DEPRESSION
November 1, 2005

Suicide Assessment, Intervention and Prevention

Morton M. Silverman, M.D.

Dr. Silverman is Senior Advisor, Suicide Prevention Resource Center Newton, MA, and Clinical Associate Professor of Psychiatry University of Chicago. Dr. Silverman reports no commercial conflict of interest.

Each year, more than 30,000 Americans take their own lives. An additional 500,000 Americans visit emergency rooms for self-inflicted injuries. Suicide is the third leading cause of death among children, teens and young adults ages 10 to 24. In the United States, about 4,000 young people die by suicide each year. Of the total number of suicides among ages 15 to 24 years, approximately 80% were male and 20% were female. And, every year, approximately 125,000 children and young people are brought to emergency rooms to receive treatment for injuries sustained while attempting suicide. The vast majority of these young people are between 15 and 24 years of age. In 2002, over 130,000 individuals were hospitalized following suicide attempts.

Males are four times more likely to die from suicide than females, while females are three times more likely than males to attempt suicide. Suicide rates are highest among Whites and second highest among Native American and Native Alaskan males. Annually, approximately 60% of all suicidal deaths in the USA involve the use of a firearm.

And, every year, approximately 125,000 children and young people are brought to emergency rooms to receive treatment for injuries sustained while attempting suicide.

Older people are also at increased risk of suicide. This is especially true of older men - 85 percent of people dying by suicide over the age of 65 are men. Over 80% of elderly suicidal deaths involve the use of firearms. Older adults who are suicidal are also more likely to be suffering from physical illnesses and be divorced or widowed.

Risk Factors
Suicidal behaviors are complex behavioral expressions that arise from many factors (psychological, biological, genetic, sociological, economic, etc.). Risk factors are anything that increases the likelihood that an individual will harm themselves, although risk factors are not necessarily causes. Research has identified the following risk factors for suicide:
  • Previous suicide attempt(s)
  • History of mental disorders, particularly depression and alcohol or other substance abuse
  • Family history of suicide
  • Acute or chronic losses (relational, social, work, financial or physical)
  • Chronic physical illness, particularly if associated with chronic pain
  • Easy access to lethal methods
  • Impulsive or aggressive tendencies
  • Feelings of hopelessness or isolation.

Ninety percent of suicides that take place in the United States are associated with mental illness, including disorders involving the abuse of alcohol and other drugs. Fifty percent of those who die by suicide were afflicted with major depression and the suicide rate of people with major depression is eight times that of the general population.

The relationship between suicide and family history is complicated and not fully understood. People with a parent, sibling or child who has died by suicide have a six-fold increased risk of doing the same. However, it is important to remember that most people who have had a close relative die by suicide do not attempt to kill themselves. Having a supportive family can protect people from suicide and self-harm. Some suicidal behavior may have a genetic component (possibly involving a predisposition to emotional illness combined with impulsiveness).

Protective Factors
Protective factors are believed to enhance resilience and serve to counterbalance risk factors. Protective factors can include:
  • An individual's genetic or neurobiological make-up
  • Attitudinal or behavioral characteristics
  • Family and community support
  • Effective and appropriate clinical care for mental, physical and substance abuse disorder
  • Easy access to effective clinical interventions and support for help-seeking
  • Restricted access to highly lethal methods of suicide
  • Cultural and religious beliefs that discourage suicide and support self-preservation instincts
  • Support from ongoing medical and mental health care relationships
  • Acquisition of learned skills for problem solving, conflict resolution and non-violent management of disputes.

The Role of Primary Care Physicians in Preventing Suicide
Since physical illness itself is a risk factor for suicide, primary care physicians and other health care providers are highly likely to see patients who are depressed and may be at risk of suicide. Most people who complete suicide signal their intention to do so before ending their lives and they often display these distress signals to their doctors. A substantial number of elderly people who die by suicide contact their primary care physicians within a month before their death.

The majority of patients who have risk factors for suicide will not die by suicide. However, the presence of multiple risk factors should alert the physician to the possibility that a patient may be at increased risk if there is the emergence of life stressors or sudden changes in their biopsychosocial environment that challenge the patient's ability to adapt and cope.

Cultural influences, including the specific ethnic and religious culture(s) that are important to the individual, may shape how they convey signs and symptoms of emotional distress.

Warning Signs
People who are in danger of harming themselves may try to reach out, often to their doctors, sometimes directly, sometimes indirectly (a "cry for help"). Rarely will potential victims immediately volunteer the information that they are thinking of harming themselves. Instead, they often describe their concerns in terms of physical symptoms.

Warning signs include:

  • Talking or writing about suicide, death or dying
  • Giving direct verbal cues, such as "I wish I were dead" and "I'm going to end it all" (suicidal threats)
  • Giving less direct verbal cues, such as "What's the point of living?," "Soon you won't have to worry about me," and "Who cares if I'm dead, anyway?"
  • Looking for ways to kill him- or herself: seeking access to pills, weapons or other means
  • Increasing alcohol or other drug abuse
  • Global insomnia
  • Isolating him- or herself from friends and family
  • Exhibiting a sudden and unexplained improvement in mood after being depressed or withdrawn
  • Neglecting his or her appearance and hygiene.

These signs are especially critical if the individual has a history or current diagnosis of a psychiatric disorder such as depression, anxiety or panic disorder, alcohol or drug abuse, bipolar disorder or schizophrenia.

People of different ages are at different levels of risk and display different types of warning signs. In addition, cultural influences, including the specific ethnic and religious culture(s) that are important to the individual, may shape how they convey signs and symptoms of emotional distress. Research indicates that many older adults who visited a primary care physician within a month of dying by suicide had an undiagnosed mental illness associated with suicide such as depression, or had a common medical condition associated with an increased risk of suicide such as diabetes, cancer (especially head and neck), kidney failure, peptic ulcer or rheumatoid arthritis. Pay careful attention to elderly individuals who are physically ill and who exhibit any of the following warning signs of suicide:

  • Stockpiling medications
  • Buying a gun
  • Giving away money or cherished personal possessions
  • Taking a sudden interest, or losing their interest, in religion
  • Failing to care for themselves in terms of the routine activities of daily living
  • Withdrawing from relationships
  • Experiencing a failure to thrive, even after appropriate medical treatment
  • Scheduling a medical appointment for vague symptoms.

Adolescents are also at an increased risk of dying by suicide, though their warning signs are different. Be alert for the following:

  • Volatile mood swings or sudden changes in their personality
  • Indications that they are in unhealthy, destructive, or abusive relationships such as unexplained bruises, a swollen face or other injuries, particularly those they refuse to explain
  • A sudden deterioration in their personal appearance
  • Self-mutilation
  • A fixation with death or violence
  • Eating disorders, especially combined with dramatic shifts in weight (other than those associated with a diet under medical supervision)
  • Gender identity issues
  • Depression.

Although rare, children are also at risk for suicide. Although the rate of suicide in 10-14 year olds has been slowly increasing over the last five years, it has been difficult to spell out the common risk factors or warning signs most often associated with suicidal behaviors in this age group.

Responding to the Warning Signs
There are no hard and fast guidelines for determining an individual's risk of suicide. However, if your doctor suspects that a family member or friend may be at risk, they should ask the sometimes difficult questions that will provide them with more evidence about the patient's state of mind and intentions, for example:
  • Do you ever wish you could go to sleep and never wake up?
  • Sometimes when people feel sad, they have thoughts of harming or killing themselves. Have you had such thoughts?
  • Are you thinking about killing yourself?
  • When was the last time that you thought about suicide?

The doctor will need to act immediately if they have any reason to believe that the patient is in imminent danger or poses a grave danger to him- or herself. Immediate action should also be taken when warning signs are combined with any of the following risk factors:

  • Past incidents of suicidal behavior or self-harm
  • A family history of suicide
  • A history of psychiatric disorders or the abuse of alcohol and other drugs
  • The patient's admission that he or she has considered suicide
  • The patient's expressed wish to die
  • Any evidence of a current psychiatric disorder.

If the person is uncooperative, combative or otherwise unwilling to seek help, and if you sense that the person is in acute danger, call 911 or (800) 273-TALK (8255). Tell the dispatcher that you are concerned that the person with you "is a danger to [him- or herself]" or "cannot take care of [him- or herself]." These key phrases will alert the dispatcher to locate immediate care for this person with the help of police. Do not hesitate to make such a call if you suspect that someone may be a danger to him- or herself. It could save that person's life.

Antidepressants and the Risk of Suicidal Behaviors
Medications and medication management can play a role in the therapy of suicidal adolescents and young adults. Medications may be helpful in cases where the diagnostic condition and related symptoms can benefit from the careful use of certain medications.10 This may be particularly true in a case where a needed level of symptom reduction allows for greater accessibility to and success with cognitive, behavioral or verbal modes of clinical psychotherapeutic intervention.

Recently, the Food and Drug Administration (FDA) has determined that there is some evidence for an association between the administration of SSRIs and the emergence of suicidal behaviors, particularly in children and adolescents.

Antidepressants are the class of medications scientifically shown to be effective in reducing the symptoms of depression. They have also been shown to be effective in the treatment of obsessive-compulsive disorder, panic disorder, eating disorder, tobacco dependence, as well as other disorders. The use of medications (especially antidepressants) should always be considered when developing a comprehensive treatment plan for patients with a major depressive disorder, or when a patient expresses suicidal ideation, intent or plans. There are reasons to believe that selective serotonin reuptake inhibitors (SSRIs) might reduce suicidality because of their potential to reduce irritability, affective response to stress, hypersensitivity, depression and anxiety. Popular SSRIs include Prozac, Zoloft and Paxil. SSRIs may effectively reduce suicidal ideation. SSRIs remain the preferred psychopharmacological treatment for young adult depression, with caution that suicidal patients on SSRIs must be watched for any increase in agitation or suicidality, especially in the early phase of treatment.

Recently, the Food and Drug Administration (FDA) has determined that there is some evidence for an association between the administration of SSRIs and the emergence of suicidal behaviors, particularly in children and adolescents. It remains speculative if SSRIs might specifically increase akathisia (the pattern of intense inner restlessness often associated with neuroleptic and antidepressant drugs) in children and adolescents. If they do, even in a very small percentage of patients, individuals will most likely needed additional medicines to counteract this side effect — at least during the initial phases of antidepressant medication treatment.

Although akathisia is a relatively rare side effect, it is extremely important that during the first few months of treatment with any antidepressant medication the mental health professional carefully monitor for this side effect as well as for the signs and symptoms of depression. Dosage levels must be considered carefully and hoarding of pills by the patient prevented. In a similar sense, access to medications by a suicidal young adult must be severely limited. While medications may be essential in the stabilization and treatment of the suicidal young adult, all administration must be carefully monitored by a third party who can report any unexpected change of mood, increase in agitation or emergency state, or unwanted side effects, and who can regulate dosage.

Because the management of suicidal patients is complex, it is highly recommended that a psychiatrist be consulted or that the patient be referred to a psychiatrist for more specialized assessment and intervention.

Voluntary Admission and Involuntary Commitment
If a determination is made that a patient needs an inpatient assessment or treatment, it is always preferable to have the patient be an active participant in the decision to be hospitalized. It is always preferable for the patient to agree voluntarily to be hospitalized and to "sign in" on their own - taking full responsibility for their decision and acknowledging the purpose of the hospitalization. When it is deemed that a patient is a danger to himself/herself or to others, and therefore needs to be hospitalized, the patient can voluntarily consent to the admission.

When the patient is incapable (or refuses) to "sign in" voluntarily, it is incumbent upon the clinician to initiate an involuntary commitment process, ideally in collaboration with the patient's family or significant other, whereby the patient is hospitalized against their will. All states have policies and procedures to initiate and complete the involuntary commitment process.

The Prevention of Suicide
Few schools and communities have comprehensive suicide prevention plans that include screening, referral and crisis intervention programs. Although many different programs have been developed, mostly aimed at high school students, very few have been systematically evaluated for their short- and long-term efficacy and effectiveness.

Suicide prevention strategies for youth have two general goals: case finding, with accompanying referral and treatment, and risk factor reduction. Case finding strategies: school-based suicide awareness curricula, screening, gatekeeper training, and crisis centers and hotlines. Risk factor reduction strategies include: restrictions of lethal means, media education, postvention (intervention after a suicide), crisis interventions and skills training (e.g., symptom management and competency enhancement for youth).

Screening programs employ a screening instrument to identify high-risk youth for further assessment and treatment. Popular programs such as SOS and TeenScreen do offer research findings which indicate that they effectively identify teens at risk, and do not themselves encourage suicidal behaviors.

The American Academy of Child and Adolescent Psychiatry identified the following public health approaches to suicide prevention in children and adolescents:

  1. crisis hotlines;
  2. method restriction;
  3. indirect case-finding by educating potential gatekeepers, teacher, parents, clergy and peers to identify the "warning signs" of an impending suicide;
  4. direct case-finding among high school or college students or among the patients of primary practitioners by screening for conditions that place teenagers at risk for suicide;
  5. media counseling to minimize imitative suicide; and
  6. training professionals to improve recognition and treatment of mood disorders.

Conclusions

To reduce the rising toll of premature deaths due to suicide, and to protect family and friends from the psychological burden and pain associated with surviving the death of a loved one, the greatest needs seem to be increased awareness, recognition and response to youth and the elderly in need and in times of crisis. This heightened sensitivity to the potential for self-injurious behaviors befalls parents, educators, school personnel, health care professionals, mental health professionals, clergy, first responders (firefighters, police, emergency technicians), and even youth and the elderly themselves.

Public education campaigns as well as professional training is needed to educate about the signs and symptoms of suicidal behavior, and how and when to intervene. For the public this means learning how to ask about suicidal thoughts and behaviors in a non-judgmental and supportive manner, how to convince a person to seek help, and how to ensure that the individual properly receives help. For the physician it means knowing when to ask, how to ask, how to listen for the tell-tale answers, and how to protect the patient from self-harm, which often includes how to work with friends and family members to provide safety, security, support and stability. Resources to provide effective interventions must be available at the community level and they must be affordable, accessible and age-appropriate. Intervention must be targeted first to the family, community (church and school) and physician's office.

The stigma of mental illness and the stigma associated with self-injurious or self-destructive behaviors remain obstacles to seeking care and remaining in care. Slowly our society is beginning to accept the fact that mental disorders are common and are treatable. As a society, we may well not be able to eliminate all the risk factors that increase the potential for suicidal behavior but suicidal behaviors are treatable and suicide is preventable.

Resources
Online Resources
American College of Emergency Physicians. (1997, reaffirmed 2001). Civil commitment: ACEP policy statement. Retrieved March 23, 2005, from www.acep.org/webportal/PracticeResources/PolicyStatementsByCategory/MentalHealth/

Bronheim, H. E., Fulop, G., Kunkel, E. J., Muskin, P. R., Schindler B. A., Yates W. R., et al. (1998). The Academy of Psychosomatic Medicine practice guidelines for psychiatric consultation in the general medical setting. Psychosomatics, 39(4), S8-S30. Retrieved March 23, 2005, from www.apm.org/prac-gui/psy39-s8.shtml

Frierson R. L., Melikian M., & Wadman, P. C. (2002). Principles of suicide risk assessment. How to interview depressed patients and tailor treatment. Postgraduate Medicine, 112(3), 65-66, 69-71. Retrieved March 23, 2005, from www.postgradmed.com/issues/2002/09_02/frierson4.htm

Gliatto, M. F., & Rai, A. K. (1999). Evaluation and treatment of patients with suicidal ideation. The American Family Physician, 59(6), 1500-1506. Retrieved March 23, 2005, from www.aafp.org/afp/990315ap/1500.html

Office of Quality and Performance, Veterans Health Administration. (2000). Major Depressive Disorder (MOD) clinical practice guidelines: Module A. Primary Care. Retrieved March 23, 2005, from www.oqp.med.va.gov/cpg/MDD/MDD_Base.htm These guidelines were developed for clinicians by the Department of Veterans Affairs and the Department of Defense. They draw heavily from the American Psychiatric Association and Agency for Health Care Policy and Research Clinical Practice Guideline No. 5: Depression in Primary Care. The guidelines include information on assessment and treatment of potentially suicidal patients, patient handouts on depression, and guidelines for treatment of depression. The guidelines, supporting documents, and tools are available online at the URL listed above.

Quinnett, P. (2000) Counseling suicidal people: A therapy of hope. Spokane, WA: QPR Institute. Retrieved March 23, 2005, from www.qprinstitute.com. This book was written for therapists, mental health workers, physicians, nurses, and others who are not clinical suicide counselors, but who might find themselves counseling people at risk of suicide. It provides tools and strategies for risk assessment and intervention.

Sharp, L. K., & Lipsky, M. S. (2002). Screening for depression across the lifespan: A review of measures for use in primary care settings. American Family Physician, 66(6), 1001-1008. Retrieved March 23, 2005, from www.aafp.org/afp/20020915/1001.html

Stovall, J., & Domino, F. J. (2003). Approaching the suicidal patient. American Family Physician, 68(9), 1814-1818. Retrieved March 23, 2005, from www.aafp.org/afp/20031101/1814.html

Books
Berman, A.L., Jobes, D.A., Silverman, M.M. (2006). Adolescent Suicide: Assessment and Intervention (2nd edition). Washington, D.C.: American Psychological Association Press.

Hawton, K., & van Heeringen, K. (Eds.). (2000). International handbook of suicide and attempted suicide. Chichester, UK: John Wiley and Sons.

Jacobs, D. (Ed.). (1999). The Harvard Medical School guide to suicide assessment and intervention. San Francisco: Jossey-Bass. Maris, R, Berman, A, and Silverman, M.M. (2000) Comprehensive Textbook of Suicidology. NY: Guilford Publications.

Articles
Center, C., Davis, M., Detre, T., Ford, D. E., Hansbrough, W., Hendin, H., et al. (2003). Confronting depression and suicide in physicians: A consensus statement. Journal of the American Medical Association, 289(23), 3161-3166.

Hamilton, N. G. (2000). Suicide prevention in primary care. Careful questioning, prompt treatment can save lives. Postgraduate Medicine, 108(6), 81-84, 87. Retrieved March 23, 2005, from www.postgradmed.com/issues/2000/11_00/hamilton.htm

Rutz, W. (2001). The role of primary physicians in preventing suicide: Possibilities, short-comings, and the challenges in reaching male suicides. In D. Lester (Ed.), Suicide prevention: Resources for the millennium (pp. 173-188). Philadelphia: Brunner-Routledge.

Videos
American Foundation for Suicide Prevention [Writer] & Kingsley Communications [Producer]. (1999). The suicidal patient: Assessment and care [Motion picture]. Available from the American Foundation for Suicide Prevention at www.afsp.org/survivor/doctor.htm.

General Resources on Suicide and Suicide Prevention
American Association of Suicidology (AAS) (www.suicidology.org). The American Association of Suicidology is a nonprofit organization dedicated to the understanding and prevention of suicide. It promotes research, public awareness programs, public education, and training for professionals and volunteers and serves as a national clearinghouse for information on suicide.

American Foundation for Suicide Prevention (AFSP) (www.afsp.org). The American Foundation for Suicide Prevention (AFSP) is dedicated to advancing our knowledge of suicide and our ability to prevent it. AFSP's activities include supporting research projects; providing information and education about depression and suicide; promoting professional education for the recognition and treatment of depressed and suicidal individuals; publicizing the magnitude of the problems of depression and suicide and the need for research, prevention, and treatment; and supporting programs for suicide survivor treatment, research, and education.

Depression and Bipolar Support Alliance (DBSA) (www.dbsalliance.org) is a patient-directed organization focusing on depression and bipolar disorder. The DBSA website includes resources that can be used to locate professional help or support groups, a wide selection of educational brochures on depression, bipolar disorder, and suicide prevention, and an online bookstore. The DBSA supports more than 1,000 peer-led support groups across the nation. These support groups can be located by using DBSA's website or calling (800) 826-3632.

National Alliance for the Mentally Ill (NAMI) (www.nami.org) is a nonprofit, grassroots, self-help, support and advocacy organization of consumers, families, and friends of people with severe mental illnesses, such as schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, obsessive-compulsive disorder, panic and other severe anxiety disorders, autism and pervasive developmental disorders, attention deficit/hyperactivity disorder, and other severe and persistent mental illnesses. NAMI has local and state affiliates in every state that can provide support and education. NAMI also provides information and referrals through its Information Helpline which can be reached at (800) 950-NAMI (6264). Hearing impaired callers should call the TTY number at (703) 516-7227 or toll free at (888) 344-6264.

National Center for Injury Prevention and Control (www.cdc.gov/ncipc/). The National Center for Injury Prevention and Control (NCIPC), located at the Centers for Disease Control and Prevention, is a valuable source of information and statistics about suicide, suicide risk, and suicide prevention. To locate information on suicide and suicide prevention, scroll down the left-hand navigation bar on the NCIPC website and click on "Suicide" under the "Violence" heading.

National Mental Health Association (NMHA) (www.nmha.org/) is a nonprofit organization addressing mental health and mental illness. Information available on the NMHA website includes fact sheets on depression, bipolar disorder, anxiety, substance abuse, and suicide; FAQs for consumers of mental health services; and a list of local affiliates who can be of assistance in finding mental health services in your area.

National Mental Health Consumers' Self-Help Clearinghouse (www.mhselfhelp.org) is a consumer-run national technical assistance center serving the mental health consumer movement. Among the resources available on the Clearinghouse Web site is a directory of mental health services that have significant consumer input (that is, input from people who use mental health services).

National Suicide Prevention Lifeline ( www.suicidepreventionlifeline.org). The National Suicide Prevention Lifeline provides immediate assistance to individuals in suicidal crisis by connecting them to the nearest available suicide prevention and mental health service provider through a toll-free telephone number: (800) 273-TALK (8255). Technical assistance, training, and other resources are available to the crisis centers and mental health service providers that participate in the network of services linked to the National Suicide Prevention Lifeline.

National Mental Health Information Center (www.mentalhealth.samhsa.gov/cmhs/) provides information on mental health and recovery for both professionals and the general public. This website includes Consumer/Survivor resources:

  • a Mental Health Services Locator featuring state directories of mental health and substance abuse treatment facilities and mental health services
  • Consumer/Survivor Publications (in the Publications menu at store.mentalhealth.org/publications/browse.asp

Suicide Prevention Action Network USA (SPAN USA) (www.spanusa.org). Suicide Prevention Action Network USA (SPAN USA) is the nation's only suicide prevention organization dedicated to leveraging grassroots support among suicide survivors (those who have lost a loved one to suicide) and others to advance public policies that help prevent suicide.

Suicide Prevention Resource Center (SPRC) (www.sprc.org). The Suicide Prevention Resource Center (SPRC) provides prevention support, training, and materials to strengthen suicide prevention efforts. Among the resources found on its website is the SPRC Library Catalog, a searchable database containing a wealth of information on suicide and suicide prevention, including publications, peer-reviewed research studies, curricula, and web-based resources. Many of these items are available online.

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