Similar to suicide protection, suicide prevention focuses on factors that can serve as obstacles to a patient’s desire or ability to commit suicide. A large systematic literature review by Mann et al24 found that only primary care physician education and restricting access to lethal means prevented suicide. When working to remove lethal means from a suicidal patient’s home, it is critical to verify that this has been done rather than merely making a suggestion to a family member. It is necessary to follow up with a phone call and document the completion of this task.
When a patient commits suicide, it is common for psychiatrists to feel like there must have been something they could have done to prevent such a tragedy. Although typically that is not the case, there is more we can do to improve our suicide risk assessment skills. Focusing on acute, modifiable suicide risk factors may help us lower a patient’s risk. Also, shortening the time frame now considered acute (within 1 year) to hours and days and looking for additional risk factors may improve mental health professionals’ ability to accurately assess acute suicide risk.
Table 2
Treatments to lower suicide risk
| Acute |
| Benzodiazepines—to diminish panic, anxiety, insomnia |
| Antipsychotics—if acute psychosis is present |
| Trazodone (or non-benzodiazepine hypnotics)—if insomnia is present without daytime anxiety |
| Diagnosis–specific |
| Clozapine—for patients with schizophrenia and high suicide risk |
| Lithium—for patients with bipolar disorder (if not contraindicated); consider for patients with refractory unipolar depression at high suicide risk |
| Electroconvulsive therapy—for patients with severe depression and high suicide risk |
| Source: References 14-20 |
CASE CONTINUED: Hospitalization and improvement
The psychiatrist determines Mr. L is at high risk for suicide and recommends psychiatric hospitalization. She starts him on citalopram, 10 mg/d, and clonazepam, 0.5 mg twice daily and 1 mg at bedtime, to help with anxiety and insomnia. After 3 days, Mr. L tolerates the medications, sleeps better, and feels more hopeful about the future. The psychiatrist increases citalopram to 20 mg/d.
Four days later, Mr. L is eating better, can concentrate, and denies further episodes of dizziness or anxiety. The inpatient psychiatrist assesses his acute suicide risk as low and discharges him to a week-long partial hospitalization program.
Related Resources
- American Association of Suicidology. www.suicidology.org.
- Harvard School of Public Health. Means Matter. www.hsph.harvard.edu/means-matter.
- Simon RI. Preventing patient suicide: clinical assessment and management. Arlington, VA: American Psychiatric Publishing; 2011.
Drug Brand Names
- Citalopram • Celexa
- Clonazepam • Klonopin
- Clozapine • Clozaril
- Lithium • Eskalith, Lithobid
- Trazodone • Desyrel, Oleptro
Disclosure
Dr. Freeman reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.