The psychiatrist is concerned about Mr. S’s suicide risk and the need for hospitalization. The psychiatrist performs a systematic suicide risk assessment that includes identification of individual and evidence-based protective factors. For example, Mr. S continued to pursue his interests and to participate in civil causes. The overall suicide risk is determined by the assessment of individual and evidence-based protective factors.
All of the following options are evidence-based protective factors except:
a) therapeutic alliance
b) survival and coping beliefs
c) responsibility to family
d) fear of suicide
e) moral objections to suicide
The best response option is A
Clinical consensus holds that the therapeutic alliance is an important protective factor against suicide. However, no evidence-based research supports or refutes this widely held belief among clinicians.
Linehan et al15 developed the Reasons for Living Inventory, a self-report instrument that identifies 6 subscales:
• survival and coping beliefs
• responsibility to family
• child-related concerns
• fear of suicide
• fear of social disapproval
• moral objections to suicide.
Survival and coping beliefs, responsibility to family, and child-related concerns were useful in differentiating between suicidal and non-suicidal individuals. Malone et al16 administered the Reasons for Living Inventory to 84 inpatients with major depression; 45 had attempted suicide. Depressed patients who had not attempted suicide demonstrated more sense of responsibility toward family, more fear of social disapproval, more moral objections to suicide, greater survival and coping skills, and greater fear of suicide than patients who attempted suicide. The authors recommended adding the Reasons for Living Inventory to the assessment of patients at risk for suicide.
Question 8
A 38-year-old mother of a newborn child is admitted to the psychiatric unit after expressing suicidal thoughts to her husband. She has been hospitalized previously after a hypomanic episode and severe depression; she has no history of suicide attempts. A psychiatrist diagnoses bipolar II disorder (recurrent major episodes with hypomanic episodes). The patient’s maternal aunt has bipolar disorder. Her paternal grandfather committed suicide.
The psychiatrist conducts a systematic suicide risk assessment and determines the patient is at high risk of suicide. He considers a suicide-risk reduction drug.
Which one of the following drugs has been shown to reduce suicide and suicide attempts in bipolar II patients?
a) clozapine
b) clonazepam
c) lorazepam
d) lithium
e) quetiapine
The best response option is D
Prospective, randomized and controlled trials consistently have found lower rates of completed suicides and suicide attempts during lithium maintenance treatments for patients with bipolar disorder and other major affective disorders.17
Bottom Line
Suicide risk assessment and management are challenging for even experienced clinicians. Suicide risk assessment guides appropriate treatment and management for patients at risk for suicide. This self-assessment helps mental health professionals identify potential gaps in their knowledge and reinforce best practices.
Related Resources
• Simon RI. Passive suicidal ideation: Still a high-risk clinical scenario. Current Psychiatry. 2014;13(3):13-15.
• Simon RI. Suicide rehearsals: A high-risk psychiatric emergency. Current Psychiatry. 2012;11(7):28-32.
• Bongar B, Sullivan GR. The suicidal patient: Clinical and legal standards of care. Washington, DC: American Psychological Association; 2013.
Drug Brand Names
Clonazepam • Klonopin Lorazepam • Ativan
Clozapine • Clozaril Quetiapine • Seroquel
Lithium • Eskalith, Lithobid
Disclosure
Dr. Simon reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Adapted with permission from: Simon RI. Preventing patient suicide: clinical assessment and management, Arlington VA: American Psychiatric Publishing; 2011.
Editor’s note: Part 2 of this self-assessment on suicide assessment and management in the November 2014 issue of Current Psychiatry poses 7 additional questions.