Suicide Assessment and Prevention _ ____________________________________________________________
• “Magical thinking” and vengeance: Associated with a feeling of power and complete control. This motivation to attempt suicide is driven by a “you’ll be really sorry when I’m dead” fantasy. A fatal outcome is intended, and this is sometimes called “aggressive suicide.” • Cultural approval: In some cultures, such as Japanese culture, society has traditionally accepted or encouraged suicide when matters of honor were concerned. • Lack of an outside source to blame for one’s misery: Evidence exists that rage and homicide is the extreme response when an external cause of one’s unhappiness can be identified, and depression and suicide is the extreme response in the absence of a perceived or iden- tifiable external source.
However, the American Academy of Pediatrics (AAP) recom- mends universal screening for suicide risk throughout adoles- cence (12 years of age and older) and clinically indicated screen- ing for children 8 to 11 years of age [94]. Screening should be performed in a developmentally and medically appropriate manner. The AAP notes that screening for depression is not the same as screening for suicide risk and that screening for depression alone misses 36% of patients at-risk for dying by suicide [94]. Screening children younger than 8 years of age is not recommended, but warning signs or parental reports of self-harm or suicidal behaviors should be assessed further; these may include [94]: • Talking about wanting to die or wanting to kill oneself • Grabbing their throat in a “choking” motion, or placing their hand in the shape of a gun pointed toward their head • Acting with impulsive aggression • Giving away their treasured toys or possessions The American Academy of Child and Adolescent Psychiatry recommends clinician awareness of patients at high risk for suicide (i.e., older male adolescents and all adolescents with current psychiatric illness or disordered mental state, particu- larly major depressive disorder), especially when complicated by comorbid substance abuse, irritability, agitation, psychosis, or previous suicide attempt [95; 125]. Suicide risk should be assessed at each visit in patients with long-term SSRI use.
SCREENING AND ASSESSMENT OF SUICIDE RISK
Many persons who die by suicide have contact with healthcare providers in the time preceding their deaths. Roughly 45% of all persons who die by suicide had contact with a mental health professional in the year before their deaths, and 75% of elderly persons who die by suicide had visited their physician in the month before their death [2; 5]. Although close to 90% of these cases had diagnosable psychiatric illness at the time of death, only 30% reported suicidal ideation or intent to a health pro- fessional before their suicide attempt [2]. These figures suggest a widespread inadequacy in identifying and assessing at-risk persons by healthcare professionals, and numerous studies have concluded that health professionals often lack sufficient training in the proper assessment, treatment, management, or referral of suicidal patients [2; 5]. Many health professionals also lack training in identifying grieving family members of loved ones who have died by suicide [5]. Primary care provid- ers occupy a niche in the healthcare system and have perhaps the greatest opportunity to impact suicidal persons through educational means [5; 46; 59; 60; 91]. SCREENING IN THE PRIMARY CARE SETTING: EXPERT CONSENSUS Many organizations have issued consensus statements regarding screening for suicide risk in the primary care setting. The U.S. Preventive Services Task Force (USPSTF) states that although suicide screening is of high national importance, it is very dif- ficult to predict who will die from suicide and has found insuf- ficient evidence for routine screening by primary care clinicians to detect suicide risk and limited evidence of the accuracy of screening tools to identify suicide risk in the primary care set- ting [92; 96]. The USPSTF recommends physicians screen all adolescents 12 to 18 years of age for major depressive disorder. The Canadian Task Force on Preventive Health Care found insufficient evidence for routine screening by primary care clinicians to detect depression and suicide risk [93].
ASSESSMENT OF SUICIDE RISK Initial Inquiry
Healthcare providers may encounter a patient they suspect is suicidal. This suspicion may be prompted by the presence of one or more of the risk factors for suicide described previ- ously, patient history, a statement expressed by the patient, or by their intuition. This scenario may present a dilemma of how to proceed. Although some healthcare professionals are uncomfortable with suicidal patients, it is essential not to ignore or deny the suspicion of suicide risk. The first and most immediate step is to allocate adequate time to the patient, even though many others may be scheduled. Showing a willingness to help begins the process of establishing a positive rapport with the patient. Closed-ended and direct questions at the beginning of the interview are not very helpful; instead, use open-ended questions such as, “You look very upset; tell me more about it.” Listening with empathy is in itself a major step in reducing the level of suicidal despair and overall distress [59; 60]. It is helpful to lead into the topic gradually with a sequence of useful questions, such as [59; 60]: • Do you feel unhappy and helpless? • Do you feel desperate? • Do you feel unable to face each day? • Do you feel life is a burden?
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