An essential part of the psychiatric examination and systematic risk assessment is inquiry about childhood abuse. A history of suicide was more than twice as likely among both men and women who were abused as children.20 Brown and colleagues21 studied a cohort of 776 randomly selected children from a mean age of 5 years to adulthood over a 17-year period. Adolescents and young adults with a history of childhood abuse were 3 times more likely to become depressed or suicidal than those without such a history. Childhood sexual abuse effects were the largest and most independent of associated factors. The risk of repeated suicide attempts was 8 times greater with a history of sexual abuse.
The nature and extent of childhood sexual abuse is associated with the severity of suicide risk. Study findings show a consistent relationship between the extent of child sexual abuse and risk of a psychiatric disorder.22 Those who reported being subjected to intercourse were at highest risk for psychiatric disorders and suicidal behaviors.
Impulsivity and aggression
Violent threats or violence toward others is a suicide risk factor. Clinicians more commonly encounter patients who threaten violence against themselves. Violence, however, has a vector: it can be directed at oneself, at others, or both, as in murder-suicide. Conner and colleagues,23 in a case-control study, found that violent behavior in the last year of life is a significant risk factor for suicide. The relationship was especially strong in those with no history of alcohol abuse, in younger persons, and in women. In the study, 753 suicide victims were compared with 2115 accident victims. Violent behavior distinguished suicide victims from accident victims, and the findings were not attributable to alcohol use disorders alone.
Higher levels of impulsivity and aggression have been found to be associated with suicide.24 Current (6-month prevalence) abuse of or dependence on alcohol or drugs increased the risk of suicide in persons with major depressive disorder (MDD). In a retrospective study of 408 patients who had schizophrenia spectrum, mood, or personality disorders, those who externally directed aggression distinguished past suicide attempters from nonattempters.25 The risk of future suicide attempts was also increased among those in the aggression group.
Melancholic features associated with MDD have been found to confer a higher risk of suicide attempts than in nonmelancholic MDD. In a case-control study, Grunebaum and colleagues26 compared suicide attempts in patients with and without melancholia.
Melancholia was associated with more serious past suicide attempts and the increased probability of suicide attempts during follow-up. While MDD is associated with a high risk of suicide, melancholia is a less commonly recognized feature of MDD that may further increase the risk of suicide attempts or completions.
Malone and colleagues27 assessed 84 patients with symptoms of MDD based on DSM-III-R criteria. Of the 84 patients, 45 had attempted suicide and 39 had not. The depressed patients who had not attempted suicide expressed more responsibility toward family, more fear of social disapproval, more moral objections to suicide, greater coping and survival skills, and more fear of suicide than depressed patients who had attempted suicide. The authors concluded that the assessment of reasons for living should be part of the assessment of patients at risk for suicide.
The Linehan Reasons for Living Inventory assesses the strength of a patient’s commitment not to die.28 The inventory is a 48-item self-report measure that takes about 10 minutes to administer. A 72-item version is also available. Internal consistency is high. The inventory’s test-retest reliability is moderately high for 3 weeks. The inventory is sensitive to reductions in depressive symptoms, hopelessness, and suicidal ideation in patients with borderline personality disorder who are being treated.
1. Scheiber SC, Kramer TAM, Adamowski SE. Core Competencies for Psychiatric Practice: What Clinicians Need to Know. Arlington, VA: American Psychiatric Publishing, Inc; 2003.
2. Simon RI. Suicide risk: assessing the unpredictable. In: Simon RI, Hales RE, eds. Textbook of Suicide Assessment and Management.
Arlington, VA: American Psychiatric Association; 2003.
3. Sokolov G, Hilty DM, Leamon M, Hales RE. Inpatient treatment and partial hospitalization. In: Simon RI, Hales RE, eds. The American Psychiatric Publishing Textbook of Suicide Assessment and Management. Arlington, VA: American Psychiatric Publishing, Inc; 2006.
4. Gabbard GO, Allison SE. Psychodynamic treatment. In: Simon RI, Hales RE, eds. Textbook of Suicide Assessment and Management.
Arlington, VA: American Psychiatric Publishing; 2006.
5. Sullivan GR, Bongar B. Psychological testing. In: Simon RI, Hales RE, eds. Suicide Risk Management in Textbook of Suicide Assessment and Management. Arlington, VA: American Psychiatric Publishing; 2006.
6. Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry. 2003;160(suppl 11):1-60.
7. Sackett DL, Rosenberg WM, Gray JA, et al. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312:71-72.
8. Gray GE. Evidence-Based Psychiatry. Arlington, VA: American Psychiatric Publishing; 2004.
9. Harris EC, Barraclough B. Suicide as an outcome for mental disorders: a meta-analysis. Br J Psychiatry. 1997;170:205-228.
10. Simon RI. Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management. Arlington, VA: American Psychiatric Publishing; 2004.
11. Quan H, Arboleda-Florez J, Fick GH, et al. Association between physical illness and suicide among the elderly. Soc Psychiatry Psychiatr Epidemiol. 2002;37:190-197.
12. Harris EC, Barraclough BM. Suicide as an outcome for medical disorders. Medicine (Baltimore). 1994;73:281-296.
13. Beautrais AL, Joyce PR, Mulder RT, et al. Prevalence and comorbidity of mental disorders in persons making serious suicide attempts: a case control study. Am J Psychiatry. 1996;153:1009-1014.
14. Hawton K, Houston K, Haw C, et al. Comorbidity of Axis I and Axis II disorders in patients who attempted suicide. Am J Psychiatry. 2003; 160:1494-1500.
15. Kessler RC, Borges G, Walters EE. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Study. Arch Gen Psychiatry. 1999;56:617-626.
15. Kessler RC, Borges G,Walters EE. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Study. Arch Gen Psychiatry. 1999;56:617-626.
16. Cooper J, Kapur N,Webb R, et al. Suicide after deliberate self-harm: a 4-year cohort study. Am J Psychiatry. 2005;162:297-303.
17. Hawton K, Zahl D,Weatherall R. Suicide following deliberate selfharm: long-term follow-up of patients who presented to a general hospital. Br J Psychiatry. 2003;182:537-542.
18. Fawcett J, Scheftner WA, Fogg L, et al. Time-related predictors of suicide in major affective disorders. Am J Psychiatry. 1990;147:1189- 1194.
19. Fawcett J. Treating impulsivity and anxiety in the suicidal patient. Ann N Y Acad Sci. 2001;932:94-105.
20. Dube SR, Anda RF, Whitfield CL, et al. Long-term consequences of childhood sexual abuse by gender of victim. Am J Prev Med. 2005; 28: 430-438.
21. Brown J, Cohen P, Johnson JG, Smailes EM. Childhood abuse and neglect: specificity of effects on adolescent and young adult depression and suicidality. J Am Acad Child Adolesc Psychiatry. 1999;38:1490- 1496.
22. Fergusson DM, Horwood LJ, Lynskey MT. Childhood sexual abuse and psychiatric disorder in young adulthood, II: psychiatric outcomes of childhood sexual abuse. J Am Acad Child Adolesc Psychiatry. 1996;35: 1365-1374.
23. Conner KR, Cox C, Duberstein PR, et al. Violence, alcohol, and completed suicide: a case-control study. Am J Psychiatry. 2001;158:1701- 1705.
24. Dumais A, Lesage AD, Alda M, et al. Risk factors for suicide completion in major depression: a case-control study of impulsive and aggressive behaviors in men. Am J Psychiatry. 2005;162:2116-2124.
25. Mann JJ, Ellis SP,Waternaux CM, et al. Classification trees distinguish suicide attempters in major psychiatric disorders: a model of clinical decision making. J Clin Psychiatry. 2008;69:23-31.
26. Grunebaum MF, Galfalvy HC, Oquendo MA, et al. Melancholia and the probability and lethality of suicide attempts. Br J Psychiatry. 2004; 184:534-535.
27. Malone KM, Oquendo MA, Hass GL, et al. Protective factors against suicidal acts in major depression: reasons for living. Am J Psychiatry. 2000;157:1084-1088.
28. Linehan MM, Goodstein JL, Nielsen SL, Chiles JA. Reasons for staying alive when you are thinking of killing yourself: the reasons for living inventory. J Consult Clin Psychol. 1983;51:276-286.
29. Dervic K, Oquendo MA, Grunebaum MF, et al. Religious affiliation and suicide attempt. Am J Psychiatry. 2004;161:2303-2308.
30. Hansen L. A critical review of akathisia, and its possible association with suicidal behavior. Hum Psychopharmacol. 2001;16:495-505. 31. Stanford EJ, Goetz RR, Bloom JD. The No Harm Contract in the emergency assessment of suicide risk. J Clin Psychiatry. 1994;55:344- 348.
32. Simon RI. Behavioral risk assessment of the guarded suicidal patient. Suicide Life Threat Behav. 2008;38:517-522.