The Suicidal Patient: Risk Assessment, Management, and Documentation

Evaluation of risk factors and protective factors
Suicide risk assessment begins with a thorough psychiatric interview with 3 goals: (1) to identify the specific factors that increase or decrease the risk for suicide; (2) to address the immediate safety of the patient so that treatment can take place in an appropriate setting; and (3) to identify psychiatric illnesses that can be targeted in treatment.

Numerous risk factors have been empirically linked to an increased risk of suicide. The APA Practice Guideline lists 56 specific risk factors divided into 10 headings: suicidal thoughts/behaviors, psychiatric diagnosis, physical illnesses, psychosocial features, childhood traumas, genetic and familial effects, psychological features, cognitive features, demographic features, and additional features.¹³ Some of these factors increase suicidal risk considerably more than others, and a clinical approach to risk assessment should be built around them. Risk factors to be examined in a fundamental suicide risk assessment are outlined in Table 1.

Several demographic factors have been associated with increased suicide risk: race (ie, white or Native American),¹³ male sex,¹⁴ marital status¹⁵ (ie, widowed, divorced, single), and age group (ie, adolescent or elderly).¹⁶ These variables should be documented. In addition, a detailed description of suicidal thoughts, plans, behaviors, and intent should be explored, as well as the specific suicide methods considered and their potential lethality.

The frequency, intensity, and duration of suicidal thoughts should also be documented. Having a suicidal plan is much more predictive of completed suicide than mere suicidal desire.¹⁷ In a plan involving a weapon, the clinician should inquire about the accessibility of the weapon and should note if there has been a recent movement of the weapon (particularly if a firearm) within the home. In addition to current suicidal ideation and plan, a thorough history of past suicide attempts and their seriousness (potential lethality), past suicidal thoughts, and the circumstances in which they occurred (eg, while alone, while drinking, after a job loss, during/ after a divorce) should be documented.

One guiding principle of risk assessment is that the current presentation should be compared with previous situations in which a serious suicide attempt occurred. If the situations are similar, a patient may be at increased risk. There is evolving evidence that patients who have a history of multiple attempts are at elevated risk when compared with those who have a history of suicidal ideation or only one attempt.¹⁸ The combination of 2 factors—having a plan and a history of multiple attempts—is particularly worrisome.¹⁹

Among precipitants and stressors, the clinician should inquire about recent significant losses (eg, financial, interpersonal, identity), acute or chronic health problems, and family instability.²⁰ Studies have repeatedly shown that people who completed suicide were more likely to have established a treatment relationship with a primary care provider and to have frequently visited their provider before the suicidal act.^21-23

All psychiatric diagnoses, with the exception of mental retardation, have been shown to increase suicide risk.²⁴ Among psychiatric diagnoses, major depression leads to a 20-fold increase in lifetime risk, and suicide risk in patients with bipolar disorder has been found to be similar to that of patients with major depression. Mood disorders, primarily during depressive phases, are the most frequent diagnoses in completed suicide.^25,26 Of all the symptoms of depression, hopelessness has been identified as being greater in suicide attempters versus nonattempters, even when the severity of depressive symptoms was rated the same.²⁷ For this reason, clinicians should assess not only the presence of hopelessness but also its severity and duration.

The risk of suicide in patients with schizophrenia is estimated to be 8.5-fold higher than in the general population. Drug abuse, depressive symptoms, and a higher number of total hospitalizations are associated with increased suicide risk in people with schizophrenia.²⁸ Studies have not clearly established the role of command auditory hallucinations in suicide risk, and this warrants further study.^29,30 Contrary to common belief, command hallucinations account for a small percentage of suicides in persons with schizophrenia. In fact, suicide in patients with schizophrenia may be more likely to occur during periods of improvement after a psychotic episode, when insight into the implications of having a schizophrenic illness induces hopelessness or depressive symptoms.^31,32

Finally, personality disorders are common in suicide attempters, with overall rates of about 40%.²⁶ Borderline and antisocial personality disorders are the most common types associated with suicide attempts.³³