Assessing Risk for Self Harm

Suicide remains the ninth leading cause of death in the US, resulting in almost 30,000 deaths annually. Self-directed violence (suicidal attempt) result in more than 600,000 emergency department visits annually. Ninety percent of people who commit suicide have a diagnosable mental disorder--commonly depression or substance abuse. Four times as many men as women die by suicide, but women are more likely to attempt suicide. White men commit 72% of all suicides. The greatest risk occurs within 3 months of the first attempt. The suicide rate among persons with alcohol dependence is 50 times that of persons without alcohol dependence. Depression combined with social isolation and the recent loss of an intimate relationship dramatically increases risk.

Patients, particularly elders, who commit suicide are more likely to have established a treatment relationship with a primary care physician (PCP). Postmortem studies have suggested that up to 75% of persons who commit suicide have physical illness. In one study, 20% of older patients who committed suicide visited their PCP on the same day as their suicide, 40% within 1 week, and 70% within 1 month. These findings put the PCPs on the front line in identifying depressed and suicidal patients and underscore the importance of suicide risk assessment in primary care.

The most consistent demographic factors associated with risk for suicide are reported to be White, male, over 45 years old, living alone and having a chronic medical illness with self-perceived poor health. Expressions of hopelessness has been identified as a particularly ominous sign, and patients who admit to an organized plan of action are at maximum risk. In a recent review of factors assessing patients for potential suicide in a Florida (Orlando) emergency room and consultation-liaison setting on a ward (N=100), the following were observed to be the most useful predictors. Suicide attempts were most common in persons who lived alone, between the ages of 17 and 35 and with anhedonia, sleep disorder and severe hopelessness with intermittent bouts of severe anxiety and/or panic. Additionally, they complained of interpersonal conflict and inability to function in school or at work, and had recently been abusing either alcohol or drugs.

The hierarchy of potential self-harm progresses from suicidal ideation to suicidal intent to suicidal plan. Almost everyone at some point in their life has had passive suicidal ideation, where an individual has no intention of self action but may not avoid at-risk situations (e.g. crossing the street without looking). Ideation may also be active wherein the individual is contemplating possible deliberate action. Active suicidal ideation is the first stage of potential self-harm requiring a formal risk assessment and therapeutic intervention. Suicidal intent is the indication of heightened risk wherein the individual has contemplated self-harm and is at some degree of emotional preparation for carrying out such action. A risk assessment and therapeutic followup is necessary when evidence of suicidal intent is presented. As with ideation, intent may be passive or active. Passive intent may be adequately addressed with outpatient treatment however active intent may require involuntary placement to assure safety. The third stage, having a plan to perform suicide, may not necessarily imply imminent risk however this must be assumed and arrangements for protection made. The following provides an outline for assessing suicidal risk and general procedures for ensuring safety.

Patients who demonstrate active suicidal ideation or passive thoughts of suicide (eg, by saying "Life doesn't seem worth living") require a formal suicide risk assessment to include consideration of:

· Current suicidal thoughts, intent, and plan

· History of suicide attempts (eg, lethality of method, circumstances)

· Family history of suicide

· History of violence (eg, weapon use, circumstances)

· Intensity of current depressive symptoms and anxiety

· Current treatment regimen and response

· Recent life stressors (eg, marital separation, job loss)

· Alcohol and drug use patterns

· Psychotic symptoms

· Current living situation (eg, social supports, availability of weapon)

The mnemonic SAD PERSONS provides an easily remembered list of the salient variables to consider when conducting a suicide risk assessment:

S	Sex (male)
A	Age (elderly or adolescent)
D	Depression (or affective disorder)
P	Previous suicide attempts
E	Ethanol abuse
R	Rational thinking loss (psychosis)
S	Social supports lacking
O	Organized plan to commit suicide
N	No spouse (divorced > widowed > single)
S	Sickness (physical illness)

When conducting a suicide risk assessment begin with an empathic, open-ended request, such as "Tell me about those thoughts. How did you come to feel this way?" Follow up with more specific, closed-ended questions, such as "How long have you had these thoughts? Do you have a specific plan? Have you told anyone?" Also inquire about the patient's reasons for not having attempted suicide, because this may provide valuable information in formulating the treatment plan.

Depressed patients who express suicidal ideation but deny plan or intent should be evaluated carefully for psychosocial stressors and treated with antidepressant medication on an outpatient basis. Even if they deny suicidal plan or intent, depressed patients with suicidal ideation and psychotic symptoms (eg, command hallucinations, delusions of control) should be hospitalized.

Depressed patients with suicidal ideation and a plan but without intent may be treated on an outpatient basis, especially when they have good social support and no access to lethal means. Outpatient treatment may consist of antidepressant therapy (preferably with antidepressants that are safe in overdose), referral to a drug and alcohol treatment program, psychotherapy, or all of these.

Depressed patients with suicidal ideation, plan, and intent should be hospitalized, especially if they have current psychosocial stressors and access to lethal means. When a patient's life is in imminent danger, the care provider may breach confidentiality and contact a family member or other responsible agent. Depressed patients who refuse hospitalization may be involuntarily committed in most states if their suicidal thinking makes them a danger to themselves or others.

It is noteworthy that many patients who “contract for safety” later commit suicide. The use of these contracts may give the care provider a false sense of security and provides no protection from legal liability.