Suicide assessment: Targeting acute risk factors

Although a history of suicide attempts and a family history of suicide are well-established risk factors,⁹ these are not acute factors. It is important to differentiate between suicide attempts and suicide completions. Although many suicide attempts are accurate substitutes for actual suicides, there is a spectrum of intent in suicide attempts that differentiates them in terms of lethality.¹⁰ Clinicians need a more thorough understanding of who is at acute risk for suicide, which will help them make decisions about patients’ imminent risk to themselves.

In the only study that examined time-related predictors of suicide, Fawcett et al¹¹ used the Schedule for Affective Disorders and Schizophrenia (SADS) to evaluate 954 patients with major affective disorders over 10 years. Raters were blinded to treatment, and clinicians could use any combination of psychotherapy or pharmacotherapy. These researchers found that acute risk factors—those associated with suicide within 1 year—were psychic anxiety, anhedonia, diminished concentration, insomnia, panic attacks, and active alcohol abuse (Table 1).¹¹ These factors were present in the context of an underlying depressive disorder. Hopelessness, suicidal ideation, and a history of suicide attempts were linked to suicide between 2 and 10 years.

Busch et al¹² performed a retrospective study on an inpatient unit using the SADS to evaluate symptoms present the week before patients’ suicides. They found that 79% of patients had extreme psychic anxiety, agitation, or both, and that 54% had active psychosis. The same authors studied an additional 12 cases of inpatient suicide and found 9 patients had severe anxiety, agitation, or both, and insomnia. The median time to suicide from admission was 3.5 days and none of the 12 patients had been started on an antidepressant, antipsychotic, or anxiolytic. This underscores the need to initiate symptomatic treatment quickly, even before reaching a definitive diagnosis.

The Columbia Suicide Severity Rating Scale (C-SSRS), which evaluates suicide ideation and behavior in the past week and lifetime, has predictive validity in determining those at highest risk for making a suicide attempt within up to 24 weeks of follow-up.¹³ A limitation of the C-SSRS is that it has predictive validity for suicide attempts only, and not suicide completions.

Table 1

Acute suicide risk factors: 3 A’s + 3 P’s

Treatments to lower risk

Although identifying risk factors such as older age, being unmarried, male sex, experiencing a recent loss, a family history of completed suicide, and being white or Native American are helpful in evaluating a patient’s suicide risk, they are not time-sensitive or modifiable, which limits their value.

In contrast, most of the acute risk factors identified by Fawcett et al potentially are treatable. Psychic anxiety, insomnia, and panic attacks can be treated with benzodiazepines or other anxiolytics and sedative/hypnotics. Active psychosis, which Busch et al identified as a risk factor for inpatient suicide, may respond to antipsychotics.

Other medications have been identified as modifying suicide risk (Table 2).^14-20 Among patients with major affective disorders, lithium has been shown to reduce suicidal acts by 93%, suicide attempts by 93%, and suicide completions by 82%.¹⁴ Lithium produces the largest suicide risk reduction in unipolar depression, at 100%, followed by bipolar II disorder (82%) and bipolar I disorder (67%).¹⁵ Several studies have demonstrated that lithium can reduce the mortality rate from suicide for patients with affective disorders, and that this effect persists.^16,17

Clozapine has been associated with reduced rates of suicide attempts and completed suicides in patients with chronic psychosis. In a meta-analysis, long-term clozapine treatment was associated with an approximately 3-fold overall reduction of risk of suicidal behaviors,¹⁸ although a prospective study found no reduction in risk of completed suicide in patients with schizophrenia treated with clozapine.¹⁹

In one study, electroconvulsive therapy (ECT) reduced suicidal thoughts and acts by 38% after 1 week and 80% overall.²⁰ There have been reports of amelioration of suicidal thoughts after just 1 ECT treatment.²¹ There are no published studies that show a reduction in suicide completions with ECT; however, this may be due to the relatively small number of patients who receive ECT and the infrequency of completed suicides.

Protective factors. The balance between protective factors and risk factors determines appropriate clinical decision making when attempting to evaluate a patient’s suicide risk. Perhaps the best measure of protective factors is the Reasons for Living Inventory, developed by Linehan et al,²² which has been validated in some populations, including adolescents and young adults.²³ This inventory delineates protective factors against suicidal ideation and behavior rather than completed suicides.