Does the patient have a psychiatric diagnosis? Mental illness has been found to be present in more than 90% of suicides,5-7 and a psychiatric diagnosis—or psychiatric symptoms such as agitation, aggression, or severe sleep disturbance2,10,16—is a key risk factor. Substance abuse is another significant risk.8,17 The risk of suicide may be especially high after discharge from a psychiatric hospital.
Is there a lack of support? The absence of a support system is a significant risk factor; conversely, marriage and children are commonly reported protective factors. In questioning patients about family and social ties, however, keep in mind that a situation that is protective for many, or most, people—eg, marriage—may represent an added stressor and risk factor for a particular patient.18
TABLE 1
Suicide assessment: Major risks vs protective factors
| Risk factors |
|---|
| Suicidality (ideation, intent, plan) |
| Prior suicide attempts2,13 |
| Hopelessness10,13 |
| Mental illness* 5-7 |
| Recent loss or crisis9 |
| Negativity, rigidity |
| Alcohol intoxication/abuse8,17 |
| Elderly12 |
| Male12 |
| Single/living alone13 |
| Gay/bisexual orientation13,25 |
| Psychiatric symptoms†10,14 |
| Impulsivity or violent/aggressive behavior |
| Family history of suicide26 |
| Unemployment2 |
| Protective factors |
| Female |
| Marriage |
| Children‡27,28 |
| Pregnancy29 |
| Interpersonal support |
| Positive coping skills30,31 |
| Religious activity32 |
| Life satisfaction33 |
| *Especially with recent psychiatric hospitalization. |
| † Including, but not limited to, anxiety, agitation, and impulsivity. |
| ‡ This includes any patient who feels responsible for children. |
Ask about suicidal ideation
The nature of suicidality, which may be the most relevant predictor of risk, can be assessed through a number of questions (TABLE 2).15 Not surprisingly, you are most likely to elicit information if you adopt an empathic, nonjudgmental, and direct communication style.
TABLE 2
Assessing suicidality: Sample questions
|
Whenever possible, begin with open-ended questions, and use follow-up questions or other cues to encourage elaboration. Ask patients whether they have thought about self-harm. If a patient acknowledges thoughts of suicide, ask additional questions to determine whether he or she has a plan and the means to carry it out. If so, what has prevented the patient from acting on it thus far?
Patients often require time to respond to such difficult questions, so resist the urge to rush through this portion of the suicide risk assessment. Simply waiting patiently may encourage a response.
CASE When directly questioned about suicidal ideation, Dr. A acknowledges that he has had thoughts of wanting to fall asleep and not wake up. Asked whether he has considered actually hurting himself, he pauses, looks away, sighs, and utters an unconvincing denial. When his FP observes, “you paused before answering that question and then looked away,” Dr. A re-establishes eye contact and admits that he has had thoughts of taking his life.
It is not uncommon for patients with suicidal ideation to initially deny it or simply fail to respond to questions, then later to open up in response to requests for clarification or further questions. This may be partly due to the patient’s own ambivalence. It may also have to do with the way the questions are presented. In order to get an accurate answer, avoid questions leading toward a negative response. Ask: ”Have you thought about killing yourself?” not “You’re not thinking about killing yourself, are you?”
Does the patient have a plan?
Suicidal ideation is defined as passive (having thoughts of wanting to die) or active (having thoughts of actually killing oneself). It is crucial to assess the level of intent and the lethality of any plan. Too often, physicians fail to probe enough to find out whether the patient has access to a lethal means of suicide, including, but not limited to, firearms or large quantities of pills that could be used as a potentially fatal overdose.
CASE Dr. A admits that he has had suicidal thoughts for the past 2 weeks, and that these thoughts have become more frequent and intense. He also says that while drinking last weekend, he thought about shooting himself.
Although Dr. A occasionally hunts and has access to guns, he denies having any intent or plan to act on his thoughts. He adds that he would never kill himself because he doesn’t want his wife and adult children to suffer.
Follow up with family or friends
For patients like Dr. A, who appear to be at significant risk, an interview with a family member or close friend may be helpful—or even necessary—to adequately gauge the extent of the danger. Patients usually consent to a physician’s request to obtain information from a loved one, particularly if the request is presented as routine or as an action taken on the patient’s behalf. A patient’s inability to name a close contact is a red flag, as individuals who are more isolated tend to be at higher risk than people with a supportive social network.19