Psychiatric diagnosis. The psychiatric diagnosis with associated suicide risk is an essential part of the clinician’s assessment screening. Harris and Barraclough6 compared the numbers of suicides in individuals with mental disorders with the expected suicide rate in the general population. The standardized mortality ratio (SMR)—a measure of the relative risk of suicide for a particular disorder compared with the expected rate in the general population (SMR of 1)—was calculated for each disorder by dividing observed mortality by expected mortality. Eating disorders, major affective disorders, substance abuse, anxiety disorders, and schizophrenia had the highest SMRs. Every psychiatric disorder, except mental retardation, was associated with suicide risk.
Comorbidity increases suicide risk. In a national population survey of 5877 respondents between 1990 and 1992, Kessler and colleagues7 found that a dose-response association existed between the number of comorbid psychiatric disorders and suicide attempts. Comorbidity is an indicator of illness severity.
Suicidal ideation and plan. Findings from the National Comorbidity Survey (N = 5877) show that the probability of transitioning from suicidal ideation to suicidal plan was 34%, from plan to attempt was 72%, and from suicidal ideation to attempt was 26%.7 Approximately 90% of unplanned and 60% of planned suicide attempts occurred within 1 year of onset of suicidal ideation.
Beck and colleagues8 found that when patients were asked about suicidal ideation at its worst point, those with high scores were 14 times more likely to complete suicide than those with low scores. Patients who have suicidal ideation must be asked if they have access to firearms. If the answer is affirmative, a gun safety management plan must be implemented.9
The clinician cannot simply rely on a patient’s denial of suicidal ideation. Other risk factors are usually present when a patient’s denial of suicidal ideation is an effort to conceal suicidal intent.3 Isometsä and colleagues10 found that the majority of 571 patients who completed suicide did not communicate their intent during the last appointment; this was particularly true among those treated in general practice and in nonpsychiatric specialist settings.
Suicide attempt(s) and deliberate self-harm. Harris and Barraclough6 found that previous suicide attempts by any method had the highest SMR (38.26) of any psychiatric disorder. The risk of completed suicide is highest during the first year after an attempt. Between 7% and 12% of cases of attempted suicide result in completed suicide within 10 years.11 Most suicides, however, occur in patients who have not made prior attempts.
In a prospective cohort study of 7968 deliberate self-harm patients, Cooper and colleagues12 found an approximate 30-fold increase in risk of suicide compared with the general population during a 4-year follow-up period. Suicide rates were highest within the first 6 months after the initial incident of self-harm.
Anxiety and depression. Fawcett13 conducted a 10-year prospective study of 954 patients with major affective disorders. Statistically significant suicide risk factors within 1 year of assessment included panic attacks, psychic anxiety (distinguished from somatic anxiety), loss of pleasure and interest, moderate alcohol(Drug information on alcohol) abuse, depressive turmoil (agitation), diminished concentration, and global insomnia. If the depression is not too severe, patients can become inured to depression. However, the combination of severe anxiety and depression can be intolerable, placing the patient at high risk for suicide. More than 50% of patients with nonbipolar MDD have comorbid anxiety and depression.14 Comorbid anxiety disorders and symptoms increase the risk of suicide among depressed patients.15