Mr. Z chose what he believed to be an efficiently lethal way of dying in accord with his religious faith, knowing that a confrontation with the police could have a fatal ending. This case represents an instrumental motivation to die by SBC that was religiously motivated.
The authors’ observations
SBC presents a specific and serious challenge for law enforcement personnel, and should be approached in a manner different than other crisis situations. Because many individuals engaging in SBC have a history of mental illness, officers with training in handling individuals with psychiatric disorders—known as Crisis Intervention Team (CIT) in many areas—should be deployed as first responders. CITs have been shown to:
- reduce arrest rates of individuals with psychiatric disorders
- increase referral rates to appropriate treatment
- decrease police injuries when responding to calls
- decrease the need for escalation with specialized tactical response teams, such as Special Weapons And Tactics.17
Identification of SBC behavior is crucial during police response. Indicators of a SBC include:
- refusal to comply with police order
- refusal to surrender
- lack of interest in getting out of a barricade or hostage situation alive.18
In approaching a SBC incident, responding officers should be non-confrontational and try to talk to the suicidal individual.8 If force is needed to resolve the crisis, non-lethal measures should be used first.8 Law enforcement and mental health professionals should suspect a SBC situation in individuals who have had prior police contact and are exhibiting behaviors outlined in the Table.16
Once suicidality is identified, it should be treated promptly. Patients who are at imminent risk to themselves or others should be hospitalized to maintain their safety. Similar to other suicide modalities, the primary risk factor for SBC is untreated or inadequately treated psychiatric illness. Therefore, the crux of managing SBC involves identifying and treating the underlying mental disorder.
Pharmacological treatment should be guided by the patient’s symptoms and psychiatric diagnosis. For suicidal behavior associated with bipolar depression and other affective disorders, lithium has evidence of reducing suicidality. Studies have shown a 5.5-fold reduction in suicide risk and a >13-fold reduction in completed suicides with lithium treatment.19 In patients with schizophrenia, clozapine has been shown to reduce suicide risk and is the only FDA-approved agent for this indication.19 Although antidepressants can effectively treat depression, there are no studies that show that 1 antidepressant is more effective than others in reducing suicidality. This might be because of the long latency period between treatment initiation and symptom relief. Ketamine, an N-methyl-d-aspartate glutamate receptor antagonist, has shown promising results because of its acute effect on depression.20 Because of its rapid symptom relief, ECT remains the standard for treating suicidality related to treatment-resistant depression, psychosis, or mania.21
OUTCOME Medication adjustment
After Mr. Z is medically stable, he is voluntarily transferred to the inpatient psychiatric unit where he is stabilized on quetiapine, 200 mg/d, and duloxetine, 60 mg/d, and attends daily group activity, milieu, and individual therapy. Because of Mr. Z’s chronic affective instability and suicidality, we consider lithium for its anti-suicide effects, but decide against it because of lithium’s high lethality in an overdose and Mr. Z’s history of poor compliance and alcohol use.
Because of Mr. Z’s socioeconomic challenges, it is necessary to contact his extended family and social support system to be part of treatment and safety planning. After a week on the psychiatric unit, his mood symptoms stabilize and he is discharged to his family and friends in the area, with a short supply of quetiapine and duloxetine, and free follow-up care within 3 days of discharge. His mood is euthymic; his affect is broad range; his thought process is coherent and logical; he denies suicidal ideation; and can verbalize a logical and concrete safety plan. His support system assures us that Mr. Z will follow up with his appointments.
His DSM-522 discharge diagnoses are borderline personality disorder, bipolar I disorder, and suicidal behavior disorder, current.
The authors’ observations
SBC increases friction and mistrust between the police and the public, traumatizes officers who are forced to use deadly measures, and results in the death of the suicidal individual. As mental health professionals, we need to be aware of this form of suicide in our screening assessment. Training police to differentiate violent offenders from psychiatric patients could reduce the number of SBCs.9 As shown by the CIT model, educating officers on behaviors indicating a mental illness could lead to more psychiatric admissions rather than incarceration17 or death. We advocate for continuous collaborative work and cross training between the police and mental health professionals and for more research on the link between religiosity and the motivation to die by SBC, because there appears to be a not-yet quantified but strong link between them.