Assessing and treating patients with suicidal behavior is not an easy task. Acts of suicide cannot be predicted; the best a psychiatrist can hope for is the ability to identify a patient's risk factors and reduce them.
To that end, psychiatrists now have help in the form of a practice guideline from the American Psychiatric Association. The Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors, the first by the APA to address these behaviors, was published in November 2003 and is being disseminated through professional meetings and journals.
Suicidal ideation occurs in about 5.6% of the U.S. population, with about 0.7% of the population attempting suicide. The incidence of completed suicide is far lower, at 0.01%. "This rarity of suicide, even in groups known to be at higher risk than the general population, contributes to the impossibility of predicting suicide," according to the guideline.
"The challenge in working with a suicidal person is that the psychiatrist has to be familiar with a wide range of treatments," Douglas G. Jacobs, M.D., told Psychiatric Times. Regardless of the disorder being treated, "The psychiatrist has to be wary of when suicide can occur in a particular patient."
Psychiatrists do a good job of assessing and treating suicide, despite the fact that "no study demonstrates that we are able to predict suicide," said Jacobs, who is chairperson of the workgroup that developed the guideline, executive director of Screening for Mental Health and associate clinical professor of psychiatry at Harvard Medical School.
None of the suicide scales used in research are recommended for use in clinical practice by the guideline, in part because they produce so many false positives and false negatives, Jacobs said. However, the questions used in suicide scales are useful for psychiatrists to know because they add to one's armamentarium about the appropriate questions to ask.
Mental illness is a major risk factor, present in 90% to 95% of suicides, with the majority suffering from depression, according to Jacobs. Basically, this means that every patient a psychiatrist treats is at some risk for suicide. "I feel that we do a pretty good job, given that the majority of people in treatment don't commit suicide."
However, psychiatry doesn't have a foolproof mechanism for preventing suicides, and even with good treatment, some people still commit suicide. For instance, 5% of all suicides occur in hospitals, so inpatient care isn't absolutely preventive, he said.
Jacobs' hope is that the guideline will provide psychiatrists with a useful structure for assessment and treatment by offering guidance for a variety of situations, such as inpatient care, partial hospitalization, risk management and even how to approach a family in which there has been a suicide.
The guideline is a combination of clinical consensus and evidence-based medicine and gives psychiatrists the most current overview of the risk factors of suicide. Its tables give the psychiatrist an organized approach in terms of assessment, diagnosis, comorbidity, the role of family and patient histories, and current treatment approaches. It also provides a structured approach for conducting a detailed suicide inquiry.
One of the things that psychiatrists sometimes do not appreciate enough is the importance of asking detailed questions about suicidal thoughts, the existence of a suicide plan and any efforts that the patient has made to actualize that plan, said Jacobs. Sometimes a self-destructive act may not be correlated with lethality, and psychiatrists need to try to focus on the intent behind a specific act.
Psychiatrists also need to be aware of the range of treatments available for reducing suicide risk. Lithium (Eskalith, Lithobid), for example, may not be helpful for treating a manic episode but may still be useful in its ability to reduce the risk of suicide in people with bipolar disorder (BD). The guideline also covers the significance of atypical antipsychotics, electroconvulsive therapy, inpatient care and psychotherapy.
Reducing the Rate
According to Jacobs, one of the hard parts of treating for suicide is that only a few treatments demonstrate evidence for actually reducing the suicide rate--lithium, clozapine (Clozaril) and ECT for short-term reduction. Antidepressants lack an evidence base for preventing suicide, but clinical consensus supports that they are also valuable for reducing suicide in people with depression.
The challenge in evaluating the role of antidepressants in reducing the suicide rate is constructing a study, Jacobs said. A handful of studies of U.S. Food and Drug Administration trial data suggest that there is little difference in the suicide rate between patients who receive an antidepressant and those who receive a placebo. That would seem to address the ethical concern of giving a placebo to a patient who is suffering from potentially life-threatening depression. Even so, clinical trials, as a rule, exclude patients who are suicidal.
A report on the adolescent suicide rate by Columbia University researchers found a 10% drop in the 1990s that suggested a link to the increase in antidepressant use. However, the finding represents an important statistical association, although not direct evidence, that the increase in antidepressant use among teens caused a reduction in suicide rates, said Jacobs.
The workgroup found the lack of evidence base supporting clinical treatments disillusioning, Jacobs said. "That means we are going to have to be creative in doing research, particularly with the antidepressants."