist the psychiatrist in many respects and may supply clinical information that will influence decisions about the level of precautions, readiness for discharge, medications, and other aspects of treatment planning.

Many patients have ongoing medical illnesses for which they receive care from one or more physicians. Particularly for individuals whose medical disorders or treatments interface with their psychiatric symptoms or treatments, it is helpful to communicate with the patient's primary care physician as well as with any specialists who are actively involved in the patient's care.

In inpatient settings, the treatment team generally consists of a psychiatrist, nurses, social workers, psychologists, and other mental health workers, with the psychiatrist acting as the team leader. In this capacity, with input from the other members of the treatment team, the psychiatrist will make the critical decisions regarding the patient's care. Such decisions include but are not limited to the patient's diagnosis, specific medications, level of precautions, passes, discharge, and follow-up treatment plan. Given the key roles and observations of other treatment team members in such decisions, the psychiatrist should encourage open communication among the staff members regarding historical and clinical features of the patient.

In an outpatient setting, there may also be other professionals involved in the care of the patient. In some instances, the patient may be referred to individuals with expertise in symptom-specific treatments (e.g., cognitive behavior therapy for hopelessness or dialectical behavior therapy for recurrent suicidal behavior). In other instances, the psychiatrist may be providing primarily psychopharmacologic management, with another psychiatrist or other mental health professional conducting the psychotherapy. During visits with the patient, it is important for the psychiatrist to review the patient's response to all aspects of the treatment. In addition, it is useful for the psychiatrist to communicate with the therapist and to establish guidelines or expectations as to when and under what conditions the therapist and the psychiatrist should be contacted in the event of a significant clinical change in the patient. Moreover, if the psychiatrist has direct supervisory responsibilities for the therapist, the level of communication should be increased and may include a chart review.

+

F. Promote Adherence to the Treatment Plan

The successful treatment of many psychiatric disorders requires close adherence to treatment plans, in some cases for long or indefinite durations. With individuals whose clinical symptoms include suicidal thoughts, plans, or behaviors, it is particularly important that management be optimized through regular adherence with the treatment plan. Facilitating adherence begins with the initial establishing of the physician-patient relationship and the collaborative development of a plan of care that is attentive to the needs and preferences of the individual patient. Within the therapeutic relationship the psychiatrist should create an atmosphere in which the patient can feel free to discuss what he or she experiences as positive or negative in the treatment process. Side effects or requirements of treatment are common causes of nonadherence. Other common contributors include financial constraints, scheduling or transportation difficulties, perceived differences of opinion with the clinician, and misunderstandings about the recommended plan of treatment or dosing of medications. Especially while symptomatic, patients may be poorly motivated, less able to care for themselves, or unduly pessimistic about their chances of recovery with treatment, or they may suffer from memory deficits or psychosis. In some instances, psychiatric disorders are associated with reductions in insight about having an illness or needing treatment, making adherence less likely. Particularly during maintenance phases of treatment, when symptoms are less salient, patients may tend to undervalue the benefits of treatment and instead focus on its burdens. The psychiatrist should recognize these possibilities, encourage the patient to articulate any concerns regarding adherence, and emphasize the importance of adherence for successful treatment and for minimizing the risk of future suicidal behaviors (306). Specific components of a message to the patient that have been shown to improve adherence include 1) when and how often to take the medicine, 2) the fact that some medications may take several weeks before beneficial effects may be noticed, 3) the need to take medication even after feeling better, 4) the need to consult with the doctor before discontinuing medication, and 5) what to do if problems or questions arise (517).

To facilitate adherence, it is helpful to reassess the treatment plan on a regular basis in collaboration with the patient and attempt to modify it in accord with the patient's preferences and needs. Some patients, particularly elderly patients, have been shown to have improved adherence when both the complexity of medication regimens and the costs of treatments are minimized. When a patient does not appear for appointments or is nonadherent in other ways, outreach, including telephone calls, may be helpful in reengaging the patient in treatment. This outreach can be carried out by the psychiatrist or other designated team members in consultation with the psychiatrist. For patients in an involuntary outpatient treatment program, the judicial system may also be involved in outreach efforts. Severe or persistent problems of nonadherence may represent psychological conflicts or psychopathology, for which psychotherapy should be considered. Educating patients about medications, aspects of suicidality, and specific psychiatric disorders and their management can be useful. When family members or other supportive individuals are involved (e.g., military command personnel, supported housing staff), they can also benefit from education and can be encouraged to play a helpful role in improving adherence.

+

G. Provide Education to the Patient and Family

Most patients can benefit from education about the symptoms and disorders being treated as well as about the therapeutic approaches employed as part of the treatment plan. When appropriate, and with the patient's permission, education should also be provided to involved family members. Understanding that psychiatric disorders are real illnesses and that effective treatments are both necessary and available may be crucial for patients who attribute their illness to a moral defect or for family members who are convinced that there is nothing wrong with the patient. Patients and family members can also benefit from an understanding of the role of psychosocial stressors and other disruptions in precipitating or exacerbating suicidality or symptoms of psychiatric disorders. Education regarding available treatment options will help patients make informed decisions, anticipate side effects, and adhere to treatments. Patients also need to be advised that improvement is not linear and that recovery may be uneven. Certain patients or family members may become overwhelmed or devastated by a recurrence of symptoms or a temporary worsening of symptoms after the initiation of treatment. Since suicidal patients tend to be overly critical of themselves, a recurrence or worsening of symptoms may be seen as evidence of personal failure; they need to be reassured that this can be part of the recovery process.

It is also useful to have an open discussion with the patient about the phenomenon of suicide. When there has been a family history of suicide, some patients will feel that it is their fate to die from suicide as well. The age at which a family member died or the specific anniversary of the family member's death may take on special significance for some patients. Education for the patient and the family should emphasize that a family history of suicide may increase risk of suicide, but it does not make suicide inevitable. It can be helpful to educate the patient and involved family members about how to identify symptoms, such as insomnia, hopelessness, anxiety, or depression, that may herald a worsening of the patient's clinical condition. In addition, patients and family members should be encouraged to think about other symptoms, specific to the individual patient, that have been associated with suicidality in the past. Furthermore, patients and family members should be aware that thoughts of suicide may return and that they should inform the psychiatrist or a significant other as soon as possible if that occurs. There should also be an open discussion about what to do in the event of an emergency and how to obtain emergency services. Under some circumstances, this discussion may include an explanation of methods for involving the police to facilitate an involuntary evaluation.

Some family members, particularly those of patients with borderline personality disorder, mistakenly view suicide attempts or communications of suicidal intent as "manipulative" or "attention-seeking" behaviors. Thus, it is important to provide family members with education about the lifetime risks of suicide in such patients and to help family members learn ways to respond in a helpful and positive manner when the patient is experiencing a suicidal crisis.

+

H. Reassess Safety and Suicide Risk

The waxing and waning nature of suicidality is one of the difficult challenges in the care of the suicidal patient and often requires that suicide assessments be repeated over time (Table 2). Although a full suicide assessment is not required at each encounter with the patient, the psychiatrist should use reasonable judgment in determining the extent of the repeat assessment needed to estimate the patient's current suicide risk. In inpatient settings, repeat suicide assessments should occur at critical stages of treatment (e.g., with a change in level of privilege, abrupt change in mental state, and before discharge). When a reassessment is done, the psychiatrist often finds that a patient who initially reported suicidal ideation with lethal intent no longer reports suicidal ideation at a subsequent visit. As stated earlier, it is not possible to predict which individuals with recent suicidal ideation will experience it again nor which patients will deny suicidal ideation even when it is present. Nonetheless, if a patient is assessed as being at high risk for suicide, a plan to address this risk must be implemented and documented. This plan may include changes in the setting of care or level of observation, changes in medication therapy or psychotherapy, or both kinds of changes.

Patients with a recent onset of severe suicidal ideation should be treated with particular caution. For those experiencing suicidal ideation in the context of an underlying depressive disorder, it can be useful to monitor other depressive symptoms. The psychiatrist also needs to be mindful of other symptoms that may be associated with increased suicide risk, such as hopelessness, anxiety, insomnia, or command hallucinations. Behaviors that may be associated with an acute increase in risk include giving away possessions, readying legal or financial affairs (e.g., finalizing a will, assigning a power of attorney), or communicating suicidal intentions or "goodbye" messages.

Patients who are responding to ongoing treatment or who are in remission with continuation or maintenance treatment should be assessed for suicide risk when there is evidence of an abrupt clinical change, a relapse or recurrence, or some major adverse life event. In this context, the new emergence of suicidality should be responded to by an alteration of the treatment plan. The nature of this alteration depends on the clinical situation and can include a change in treatment setting or level of observation, increased visits, a change of medication or psychotherapeutic approach, inclusion of a significant other person, and consultation. With changes in clinical status or as new information becomes available, the psychiatrist must also be prepared to reevaluate the patient's psychiatric diagnosis and also evaluate the nature and strength of the therapeutic alliance.

+
1. Patients in a suicidal crisis

There will be times when a patient in ongoing treatment is in an acute suicidal crisis and the psychiatrist has to respond immediately. There may be communications directly from the patient, the family, or significant others, including employers or co-workers. In urgent situations, it may be necessary to have telephone calls traced or involve the police. The challenge for the psychiatrist is not only to evaluate the extent of the emergency but also to assess the content of the communication and its source. To better assess the situation, it is critical to speak with the patient directly, if at all possible. In addition, the psychiatrist should remain mindful of issues relating to confidentiality and breach confidentiality only to the extent needed to address the patient's safety (see also Section V.C, "Communication With Significant Others").

Under some circumstances, the psychiatrist may need to refer a suicidal patient to an emergency department for evaluation or hospitalization. When doing so, it is important for the psychiatrist to communicate with the psychiatric evaluator in the emergency department. Although such communication may not always be possible because of the exigencies of the emergency situation, such contact does provide hospital personnel with the context for the emergency. Particularly when a patient is brought to the hospital by police, it is not unusual for the patient to minimize the symptoms and reasons for the referral after arriving in the emergency setting. Adequate information about the reasons for the emergency department referral and about the patient's previous and recent history can be crucial in helping the emergency department evaluator determine a safe and appropriate setting for treatment. When hospitalization is recommended by the referring psychiatrist, the reasons for that recommendation should similarly be communicated to the emergency department evaluator who will be making the final determination about the need for hospital admission.

+
2. Patients with chronic suicidality

For some individuals, self-injurious behaviors and/or suicidality are chronic and repetitive, resulting in frequent contacts with the health care system for assessment of suicide potential. It is important to recognize that self-injurious behaviors may or may not be associated with suicidal intent (518). Although self-injurious behaviors are sometimes characterized as "gestures" aimed at achieving secondary gains (e.g., receiving attention, avoiding responsibility through hospitalization), patients' motivations for such behaviors are quite different. For example, without having any desire for death, individuals may intentionally injure themselves to express anger, relieve anxiety or tension, generate a feeling of "normality or self-control," terminate a state of depersonalization, or distract or punish themselves (519, 520). Conceptualizing such behaviors as "gestures" is also problematic because suicide attempts may be downplayed when associated with minimal self-harm. Self-destructive acting out can also result in accidentally lethal self-destructive behaviors even in the absence of suicidal intent. Furthermore, a past or current history of nonlethal self-injurious behaviors does not preclude development of suicidal ideas, plans, or attempts with serious intent and lethality (521). In fact, among suicide attempters with suicidal intent, those who also had histories of self-injurious behaviors without suicidal intent were more likely to underestimate the objective lethality of their attempt and to have symptoms associated with greater suicide risk (251). Thus, in assessing chronic self-injurious behaviors, it is important to determine whether suicidal intent is present with self-injury and, if so, to what extent and with what frequency. In addition, an absence of suicidal intent or a minimal degree of self-injury should not lead the psychiatrist to overlook other evidence of increased suicide risk.

For patients who are prone to chronic self-injurious behavior, each act needs to be assessed in the context of the current situation; there is not a single response to self-injurious behaviors that can be recommended. For example, there are times when outpatient management is most appropriate; under other circumstances, hospitalization may be indicated. In general, for such individuals, hospitalization should be used for short-term stabilization, since prolonged hospital stays may potentiate dependency, regression, and acting-out behaviors. When chronic self-injurious behaviors are present, behavioral techniques such as dialectical behavior therapy can be helpful (522, 523). In addition, at times when care of the patient is being transitioned to another clinician, the risk of suicidal behaviors may increase.

Diagnostically, severe personality disorders, particularly borderline (521) and antisocial personality disorders, predominate among patients who exhibit chronic self-injurious behaviors without associated suicidal intent. Such individuals may also have higher rates of comorbid panic disorder and posttraumatic stress disorder (524). Patients with schizoaffective disorder, bipolar disorder, and schizophrenia may also be represented, but more often such patients have ongoing thoughts of suicide or repeated suicide attempts in the presence of suicidal intent. There is evidence that the presence of comorbid personality disorders or substance use disorders not only increases suicide risk in these individuals but also decreases treatment response. For example, patients with a combination of affective disorder and personality disorder are prone to frequent suicidal crises, difficulties with mood instability and impulse control, and problems with treatment adherence. Consequently, for patients whose nonadherence contributes to a chronic risk for suicide, psychiatrists should be familiar with statutes on involuntary outpatient treatment, if it is applicable in their jurisdiction (525).

When treating chronically suicidal individuals, it is important for the psychiatrist to monitor his or her own feelings, including countertransference reactions. Careful attention to the treatment relationship and the psychosocial context of the patient is also critical. Consistency and limit-setting are often needed, but the latter needs to be established on the basis of clinical judgment and should not be framed in punitive terms. Helping patients develop skills for coping with self-injurious impulses is often a valuable part of treatment.

In outlining a detailed treatment plan, it is helpful to incorporate input from the patient and significant others, when clinically appropriate. During periods of crisis, disagreements may occur about the need for hospitalization. In some circumstances, the psychiatrist may view hospitalization as essential, whereas the patient or family members may not. Alternatively, the patient, family members, or other involved persons may demand hospitalization when outpatient management may seem more appropriate. When such disagreements occur, power struggles are best avoided. Instead, gaining a deeper understanding of the conflicting viewpoints will often lead to a successful resolution. In addition, educational efforts with the patient and others should discuss the fact that risk in chronically suicidal individuals will be increased on an ongoing basis. Thus, the risk of suicide outside of the hospital must be balanced against the potentially detrimental effects of hospitalization (see Section III.C, "Determine a Treatment Setting").

+

I. Monitor Psychiatric Status and Response to Treatment

In addition to reassessing the patient's safety and degree of suicidality, it is equally important for the psychiatrist to monitor the patient's psychiatric status and response to treatment. This is particularly the case during the early phases of treatment, since some medications, particularly antidepressants, may take several weeks to reach therapeutic benefit. Also, with the exception of suicides in persons with alcoholism, suicides tend to occur early in the course of most psychiatric disorders, when individuals are least likely to have insight into having an illness and are least likely to adhere to treatment. Moreover, clinical observations suggest that there may be an early increase in suicide risk as depressive symptoms begin to lift but before they are fully resolved. Thus, ongoing monitoring of the patient's clinical condition is needed to determine the patient's symptoms and response to treatment (e.g., determining the optimal dose of a drug and evaluating its efficacy). Often the course of treatment is uneven, with periodic setbacks, for example, at times of stress. Such setbacks do not necessarily indicate that the treatment is ineffective. Nonetheless, ultimate improvement should be a reasonably expected outcome. Furthermore, as treatment progresses, different features and symptoms of the patient's illness may emerge or subside. Significant changes in a patient's psychiatric status or the emergence of new symptoms may indicate a need for a diagnostic reevaluation, a change in treatment plan, or both. Such modifications may include a change in treatment setting, medication, or frequency of visits; involvement of significant others; referral for additional treatments (e.g., dialectical behavior therapy, ECT) that are targeted at specific symptoms or syndromes; and consultation.

+

J. Obtain Consultation, if Indicated

In treating suicidal patients, particularly those with severe or chronic suicidality, consultation may be helpful from a number of standpoints. The use of consultation or supervision from a colleague may be of help in monitoring and addressing countertransference issues. Since clinical judgments regarding assessment and treatment issues with suicidal patients may be quite difficult, input from other colleagues may be important in affirming the appropriateness of the treatment plan or suggesting other possible therapeutic approaches. For complex clinical presentations in which alcohol or other substance use disorders might be present, referral to a psychiatrist specializing in the treatment of addictive disorders may be helpful for consultation, management, or involvement in a program of recovery. However, in the context of a suicidal crisis, psychiatrists need to be careful in referring a long-term patient for consultation. Some patients may perceive such a referral as the first step to termination of therapy and may need to be reassured that the referral is only for consultation.

+

IV. Specific Treatment Modalities

+

A. Somatic Therapies

For the purposes of this practice guideline, psychiatrists should be familiar with specific psychotropic medicines that have been found to be useful in the care of the suicidal patient. In general, somatic therapies such as antidepressants, antipsychotics, or mood-stabilizing agents will be targeted to specific axis I and/or axis II psychiatric disorders. However, early use of supplemental medicines, including sedative-anxiolytics or low doses of second-generation antipsychotics, may also be helpful to rapidly address agitation, anxiety, and insomnia, which are additional risk factors for suicide.

+
1. Antidepressants

A mainstay of the treatment of suicidal patients suffering from acute, recurrent, and chronic depressive illness is the administration of antidepressant medication in an adequate dose (526). Antidepressants also have demonstrated efficacy in the treatment of anxiety disorders (526). They have also been used successfully in treating suicidal patients with comorbid depression and substance use disorders (527). Remarkably, however, there is relatively limited evidence that antidepressant treatment reduces risk (69, 526, 528–533). On the basis of a large number of short-term randomized, placebo-controlled trials for acute major depression (534–546) that were subjected to meta-analysis (533), antidepressant treatment has not been shown to reduce rates of suicide or suicide attempts. Studies using data on antidepressants from Food and Drug Administration clinical trial databases also do not show differences in rates of suicide or suicide attempts with antidepressant treatment (546–548). However, reductions in risk might not be observed as readily over short time periods or in studies in which suicidality was used as an exclusion criterion. Furthermore, long-term studies with relevant data are rare and too small to support any conclusions (526). However, since the late 1980s, suicide rates in several countries, regions, or subpopulations have fallen appreciably (69, 531, 532, 549, 550), coinciding with the increasing clinical use of nontricyclic and non–monoamine oxidase inhibitor (non-MAOI) antidepressants in adequate doses and perhaps providing indirect evidence for a role of antidepressant treatment in the treatment of suicidal behaviors.

After publication of several case reports suggesting that SSRI antidepressants might be associated with increased risks of aggressive or impulsive acts, including suicide (551–553), a number of investigators retrospectively analyzed clinical trial data to determine whether suicidality and/or suicide rates are increased with SSRI treatment (537, 548, 554, 555). These studies did not show evidence that suicide or suicidality is increased by treatment with specific types of antidepressants. At the same time, these medications are prescribed in order to treat disorders that may have anxiety, agitation, and suicidality as part of the illness course, making it difficult to distinguish the etiology of symptoms that emerge in the course of treatment. Thus, as treatment begins, it is important to determine baseline levels of symptoms and then to observe patients for symptoms such as anxiety, agitation, or sleep disturbance as well as for the development of mixed states or psychosis, all of which may increase their subjective sense of distress and increase suicide risk. In addition, antidepressant therapy typically involves a substantial delay before clinically obvious improvements occur. During initial, partial recovery, it is possible that suicidal impulses as well as the energy to act on them may increase. Patients should be forewarned of this likely delay in treatment effects and should be given encouragement and monitored especially closely in the initial days and weeks of treatment. If full response to treatment is not observed, adjustments in medication dosage or a change to a different antidepressant medication may be necessary. Nontricyclic, non-MAOI antidepressants are relatively safe and present virtually negligible risks of lethality on overdose (526). Nevertheless, it is wise to request that conservative quantities of medication be dispensed for suicidal patients, especially for patients who are not well known. Although the tricyclic antidepressants and MAOIs are much more toxic in overdose and more limited in their use, they may still be valuable in treating individuals with suicidal behaviors and depressive disorders who have not responded to treatment with SSRIs or other newer antidepressants (526, 556, 557). Overall, from a clinical perspective, the strong association between clinical depression and suicide and the availability of reasonably effective and quite safe antidepressants support their use, in adequate doses and for an adequate duration, as part of a comprehensive program of care for potentially suicidal patients, including long-term use in patients with recurrent forms of depressive or severe anxiety disorders.

+
2. Lithium

There is strong and consistent evidence in patients with recurring bipolar disorder and major depressive disorder that long-term maintenance treatment with lithium salts is associated with major reductions in risk of both suicide and suicide attempts (69, 558–565). A recent meta-analysis (563) of available studies of suicide rates with versus without long-term lithium maintenance treatment (76, 534, 559, 565–595) found a highly statistically significant decrease in suicidal acts (i.e., suicide or suicide attempts) of almost 14-fold. For suicide, lithium maintenance treatment was associated with an 80%–90% decrease in risk, whereas the reduction in suicide attempt rates was more than 90%. Although suicide rates during lithium treatment are still greater than those in the general population, maintenance therapy with lithium for bipolar disorder patients is associated with substantial and significant reductions in suicide risk, compared to non-lithium-treated bipolar disorder patients. As with antidepressants, the potential lethality of lithium in overdose (596) should be taken into consideration when deciding on the quantity of lithium to give with each prescription. However, given the long-term benefits of lithium in reducing risks of suicidal behaviors, the potential for overdose effects should not preclude treatment of suicidal patients with lithium when it is clinically indicated.

+
3. "Mood-stabilizing" anticonvulsant agents

Despite the increased use and antimanic efficacy of specific anticonvulsant and antipsychotic agents (e.g., divalproex, olanzapine), their long-term effectiveness in protecting against recurrent mood episodes is less well established. Moreover, there is no established evidence of a reduced risk of suicidal behavior with any other "mood-stabilizing" anticonvulsants. Although treatment with these agents may be associated with some decrease in suicidal behaviors, lithium treatment is still associated with a greater diminution in rates of suicidal acts than treatment with carbamazepine or divalproex (592, 597, 598). 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.

+
4. Antipsychotic agents

Analogous to the use of antidepressants for patients with depression, the antipsychotic medications have been the mainstay of somatic treatment for suicidal patients with psychotic disorders. First-generation antipsychotic agents are highly effective in treating delusions and hallucinations as well as agitation, aggression, and confusion and may also have some beneficial actions in major affective disorders. Their potential effects in limiting suicidal risk in psychotic patients are unknown, although annual rates of suicide associated with schizophrenia have not fallen appreciably since their introduction (599–602).

Particularly in highly agitated patients, the beneficial effects of first-generation and modern antipsychotics may serve to reduce suicide risk (603). However, use of older neuroleptic agents may also be associated with adverse effects, including extrapyramidal neurological side effects and possible worsening of depression as a result of induction of akathisia (603–606). Given the fact that treatment of psychotic disorders with second-generation antipsychotic agents is associated with lower risks of some, particularly extrapyramidal-neurological, adverse effects (512, 513, 596), use of first-generation antipsychotics in individuals with suicidal behaviors currently is usually reserved for those needing the enhanced treatment adherence afforded by depot forms of medication or those whose psychosis has not responded to a second-generation antipsychotic, or when economic considerations are compelling.

In the United States, the second-generation antipsychotic medications, such as aripiprazole, clozapine, olanzapine, quetiapine, risperidone, and ziprasidone, are now used to treat the majority of individuals with schizophrenia or schizoaffective disorder. In addition to their use as first-line agents in the treatment of schizophrenia, the second-generation antipsychotic agents may also be indicated for use in individuals with other psychotic disorders as well as in patients with bipolar disorder, particularly during manic episodes. Among the second-generation antipsychotic agents, clozapine has generally been reserved for use when psychotic symptoms have not responded to other antipsychotic medications. As for effects on suicide attempts and suicide, clozapine is the best studied of any of the antipsychotic agents. Reductions in the rates of suicide attempts and suicides have been reported in specific studies of patients with schizophrenia treated with clozapine (607) as well as in registry studies (533, 606, 608–613), which may include patients with other psychotic diagnoses. Earlier studies could not eliminate the possibility that suicide rates were decreased by a nonspecific effect of increased clinical contact due to hematologic monitoring during clozapine therapy. However, significant reductions in suicide attempts and hospitalization for suicidality were also seen in a more recent blinded study comparing clozapine and olanzapine (603). The reduction of suicide attempts in both groups, compared to the rate in the year preceding the study, suggests that olanzapine may also offer some protection against suicide attempts. These findings suggest that use of clozapine might be considered earlier in the treatment of individuals with schizophrenia or schizoaffective disorders. At the same time, the potential benefits of treatment with clozapine need to be weighed against the potential for adverse effects with long-term clozapine treatment, including agranulocytosis, myocarditis, weight gain, and glucose dysregulation. Further study is needed to determine whether clozapine can reduce suicide risk in patients with other diagnoses or whether other second-generation antipsychotic drugs may reduce suicide risk in schizophrenia in comparison with one another or with first-generation antipsychotic drugs.

+
5. Antianxiety agents

Since anxiety is a significant and modifiable risk factor for suicide, utilization of antianxiety agents may have the potential to decrease this risk. More specifically, before accompanying depression has resolved, acute suicide risk may be associated with severe psychic anxiety, panic attacks, agitation, and severe insomnia (79). Although these symptoms may be reduced by aggressive short-term benzodiazepine treatment (lasting 1–4 weeks), research on suicide risk with antianxiety treatment is quite limited, with no clinical trial of antianxiety treatment showing short- or long-term antisuicide effects. However, a recent analysis of data obtained in controlled trials of treatments for anxiety disorders showed no significant differences in rates of suicidal behavior between those treated with active agents and those taking placebo (118).

To minimize severe recurrent (rebound) anxiety/agitation, long-acting benzodiazepines may be preferable to short-acting ones. At the same time, long-acting benzodiazepines may be more likely to cause daytime sedation. Psychiatrists should also keep in mind that benzodiazepines occasionally disinhibit aggressive and dangerous behaviors and enhance impulsivity, particularly in patients with borderline personality disorder (614, 615). For patients treated with benzodiazepines on a chronic basis, discontinuation of the benzodiazepine may be associated with an increase in suicide risk (616). As alternatives to benzodiazepines, second-generation antipsychotic medications or anticonvulsant medications such as divalproex or gabapentin may be helpful, although no specific research information on their potential to limit anxiety is available. Persistent, severe insomnia is also a modifiable risk factor for suicide and can be addressed with the use of benzodiazepines or sedating second-generation antipsychotics (617–619). Choice of a sedating antidepressant can also be considered for depressed patients with prominent insomnia.

+
6. ECT

ECT is sometimes used to treat patients who are acutely suicidal, and available evidence suggests that ECT reduces short-term suicidal ideation (620–622). The efficacy of ECT is best established in patients with severe depressive illness, but ECT may also be used in treating individuals with manic or mixed episodes of bipolar disorder, schizoaffective disorder, or schizophrenia, under certain clinical circumstances (623). ECT is especially likely to be considered for patients for whom a delay in treatment response is considered life-threatening. Such patients may include individuals who are refusing to eat because of psychosis or depressive symptoms as well as those with catatonic features or prominent psychosis. 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. Although ECT is often raised as a possible treatment for chronically suicidal individuals with borderline personality disorder, ECT in such patients should target comorbid disorders that may be present, particularly comorbid major depressive disorder. In the absence of another indication for use, ECT is not indicated for the treatment of suicidality in borderline personality disorder. For further details on the clinical use of ECT, including the pre-ECT evaluation, the informed consent process, the numbers of treatments generally given, and the technical aspects of ECT administration, the reader is referred to APA's 2001 report, The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging: A Task Force Report of the American Psychiatric Association (623). Since there is no evidence for long-term or sustained reduction of suicide risk after an acute course of ECT, close clinical supervision and additional treatment with psychotropic medications are usually required during subsequent weeks and months.

+

B. Psychotherapies

In addition to pharmacotherapies and ECT, psychotherapies play a central role in the management of suicidal behavior in clinical practice. Although few rigorous studies have directly examined whether these interventions reduce suicide morbidity or mortality per se, clinical consensus suggests that psychosocial interventions and specific psychotherapeutic approaches are of benefit to the suicidal patient. Furthermore, in recent years, studies of psychotherapy have demonstrated its efficacy in treating disorders such as depression and borderline personality disorder that are associated with increased suicide risk. For example, cognitive behavior therapy, psychodynamic therapy, and interpersonal psychotherapy have been found effective in clinical trials for the treatment of these disorders (511, 515). A small randomized, controlled trial of psychoanalytically oriented partial hospital treatment for individuals with borderline personality disorder showed a beneficial effect on suicide attempts and self-harming behaviors during treatment and follow-up (624, 625). These observations as well as clinical experience lend support to the use of such psychotherapeutic approaches in the treatment of suicidal ideation and behaviors.

A number of other specific and nonspecific interventions have been assessed in small methodologically sound, randomized, controlled trials involving individuals with suicidal ideation or attempts as well as other forms of deliberate self-harm (626, 627). Dialectical behavior therapy has been studied for effects in a narrow range of potentially suicidal patients, particularly chronically suicidal or self-harming women with personality disorders. By targeting deficits in specific skills, such as emotional regulation, impulse control, anger management, and interpersonal assertiveness, dialectical behavior therapy may be effective in reducing suicide attempts when applied over longer time frames, especially for patients with personality disorders. There is also some preliminary evidence that cognitive and behavioral psychotherapy may reduce the incidence of suicide attempts in depressed outpatients (236, 626). However, other forms of cognitive behavior therapy that include a problem-solving component have shown mixed results (524, 628–632), suggesting the need for additional study. Other nonspecific interventions have been studied in relatively small samples and have similarly shown mixed results. Most of these studies are limited in the size and scope of the patient population and provide only narrow support for an effect on suicidal behaviors (633).

+

V. Documentation and Risk Management

+

A. General Risk Management and Documentation Issues Specific to Suicide

Risk management is an important component of psychiatric practice, especially in the assessment and management of patients at risk for suicide. Clinically based risk management is patient centered and supports the therapeutic alliance and the treatment process. The most frequent lawsuits, settlements, and verdicts against psychiatrists are for patients' suicides. Thus, when treating a patient with suicidal behaviors, it is important to be aware of and pay attention to certain general risk management considerations, which are summarized in Table 9.

+
Table Reference Number
Table 9. General Risk Management and Documentation Considerations in the Assessment and Management of Patients at Risk for Suicide

Documentation of patient care is a cornerstone of medical practice, but it is also essential to risk management (634, 635). If a malpractice claim is brought against the psychiatrist, documentation of suicide risk assessments assists the court in evaluating the many clinical complexities and ambiguities that exist in the treatment and management of patients at suicide risk. The failure to document suicide risk assessments and interventions may give the court reason to conclude they were not done. For patients who are hospitalized, it is also important to document the aspects of the risk assessment that justify inpatient treatment, particularly when it is occurring on an involuntary basis (636). Thus, it is crucial for the suicide risk assessment to be documented in the medical record.

Despite the time burdens faced by the psychiatrist, documentation is best done just after the suicide assessment is completed. Reference to the reason for the assessment (e.g., relapse, worsening, a reversal in the patient's life) will set the context for the evaluation. Subsequent discussion reviews the factors that may contribute to increased shorter-term or longer-term suicide risk as well as the reasoning process that went into the assessment. Clinical conclusions and any changes in the treatment plan should also be noted, along with the rationale for such actions. If other interventions or actions were considered but rejected, that reasoning should be recorded as well.

Consider the example of a patient who was in remission after a prior hospitalization for a suicide attempt but who recently had a relapse or a recurrent episode. The psychiatrist may document that suicidal ideation is present but that there is no evidence of a specific plan or specific symptoms that would augment risk (i.e., agitation, severe anxiety, severe insomnia). It may also be noted that the patient is under increased stress and is in some distress but is responsive to support. On the basis of the patient's willingness to accept help and the lack of evidence of acute suicide risk factors, continued outpatient management may be reasonable, with changes in the treatment plan, such as increasing the frequency of visits, perhaps increasing anxiolytic medication doses temporarily, and perhaps talking with a supportive relative or friend to obtain more information and to solidify the patient's support system.

In all settings, the psychiatrist should be aware that suicide risk assessment is a process and never simply an isolated event. Specific points at which reassessment may be indicated have been detailed in Table 2. On inpatient units, important points of documentation of assessment occur at admission, changes in the level of precautions or observations, transitions between treatment units, the issuance of passes, marked changes in the clinical condition of the patient, and evaluation for discharge (637). In particular, the determination of the level of suicide precautions (one-to-one versus every-15-minute checks, etc.) should be based on the patient's clinical presentation and be supported by a clinical rationale. Because care in inpatient settings is generally delivered by a multidisciplinary treatment team, it is important for the psychiatrist either to review the patient's records regularly or to communicate verbally with staff throughout the patient's hospital stay. At the time of the patient's discharge from the hospital, risk-benefit assessments for both continued hospitalization and discharge should be documented, and follow-up arrangements for the patient's outpatient care should be recorded.

In outpatient settings, the process of suicide risk assessment and documentation typically occurs during the initial interview; at the emergence or reemergence of suicidal ideation, plans, or behavior; and when there are other significant changes in the patient's condition. Revisions of the treatment plan are appropriately noted at these times. For patients in psychoanalysis or modified psychoanalytic treatment, the psychiatrist may elect to follow the charting recommendations of the psychoanalytic subspecialty practice guideline (638).

+

B. Suicide Contracts: Usefulness and Limitations

As originally designed, the suicide prevention contract, which is sometimes known as a no-harm contract, was intended to facilitate management of the patient at suicide risk (639). Although in the era of managed care, suicide prevention contracts are increasingly being used with patients at risk for suicide, the patient's willingness (or reluctance) to enter into a suicide prevention contract should not be viewed as an absolute indicator of suitability for discharge (or hospitalization). In addition, since the utility of the suicide prevention contract is based on subjective belief rather than objective evidence, it is overvalued as a clinical or risk management technique. Furthermore, the suicide prevention contract is not a legal document and cannot be used as exculpatory evidence in the event of litigation (640). Thus, the suicide prevention contract cannot and should not take the place of a thorough suicide risk assessment (637).

Although suicide prevention contracts are commonly used in clinical practice (429), no studies have shown their effectiveness in reducing suicide. In fact, studies of suicide attempters and of inpatients who died by suicide have shown that a significant number had a suicide prevention contract in place at the time of their suicidal act (212, 218, 430). Consequently, although verbal and written suicide prevention contracts have each been proposed as aids to assessing the therapeutic alliance, their limitations should also be clearly understood (641). Relying on suicide prevention contracts may reflect the clinician's understandable but not necessarily effective attempt to control the inevitable anxiety associated with treating patients at suicide risk. At the same time, undue reliance on a patient's suicide prevention contract may falsely lower clinical vigilance without altering the patient's suicidal state.

Some clinicians gauge the patient's suicidal intent by his or her willingness to formalize the alliance by a written or an oral contract. For example, when discussing a suicide prevention contract, some patients will state openly that they cannot be sure that they can (or will want to) call the psychiatrist or other treatment team members if self-destructive impulses threaten. Patients who reject a suicide prevention contract are communicating that they see the therapeutic alliance as suboptimal or that they feel unable to adhere to such a contract. Consequently, patients who refuse to commit to contracts against suicide put the clinician on notice that the therapeutic alliance and the level of suicide risk should be reassessed. An alternative approach to suicide prevention contracts proposed by Miller et al. (642) relies on the basic tenets of informed consent and includes discussion of the risks and benefits of treatment and management options with the patient as a means of assessing his or her ability to develop and maintain a therapeutic alliance. In inpatient settings such discussions can emphasize the availability of the clinical staff and be used as a way to educate the patient about options for dealing with suicidal impulses.

Regardless of their potential advantages, suicide prevention contracts are only as reliable as the state of the therapeutic alliance. Thus, with a new patient, the psychiatrist may not have had sufficient time to make an adequate assessment or to evaluate the patient's capacity to form a therapeutic alliance, creating little or no basis for relying on a suicide prevention contract. As a result, the use of suicide prevention contracts in emergency settings or with newly admitted and unknown inpatients is not recommended. Furthermore, patients in crisis may not be able to adhere to a contract because of the severity of their illness. Suicide prevention contracts are also ill-advised with agitated, psychotic, or impulsive patients or when the patient is under the influence of an intoxicating substance. For these individuals, as for all patients presenting with suicidal behaviors, the psychiatrist must be ever mindful of the need for ongoing suicide assessments.

+

C. Communication With Significant Others

The confidential nature of the doctor-patient relationship is a fundamental aspect of the psychotherapeutic process. Consequently, the psychiatrist will need to manage the tension between this requirement and the wish to act in the patient's best interest. The default position is to maintain confidentiality unless the patient gives consent to a specific intervention or communication. However, in maintaining a safe environment for the patient, significant others may need to be contacted to furnish historical information or carry out specific tasks such as removing firearms from the home. If the psychiatrist determines that the patient is (or is likely to become) dangerous to him- or herself or to others and the patient will not consent to interventions that aim to reduce those risks, then the psychiatrist is justified in attenuating confidentiality to the extent needed to address the safety of the patient and others. More specifically, the 2001 edition of The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry states: "[P]sychiatrists 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 IV, Annotation 8) (643). As with many situations involving the suicidal patient, such decisions require much clinical judgment in weighing the effects of breaching confidentiality on the therapeutic relationship against the potential safety risks for the patient or others. It should also be noted that the psychiatrist can listen to information provided by friends or family without violating confidentiality by disclosing information about the patient to the informant. In addition, in an emergency situation, necessary information about the patient can be communicated with police and with emergency personnel, including medical staff and emergency medical technicians.

+

D. Management of Suicide in One's Practice

Because psychiatrists work with individuals who are by definition at increased risk for suicide, suicides can and do occur in clinical practice despite the best efforts at suicide assessment and treatment (489, 491). At least half of psychiatrists can expect in the course of their practice that one of their patients will die from suicide (644, 645). A patient's suicide is among the most difficult professional experiences encountered by a psychiatrist. It can lead to symptoms of posttraumatic stress disorder, shock, anger, grief, guilt, isolation, shame, diminished self-esteem, and concern about reactions of colleagues (646, 647). In one study (644), approximately half of the psychiatrists who had lost a patient to suicide experienced stress levels comparable with those of persons recovering from a parent's death. The significant effects of a patient's suicide on the psychiatrist, especially posttraumatic stress responses (644), suggest that support for the psychiatrist and a review of events leading to the suicide are warranted. Specific training may also be useful in helping the psychiatrist deal with the aftermath of a patient's suicide (644). In addition to receiving support from colleagues after a patient's suicide, some psychiatrists find it helpful to seek consultation or supervision to enable them to continue to respond effectively in working with other patients.

After a patient's suicide, clinicians may experience conflicting roles and concerns. However, a number of steps can be taken to facilitate the aftercare process. Many psychiatrists find it helpful to consult with a colleague or with an attorney. In addition, the psychiatrist should ensure that the patient's records are complete. 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.

Conversations with family members can be appropriate and can allay grief and assist devastated family members in obtaining help after a suicide. This recommendation is based primarily on humanitarian concerns for survivors, but this approach may also have a powerful, though incidental, risk management aspect. Nonetheless, attorneys advise clinicians in two very different ways on the issue of suicide aftercare. After a bad outcome, some attorneys recommend that the case be sealed and no communication be established with the family, except through the attorney. Other attorneys encourage judicious communication or consultation, if indicated. If this approach is taken, the psychiatrist should concentrate on addressing the feelings of the family members rather than specific details of the patient's care. In addition, in speaking with survivors, care must be exercised not to reveal confidential information about the patient and not to make self-incriminating or self-exonerating statements, since these statements may further distress the family and provide a spur to litigation. The individuals who lived with the patient before the suicide not only currently experience intense emotional pain but also shared it with the patient before death. Thus, a number of lawsuits are filed because of the clinician's refusal to express, in any way, feelings of condolence, sadness, sympathy, or regret for the patient's death. A number of states have statutes that prohibit statements, writings, or benevolent human expressions of sympathy such as condolences and regrets from being admissible as evidence of an admission of liability in a civil action (648). However, statutes often distinguish between the part of a statement that is an expression of sympathy and the part of a statement that expresses fault, e.g., in the case of an automobile accident, "I'm sorry you were hurt" (inadmissible as evidence of liability) versus "I was using my cell phone and just didn't see you coming" (admissible as evidence of liability). Consequently, it may be useful for psychiatrists to know whether an apology statute is applicable within their jurisdiction and, if so, to know the specific provisions of the statute. The individual psychiatrist must use his or her clinical judgment to decide whether attending the patient's funeral would be appropriate. It may also be helpful to include a risk manager in this decision process.

Many occasions arise in which information is requested after a patient's death. As a general rule, written authorization should be obtained from the executor or administrator of the deceased patient's estate before releasing a copy of the medical records. If the estate has been settled and an executor or administrator no longer exists, a copy of the medical records should be released only to properly appointed legal representatives (649).

+

E. Mental Health Interventions for Surviving Family and Friends After a Suicide

The survivors of suicide are more vulnerable to physical and psychological disorders and are at increased risk of suicide themselves (see Section II.E.6, "Family History"). Although there are relatively few systematic studies of adult bereavement after suicide, existing studies suggest that emotional, social, and physical conditions of survivors are significantly changed after the suicide of a relative. Within 6 months after a suicide, 45% of bereaved adults report mental deterioration, with physical deterioration in 20% (650). Symptoms of depression, posttraumatic stress, guilt, and shame as well as somatic complaints are prevalent during that period and are more severe among parents of deceased children (650–652). While the majority of bereaved adults within 6 months after a suicide acknowledge a need for intervention, only approximately 25% seek psychiatric treatment (650). Despite this low rate of treatment, the majority of bereaved adults adapt well in the long term (653, 654).

The most comprehensive data on bereavement after suicide exist for youths. These data indicate that within 6 months after the suicide of a friend or sibling, symptoms of major depressive and posttraumatic stress disorders are prevalent among bereaved youths (145, 651, 655). The long-term outcomes, up to 18 months, of adolescents whose friends had died by suicide suggest the incidence of major depressive disorder is higher in those who had depression before the friend's suicide, intermediate in those who developed depression immediately after the suicide, and lowest in those who were not depressed immediately after the suicide (656). Those who became depressed after the death were closer to the friend who died by suicide, showed more intense grief, and had more intense exposure to the suicide. Within 6 years of the suicide of a friend, adolescents with syndromal levels of traumatic grief were five times more likely to report suicidal ideation than those without traumatic grief (657). However, there was no greater incidence of suicide attempts among adolescents with a friend who had died by suicide than among adolescents who did not know someone who died by suicide. Adolescent siblings of youths who died by suicide had a sevenfold increased risk for developing major depressive disorder within 6 months (651). However, in a related 3-year follow-up of siblings of adolescents who died by suicide, the siblings suffered more significant grief than the friends of the adolescents who died by suicide, although the rates of psychiatric disorders in follow-up were similar to those for adolescents who did not have a friend or sibling who died by suicide (651).

These studies suggest an increased risk of psychiatric symptoms and impairment after the suicide of a relative. As a result, psychiatric intervention should be offered to family members shortly after the death and maintained to reduce risk for psychiatric impairment. Such intervention is particularly important for youths and for those who witnessed the suicide or were at the scene of the death. The goals of psychiatric intervention include the identification and treatment of major depressive and posttraumatic stress disorders as well as related symptoms (658, 659). Longer-term follow-up with evaluation and intervention for adolescents bereaved after the suicide of a relative or friend is also indicated to decrease the risk for recurrent depression and other morbidities (660). Furthermore, a family approach to evaluation and intervention is needed for those who are bereaved after an adolescent's suicide. Evaluation and treatment of grief may be similarly important in reducing risk for suicidal ideation among youths who are bereaved as a result of the suicide of a person who is emotionally important to them. For all family members and close friends of individuals who die by suicide, referral to a survivor support group can be helpful.

+

Part B: Background Information and Review of Available Evidence

+

VI. Review and Synthesis of Available Evidence

+

A. Factors Altering Risk of Suicide and Attempted Suicide

+
1. Demographic factors
+
a) Age

As shown in Table 10, suicide rates vary with age, gender, and race or ethnicity. Annual rates in the general U.S. population rise sharply in adolescence and young adulthood, plateau through midlife, then rise again in individuals over age 65. The increased rates of suicide in youths are even more dramatic in some ethnic and racial subgroups of the population. For example, the suicide rate among American Indian males between ages 15 and 34 years averaged about 36 per 100,000 during the period from 1979 to 1993, whereas Alaska Native males between ages 14 and 19 years had an even more dramatic rate, at 120 per 100,000 (661). Black male youths, who were historically at low risk for suicide, now have a suicide rate comparable to their white peers. Although the suicide rate in adolescents, like the overall U.S. suicide rate, has dropped in the past decade, the relative suicide risk of youths remains high, and this has been attributed to increases in alcohol and substance abuse (662), breakdown in extended family and intergenerational support, and increased availability of firearms, especially for young African American males (663).

+
Table Reference Number
Table 10. Suicide Rates in the United States by Age, Gender, and Race or Ethnicitya

Individuals over age 65 are disproportionately represented among those who die by suicide. Compared with suicide rates in men ages 55 to 64 years, suicide rates in men over age 85 are two- to threefold higher for all races except African Americans. For elderly women, suicide rates are relatively unchanged with increasing age, with the exception of Asian women over age 85, whose suicide rate increases threefold from middle age.

Overall suicide rates among those over age 65 have decreased substantially over the course of the last century, with a further decrease over the past decade. Although the reasons for the decline are unknown, a variety of mechanisms have been postulated, including improved access to social and health care resources by older adults with the implementation of Social Security and Medicare legislation and the more widespread use of safe and effective antidepressant medications (664). The incidence of suicide among elderly persons may increase again, however, as the large, post–World War II baby boom generation continues to age. Relative to age groups born in earlier or later periods, baby boomers have been distinguished by suicide rates that have been comparatively higher at all ages (665). Of additional concern is the fact that elders are the fastest growing segment of the U.S. population. Thus, as large numbers of this high-risk cohort enter the phase of life associated with greatest risk, the absolute number of suicides among older adults may increase dramatically (666).

Suicidal ideation and suicide attempts are more frequent in younger age groups than in later life (14). Kuo et al. (29), using prospectively gathered data from the Epidemiologic Catchment Area (ECA) survey, found a progressive decrease in the annual incidences of suicidal ideation and suicide attempts with increasing age. Compared with the rate in individuals over age 65, the rate of suicide attempts was 10-fold greater in those ages 18 to 29 years, at approximately 310 per 100,000 person-years. The rate of suicidal ideation in individuals ages 18 to 29 was approximately 630 per 100,000 person-years, a rate that was sixfold greater than that in those over age 65. Duberstein et al. (13), in a study of adults age 50 years and older, also found that people are less likely to report suicidal ideation as they age.

In other studies, estimates of the prevalence of suicidal ideation in older adults have varied with the population sampled and the site, time frame, and study methods. Lish and colleagues (667) found that 7.3% of an older sample in Department of Veterans Affairs (VA) primary care practices had thoughts of suicide, and elders with a history of mental health treatment were at far greater risk. Callahan and colleagues (668) used a far more stringent definition of suicidal ideation, limited ascertainment to within the past week, and required the ideation to include a specific suicide plan. They found that 0.7%–1.2% of elders in primary care had suicidal ideation, all of whom had a simultaneous mood disorder. Skoog et al. (669), in a survey of nondemented Swedes age 85 years and older, inquired about the presence of both active and passive suicidal ideation in the month preceding the interview. They found that 16% of the subjects had thoughts of suicide. Again, the rate was higher in subjects with mental disorder, in those taking anxiolytic and neuroleptic agents, and in those with significant physical illness. Among community-dwelling Floridians 60 years of age and older, less than 6% reported ever having had suicidal thoughts in a study by Schwab et al. (670), while in the Berlin Aging Study (671) 21% of subjects over age 70 reported having had suicidal ideation. Again, psychiatric illness was present in virtually all subjects, suggesting a need for careful screening for psychiatric disorder in elders with suicidal ideation.

+
b) Gender

In the United States, epidemiologic data show that suicide is more frequent in men than in women. For example, data from the National Center for Health Statistics for the year 2000 showed an age-adjusted suicide rate for males that was approximately 4.5-fold that for females (18.08 per 100,000 and 4.03 per 100,000, respectively) (11). This differential is comparable to the male-to-female ratio for suicide found in the National Longitudinal Mortality Study for the years 1979 to 1989 (672). Within the U.S. population, males are disproportionately represented among deaths by suicide in all racial and ethnic groups, with rates that range from more than 5.5-fold greater than that for females among African Americans and Hispanics to threefold greater than that for females among Asian/Pacific Islanders. This is not the case in other parts of the world, however. For example, in China the suicide rate for women is 25% higher than that for men (18).

The male-to-female predominance in suicide in the United States persists across the lifespan. Adolescent and young adult males are about 5.5 times more likely to die from suicide than females, whereas in midlife the male-to-female ratio is approximately 3.5 to 1. After about age 65, however, there is a steadily widening male-to-female ratio of suicide rates in all groups except Asians, with differences of more than 10-fold after age 80.

Differences in suicide risk with gender may be explained in part by factors that contribute to risk in general but that are present to differing degrees in men and in women. For example, men are less likely than women to seek help, admit the severity of their symptoms, or accept treatment, increasing their likelihood of suicide. In contrast, women tend to be less impulsive, have more social support, and have lower rates of comorbid alcohol and substance use disorders, all of which may have a protective effect (21). Among African American women, the potential protective factors of religion and extended kin networks have been suggested as possible explanations for this group's very low rate of suicide (22).

Despite their lower rate of suicide, women have higher rates of depressive illness than men (23, 673). Furthermore, in a 10-year follow-up study using data from the National Longitudinal Mortality Study, unemployment was associated with a greater and longer-lasting effect on the suicide rate of women compared to men (24). Compared to men, women also have an increased likelihood of having been physically or sexually abused, which may also increase the risk for suicide (36). The relative lethality of the suicide methods chosen by women remains less than those chosen by men; however, the recent, more frequent use of firearms among women suggests that this distinction may be diminishing (11, 674).

Suicide rates have also been examined in pregnant women and during the postpartum period. Dannenberg et al. (675) reviewed New York City medical examiner records of 293 pregnant or recently pregnant women ages 15 to 44 years who died of injury during a 4-year period. Of these, 15 died by suicide, a rate that was not significantly different from the expected age- and race-specific rates in the general population. However, Marzuk et al. (676) analyzed autopsy data from female residents of New York City who were of childbearing age and found the standardized mortality rate for suicide during pregnancy to be one-third the expected rate. Appleby (677), using retrospective population data for England and Wales from 1973 to 1984, also noted decreased rates of suicide among pregnant women and among women during the first year after childbirth, with SMRs of 0.05 and 0.17, respectively. In contrast to decreased suicide rates for women in general during pregnancy and the puerperium, Appleby et al. (27) subsequently found an extremely high suicide rate among women who had been psychiatrically hospitalized during the postpartum period. In this study of 1,567 women admitted to Danish psychiatric hospitals within the first year after childbirth, the SMR for suicide within 1 year was more than 70 times the expected rate. Although risk was greatest within the first month postpartum, it persisted throughout the initial year after childbirth. In addition, women who died by suicide after childbirth often used violent methods. Thus, although evidence is limited, women with severe postpartum psychiatric disturbances appear to be at significantly increased risk during the initial year after childbirth. Other groups with a particularly increased postpartum risk include teenagers and women of lower socioeconomic status (27, 28). For women as a group, however, a protective effect seems to be present during pregnancy and the postpartum period (25).

In terms of suicide attempts, women in the United States are reported to attempt suicide three times as often as men. This female predominance of suicide attempters varies with age, however, and in older adults the ratio of female-to-male suicide attempters approaches 1:1 (11). Similar trends are observed in the incidence of suicidal ideation. For example, Kuo et al. (29), using data from 3,481 prospectively followed individuals from the Baltimore ECA study, found that females ages 18 to 29 years had a higher incidence of suicidal ideation and suicide attempts than their male peers. However, this female-to-male predominance in suicidal ideation and suicide attempts was not observed for older age groups or for the sample as a whole.

As noted earlier, women are more likely to have experienced domestic violence or physical or sexual abuse, all of which have been associated with higher rates of suicidal ideation and suicide attempts (32–34). In a study of psychosocial outcomes in 1,991 same-sex twin pairs, Nelson et al. (35) found that childhood sexual abuse was three times more common in women and was associated with an increased risk of attempting suicide. Borderline personality disorder is also present more often in women (515) and is itself associated with increased rates of suicidal ideation, suicide, suicide attempts, and other self-injurious behaviors. In addition, borderline personality disorder is particularly common in women who have experienced childhood sexual abuse, physical abuse, or both (31). As a result, physical and sexual abuse and domestic violence should be given particular consideration in the assessment and treatment of women with suicidal ideation, suicide attempts, and other self-injurious behaviors.

+
c) Race, ethnicity, and culture

Race, ethnicity, and culture are all associated with variations in rates of suicide. In the United States for the year 2000, the overall age-adjusted rates of suicide were highest in Native Americans and non-Hispanic whites, at 13.6 and 12.1 per 100,000, respectively (11). In contrast, the age-adjusted rate of suicide in Hispanics was substantially less, at 6.13 per 100,000, and was similar to the rates for non-Hispanic African Americans and Asian/Pacific Islanders, at 5.8 and 6.0 per 100,000, respectively.

For immigrant groups, suicide rates in general tend to mirror rates in the countries of origin, with trends converging toward the host country over time (40, 41). In a large epidemiological study, Singh and Siahpush (39) found that between 1979 and 1989, foreign-born men in the United States were 52% less likely to die by suicide than native-born men, but the difference narrowed in the older age cohorts. Data for immigrant women were not statistically significant because of the small number of deaths.

In the United States, racial and ethnic differences are also seen in the rates of suicide across the lifespan (Table 10). Among European-American non-Hispanic whites, Hispanics, and Asian/Pacific Islanders, the highest suicide rates occur during the senior years, in those over age 65. In contrast, among Native Americans and African Americans, the highest suicide rates occur during adolescence and young adulthood. For example, in Native American and African American males ages 15 to 24, suicide rates in the year 2000 were 36.81 and 14.66 per 100,000, respectively. Young African American men have been described as being caught in a cycle of drug abuse, criminal activity, and self-devaluation and may view an early death as inevitable or as an alternative to the wearying struggle that life has become (678). Additional risk factors for suicide in young African American males include substance abuse (662, 679), presence of a firearm (663), and in particular the combination of cocaine abuse and the presence of a firearm (679). Suicidal ideation and suicide attempts are also common in urban African American young adults, with 6-month prevalences of 1.9% and 0.4%, respectively (680).

In contrast to young African American males, African American women have a very low rate of suicide. Gibbs (22) attributes this low rate 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. Women-dominated kinship networks are also believed to be protective, providing flexible roles, resource sharing, and social support (681).

Although black women are less likely to die from suicide than white women, they attempt suicide and express negative emotional states such as hopelessness and depression just as frequently. In addition, both black men and black women are less likely than their white counterparts to pursue professional counseling in the face of depression or other mental illness. Instead, African Americans are more likely to view depression as a "personal weakness" that can be successfully treated with prayer and faith alone some or almost all of the time (682). When depression is discussed, it may be described in different terms such as having "the blues" or "the aching misery" or "being down" (678). Consequently, sensitivity to language and beliefs about illness are important in recognizing depression and other risk factors for suicide among African Americans.

Among Native Americans (American Indians and Alaska Natives), suicide also is predominately an epidemic of the young and is the second leading cause of death for Native Americans between ages 15 and 24 years. As with other racial and ethnic groups, Native American and Alaska Natives are a very heterogeneous population, with different tribal identities, varying degrees of urbanization, different levels of tribal organization, and diverse approaches to historical and cultural integration. For example, in a study of three groups of Native Americans in New Mexico, the Apache had the highest suicide rate (43.3 per 100,000) and the highest degree of acculturation but also had the lowest degree of social integration and generally viewed religion as unimportant (683). In contrast, the Navajo had the lowest suicide rate (12.0 per 100,000) and the lowest level of acculturation but had moderate social integration and were organized into bands with a strong matrilineal clan influence. In the third group, the Pueblo, the subgroup with the most acculturation, had a higher suicide rate than the most traditional subgroup, again suggesting an effect of acculturation on suicide risk. Acculturation has also been proposed as a contributor to the extremely high suicide rate in Alaska Native youths, which in one study approached 120 per 100,000 (661). Theories to explain these high rates tend to rely on family disintegration, social disruption, and alcohol use (684), as well as rapid social and cultural changes associated with intensive energy development projects in the Arctic and the resulting stress of acculturation. In contrast, in Hawaiian youths, the relationship between acculturation and suicidal behavior is less clear, with increased numbers of suicide attempts in those with stronger Hawaiian cultural affiliation (685).

Research on suicide among Hispanics in the United States is limited and rarely differentiates among different Hispanic groups. In addition, many individuals of Hispanic origin are undocumented workers who are not represented in census data or epidemiological studies. Large-scale grouping of diverse ethnic groups also obscures intracultural variations in important social and economic categories. For example, Cuban American women and Mexican Americans and Puerto Ricans of both genders were reported to have lower than expected suicide rates, relative to 1-year prevalence of major depression, than were whites, blacks, and Cuban American males (23). In terms of suicidal ideation, higher levels have been reported in Central American immigrants experiencing heightened levels of acculturative stress (43). In addition, lifetime age- and gender-adjusted rates of suicidal ideation were significantly lower for Mexican Americans born in Mexico (4.5%) than for Mexican Americans born in the United States (13%) or for non-Latino whites (19.2%) (686). Similarly, rates of suicide attempt were lower 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%). The rate of suicide attempt is also elevated among Hispanic youths, who had higher numbers of reported suicide attempts compared to non-Hispanic youths in a nationwide survey of high school students (687).

The suicide rate for Asians overall is the lowest of all of the major American ethnic groups, but Asian Americans themselves have diverse ethnic backgrounds, languages, and cultures. Some groups, such as the Japanese, have been in the United States for generations. Others, such as the Chinese, include both recent immigrants and descendants of 19th-century immigrants, whereas the Vietnamese have arrived in large numbers only since the 1960s. These individuals bring with them attitudes toward coping and suicide from their home countries, which can influence the circumstances of suicidal behavior (688). In Japan, for example, suicide is permissible or even appropriate in particular contexts, and ritual suicide has been an honorable solution to certain social dilemmas. For example, the disgrace of bankruptcy in Japan can shame the family for generations, making suicide a preferable way to resolve debt. When it is culturally important for a man to be physically healthy and able to support his family, suicide may be viewed as an option if a serious physical illness impairs his ability to function. For example, in Hawaii, 20.5% of suicides by Japanese American men occurred in individuals with health problems, in contrast to only 11.8% of suicides by Caucasian men and 3.0% by Hawaiian men (42). In addition, for individuals who come from a culture in which mental illness is highly stigmatized, receipt of a psychiatric diagnosis may increase the risk for suicide. Although Chinese societies have not generally codified suicide as socially acceptable, more recent suicide rates in China are quite high, particularly in women and in rural settings, where use of agricultural poisons is a common suicide method (18).

In the United States, acculturation and acculturative stress may be a contributor to suicide risk among Asian Americans. For most Asian Americans, the family unit is central to identity. Children are socialized into awareness that their individual actions reflect upon the entire family, including extended family members (689). While this feature may impede a family's willingness to seek treatment for a troubled relative, the strong sense of family as a support and source of obligation protects against suicide as well. At the same time, family conflict as a reason for suicide is more common in Eastern societies (42). For example, if a young woman from a traditional society experiences conflicts with her in-laws that have no apparent solution, the woman may be more likely to view suicide as an option than would someone from a different family system in which close family relationships are not as imperative. Transition to the individualistic, communication-oriented U.S. society is a major and stressful change for many families (44). The group most at risk appears to be 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 elders and contributes to suicide in the style of the old country (44). For example, a major factor in the high suicide rate of elderly Asian/Pacific Islander women was reported to be the failure of younger family members to provide support for their elderly parents, especially widowed mothers (690). Such deaths occurred predominantly by hanging, which was traditionally seen as an act of revenge, since someone who died by hanging was believed to return to haunt the living as a ghost (690).

In summary, race, ethnicity, and culture may all influence population-based rates of suicide and suicide attempts. Of equal importance to the clinician, however, each of these factors may modify suicide risk within the individual. Views of death and cultural beliefs regarding suicide can vary widely, even among members of apparently homogeneous racial, ethnic, or cultural groups. Thus, as part of the assessment and treatment planning process, it can be helpful for the psychiatrist to explore the patient's beliefs about death and suicide and the role of cultural and family dynamics in these beliefs.

+
d) Marital status

Marital status has been correlated with variations in suicide mortality in a number of studies. Smith et al. (691) used data from the U.S. National Center for Health Statistics for the years 1979 to 1981 to calculate age-adjusted suicide rates for each marital status. Regardless of age or racial group, the suicide rate was consistently lowest in married individuals. An intermediate rate was seen in those who had never been married, with a relative risk that was about twice that in married individuals. The highest suicide rate was found for divorced or widowed individuals, with a relative risk that was about threefold greater than that in married individuals. Whereas divorced women had a higher age-adjusted suicide rate than widowed women, the opposite was true among men, with a particularly striking rate of suicide in young widowed men.

Kposowa (672) applied Cox proportional hazards regression models to data from the 1979–1989 follow-up of the National Longitudinal Mortality Study and made adjustments for age, sex, race, education, family income, and region of residence to estimate the effect of marital status on suicide risk. Although in this sample being single or widowed had no significant effect on suicide risk, divorced and separated persons had suicide rates that were more than twice that of married persons. Stratification of the sample by sex showed that the effect of marital status on suicide rates occurred only among men.

Luoma and Pearson (46) also examined whether marital status is associated with variations in suicide rates. Suicide rates broken down by race, 5-year age groups, sex, and marital status were calculated by using data compiled from the U.S. National Center for Health Statistics Multiple-Cause-of-Death Files for the years 1991 to 1996. Widowed white and African American men under age 50 were found to have substantial elevations in suicide rates, with 17-fold and ninefold higher rates, respectively, compared with married men under age 50. At younger ages, for women as well as for men, being widowed was associated with a higher suicide rate, compared with being married.

Using data from the National Suicide Prevention Project in Finland, Heikkinen et al. (402) investigated age-related variations in marital status as well as other social factors in a sample of 1,067 individuals who died by suicide during a 1-year period and for whom relevant data were available. Compared with the general population, individuals who died by suicide were more commonly divorced, widowed, or never married. Among individuals under age 50 who died by suicide, more males than females had never been married. Among those over age 50, more women than men were widowed.

Other data from Finland obtained through the Finnish Population Register and cause-of-death files also suggest that the rate of suicide is elevated among widowed individuals (45). Among 95,647 persons who were widowed during 1972–1976 and followed up to the end of 1976, 7,635 deaths were observed, of which 144 were due to suicide. During the initial month of bereavement, men had a much greater increase in suicide mortality than women (17.2-fold versus 4.5-fold), but this disproportionate ratio primarily resulted from occurrences of homicide-suicide. In the remaining first year of bereavement, men had a 3.1-fold increase in suicide mortality and women a 2.2-fold increase, and rates remained higher than expected throughout the follow-up period.

Overall, these studies suggest that married individuals have a significantly lower rate of suicide than unmarried individuals. In addition, elevations in the suicide rate are especially striking for widowed men in general and young widowed men in particular. What remains unclear is whether this protective effect of marriage on the suicide rate relates to specific benefits of marriage, such as a greater likelihood of social integration. In contrast, the decrease in social integration and the psychological experience of loss with widowhood and with divorce may increase the tendency for suicide. The suicide rate among divorced individuals could also be higher because individuals who stay married have a greater likelihood of stable mental health at baseline. Other confounding factors, such as differences in substance use or socioeconomic status with marital status, could play additional roles that should be considered in the assessment process.

+
e) Sexual orientation

It remains unclear whether suicide rates in gay, lesbian, and bisexual individuals differ from the suicide rate among heterosexual individuals. One psychological autopsy study compared gay males to all other similarly aged males in the sample and did not find any characteristics that distinguished the two groups (692). However, research on suicide among gay, lesbian, and bisexual individuals is particularly complex because of many factors, including small sample sizes, difficulties in achieving random sampling, problems in obtaining baseline prevalences, and problems in reliability of postmortem reports of sexual orientation. In addition, individuals may choose not to disclose their sexual orientation to researchers or may engage in same-sex behavior but not identify themselves as gay or lesbian.

The risks for suicide attempts and suicidal ideation in gay, lesbian, and bisexual individuals have been assessed by using several approaches. Fergusson et al. (51), analyzing longitudinal data gathered on a New Zealand birth cohort, found that those who identified themselves as gay, lesbian, and bisexual or reported having a same-sex partner since the age of 16 had elevated rates of suicidal ideation (odds ratio=5.4) and suicide attempts (odds ratio=6.2). A study by Cochran and Mays (50) examined lifetime prevalences of suicide-related symptoms among men with same-gender partners and found that approximately one-half (53.2%) of the men reported experiencing at least one suicide-related symptom in their lifetime, with a suicide attempt reported by 19.3%. In contrast, in men with female partners only, 33.2% had at least one suicide-related symptom and 3.6% reported a suicide attempt. Corresponding figures for those with no sexual partners were 28.1% and 0.5%, respectively. Using the population-based Vietnam Era Twin Registry, Herrell et al. (52) identified a subsample of 103 middle-aged male twin pairs in which one of the twins from each pair reported having a male sexual partner after age 18 while the other did not. Suicide attempts were more common in the men with same-gender sexual orientation, with 15% reporting a suicide attempt, compared with only 4% of their twin brothers. In the Twin Registry sample as a whole, which included 16 twin pairs concordant for having a male sexual partner after age 18 and 6,434 twin pairs concordant for having no adult same-gender partners, the men with same-gender sexual orientation had more than a fourfold increase in suicidal ideation and more than a 6.5-fold increase in suicide attempts.

Gay, lesbian, and bisexual youths may be at particular risk for suicidal behaviors. Paul et al. (53), in a study of a large urban population–based telephone probability sample of gay men, found that 21% had made a suicide plan and 12% had attempted suicide. Of the latter, almost one-half had made multiple attempts, and most had made their first attempt before age 25. The importance of sexual orientation to suicidal behaviors in youths is also highlighted by the findings of a statewide population-based study of public high school students by Remafedi et al. (48). In this study, suicide attempts were reported by 28.1% of bisexual/homosexual males, 20.5% of bisexual/homosexual females, 14.5% of heterosexual females, and 4.2% of heterosexual males. For males, but not for females, a bisexual/homosexual orientation was associated with suicidal intent (odds ratio=3.61) and with suicide attempts (odds ratio=7.10).

Thus, although evidence is limited, there is clearly an elevated risk for suicide attempts among cohorts of gay, lesbian, and bisexual individuals that is particularly striking among youths. In addition to addressing risk factors such as psychiatric and substance use disorders in the assessment and treatment planning processes, it is also important for the clinician to address stresses that are unique to being gay, lesbian, or bisexual (e.g., disclosure of sexual orientation to friends and family, homophobia, harassment, and gender nonconformity). Since suicide attempts themselves increase the risk for later suicide, it is presumed that suicide rates may also be increased in gay, lesbian, and bisexual individuals. However, this hypothesis remains to be tested empirically.

+
f) Occupation

Occupational groups differ in a number of factors contributing to suicide risk. These factors include demographics (e.g., race, gender, socioeconomic class, and marital status), occupational stress, psychiatric morbidity, and occupationally associated opportunities for suicide. Although many studies have reported increased rates of suicide in specific occupational groups, most have not controlled for other suicide risk factors. In one study, however, that controlled for basic demographic correlates of suicide across 32 occupations (54), risk was found to be highest among dentists and physicians, compared with the rest of the working-age population, with multivariate logistic regression odds ratios of 5.43 and 2.31, respectively. The odds of suicide were also significantly higher in nurses (1.58 times the risk), social workers (1.52 times the risk), mathematicians and scientists (1.47 times the risk), and artists (1.30 times the risk). Rates of suicide among physicians have also been found to be elevated, compared with rates for other white male professionals, with white male physicians having a 70% greater proportionate mortality ratio for suicide (58). In well-designed epidemiological studies, police officers have generally not been found to be at higher risk for suicide than age- and sex-matched comparison subjects (54, 57).

Factors that may play a role in the increased suicide rates in specific professions may include occupational stresses, as is seen in helping professionals (54), or social isolation, as is seen in sheepherders, who had the highest suicide rate of 22 occupational groups studied in Washington State (56). Although data are inconsistent, additional work stress may occur with infrequent role sets such as female laborers or pilots (55, 57) or in nontraditional occupations (693). In some occupations, suicide rates may be influenced by greater access to lethal methods such as medications or chemicals, as in health care professionals, scientists, and agricultural workers (57).

Differential rates of psychiatric illness may be present in some occupations and may predate employment. Artists, for example, have higher rates of psychiatric morbidity and suicide than the general population. Highly educated people with depressive disorders also have a higher suicide rate. Among physicians, such individuals may tend to specialize in psychiatry (56).

In general, specific occupations do seem to be associated with an increased risk for suicide, but more research is needed to distinguish occupational from nonoccupational stressors (56) and to determine whether it is the occupation itself or associated factors such as psychiatric morbidity that affect suicide risk.

+
2. Major psychiatric syndromes
+
a) Mood disorders

Major depressive disorder and other depressive syndromes are the most commonly and most consistently identified axis I diagnoses in individuals who die by suicide (694, 695). For example, Robins et al. (60) found that among 134 persons who died by suicide, 98% were psychiatrically ill and most had depression or chronic alcoholism. Barraclough et al. (65), in a similar study, found that of 100 individuals who died by suicide, 93% were mentally ill and 85% had either depression or alcoholism. Henriksson et al. (59), using psychological autopsy methods to investigate current mental disorders among a random sample of 229 persons who died by suicide during a 1-year period in Finland, found that 93% of those persons had received at least one axis I diagnosis and that 59% had a depressive disorder.

In patients with bipolar disorder who die by suicide, the majority are experiencing either a depressive or mixed episode of illness (69, 72, 315). For example, Isometsa et al. (68) noted that among 31 patients with bipolar disorder identified in a group of 1,397 persons who died by suicide in Finland in a 12-month period, 79% died while in a major depressive episode and 11% while in a mixed state. In a study of more than 300 patients who were discontinued from lithium treatment, Baldessarini et al. (696) found that the majority of suicidal acts occurred either during a major depressive episode (73%) or during a dysphoric-mixed episode (16%).

In addition to being highly prevalent in individuals who die from suicide, mood disorders have long been associated with an increased risk for suicide. For example, in 1970, Guze and Robins (697) reviewed 17 studies that assessed the risk of suicide in individuals with primary affective disorders and calculated the frequency of suicide as a percentage of all deaths. High suicide rates were found, with the ultimate risk of suicide estimated to be about 15%, or approximately 30 times that seen in the general population. For major depression, review of the literature suggests that overall rates of suicide mortality range from 5% to 26% and are about twice as high for men as for women (694). However, these studies generally assessed severely ill patient populations and individuals early in the course of their illness, when suicide rates are known to be highest.

Several investigators have subsequently reexamined these estimates of lifetime suicide risk in individuals with mood disorders. For example, Inskip et al. (94), using cohort-based curve-fitting techniques and data from previous studies, estimated the lifetime risk for suicide in mood disorders to be 6%. In addition, Bostwick and Pankratz (77) used data from prior studies to calculate case fatality prevalences (the ratio of suicides to the total number of subjects) to determine suicide risks for three groups of patients with affective disorders—outpatients, inpatients, and suicidal inpatients. With this method, which provides a less biased estimate of risk, they found a gradation in suicide risk that varied with treatment setting as well as with hospitalization for suicidality. For example, in patients with mood disorders who were previously hospitalized for suicidality, the estimated lifetime prevalence of suicide was 8.6%, compared to a lifetime risk of 4% for those with a psychiatric hospitalization for any reason. For mixed inpatient/outpatient populations, the prevalence of suicide was 2.2%, whereas for the populations without affective illness, it was less than 0.5%. For individuals with major depressive disorder, Blair-West et al. (205) used age- and gender-stratified calculations to arrive at comparable estimates for lifetime suicide risk of 3.4%, with a lifetime risk for males more than six times than for females (6.8% versus 1.1%).

Harris and Barraclough (64), in their meta-analysis of suicide as an outcome in psychiatric illness, assessed relative suicide risk in mood disorder by calculating SMRs. Their analysis used data from published English-language studies that had mean or median follow-up periods of at least 2 years and that provided sufficient data to calculate ratios of observed to expected numbers of suicides. For patients with major depressive disorder, 23 studies that included a total of 351 suicides among more than 8,000 patients yielded an SMR of 20.35, or a 20-fold increase in risk. A key finding was that risk in patients with major depressive disorder was highest immediately after hospital discharge (698, 699). For patients with bipolar disorder, data from 15 studies including a total of 93 suicides among 3,700 subjects yielded an SMR for suicide of 15.05. Although patients with dysthymia also had an elevated SMR for suicide, of 12.12, the nine studies that contributed to this estimate were extremely heterogeneous in their findings and most had extremely small samples, which raises some question about the validity of this approximation.

Several studies have examined rates of suicide in longitudinal follow-up in individuals hospitalized for mood disorder. Hoyer et al. (75) used data from the Danish Psychiatric Case Register to determine SMRs for suicide among 54,103 patients (19,638 male and 34,465 female patients) who had an initial admission to a Danish psychiatric hospital between 1973 and 1993 and who received a mood disorder diagnosis. During the study period, 29% of the patients died, and of those, suicide occurred in 20%. Standardized mortalities for suicide were comparable for patients with ICD-8 diagnoses of unipolar major depression, psychotic reactive depression, and bipolar disorder, with SMRs of 19.33, 18.67, and 18.09, respectively. In contrast, the SMR for suicide in patients with neurotic depression was significantly less, at 10.51. In all diagnostic subgroups and regardless of age and gender, the risk of suicide was greatest during the first year after the initial admission, decreased over the subsequent 5 years, and then stabilized. Overall, the risk for suicide was comparable in men and women, except in patients with bipolar disorder, for whom the SMR for suicide was somewhat greater in women than in men (20.31 versus 18.09).

In a similarly designed study using data from a Swedish inpatient register, Osby et al. (73) obtained the date and cause of death for patients hospitalized between 1973 and 1995 with a diagnosis of bipolar disorder (N=15,386) or unipolar depressive disorder (N= 39,182). SMRs for suicide were found to be significantly increased in women and in patients with a unipolar depressive disorder diagnosis (15.0 for male bipolar disorder patients, 20.9 for male unipolar depressive disorder patients, 22.4 for female bipolar disorder patients, and 27.0 for female unipolar depressive disorder patients). Suicide mortality was more pronounced in younger individuals and with shorter intervals from the index hospitalization. Although SMRs decreased in all age groups with increasing time of follow-up, some suicide risk persisted even at long follow-up intervals.

Baxter and Appleby (188) used the Salford (U.K.) Psychiatric Case Register to identify 7,921 individuals who had received psychiatric or mental health care and determined their mortality rates (estimated as rate ratios) over a follow-up period of up to 18 years. Among individuals with affective disorders, there was a 12.2-fold elevation in observed suicide mortality in men, compared to expected mortality based on population rates. For women, the relative increase in suicide mortality was even greater, with a 16.3-fold elevation.

Angst et al. (74) followed a sample of 406 hospitalized patients with mood disorders (220 with bipolar disorder and 186 with unipolar depressive disorder) on a prospective basis for 22 years or more and found an overall standardized mortality rate for suicide of 18.04, comparable to the SMRs found in the Swedish and Danish longitudinal follow-up studies. Sixty-one percent of the sample had manifested psychotic symptoms at least once over their lifetime, suggesting that this was a particularly ill group of patients. The suicide rate was greatest near the age of illness onset; however, from ages 30 to 70 years, the rate was remarkably constant, suggesting a persistence of risk throughout the illness course. The suicide mortality in women was greater than that in men (SMR of 21.87 for women, compared to 13.49 for men), in part reflecting the greater rate of suicide for men in the general population. Patients with unipolar depressive disorder had a significantly higher rate of suicide than patients with bipolar I disorder or bipolar II disorder, with an SMR for suicide of 26.7, compared with 12.3 for bipolar disorder patients. The SMR for suicide did not differ significantly between bipolar I disorder patients and bipolar II disorder patients.

Some evidence suggests that in individuals with mood disorders, the rate of suicide may be increasing over time. For example, Harris and Barraclough (64) noted that the suicide risk for patients with major depression in cohorts treated before 1970 was increased by 17-fold in contrast to a 36-fold increase in risk for cohorts treated after 1970. In the study described earlier, Hoyer et al. (75) noted an increase in both the absolute and relative risks for suicide over the 20-year study time period, and they suggested that the increase may have been related to changes in the health care delivery system and the availability of psychiatric inpatient services. In addition, Baldessarini et al. (563) observed that the annualized rates of suicide and suicide attempts in patients with major affective disorders appear to have risen across the decades since 1970. This trend was sustained and statistically significant for both suicides and suicide attempts, as well as for treated and untreated samples considered separately. Although this apparent secular trend could reflect increased recruitment of more severely ill patients to more recent studies or increased reporting of suicidal behaviors, the percentage reduction of suicide risk with lithium treatment did not decline across the years, suggesting that the patient populations are in fact comparable and that the prevention of suicide in major affective disorders is becoming increasingly challenging (558). Furthermore, suicide attempts that do occur in individuals with major mood disorders may be more lethal than suicide attempts by individuals in the general population. The reported ratio of suicide attempts to deaths from suicide averages between 3:1 and 5:1 among persons with mood disorders, whereas in the general population the suicide attempt rate has been estimated to be about 10–20 times (average, 18 times) greater than the suicide rate, or about 0.3% per year (700).

For individuals with mood disorders, it is also important to note factors that are particularly associated with increased risk. Fawcett et al. (79, 313) determined time-related predictors of suicide in a sample of 954 psychiatric inpatients in the NIMH Collaborative Program on the Psychobiology of Depression, about one-third of whom had bipolar disorder and the rest of whom had other mood disorders. During the initial 10 years of follow-up, 34 patients died by suicide, an overall rate that was extremely low, at 0.36% per year. The first year of follow-up was the time of highest risk, with 38% of suicides occurring during that period. Within 1 year of admission, six factors were associated with suicide: panic attacks, severe psychic anxiety, diminished concentration, global insomnia, moderate alcohol abuse, and anhedonia. The three factors associated with suicide that occurred after 1 year were severe hopelessness, suicidal ideation, and history of previous suicide attempts. By 14 years, among individuals for whom follow-up information was available, 36 had died by suicide, 120 had attempted suicide, and 373 had no recorded suicide attempt (247). Analysis at that time point showed that patients who died by suicide and patients with suicide attempts shared core characteristics, including a history of previous suicide attempts, alcohol and substance abuse, impulsivity, and psychic turmoil within a cycling/mixed bipolar disorder. In contrast to suicide within 12 months of intake, which was predicted by clinical variables, suicide beyond 12 months was prospectively predicted by temperament attributes, such as higher levels of impulsivity and assertiveness. Stressful life events (701), executive dysfunction (702), and higher levels of depression (10, 78, 221, 222, 703) may also be associated with greater risk, as may an awareness of the discrepancies between a previously envisioned "normal" future and the patient's likely degree of future chronic disability (273).

In summary, mood disorders are consistently identified as conferring a significant increase in the risk for suicide as well as for suicide attempts. However, among individuals with mood disorders, a variety of factors commonly modify that risk and should be taken into consideration during the assessment and treatment planning processes. These factors include the specific mood disorder diagnosis and duration of illness, the type and severity of the mood episode, the prior history of treatment, the presence of comorbid diagnoses or specific psychiatric symptoms such as severe anxiety or agitation, and the occurrence of significant psychosocial stressors. It is important to note, however, that this increased risk of suicidal behaviors among individuals with mood disorders has been consistently shown to be modifiable with treatment (see Section VI.D, "Somatic Therapies").

+
b) Schizophrenia

Schizophrenia has also been associated with an increase risk of suicide in multiple studies. Harris and Barraclough (172), for example, analyzed data from 38 studies that had follow-up periods of up to 60 years. Acknowledging that some heterogeneity in the diagnosis of schizophrenia across studies was likely as a result of changes in diagnostic criteria, the authors noted 1,176 suicides among more than 30,000 patients with schizophrenia, yielding an SMR for suicide in schizophrenia of 8.45. Baxter and Appleby (188), in a case registry study of long-term suicide risk in the United Kingdom, found an even higher 14-fold increase in rate ratios for suicide among individuals with schizophrenia. In contrast, using cohort-based curve-fitting techniques and data from 29 studies of mortality in schizophrenia, Inskip et al. (94) estimated the lifetime risk for suicide as 4%.

In addition to assessing suicide rates among patients with schizophrenia, longitudinal follow-up studies have also examined factors associated with increased risk of suicide. Black et al. (98) found that suicide occurred in 14 of 688 schizophrenia patients (2%) who were admitted to an Iowa psychiatric hospital over a 10-year period, with the majority of deaths occurring within 2 years of hospital discharge. Although women were found to be at relatively greater risk, the numbers of suicides significantly exceeded expected rates for both male and female patients. Nyman and Jonsson (101) found that suicide occurred in 10 of 110 (9%) young patients with schizophrenia who were hospitalized between 1964 and 1967 and followed for up to 17 years. In this group, suicide was associated with a more chronic course as well as with social and financial dependency. Dingman and McGlashan (103) longitudinally followed 163 Chestnut Lodge patients with a diagnosis of schizophrenia and noted that the 13 patients who died by suicide were predominantly male and had a later onset of illness, less chronic illness, better premorbid functioning, and a greater ability for abstract and conceptual thinking. At a later follow-up (mean=19 years), 6.4% of the Chestnut Lodge sample had died by suicide, and this group had exhibited fewer negative symptoms but more severe delusions and suspiciousness at index admission than those who did not die by suicide (93). A group of young psychotic patients who had not exhibited a chronic course was followed after discharge from an index hospitalization by Westermeyer et al. (83), who found that 36 patients died by suicide and 550 did not. Suicide occurred in about 9% of individuals with schizophrenia and was more likely during the early years of their illness, particularly within 6 years of initial hospitalization. At greater risk for suicide were unmarried white male patients with chronic symptoms, relatively high IQs, and a gradual onset of illness.

De Hert et al. (89) studied outcomes for 870 patients (536 men and 334 women) with schizophrenia (87%) or schizoaffective disorder (13%) after a mean duration of follow-up of 11.4 years. Sixty-three individuals died by suicide, yielding a suicide rate of 635 per 100,000 per year and an SMR for suicide of 39.7. The frequency of suicide in men was twice that in women, although the SMR and the age at the time of suicide did not differ significantly between the sexes. Of the suicides, 33 (52.4%) occurred while the patient was hospitalized (although only nine actually took place in the hospital) and 12 (19.1%) occurred during the first 6 months after discharge. When the patients who died by suicide were compared with an age- and sex-matched group of 63 patients from the remaining sample, a number of differences between the groups were observed. Those who died by suicide were more likely to have a family history of suicide, had had more and shorter hospitalizations and more past suicide attempts, and were more likely to have used a highly lethal method in prior suicide attempts. They also had higher total WAIS IQ scores and were more likely to have been psychotic or depressed or to have suffered a major loss in the 6 months before death or follow-up. Compared with control subjects, the patients who died by suicide were also less likely to have received community-based care and were less likely to have had a useful daily activity, remission of symptoms, or an early onset of prominent negative symptoms.

Among individuals with schizophrenia who die by suicide, a number of demographic factors seem to be present more often than in living control subjects. In a cohort of 9,156 patients with schizophrenia, Rossau and Mortensen (95) individually matched 10 control subjects to each of 508 individuals who were admitted to Danish hospitals between 1970 and 1987 and who later died by suicide. They found suicide risk to be particularly high during the first 5 days after discharge, with some excess suicides during temporary hospital leaves. Increases in risk were also associated with multiple psychiatric admissions during the previous year, previous suicide attempts, previous diagnosis of depression, male sex, and previous admissions to general hospitals for physical disorders. Breier and Astrachan (102) compared 20 schizophrenia patients who died by suicide with a randomly selected sex-matched group of nonsuicidal schizophrenia patients and a group of persons without schizophrenia who died by suicide. Patients with schizophrenia who died by suicide were more likely to be men and tended to be young, white, and never married. In contrast to the persons without schizophrenia who died by suicide, the schizophrenia patients who died by suicide tended not to show a temporal relationship of suicide with suicide attempts or stressful life events.

Among individuals who died by suicide, comparisons have also been made between those with schizophrenia and those with other diagnoses. Heila et al. (100) used psychological autopsy data for 1,397 individuals who died by suicide over a 1-year period in Finland and compared the 92 individuals with schizophrenia (7%) to the remainder of the sample. They found that suicide occurred at any point during the course of schizophrenia and over a large age range. In addition, among the individuals with schizophrenia, 71% had a history of suicide attempts, and, particularly in women, active illness and depressive symptoms were often observed immediately before the suicide. Significant life events, however, were seen less often before suicide in individuals with schizophrenia than in those with other diagnoses (46% and 83%, respectively).

Other studies have found suicidal ideation and suicide attempts to be common among individuals with schizophrenia. For example, in the Chestnut Lodge sample, over an average of 19 years of follow-up, 40% of the patients with schizophrenia spectrum disorders reported suicidal ideation since their initial hospitalization, and 23% reported at least one suicide attempt (93). Radomsky et al. (80) evaluated lifetime rates of suicidal behavior among 1,048 consecutively admitted psychiatric inpatients with DSM-III-R psychotic disorders. Of the 454 individuals with a diagnosis of schizophrenia, 27.3% reported at least one lifetime suicide attempt, with an additional 26.4% reporting suicidal ideation only. For the 159 patients with schizoaffective disorder, 42.8% and 27% reported suicide attempts and suicidal ideation, respectively. Roy et al. (117) found that 55% of a series of 127 consecutively admitted patients with chronic schizophrenia had previously made a suicide attempt. Harkavy-Friedman et al. (108), in a sample of 104 individuals with schizophrenia or schizoaffective disorder, found that 33% had made a suicide attempt, with 60% of those reporting multiple attempts. Attempts were often medically serious, requiring medical inpatient care in 57% of cases and emergency medical evaluation in an additional 11%, and were associated with strong suicidal intent (in the 76% of patients for whom this information was available). As with suicide in schizophrenia, initial suicide attempts tended to occur early during the course of the illness.

A number of specific factors appear to increase the likelihood of a suicide attempt among individuals with schizophrenia. For example, in the study by Roy et al. (117), those who had attempted suicide had significantly more psychiatric admissions and were more likely to have experienced a major depressive episode or received antidepressant treatment, compared with those who had not attempted suicide. Young et al. (704), in a longitudinal study of 96 individuals with recent-onset schizophrenia who were followed for a 1-year period, noted that depression was moderately correlated with concurrent suicidality but was not independently associated with future suicidality, whereas the presence of suicidal ideation even at low levels increased the risk for significant suicidal ideation or a suicide attempt during the subsequent 3 months. In their sample, Harkavy-Friedman et al. (108) found that suicide attempts were reported to be precipitated by depression (27%), loss of a significant other or other stressful life event (24%), being bothered by psychotic symptoms (11%), and responding to command hallucinations (4%). In a subsequent study of 100 individuals with schizophrenia, Harkavy-Friedman et al. (106) found that 8% of suicide attempts were associated with command auditory hallucinations for suicide and that individuals with previous suicide attempts were at particularly increased risk. In a prospective study of 333 patients with chronic schizophrenia (705), multivariate analysis suggested that current and lifetime suicide attempts and suicidal ideation were associated with hopelessness and possibly with greater levels of insight or higher cognitive functioning. Increased insight,