Principles of suicide riskassessment

How to interview depressed patients and tailortreatment

Richard L. Frierson, MD; Margaret Melikian, DO; Peggy C.Wadman, MD

VOL 112 / NO 3 / SEPTEMBER 2002 / POSTGRADUATE MEDICINE

CME learning objectives

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To become familiar with the major risk factors of suicide indepressed patients

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To learn the elements of a formal risk assessment for suicide indepressed patients

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To understand which symptoms of depression require aggressiveintervention through psychiatric referral or hospitalization

The authors disclose no ﬁnancial interest in this article.

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: Suicide is a signiﬁcant cause of death in the United States.Because many patients who commit suicide visit their primary carephysician in the weeks before their death, physicians need to be familiarwith suicide risk assessment techniques. In this article, Drs Frierson,Melikian, and Wadman discuss the demographics and risk factors of

suicide and propose a methodical, practical approach to assessing andmanaging suicide risk in depressed patients.

Frierson RL, Melikian M, Wadman PC. Principles of suicide risk assessment. Postgrad Med 2002;112(3):65-71

uicide is the eighth leading cause of death in the United States (1). In2002, more than 30,000 people will commit suicide in this country, theequivalent of more than 80 suicides a day or one every 20 minutes. Self-directed violence will result in more than 600,000 emergency departmentvisits.In 1999, in response to alarming statistics about suicide, US SurgeonGeneral David Satcher issued a call to action, stating that "the nation mustaddress suicide as a significant public health problem and put into placenational strategies to prevent the loss of life and the suffering suicidecauses" (2). This goal is enormous, and primary care physicians are crucialto achieving it.Because primary care physicians are trained to diagnose and treat medicalillness (including depression), they are accustomed to dealing with patientswho seek help for problems and who desire to live rather than to die. Asuicidal patient may evoke significant strong emotions in a physician, suchas anger toward the patient or fear of losing the patient, of personal failurein preventing suicide, or of medicolegal consequences if the patient makesa serious or successful suicide attempt. However, despite these emotions,physicians have tremendous potential to respond to this call to action byarming themselves with the knowledge and skill to successfully treatdepressed patients and prevent suicide.The confidential and personal nature of the physician-patient relationshipis unique. Patients often disclose information to their physicians that theywould not disclose to even a spouse or family member. These disclosuresmay include feelings of hopelessness or despair or frank suicidal thoughts.Furthermore, patients who commit suicide are more likely to haveestablished a treatment relationship with a primary care physician (3) and

to have visited their physician in the days or weeks before the suicide (4);this is especially true of older patients (5). According to one study (6),20% of older patients who committed suicide visited their primary carephysician on the same day as their suicide, 40% within 1 week, and 70%within 1 month. These findings put primary care physicians on the frontline in identifying depressed and suicidal patients and underscore theimportance of suicide risk assessment in primary care.A recent survey of physicians who lost a patient to suicide found that riskassessments had been completed in only 38% of cases (7). Another study(8) suggests that many primary care physicians have an age bias thatmakes them less likely to intervene or contemplate treating elderly suicidalpatients. Also, adequate assessment and management of suicidal ideationbecome a time-consuming process that may significantly increase jobstress for already stressed physicians (9). We may be reluctant to ask whatwe do not want to hear. A patient's admission of suicidal ideation makesour jobs more difficult, and suicide risk assessment cannot be donequickly.Through greater awareness of suicide risk assessment techniques,physicians may become more confident in dealing with depressed, suicidalpatients. Understanding the demographic variables and risk factors of suicide attempts can facilitate assessment of suicide risk.

Demographics

The rate of suicide in the United States is 10.6 per 100,000. Ninety percentof people who commit suicide have a diagnosable mental disorder--commonly depression or substance abuse (10). In 1997, suicidesoutnumbered homicides by a 3:2 ratio. Suicides were twice as common asdeaths due to HIV and AIDS. Firearm use is the most common method of committing suicide for both men and women and accounts for 58% of allsuicides. Four times as many men as women die by suicide, but women aremore likely to attempt suicide. White men commit 72% of all suicides(11).Suicide is most common in elderly people and adolescents. The highestrate of suicide is in men older than 85, occurring at a rate of 65 per