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A. Assessment of Patients With Suicidal Behaviors

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  • Refer to Table 1 for circumstances in which suicide assessment may be indicated.

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TABLE 1. Circumstances in Which a Suicide Assessment May Be Indicated Clinically

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Table Reference Number
TABLE 1. Circumstances in Which a Suicide Assessment May Be Indicated Clinically
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1. Conduct a thorough psychiatric evaluation.

  • Identify psychiatric signs and symptoms.

    • Determine the presence or absence of signs and symptoms associated with specific psychiatric diagnoses.

    • Identify specific psychiatric symptoms that may influence suicide risk, including aggression, violence toward others, impulsiveness, hopelessness, agitation, psychic anxiety, anhedonia, global insomnia, and panic attacks.

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

    • For each attempt, obtain details about the precipitants, timing, intent, consequences, and medical severity.

    • Ascertain if alcohol and drugs were consumed before the attempt.

    • Delineate interpersonal aspects of the attempt in order to understand issues that culminated in the attempt (e.g., persons present at the time of the attempt or to whom the attempt was communicated).

    • Determine the patient's thoughts about the attempt (e.g., perception of potential for lethality, ambivalence toward living, visualization of death, degree of premeditation, persistence of suicidal ideation, and reaction to the attempt).

  • Review past treatment history and treatment relationships.

    • Review psychiatric history (e.g., previous and comorbid diagnoses, prior hospitalizations and other treatment, past suicidal ideation).

    • Review history of medical treatment (e.g., identify medically serious suicide attempts and past or current medical diagnoses).

    • Gauge the strength and stability of current and past therapeutic relationships.

  • Identify family history of suicide, mental illness, and dysfunction.

    • Inquire about family history of suicide and suicide attempts and psychiatric hospitalizations or mental illness, including substance use disorders.

    • Determine the circumstances of suicides in first-degree relatives, including the patient's involvement and the patient's and relative's ages at the time.

    • Determine childhood and current family milieu, including history of family conflict or separation, parental legal trouble, family substance use, domestic violence, and physical and/or sexual abuse.

  • Identify current psychosocial situation and nature of crisis.

    Consider 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).

  • Appreciate psychological strengths and vulnerabilities of the individual patient.

    Consider how coping skills, personality traits, thinking style, and developmental and psychological needs may affect the patients' suicide risk and the formulation of the treatment plan.

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2. Specifically inquire about suicidal thoughts, plans, and behaviors.

  • Refer to Table 2 for specific issues to address.

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TABLE 2. Questions That May Be Helpful in Inquiring About Specific Aspects of Suicidal Thoughts, Plans, and Behaviors

  • Elicit the presence or absence of suicidal ideation.

    • Address the patient's feelings about living with questions 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?"

    • Focus on the nature, frequency, extent, and timing of suicidal thoughts, and consider their interpersonal, situational, and symptomatic context.

    • 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.

    • If the patient is intoxicated with alcohol or other substances when initially interviewed, the patient's suicidality will need to be reassessed at a later time.

  • Elicit the presence or absence of a suicide plan.

    • Probe for detailed information about specific plans for suicide and any steps that have been taken toward enacting those plans.

    • Determine the patient's belief about the lethality of the method, which may be as important as the actual lethality of the method.

    • Determine the conditions under which the patient would consider suicide (e.g., divorce, going to jail, housing loss) and estimate the likelihood that such a plan will be formed or acted on in the near future.

    • Inquire about the presence of a firearm in the home or workplace. If a firearm is present, discuss with the patient or a significant other the importance of restricting access to, securing, or removing this and other weapons.

  • Assess the patient's degree of suicidality, including suicidal intent and lethality of plan.

    Determine motivation for suicide, seriousness and extent of the patient's aim to die, associated behaviors or planning for suicide, and lethality of the method.

  • Recognize that suicide assessment scales have very low predictive values and do not provide reliable estimates of suicide risk.

    Nonetheless, they may be useful in developing a thorough line of questioning about suicide or in opening communication with the patient.

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3. Establish a multiaxial diagnosis.

  • Note all current or past axis I or axis II diagnoses, including those that may currently be in remission.

  • Identify physical illnesses (axis III), since such diagnoses may also be associated with an increased risk of suicide.

  • Record psychosocial stressors (axis IV), which may be either acute or chronic. Consider the perceived importance of the life event for the individual patient.

  • Assess the patient's baseline and current levels of functioning (axis V).

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4. Estimate suicide risk.

  • Identify factors that may increase or decrease the patient's level of risk.

    • The presence of a psychiatric disorder is the most significant risk factor.

    • Medical illness is also associated with increased likelihood of suicide. See Table 3 for specific medical conditions that have been associated with increased risk.

    • See Table 3 for additional factors that increase risk and Table 4 for protective effects.

    • Almost all psychiatric disorders have been shown to increase suicide risk (Table 5).

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Table Reference Number
TABLE 3. Factors Associated With Increased Risk for Suicide
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TABLE 4. Factors Associated With Protective Effects for Suicide
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Table Reference Number
TABLE 5. Risk of Suicide in Persons With Previous Suicide Attempts and Psychiatric Disordersa
Table Reference Number
TABLE 1. Circumstances in Which a Suicide Assessment May Be Indicated Clinically
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TABLE 2. Questions That May Be Helpful in Inquiring About Specific Aspects of Suicidal Thoughts, Plans, and Behaviors
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TABLE 3. Factors Associated With Increased Risk for Suicide
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TABLE 4. Factors Associated With Protective Effects for Suicide
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TABLE 5. Risk of Suicide in Persons With Previous Suicide Attempts and Psychiatric Disordersa

References

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