How important are religious beliefs in preventing suicide? Dervic and colleagues29 evaluated 371 depressed inpatients about their religious affiliation. Patients who were without a religious affiliation had significantly more suicide attempts and more first-degree relatives who completed suicide than did patients who had religious affiliations. Patients with no religious affiliation were younger and less likely to be married or have children; they had less contact with family members. These patients felt they had fewer reasons for living and had relatively few moral objections to suicide. There was no difference in subjective and objective depression, hopelessness, or stressful life events between persons with religious affiliations and those without. Their findings indicate that greater moral objection to suicide and lower aggression level in religiously affiliated patients may act as protective factors.
Religious beliefs, however, may not necessarily protect against suicide—severe mental illness can overcome protective factors. For example, a patient with bipolar disorder stated hopelessly that “God has forsaken me.” A devout, severely depressed patient hurled blasphemous insults at God. In a twist, where religion became a facilitating risk factor, a suicidal patient stated, “God will forgive me if I kill myself.”
Case reports, case series, and clinical consensus, though not evidence-based, can aid suicide risk assessment. For example, in a systematic review of the relevant literature, Hansen30 found that akathisia could not be definitively linked to suicidal behavior. In individual cases, however, clinical judgment may determine that akathisia adds to the patient’s total illness burden, thus potentially increasing suicide risk. Evidence-based studies must be interpreted through the lens of the clinician’s education, training, experience, and reasoned clinical judgment.
The suicide prevention contract (SPC), also referred to as a no-harm contract, is a classic example of misconception. The SPC often masquerades as a protective factor, but it can be an iatrogenic suicide risk factor. The SPC can falsely reassure the clinician, which may preempt an adequate suicide risk assessment and increase the patient’s risk of suicide.10 There have not been any studies that demonstrate that the SPC is effective in preventing suicide attempts or completions.31
Managed care settings become a potential suicide risk factor if clinicians allow third-party payers to dictate premature discharges of suicidal patients. Very often, these decisions are made based on so-called safety contracts with severely mentally ill suicidal patients, who are rapidly treated and discharged, compounding suicide risk.
Beyond evidence-based general suicide risk factors, suicidal patients have individual “signature” symptoms and behaviors that are associated with suicide risk. “Signature” risk factors recur during subsequent suicide crises. A patient’s distinctive suicide risk factor pattern should receive high priority in assessing suicide risk.32 An example is when a guarded, schizophrenic patient with a severe stutter speaks clearly when at high risk for suicide. Once his stutter returns, he is discharged from the hospital at low suicide risk. This individual specific behavior is repeated a number of times and the clinician considers it to be a reliable behavioral indicator of suicide risk. The assessment of behavioral risk factors is important, especially with guarded or deceptive suicidal patients.2 Employing evidence-based risk factors in suicide assessment is essential, but knowing a patient’s unique suicide risk profile is critical.
There are a number of suicide risk assessment methods.2 Clinicians, however, must fashion their own approach based on their training, clinical experience, and familiarity with the suicide literature. Because of its singular importance, the suicide risk assessment should be documented as a separate narrative paragraph in the initial psychiatric evaluation and thereafter in the progress notes.
Armed with the ability to perform competent suicide risk assessments, the psychiatrist can confidently treat the patient at risk for suicide, one of the most complex, difficult, and challenging clinical tasks in psychiatry.
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.