How do you score on this self-assessment of suicide risk management?: First of 2 parts

The assessment and management of suicide risk are com­plex and difficult tasks that raise clinical issues without clear-cut, easy answers. This case-based, multiple-choice self-assessment with accompanying commentaries is a teach­ing instrument that I designed to enhance a clinician’s ability to provide care for patients at risk for suicide. Part 1 of this article poses 8 of the 15 questions; the balance of questions will appear in Part 2, in the November 2014 issue of Current Psychiatry.

The questions and commentaries in this self-assessment orig­inate in the referenced work of others and my clinical experi­ence. Therefore, I use the preferred “best response” option—not the customary and more restrictive “correct answer” format.

How do you score?

Question 1
Mr. J, age 34, is a professional basketball player complaining of weight loss, early morning waking, and a dysphoric mood last­ing for 1 month. His performance on the basketball court has declined and his wife is seeking a separation. He describes “fleet­ing” suicidal thoughts. He has no history of suicide attempts or depression. The patient does not abuse alcohol or drugs.

The initial assessment approach is to:
a) obtain a suicide prevention contract
b) assess suicide risk and protective factors
c) determine the cause of Mr. J’s depression
d) have Mr. J complete a suicide risk self-assessment form
e) contact his wife for additional history

The best response option is B
Suicide prevention contracts do not prevent suicide.¹ Contacting the patient’s wife may be an option at a later stage of evaluation or treat­ment, if Mr. J grants permission. Determining the cause of his depression likely will require ongoing work up. Assessing suicide risk fac­tors without also looking at protective factors is a common error. A comprehensive suicide risk assessment evaluation requires evaluat­ing both risk and protective factors.^2,3 Suicide risk assessment forms often omit questions about protective factors.⁴ Do not rely on self-assessment suicide risk forms because they are dependent on the patient’s truthfulness. Patients who are determined to commit sui­cide might regard the psychiatrist and other mental health professionals as the enemy.⁵

Question 2
Ms. P, a 56-year-old, single schoolteacher, is admitted to a psychiatric unit for severe depres­sion and suicidal ideation without a plan. She is devoutly religious, stating, “I won’t kill myself, because I don’t want to go to hell.” Ms. P attends religious services regularly. She has a history of chronic recurrent depression with suicidal ide­ation and no history of suicide attempts. You suspect a diagnosis of bipolar II disorder.

In assessing religious affiliation as a protective factor against suicide, you should consider:
a) the nature of the patient’s religious conviction
b) the religion’s stated position on suicide
c) severity of the patient’s illness
d) presence of delusional religious beliefs
e) all of the above

The best response option is E
Dervic et al⁶ evaluated 371 depressed inpa­tients according to their religious or non-religious affiliation. Patients with no religious affiliation made significantly more suicide attempts, had more first-degree relatives who committed suicide, were younger, were less likely to be married or have children, and had fewer contacts with family members.

In general, religious affiliation is a protec­tive factor against suicide but may not be a protective factor in an individual patient. Religious affiliation, similar to other pre­summed general protective factors, requires further scrutiny. Avoid making assumptions. For example, a depressed, devoutly religious patient may curse God for abandonment. A patient with bipolar disorder may believe that God would forgive her for committing suicide. A presumed protective factor may not be protective or might even be a risk fac­tor, such as psychotic patients with religious delusions.

Abrahamic religions—ie, Judaism, Christianity, and Islam—prohibit sui­cide. Severe mental illness, however, can overcome the strongest religious prohibi­tions against suicide, including the fear of eternal damnation. For many psychiatric patients, religious affiliations and beliefs are protective factors against suicide, but only relatively. No protective factor against suicide, however strong, provides absolute protection against suicide. Moreover, other risk and protective factors also must be assessed comprehensively.

Question 3
Mr. W, age 18, is admitted to an inpatient psy­chiatric unit with severe agitation, thought disorder, disorganization, and auditory hal­lucinations. He is threatening to jump from a nearby building. He has no history of sub­stance abuse.

The psychiatrist conducts a comprehen­sive suicide risk assessment that includes the patient’s psychiatric diagnosis as a risk factor.

Which psychiatric disorder has the highest associated suicide mortality rate?
a) schizophrenia
b) eating disorders
c) bipolar disorder
d) major depressive disorder
e) borderline personality disorder

The best response option is B
Harris and Barraclough (Table)⁷ calculated the standardized mortality ratio (SMR) for suicide among psychiat­ric disorders. SMR is calculated by divid­ing observed mortality by suicide by the expected mortality by suicide in the general population. Every psychiatric disorder in their study, except for mental retardation, was associated with a varying degree of suicide risk. Eating disorders had the high­est SMR. The patient’s psychiatric diagno­sis is a risk factor that informs the clinician’s suicide risk assessment.

Question 4
Mr. Z, a 64-year-old, recently divorced lawyer, is admitted to the psychiatric unit from the emergency room. His colleagues brought Mr. Z to the emergency room because of his sui­cide threats.