Screening for Suicide Risk in a Brief Medication Management Appointment
The Suicide Risk Screening Alert is a clinical tool that assists the psychiatrist and nonpsychiatric physician in identifying patients at risk for suicide during brief medication management appointments.
The brief medication management appointment confronts clinicians with challenges in identifying and treating patients at risk for suicide. The appointment can be as short as a “5-minute med check,” especially in high-volume practices. In this setting, screening for suicide risk is often overlooked for a variety of reasons, including heavy patient loads.1
Psychiatrists prescribe only 23% of all psychotropic medications in the United States.2 General practitioners, obstetricians, gynecologists, and pediatricians write 59% of psychotropic prescriptions; other physicians and nonphysician providers prescribe 19%. Nonpsychiatric physicians prescribe psychotropic medications to treat psychological symptoms associated with medical illnesses as well as psychiatric conditions. When the focus is on medical issues, the psychotropic drugs may not be assessed regularly.
Psychoactive drugs as lethal means
The opportunity for drug overdose exists when clinicians prescribe large amounts of medication for at-risk patients who are seen briefly and infrequently.3 For example, daily 1000 mg of an anticonvulsant, 1200 mg of lithium, 40 mg of an antidepressant, 5 mg of an atypical antipsychotic, and 10 mg of a sleep medication are prescribed for a depressed bipolar patient. Thus, a 90-day prescription, provides the patient with 90,000 mg of an anticonvulsant, 108,000 mg of lithium, 3600 mg of an antidepressant, 450 mg of an atypical antipsychotic, and 900 mg of a sleep medication. A 30-day supply of these medications would be lethal if taken all at once. Nonadherence with the medication regimen can result in a lethal supply of prescribed drugs for the suicidal patient.4
Suicide attempts and completions with stockpiled, prescribed drugs are more likely to occur when visits are infrequent. Clinical continuity and vigilant monitoring break down. The therapeutic alliance can become attenuated or nonexistent. As a consequence, the high-risk suicidal patient may not contact the clinician for help when experiencing an acute crisis.
Screening for suicide risk
The Suicide Risk Screening Alert (Table 1) is derived from general evidence-based, commonly occurring, acute and chronic risk factors. The alert is not a comprehensive suicide risk assessment instrument. It has no psychometric properties. It is a clinical tool that assists the clinician in identifying evidence-based suicide risk factors quickly. Then if indicated, it assists in performing a comprehensive suicide risk assessment that systematically evaluates both risk and protective factors.3
Patients with complicated psychiatric conditions are routinely treated in split-treatment arrangements. Patients who have been recently discharged from psychiatric hospitals or from partial hospitalization programs remain at substantial suicide risk. Collaborative relationships can enhance identification and treatment of the suicidal patient. However, contact between the medication prescriber and therapist tends to be infrequent or nonexistent-insurance does not cover time spent in communicating about patients.
Table 1: Suicide Risk Screening Alert:
a clinical tool that assists clinicians in
identifying suicide risk factors
• Psychiatric diagnosis
• Suicidal ideation and plan
• Prior attempt(s) and deliberate self-harm
• Anxiety and depression
• Hopelessness
• Substance abuse
• Recent interpersonal loss
• Impulsivity and aggression
• Family history of suicide
• Recent discharge from a psychiatric hospital
• History of physical and sexual abuse
Table 2 lists intervention options available to the clinician treating the suicidal patient. The severity of the patient’s psychiatric condition and the clinician’s experience and training will determine the interventions. Consultation tends to be underused, often because consultations are not usually covered by insurance.
Table 2: Clinical intervention options
for patients at risk for suicide
• Conduct systematic suicide risk assessments
• Increase frequency and length of visits
• Review and adjust medications
• Refer patient to intensive outpatient psychotherapy program
• Refer patient to partial hospitalization program
• Maintain contact with therapist in split-treatment arrangements
• Obtain consultation; “never worry alone”
• Hospitalize patient
The distinction between acute and chronic high suicide risk informs clinical interventions. However, no bright line separates acute from chronic high suicide risk. The term “acute” describes the intensity (severity) and magnitude (duration) of the symptom. A high-risk factor is supported by an evidence-based association with suicide.5 Some patients remain at high risk for suicide for periods that can last for hours, days, weeks, or even a few months.5 Patients at chronic high risk for suicide can become acutely suicidal in response to specific psychosocial stressors or to idiopathic worsening of their disorders.
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 Isomets 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 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
Antidepressant activation of suicidal symptoms and behaviors can occur at any time during treatment, but it usually occurs early in treatment. All depressed patients require careful monitoring, especially during the first few months following initiation of treatment.16
Hopelessness. Using the Beck Hopelessness Scale (BHS), Beck and colleagues17 found that scores of 9 or more identified eventual suicide in 10 of 11 depressed patients with suicidal ideation who were followed for 5 to 10 years after hospital discharge. In a subsequent study of outpatients, a BHS cutoff score of 9 or higher identified 16 of the 17 eventual suicides.18 The high-risk group was 11 times more likely to complete suicide than the other outpatients.
Substance abuse. Suicide mortality for alcoholics is approximately 6 times the rate for the general population.19 In addition to alcohol, abuse of other substances is associated with increased suicide completions. Comorbid psychiatric disorders are common.
Recent interpersonal loss. The loss of an important relationship is a high–suicide risk factor when associated with depression, prior suicide attempt(s), hopelessness, suicidal ideation, and substance abuse.20 Other recent life events associated with completed suicides in patients with personality disorders include family discord, financial problems, and unemployment.21 Multiple adverse life events incur additional suicide risk.
Impulsivity and aggression. Impulsivity is a trait factor or predisposition associated with suicide. Impulsivity can be acute or chronic. Life stressors intensify the tendency to act impulsively. A case-control study of 153 case subjects found that 24% spent less than 5 minutes between the decision to attempt suicide and a near-lethal attempt.22 Attempters with major depression manifest great-er aggression and impulsivity than do nonattempters.23
Family history of suicide. Adoption and twin studies demonstrate a concordance between biological relatives for suicidal behaviors.24 In The Copenhagen Adoption Study,there was a 6-fold increase in suicide among biological relatives of adoptees who completed suicide compared with biological relatives of matched adoptees who had not completed suicide.25 No suicides occurred among the adopting relatives of the suicide group or of the con-trol groups. Suicide was an independent variable from the transmission of psychiatric disorders.
A family history of suicide is a chronic risk factor, especially for patients with mood disorders. A genetic component exists in the etiology of affective disorders, schizophrenia, alcoholism and substance abuse, and cluster B personality disorders.26
Recent psychiatric hospital discharge. After brief hospitalization, psychiatric inpatients are frequently discharged at some level of suicide risk, and they require close follow-up medication management and psychotherapy. Postdischarge suicides tend to occur within 3 months of discharge, often within a week or on the day of discharge.27 Screening for ongoing suicide risk is critical for this group of psychiatric patients.
Conclusion
Unique, individual patient suicide risk factors as well as a patient’s prodromal escalation of suicide risk can escape detection in the brief medication management appointment. The Suicide Risk Screening Alert is a clinical tool that assists the psychiatrist and nonpsychiatric physician in identifying patients at risk for suicide during brief medication management appointments. It can be especially useful for identifying suicide risk in new patients and at the early stages of medication management. Patients who are identified to be at significant suicide risk usually require systematic suicide risk assessment.
References:
References
1. Meyer DJ, Simon RI. Split treatment. In: Simon RI, Hales RE, eds. The American Psychiatric Publishing Textbook of Suicide Assessment and Management. Arlington, VA, American Psychiatric Publishing, Inc; 2006.
2. Mark TL, Levit KR, Buck JA. Datapoints: psychotropic drug prescriptions by medical specialty. Psychiatr Serv. 2009;60:1167.
3. Simon RI. Preventing Patient Suicide: Clinical Assessment and Management. Arlington, VA: American Psychiatric Publishing, Inc; 2011.
4. Breen R, Thornhill JT. Noncompliance with medications for psychiatric disorders: reasons and remedies. CNS Drugs. 1998;9:457-471.
5. Fawcett J. Depressive disorders. In: Simon RI, Hales RE, eds. The American Psychiatric Publishing Textbook of Suicide Assessment and Management. 2nd ed. Washington, DC: American Psychiatric Publishing; 2012.
6. Harris CE, Barraclough B. Suicide as an outcome for mental disorders. A meta-analysis. Br J Psychiatry. 1997;170:205-228.
7. Kessler RC, Borges G, Walters EE. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry. 1999;56:617-626.
8. Beck AT, Steer RA, Ranieri WF. Scale for suicidal ideation: psychometric properties of a self-report version. J Clin Psychol. 1988;44:499-505.
9. Simon RI. Gun safety management with patients at risk for suicide. Suicide Life Threat Behav. 2007;37:518-526.
10. Isometsä ET, Heikkinen ME, Marttunen MJ, et al. The last appointment before suicide: is suicide intent communicated? Am J Psychiatry. 1995;152:919-922.
11. Fawcett J, Scheftner W, Clark D, et al. Clinical predictors of suicide in patients with major affective disorders: a controlled prospective study. Am J Psychiatry. 1987;144:35-40.
12. Cooper J, Kapur N, Webb R, et al. Suicide after deliberate self-harm: a 4-year cohort study. Am J Psychiatry. 2005;162:297-303.
13. Fawcett J. Treating impulsivity and anxiety in the suicidal patient. Ann N Y Acad Sci. 2001;932:94-105.
14. Zimmerman M, Chelminski I, McDermut W. Major depressive disorder and axis I diagnostic comorbidity. J Clin Psychiatry. 2002;63:187-193.
15. Pfeiffer PN, Ganoczy D, Ilgen M, et al. Comorbid anxiety as a suicide risk factor among depressed veterans. Depress Anxiety. 2009;26:752-757.
16. Trivedi MH, Wisniewski SR, Morris DW, et al. Concise Associated Symptoms Tracking scale: a brief self-report and clinician rating of symptoms associated with suicidality. J Clin Psychiatry. 2011;72:765-774.
17. Beck AT, Steer RA, Kovacs M, Garrison B. Hopelessness and eventual suicide: a 10-year prospective study of patients hospitalized with suicidal ideation. Am J Psychiatry. 1985;142:559-563.
18. Beck AT, Brown G, Berchick RJ, et al. Relationship between hopelessness and ultimate suicide: a replication with psychiatric outpatients. Am J Psychiatry. 1990;147:190-195.
19. Mann JJ, Waternaux C, Haas GL, Malone KM. Toward a clinical model of suicidal behavior in psychiatric patients. Am J Psychiatry. 1999;156:181-189.
20. American Psychiatric Association. Practice guideline for assessment and treatment of patients with suicidal behaviors [published correction appears in Am J Psychiatry. 2004;161:776]. Am J Psychiatry. 2003;160(11 suppl):1-60.
21. Murphy GE, Wetzel RD, Robins E, McEvoy L. Multiple risk factors predict suicide in alcoholism. Arch Gen Psychiatry. 1992;49:459-463.
22. Heikkinen ME, Henriksson MM, Isometsä ET, et al. Recent life events and suicide in personality disorders. J Nerv Ment Dis. 1997;185:373-381.
23. Simon OR, Swann AC, Powell KE, et al. Characteristics of impulsive suicide attempts and attempters. Suicide Life Threat Behav. 2001;32(1 suppl):49-59.
24. Brent DA, Bridge J, Johnson BA, Connolly J. Suicidal behavior runs in families. A controlled family study of adolescent suicide victims. Arch Gen Psychiatry. 1996;53:1145-1152.
25. Schulsinger F, Kety SS, Rosenthal D, Wender PH. A family study of suicide. In: Schou M, Stromgren E, eds. Origin, Prevention and Treatment of Affective Disorders. Orlando, FL: Academic Press Inc; 1979:277-287.
26. Mann JJ, Arango V. The neurobiology of suicidal behavior. In: Jacobs DG, ed. Harvard Medical School Guide to Suicide Assessment and Intervention. San Francisco: Jossey-Bass Publishers; 1998:98-114.
27. Meehan J, Kapur N, Hunt IM, et al. Suicide in mental health in-patients within 3 months of discharge. Br J Psychiatry. 2006;188:129-134.
