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Enhancing Suicide Risk Assessment Through Evidence-Based Psychiatry: Page 3 of 4

Enhancing Suicide Risk Assessment Through Evidence-Based Psychiatry: Page 3 of 4

Childhood abuse
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.

Protective factors
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.


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