Introduction: Risk Factors, Pharmacological Interventions, and Sequelae of Suicidal Behavior

December 31, 2014

The articles in this Special Report address suicidal behavior in the context of the role of sexual identity, the effects of antidepressants and lithium on suicidal behavior, and clinicians’ reactions in the aftermath of suicide.

Death by suicide is more common than death due to homicide or motor vehicle accidents. Indeed, the suicide rate has been increasing in the past years for which data are available. In 2010, 38,364 Americans died by suicide, surpassing the alarming 2009 toll of 36,891.1 That there are 25 suicide attempts per completed suicide underscores the magnitude of the issue.1 The lack of reduction in suicide rates may be partly because suicidal behavior is complex and heterogeneous. It can be impulsive or methodically planned, violent or not, or it can be reactive to stress or occur with no obvious stressors.2-6 This heterogeneity poses an extra challenge to identification of effective preventive measures at the individual and population levels. The articles in this Special Report address suicidal behavior in the context of the role of sexual identity, the effects of antidepressants and lithium on suicidal behavior, and clinicians’ reactions in the aftermath of suicide.

[[{"type":"media","view_mode":"media_crop","fid":"30557","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_3170953619348","media_crop_h":"270","media_crop_image_style":"-1","media_crop_instance":"3210","media_crop_rotate":"0","media_crop_scale_h":"200","media_crop_scale_w":"119","media_crop_w":"160","media_crop_x":"72","media_crop_y":"39","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]In “What Role Does (Should) Lithium Play in Suicide Treatment/Prevention?” Drs Ute Lewitzka and Michael Bauer review lithium’s putative antisuicidal effects and its potential mechanisms of action. Discussion of the consequences of lithium overdose is also included, giving the clinician a compact description of this key issue.

Dr Jane G. Tillman briefly outlines management of a patient’s suicide in “Patient Suicide: Impact on Clinicians.” She provides thoughtful recommendations about such matters as contacting the family and attending the funeral. This most dreaded outcome typically leaves clinicians shocked-even traumatized-and as a succinct primer on managing reactions, this article has great utility and practical implications.

Scholarly and comprehensive, the article “The Relationship Between Antidepressant Initiation and Suicide Risk” by Drs Robert D. Gibbons and J. John Mann presents data regarding the effect of anti­depressants on suicides. A description of the findings, their limitations, and challenges in interpreting the data are noted in a lucid, accessible manner.

Drs Ann P. Haas and Jack Drescher address a critical but often neglected issue in suicide research or prevention efforts in “Impact of Sexual Orientation and Gender Identity on Suicide Risk: Implications for Assessment and Treatment.” The article not only describes risk factors for suicide in the LGBT population but also offers additional resources to aid the clinician in the management of suicidal behaviors in this group of patients.

Together, these articles span several critical issues for the management of suicide risk. We hope you find these articles useful in your work with patients at risk for suicidal behavior who may have all manner of diagnoses and pre­sent clinical challenges to safe management.


Dr Oquendo is Professor and Vice Chair in Psychiatry at Columbia University and the New York State Psychiatric Institute, New York. She reports that she receives royalties for the commercial use of the Columbia Suicide Severity Rating Scale and that her family owns stock in Bristol-Myers Squibb.


1. US Department of Health and Human Services. Suicide: facts at a glance; 2012. Accessed November 11, 2014.

2. Bender TW, Gordon KH, Bresin K, Joiner TE Jr. Impulsivity and suicidality: the mediating role of painful and provocative experiences. J Affect Disord. 2011;129:301-307.

3. Dombrovski AY, Szanto K, Clark L, et al. Reward signals, attempted suicide, and impulsivity in late-life depression. JAMA Psychiatry. 2013 Aug 7; [Epub ahead of print].

4. Conner KR, Hesselbrock VM, Meldrum SC, et al. Transitions to, and correlates of, suicidal ideation, plans, and unplanned and planned suicide attempts among 3,729 men and women with alcohol dependence. J Stud Alcohol Drugs. 2007;68:654-662.

5. Bogdanovica I, Jiang GX, Löhr C, et al. Changes in rates, methods and characteristics of suicide attempters over a 15-year period: comparison between Stockholm, Sweden, and Würzburg, Germany. Soc Psychiatry Psychiatr Epidemiol. 2011;46:1103-1114.

6. Apter A, Bleich A, King RA, et al. Death without warning? A clinical postmortem study of suicide in 43 Israeli adolescent males. Arch Gen Psychiatry. 1993;50:138-142.