CHICAGO – The literature is clear that suicide cannot be predicted, but clinicians are obliged to assess it, said Dr. Cathy Frank, vice chair of clinical affairs in the department of psychiatry and behavioral sciences at Northwestern University, Chicago.
There is no perfect algorithm, she said, and no standardized scale is associated with a high predictive value, despite a number of proposals.
Dr. Cathy Frank
And so, most frustrating for the physician is the inability to accurately identify the potential suicide, Dr. Frank said as she reviewed current data on risk assessment and therapy, epidemiology, and risk factors at a seminar on reinventing inpatient psychiatry.
In the United States alone, suicide claims a life every 16 minutes, adding up to 33,300 people annually, compared with 20,000 deaths by homicide, Dr. Frank reported, citing data from the Centers for Disease Control and Prevention.
And, she explained, "It’s not just an illness of industrial populations." Worldwide, 1 million people die from suicide each year, a ratio of 16.7 suicides/100,000 lives (Lancet 2009;373:1372-81).
Nonfatal self-injury is more common in females than males. "Men are three times as likely to complete a suicide ... so gender matters," Dr. Frank said. Patients who have attempted suicide once are five to six times more likely to attempt it again (Arch. Gen. Psychiatry 1983;40:249-57).
Adolescents and young adults are the most likely to attempt suicide, and emergency department data suggest that 75% have a mental disorder and 9% have a diagnosis of alcohol abuse.
There are a variety of social and biological risk factors. Social risk factors include parental separation, family discord, child abuse, bullying, peer victimization, unemployment, living alone, and never having been married.
Physicians and dentists are the occupations most at risk, followed by police officers and military personnel. In 2006, male veterans of the Iraq and Afghanistan wars aged 18-29 years suffered 46 suicides/100,000 lives, a rate 2.3 times higher than in matched civilian population, according to the U.S. Department of Veterans Affairs. The availability of lethal weapons is key risk factor, because 60% of lethal attempts involve firearms. Men are more likely than are women to choose a violent death.
Biological and genetic risk factors have also been identified for suicide. Suicide attempts and completions run in families, independent of psychiatric diagnosis, and adoption studies provide evidence of a genetic basis of, Dr. Frank reported.
"The effectiveness of lithium and clozapine suggests a biological mechanism for suicide," Dr. Frank said. Lithium has both antiaggressive and anti-impulsive effects, she said.
High-risk patients include those with absence of social support, with family conflict, and patients diagnosed with schizophrenia or a mood disorder, along with those who have a history of suicide attempts.
Known markers of acute risk are moderate to severe depression; current mania and/or psychosis; alcohol and/or substance abuse within the last month; hopelessness; and suicidal intent. Markers of moderate risk include mild depression, moderate anxiety, and a history of suicide attempts, as well as chronic pain. Patients at low risk might have anxiety that is neither moderate nor severe, depressive disorder, or bipolar disorder in remission.
Treatment interventions depend on the patient’s mental state, and can range from electroconvulsive therapy and the use of psychotropic medications to straightforward self-management. Self-management is a key to successful treatment, said Dr. Frank, and should begin at admission, making patients active members of the treatment team and letting them help direct the course of treatment.
Family involvement is a particularly essential part of the guidelines and an integral part of treatment, Dr. Frank said. Families "are your eyes and ears." They can provide important collateral information and help assess risk, and family involvement may lower litigation risk. Family conflict, however, has been linked to inpatient suicide (J. Nerv. Ment. Dis. 2010;198:315-28).
The patient’s "community" is now also part of every treatment plan at Dr. Frank’s institution. "No clinician can be everything at all moments to the patient. So how do we involve community?" she said. Community support might include the National Alliance on Mental Illness, Alcoholics Anonymous, Narcotics Anonymous, and bereavement support groups, for example. Dr. Frank also suggests removing weapons from the patient’s home.
Dr. Frank disclosed no relevant conflicts of interest.