Suicide

Whether treated or untreated, if the outcome of mental illness is suicide, it is a devastating end to a life and it wreaks havoc on family members left behind. Child psychiatrist Nancy Rappaport of Cambridge, Mass, has written a moving memoir of her mother’s suicide that took place during an acrimonious custody battle. Rappaport, at age 4 years, was the youngest of 6 children left behind. She shows great courage as she risks discovering painful information and creating potential ruptures with her father and siblings, some of whom disagree with her decision to write the book.

A few simple steps can enhance your assessment of a patient’s suicide risk-and thereby reduce your own risk for liability if the patient does commit suicide. Phillip J. Resnick, MD, professor of psychiatry and director of forensic psychiatry at Case Western Reserve University in Cleveland, described those measures in a lecture today at the US Psychiatric Congress in Las Vegas.

While violence is often portrayed in the media as related to persons with mental illnesses, there are limited research data to support this idea. This article reviews laws and obligations for mental health professionals.

The FDA is forcing manufacturers of all antiepileptic drugs to include new warnings of possible suicide ideation in the prescribing information and also to prepare a new Medication Guide to be distributed by pharmacies to consumers. In addition, the companies will have to produce a Risk Evaluation and Mitigation Strategy for each drug, which the FDA only requires for drugs with possible adverse effects it considers especially dangerous.

Suicide risk assessment is a core competency that all psychiatrists must have.1 A competent suicide assessment identifies modifiable and treatable protective factors that inform patient treatment and safety management.2 Psychiatrists, unlike other medical specialists, do not often experience patient deaths, except by suicide. Patient suicide is an occupational hazard. A clinical axiom holds that there are 2 kinds of psychiatrists: those who have had patients commit suicide-and those who will.

An increasing youth suicide rate may point toward an emerging public health crisis, necessitating national efforts to develop effective interventions, experts recently warned.

A Blue Ribbon report and a hearing in a House subcommittee raised fresh questions about the sufficiency of the Department of Veterans Affairs (VA) response to suicides among veterans-especially those returning from Iraq and Afghanistan.

In “SSRI Prescribing Rates and Adolescent Suicide: Is the Black Box Hurting or Helping?” (Psychiatric Times, October 2007, page 33) Gibbons and associates primarily use data from their American Journal of Psychiatry article that appeared in September 2007, in a not very veiled attempt to influence doctors and the FDA to roll back the “black-box” warning on the prescription of SSRIs for adolescents.

The Golden Gate Bridge in San Francisco has the regrettable distinction of being the number one spot for suicide in the world. There have been more than 1300 known suicides from the bridge, and in 2007 at least 35 people committed suicide by jumping off the Golden Gate Bridge, more than in any other year.

Suicide is a devastating, tragically frequent outcome for persons with varying psychiatric conditions, including schizophrenia. An estimated 5% to 10% of persons with schizophrenia commit suicide and 20% to 50% attempt suicide during their lifetime.1,2 Patients with schizophrenia have more than an 8-fold increased risk of completing suicide (based on the standardized mortality ratio) than the general population.3

When a suicidal patient in crisis calls the psychiatrist and hears the recorded message, "If you have a 'true' emergency, go to your nearest emergency room or call 911," the patient's risk of suicide may increase.

Some studies have linked antidepressants to suicide ideation in children and adolescents, but could adult suicides be linked to antidepressant use? Andrew C. Leon and associates reviewed the medical examiner reports of 1419 adults who completed suicide from 2001 to 2004 in New York City and determined that there does not appear to be a link between the two.

Suicide is the third leading cause of death in younger (10- to 14-year-old) adolescents in the United States and the leading cause of death in this age group in other countries, including China, Sweden, Ireland, Australia, and New Zealand.

This May, the FDA called for a black box warning on antidepressants to indicate that patients aged 18 to 24 years are at heightened risk for treatment-emergent suicidality. But a member of the FDA advisory committee that recommended that warning has issued his own warning, saying that the "real killer in this story is untreated depression and the possible risk from antidepressant treatment is dwarfed by that from the disease."

The role of no-suicide contracts is but a small tactical piece of the larger strategic approach to the assessment and prevention of suicide. Its many obvious limitations-to some degree in assessment, but primarily in suicide prevention-should have driven serious discussion of no-suicide contracts out of consideration as a practical measure in clinical practice and a legal talking point in the courtroom.

Proper suicide assessment is probably the most important part of a clinician's job; appropriately, heavy emphasis is placed on this in our education. Unfortunately, psychiatrists receive comparatively little practical guidance in documenting the history and physical examination (H&P) of a suicidal patient.

González-Pinto A, Aldama A, González C, et al. Predictors of suicide in first-episode affective and nonaffective psychotic inpatients: five-year follow-up of patients from a catchment area in Vitoria, Spain. J Clin Psychiatry. 2007;68:242-247.

According to the CDC, in 2004, suicide was the 11th leading cause of death across all age groups and the 10th leading cause of death for persons aged 14 to 64 years; 32,439 people in the United States took their own lives. Women attempt suicide about 3 times more often than men, although men are 4 times as likely to complete suicide. Anderson and Smith3 reported that suicide was the eighth leading cause of death among men in 2001. Of the 24,672 completed suicides among men, 60% involved the use of a firearm (the use of a firearm was the means of suicide in 55% of all cases).

Assessing bullying behavior and suicide attempts in victims of bullying.

Although suicidal ideation occurs in roughly 5% to 14% of pregnancies,1 suicide attempts are relatively rare (0.04%) and are associated with substance abuse and poor pregnancy outcome.2 After a suicide attempt, the clinician must first consider the possibility of recurrence of self-destructive behavior by assessing the woman's motivation, her attitude toward the pregnancy, and the severity of her depressive symptoms.

Risk Factors for Suicide in Patients With Schizophrenia

Beyond demographic characteristics, risk and protective factors for suicide in older adults have been much more clearly defined in recent years by a series of methodologically rigorous, case-controlled psychological autopsy studies.

Concerns about senior suicide and the lack of geriatric mental health services took center stage at hearings in the Senate Special Committee on Aging on September 14. Geriatric psychiatrists reviewed unfavorable trends such as faltering numbers of medical school graduates going into primary care and already small numbers of geriatric psychiatrists getting even smaller.

Older adults have higher rates of suicide than younger adults in many industrialized nations.

College students are far less likely to kill themselves than are nonstudent peers, according to a 10-year research study examining suicide rates at 12 Midwestern campuses.