PRACTICE RECOMMENDATIONS
• An individualized assessment is essential to identifying relevant risk factors. C
• Use direct questions, such as, “Have you had any thoughts about killing yourself?” to screen for suicidal ideation. B
• Ask a family member or close friend to ensure that any guns or other lethal means of suicide are inaccessible to the patient at risk. C
• Avoid the use of “no harm” contracts, which are controversial and lack demonstrated effectiveness. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE When Dr. A, a 68-year-old retired gastroenterologist with a history of hypertension and hypertriglyceridemia, sees his family physician (FP) for a routine check-up, his blood pressure, at 146/88 mm Hg, is uncharacteristically high. When the physician questions him about it, the patient reports taking his hydrochlorothiazide intermittently.
Dr. A, whom the FP treated for depression 5 years ago, appears downcast. in response to queries about his current mood, the patient describes a full depressive syndrome that has progressively worsened over the past month or so. The FP decides to assess his risk of suicide. But how best to proceed?
Assessing suicide risk is an essential skill for a primary care physician. It is also a daunting task, complicated by the fact that, while mental illness often predisposes patients to suicide, large numbers of people who suffer from major depression or other mental disorders are at low risk for suicide. Yet FPs, who are often the first health care practitioners patients turn to for treatment of mental health problems1 and who frequently care for the same patients for years, are well positioned to recognize when something is seriously amiss.
The difficulty comes in knowing what the next step should be. Many researchers have attempted to develop algorithms, questionnaires, and scales to facilitate rapid screening for suicide risk. But the validity and utility of such tools are questionable. Most have a low positive predictive value and generate large numbers of false-positive results.2-4 Thus, while a standard short screen or set of questions may be included in a suicide risk assessment, these measures alone are inadequate.2,3
What’s needed is an individualized approach that focuses on evaluating patients within the context of their health status, personal strengths, unique vulnerabilities, and specific circumstances. Here’s what we recommend.
Identify patients in need
Consider an individualized suicide risk assessment for patients with any of the following:
- A presentation suggestive of a mental disorder or substance abuse5-8
- the onset of, change in, or worsening of a serious medical condition
- a recent (or anticipated) major loss or psychosocial stressor9
- an expression of hopelessness10
- an acknowledgement of suicidal ideation.
CASE Dr. A fits more than 1 of the criteria: in addition to the recurrence of his depressive symptoms, he expresses hopelessness—noting that he stopped taking his medication 2 weeks ago because ”it just doesn’t matter.”
Dig deeper to assess risk
There are 4 key components of the assessment and documentation of suicide risk: (1) An overall assessment of risk, eg, low, moderate, or high; (2) a summary of the most salient risk factors and protective factors; (3) a plan to address modifiable risk factors; and (4) a rationale for the level of care and treatment provided. A thorough evaluation is the core element of the suicide risk assessment.2,11
The depth of the evaluation depends on the apparent risk, with more effort required for those at moderate or higher risk. (For high-risk patients, severe symptoms may impede a lengthy interview, and the need for hospitalization may be obvious.)
Some of the information needed may be available from the patient’s prior history. The rest can be obtained from a current medical history, including a discussion of factors known to exacerbate—or mitigate—risk (TABLE 1). The most robust predictors of suicide include being male,12 single or living alone;13 inpatient psychiatric treatment;10,14 hopelessness;10,13 and a suicide plan or a prior suicide attempt (although most “successful” suicides are completed on the first try14,15). In addition, suicide is often precipitated by a crisis, including financial, legal, or interpersonal difficulties, housing problems, educational failure, or job loss.
Sex and age considerations. For women, the incidence of suicide is highest for those in their late 40s. For men, who have a higher risk overall, the incidence increases dramatically in adolescence and remains elevated through adulthood, with a second large increase occurring after the age of 70.12