Abstract
This article presents charts from The American Psychiatric Association Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors, part of the Practice Guidelines for the Treatment of Psychiatric Disorders Compendium, and a summary of the assessment information in a format that can be used in routine clinical practice. Four steps in the assessment process are presented: the use of a thorough psychiatric examination to obtain information about the patient’s current presentation, history, diagnosis, and to recognize suicide risk factors therein; the necessity of asking very specific questions about suicidal ideation, intent, plans, and attempts; the process of making an estimation of the patient’s level of suicide risk is explained; and the use of modifiable risk and protective factors as the basis for treatment planning is demonstrated. Case reports are used to clarify use of each step in this process.
Introduction
The American Psychiatric Association’s Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors
1 distills an exhaustive survey of current understanding of the topic. The entire document is essential for appreciating the complexity of the subject. However, a summary of highlights can be adapted for everyday use in most situations calling for a suicide assessment by a psychiatrist. The steps illustrated in this review are:
• A thorough psychiatric evaluation with the identification of risk and protective factors;
• Specific questioning about suicide;
• Estimation of the level of suicide risk; and
• Treatment planning focused on modifiable risk factors
Case reports will demonstrate the utility of the Guideline.
Information Gathered from a Thorough Psychiatric Evaluation
The Guideline strongly emphasizes that a thorough psychiatric evaluation is the foundation of a suicide assessment. The psychiatrist’s knowledge of suicide risk factors and protective factors is used during the evaluation process to identify relevant factors for the individual patient. Areas to be evaluated include the patient’s current and past psychiatric diagnoses (with special attention to comorbidity); history of suicidal thoughts and actions; family history of suicide, attempts, and mental illness; personal strengths and vulnerabilities; acute and chronic life stressors; and; current complaints, symptoms, and mental state. The psychiatric symptoms of hopelessness and anxiety can be particularly relevant and substance use should also be assessed. Table 1 provides a concise summary of the wealth of information that comes from the psychiatric evaluation of patients with suicidal behavior.
Specific Questioning about Suicide
Direct and specific questions about suicide are essential in suicide assessment. The psychiatrist should ask about suicidal thoughts, plans, and behaviors. Accepting a negative response to an initial question about suicidal ideation may not be enough to determine actual suicide risk. A denial of suicidal ideation that is inconsistent with the patient’s presentation or current depressive symptomatology may indicate a need for additional questioning or collateral sources of information. The following questions may be helpful when asking about specific aspects of a patient’s suicidal thoughts, plans and behaviors (Table 2).
Estimation of the Level of Suicide Risk
Suicide occurs infrequently, even in high-risk populations. This statistical rarity makes suicide prediction, based on risk factors, either alone or in combination, impossible. Psychiatrists, however, can use the assessment of relevant suicide risk factors to help determine appropriate treatment settings and individual treatment plans. The objective of suicide risk assessment is to clarify the presence or absence of relevant risk and protective factors, and then estimate the patient’s individual risk for suicide. The primary and ongoing goal of this assessment is to reduce the patient’s suicide risk (Table 3).
Treatment Planning with a Focus on Modifiable Risk Factors
After the patient’s risk factors and protective factors are identified the clinician can focus on those factors that can be modified in order to reduce suicide risk. Immutable risk factors, such as the patient’s history, family history, and demographic characteristics, need to be recognized but they cannot be modified. Circumstantial risk factors that are difficult to modify, at least in the short term, include unemployment and marital difficulties. The focus of intervention needs to be factors that can be changed, risk factors that can be lessened, and protective factors that can be strengthened. Initial treatment should attend to the patient’s immediate safety and address their psychiatric disorders (mood disorders, psychotic disorders, substance use disorders, and personality disorders) and symptoms, such as anxiety, agitation, hopelessness, or insomnia. Reducing these risk factors will reduce the patient’s risk of suicide. Strengthening of protective factors, such as the social support system, is often done by educating family members or arranging for additional care through a hospital or day program. The treatment plan and each suicide assessment should be accurately documented (Table 4).
Case Report 1
A 68-year-old white widower is brought into the Emergency Department after he was prevented from shooting himself by his son (Table 5).
Step 1: History and Diagnosis
The psychiatric evaluation reveals a likely diagnosis of major depression, recurrent, severe and a history of one prior suicide attempt, an overdose, shortly after his wife died 3 years prior. He was hospitalized and treated with antidepressant medication and referred to a bereavement support group. He responded well and has not been on any medication for 2 years. (He was tapered off of his selective serotonin reuptake inhibitor [SSRI] after 1 year of treatment. He had experienced minor side effects.) Three months prior he had retired and he found the unstructured time to be more of a burden than a freedom. He began worrying more and more about what he would do the next day to fill his time. His sleep was disturbed and he began awakening earlier and earlier each morning; suicide seemed to him to be the only solution.
Step 2: Specific Suicide Inquiry
The patient reluctantly admits to increasingly persistent suicidal ideation over the past 2 months. The thoughts began as fleeting but became more prevalent and intense until he felt he had no choice but to “blow my brains out”. His son, who shares a two-family house with the patient, discovered the patient loading his shotgun early one morning.
Step 3: Level of Risk
There is little question that this patient represents a high risk of suicide. He should be admitted to the hospital on strict suicide precautions.
Step 4: Modify Risk Factors
His previous suicide attempt and recent retirement are significant risk factors for this patient.However, those factors cannot be changed. His depression can be treated and has responded to medication in the past. Aggressive treatment of the attendant symptoms of anxiety and insomnia will further reduce his short-term risk of suicide. A careful and well-documented discussion of the availability of weapons should take place with his son before he is discharged. Education of the patient and family should include a discussion of early symptoms of returning depression and the encouragement to seek treatment when symptoms first appear. Given the element of psychosocial precipitants present in both episodes of depression a referral to a psychotherapist would benefit this patient. Additionally, he could be encouraged to add some structured activity to his life, such as part-time or volunteer work. He should be advised to stay on antidepressant medication for a longer time period.
Case Report 2
A 32-year-old married, white woman is referred for a consultation by her obstetrician (Table 6).
Step 1: History and Diagnosis
She is 6-weeks postpartum with her second child and is experiencing symptoms of postpartum depression. After the birth of her first child 3 years ago she experienced some feelings of depression with insomnia and fleeting thoughts of harming herself and her baby. She was treated with an SSRI by her obstetrician and responded well. Her symptoms resolved. She was tapered off of the medication after 9 months and she was aware of the risk of recurrence with the birth of her second child and was started on antidepressant shortly after she began experiencing insomnia, 2-weeks postpartum. She is on a full dose of medication but her symptoms have not responded. She has trouble sleeping, worries about the safety of her children, has no appetite, and has anhedonia.
Step 2: Specific Suicide Inquiry
She has suicidal ideation accompanied with a feeling of persistent guilt about having a second child. She feels she is being punished for this “selfish decision”. She thinks about driving her car off a bridge with her children in it. This began as a passing thought but has become so frequent that the patient no longer drives. She has not thought about any other methods.
Step 3: Level of Risk
This patient is a moderate to high suicide risk and could rapidly become high risk for both suicide and homicide. She is resistant to hospitalization and has significant family and community support. Her mother moved in with the family and is able to stay for another month or so. Her husband is able to take family leave after her mother leaves. Both her mother and her husband understand the diagnosis and the need for close monitoring of the patient. The patient consents to information exchange between the psychiatrist and her mother and husband. Frequent visits and phone contact with the patient and her family members may be an alternative to hospitalization.
Step 4: Modify Risk Factors
The family should be educated about removing any guns or other potential methods of self-harm from the home. Increases in medication dosage and augmentation with another agent should be considered. Specific treatment for anxiety and insomnia will reduce her suicide risk by addressing those risk factors. The patient is breast-feeding and wishes to continue doing so. Therefore, psychotherapeutic interventions may be more acceptable to her than additional medications. Electroconvulsive therapy would be an appropriate treatment consideration if her depression continues. Frequent re-assessment is necessary with the understanding that more aggressive intervention may be needed. The patient and family might benefit from additional support at home, such as a nurse for the infant or a home health aide.
Conclusion
The APA Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors offers both an extensive discussion of the current understanding of the subject and a practical outline for conducting suicide assessments. It is suggested that the reader review the complete Guideline. This brief example of uses for the Guideline does not encompass the breadth and scope of the original nor does it offer the benefit of the extensive bibliography. The complete Guideline is
http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm.
Reference
1. American Psychiatric Association. Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors. 2nd ed. In:
Practice Guidelines for the Treatment of Psychiatric Disorders Compendium. Arlington, Va; 2004: 835-1027.