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Suicide Risk: Comprehensive Assessment and Clinical Management. David A. Brent, M.D. Western Psychiatric Institute and Clinic March 28, 2006. Objectives. Review descriptive epidemiology of suicidal ideation, attempts, and completion

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suicide risk comprehensive assessment and clinical management

Suicide Risk: Comprehensive Assessment and Clinical Management

David A. Brent, M.D.

Western Psychiatric Institute and Clinic

March 28, 2006

  • Review descriptive epidemiology of suicidal ideation, attempts, and completion
  • Review risk factors for suicidality across the life span and diagnostic groups
  • Use risk factors for purposes of suicide risk assessment
  • Review management and treatment of patients who are suicidal or at high risk for suicide
descriptive epidemiology adolescents
Descriptive Epidemiology: Adolescents

Suicidal ideation 20%

Suicide attempts 1.3-3.8% males 1.5-10% females

Risk for recurrent attempts 15-30%/year

Risk for completed suicide 0.5-1.0%/year

Increased risk of suicideamong attempters 10-60-fold increased

descriptive epidemiology of suicidal ideation and behavior in adults
Descriptive Epidemiology of Suicidal Ideation and Behavior in Adults*

Lifetime ideation 13.5%

Ideation with a plan 3.9%

Attempt 4.6%

*Kessler et al., 1999


Hazard Functions of First Onset of Suicide Ideation, Plan, and Attempt (N=5877)*

*Kessler et al., 1999

suicide rates by age 1982 2002
Suicide Rates by Age, 1982-2002

Data are from Center for Disease Control and Prevention

2002 suicide rates by race gender age
2002 Suicide Rates by Race, Gender & Age

Data from the Center for Disease Control and Prevention

assessment of suicidal patients
Assessment of Suicidal Patients
  • Characteristics of suicidality
  • Current and lifetime psychopathology
  • Psychological characteristics
  • Family and environmental factors
  • Availability of lethal agents
characteristics of suicidality
Characteristics of Suicidality
  • Intent / current ideation
  • Lethality
  • Precipitant
  • Motivation
  • Environmental response
suicidal intent
Suicidal Intent
  • “Wish to die”— based on self-report of observable behavior
  • Belief about intent
  • Preparatory behavior
  • Prevention of discovery
  • Communication of intent
  • Higher in completers than attempters
  • Predicts reattempt and completion
assessment of suicidal ideation
Assessment of Suicidal Ideation
  • Have you ever thought you would be better off dead?
  • Do you have thoughts of wanting to hurt yourself? (intensity and frequency)
  • Do you have a plan?
  • Do you intend to carry it out?
  • What things keep you from acting on your thoughts (Reasons for Living)?
  • What things would increase the likelihood of trying to hurt yourself?
current suicidal ideation past behavior
Current Suicidal Ideation / Past Behavior
  • Intensity, now and worst ever
  • Frequency
  • Presence of active plan
  • Wish to carry out plan
  • Past history of attempt particularly within the past 6 months
progression of suicidality
Progression of Suicidality*

Ideation to plan 34%

Ideation to attempt 26% (90% in 1 yr)

Plan to attempt 72% (60% in 1 yr)

*Kessler et al., 1999

  • Modestly associated with intent
  • But impulsive acts can be very lethal
  • Children can have high intent and low lethality
  • High lethality is associated with higher risk of completion
  • Availability of lethal agents important in younger, impulsive suicides
  • Ratio of attempts to completions drops with age
non suicidal self harm
Non-Suicidal Self-Harm
  • Self-cutting, repetitive and stereotypical
  • To relieve distress/anger, pain, loneliness rather than to die
  • Often co-occurs with suicidal behavior
  • Abuse
  • Family discord
  • Romantic attachment disruption
  • Legal/disciplinary problems
  • Disruption of relationship very high risk for alcoholic suicides
  • Bereavement very important factor in geriatric suicidal behavior
  • Assess likelihood of recurrence
  • Wish to die or permanently escape psychological painful situation(1/3 in younger individuals, but increases with age)
  • To influence others
  • Get attention
  • Express hostility
  • Induce guilt
  • Over 80% of attempters and 90% of completers have at least one Axis I disorder
  • Most commonly mood disorder
  • High risk for bipolar disorder, particularly mixed state
  • Substance abuse
  • Cluster B disorders
  • Schizophrenia
  • Comorbidity, chronicity, severity
age and suicide
Age and Suicide
  • Suicide attempts and ideation more common in the young
  • Younger suicides more often involve Cluster B, substance abuse, impulsivity, aggression
  • Depression, schizophrenia-- suicide occurs relatively early in course
  • “Pure” depression and planned suicide more common in older adults
  • Alcoholics tend to commit suicide later in the course of the disorder
prediction of suicide attempt in community samples
Prediction of Suicide Attempt in Community Samples*
  • Demographic: Age 15-24, female, <12 years old
  • Psychiatric: Mood disorder, psychoses, PTSD, substance abuse, ASP
  • Those with 3+ risk factors are 9.2% of population, but make up 55.1% of all attempters

*Kessler et al., 1999

psychological characteristics
Psychological Characteristics
  • Hopelessness(dropout, poor treatment response, attempt)
  • Impulsivity and aggression (strong predictor of suicidal behavior, especially in presence of a mood disorder, familial component) - More important in suicide earlier in life
  • Social skills deficits(interpersonal problems)
  • Homosexuality, bisexuality(bullying, family rejection)
  • Inflexibility(in older suicides)
family and social factors
Family and Social Factors
  • Parental history of psychiatric illness and suicidal behavior
  • Abuse and neglect
  • Discord
  • Disruption of interpersonal relationships
  • Grief
  • Disconnection and “drifting”
abuse and neglect
Abuse and Neglect
  • Related to attempt and completed suicide
  • Sexual abuse prominent in early-onset disorders and attempts
  • Parental history of sexual abuse increases risk of attempt in offspring
  • Risk related to severity of abuse
  • Leads to cascade of mental health difficulties: early sexual activity, sexual assault, early pregnancy, marriage, divorce
  • Adversely affects course, adherence to treatment, response to treatment
family and social protective factors in adolescents
Family and Social Protective Factors in Adolescents
  • Parent-child connection
  • High parental expectations
  • Parental supervision and availability
  • School connection
  • Religious affiliation
  • Non-deviant peer group
protective factors in adults
Protective Factors in Adults
  • Supportive family
  • Live with other people (spouse, child)
  • Children at home
  • Sense of connection and support
  • In older people, “pride in aging”
  • Sense of purpose
availability of lethal agents
Availability of Lethal Agents
  • Case control and quasi-experimental study and guns
  • Detoxification of domestic gas
  • Blister packs for acetaminophen
  • SSRIs vs. TCAs
guns in the home suicide or age
Guns in the Home & Suicide (OR): Age †

*95% CI excludes 1.0

† Kellermann et al., 1992


Rates of Suicide by Firearm During the Six Years After Purchase Among Persons Who Purchased Handguns inCalifornia in 1991

The horizontal line indicates the age- and sex-adjusted average annual rate of suicide by firearm in California in 1991 through 1996 (10.7 per 100,000 persons per year).

Abstracted from Wintemute et al., New England Journal of Medicine, 341:1583-1589

acetominophen paracetomol and suicide
Acetominophen (Paracetomol) and Suicide
  • Liver damage associated with > 25 tablets (OR= 4.5)
  • Those with access to bottle vs. blister pack 3 times more likely to take > 25 tablets
  • Only 20% thought a warning would deter them
mnemonic for assessing suicide risk
Mnemonic for Assessing Suicide Risk




proximal risk factors
Proximal Risk Factors

Agitation - Anxiety, agitation, EPS, insomnia

Ideation - Active ideation with a plan

Depression - Depression and decline, hopelessness

Instability - Substance use, affective lability, mixed state or rapid cycling, brain injury

Loss - Of relationship, work, health, or function

Lethal agent- Availability of a gun

distal risk factors
Distal Risk Factors

Suicidal history - Personal or in family

Aggression and impulsivity

Difficult course - Poor treatment response, comorbid, severe

Difficult patient - Non-adherent

Abuse and trauma history

Disconnection from support, work, relationships

Substance or alcohol abuse

suicide among inpatients
Suicide Among Inpatients*
  • Risk 137 / 100,000 admissions
  • Majority on weekend pass
  • In hospital - not on constant observation
  • Admitted for either planning or making an actual attempt
  • Recent bereavement
  • Chronic disorder, psychotic
  • Family history of suicide

*Powell et al. 2000

suicide in psychiatric inpatients
Suicide in Psychiatric Inpatients*
  • 31% of inpatient suicides on unit, usually not on intense observation
  • Judged to be at low risk
  • Staffing, ward design, staff training, observation
  • Often homeless, SPMI, multiple admissions, previous non-adherence and self-harm

*Meehan et al., 2006

suicide within 3 months of discharge
Suicide within 3 Months of Discharge*
  • 32% occur within 2 weeks of discharge
  • Greatest number on first day post-discharge
  • 40% occurred before post-discharge contact with treatment in the community
  • Drugs and alcohol, non-adherence, previous self-harm, personality disorder
  • Prevention through improved treatment adherence and closer supervision (?)

*Meehan et al., 2006

suicide within 12 months of mental health service contact
Suicide within 12 Months of Mental Health Service Contact*
  • Youngest and oldest suicide victims least likely to be engaged in treatment
  • In those under 25 - outreach to those with schizophrenia substance abuse, non-adherence, legal or relationship issues
  • In the elderly, recognition of depression, especially in context of bereavement and decline in physical health; suicide pacts most common in those with ill health in themselves, partner, living alone, low support

*Hunt et al., 2006

risk for suicide in mood disorders bostwick 2000
Risk for Suicide in Mood Disorders (Bostwick, 2000)

Hospitalized for suicidality 8.6%

Hospitalized 4.0%

Outpatient 2.2%

Non-affectively ill 0.5%

Tends to occur relatively early in the course of illness

proximal risk factors for suicide in depression
Proximal Risk Factors for Suicide in Depression*
  • Agitation - Panic attacks, agitation, insomnia, poor concentration
  • Ideation - More specific (intent or planning)
  • Depression – Anhedonia; decline in health in elderly
  • Instability - Alcohol abuse
  • Loss, especially in elderly
  • Lethal agents

*Fawcett et al., 1990

distal risk factors for suicide in depression
Distal Risk Factors for Suicide in Depression
  • Suicide history - Personal and family
  • Aggression - Impulsive aggression
  • Difficult course – Hopelessness
  • Difficult patient - BPD
  • Abuse and trauma
  • Disconnection
  • Substance abuse
proximal risk factors for suicide in bipolar disorder
Proximal Risk Factors for Suicide in Bipolar Disorder*
  • Agitation - Anxiety
  • Ideation - Ideation and recent attempt
  • Depression - More prominent
  • Instability - Mixed state, rapid cycling, substance abuse
  • Loss
  • Lethal agents

*Hawton, 2005a

distal risk factors for suicide in bipolar disorder
Distal Risk Factors for Suicide in Bipolar Disorder*
  • Suicide history - Personal and family
  • Aggression and impulsivity - ? Role of lithium
  • Difficult course - More time in depressive state
  • Difficult patient – Non-compliant
  • Abuse and trauma
  • Disconnection
  • Substance abuse

*Hawton et al., 2005a

proximal risk factors for suicide in schizophrenia
Proximal Risk Factors for Suicide in Schizophrenia*
  • Agitation, EPS (Extra- pyramidal Symptoms)
  • Ideation
  • Depression and decline
  • Instability - Drug abuse
  • Loss - Recent loss, fear of mental isintegration
  • Lethal agent

*Hawton et al., 2005b

distal risk factors for suicide in schizophrenia
Distal Risk Factors for Suicide in Schizophrenia*
  • Suicide history - Personal and family
  • Aggression and impulsivity
  • Difficult course
  • Difficult patient - Non-adherent
  • Abuse and trauma
  • Disconnection
  • Substance abuse

*Hawton et al., 2005b

proximal risk factors for suicide in alcoholics
Proximal Risk Factors for Suicide in Alcoholics*
  • Agitation
  • Ideation - Ideation, threat, attempt
  • Depression and hopelessness
  • Instability - Recent heavy drinking, drug abuse
  • Loss - Recent interpersonal loss (within 6 weeks)
  • Lethal agents

*Murphy, 1992; Conner et al., 2003, 2004

distal risk factors for suicide in alcoholics
Distal Risk Factors for Suicide in Alcoholics*
  • Suicide history - Personal and family
  • Aggression - Impulsive aggression
  • Difficult disorder - Early onset, comorbid, chronic course
  • Difficult patient - Non-adherent
  • Abuse and trauma
  • Disconnection
  • Substance abuse (especially polysubstance abuse)

*Murphy, 1992; Conner et al., 2003, 2004

proximal risk factors for suicide in eating disorders
Proximal Risk Factors for Suicide in Eating Disorders
  • Agitation – Obsessive concern about weight
  • Ideation
  • Depression and hopelessness
  • Instability - Drug and alcohol abuse, mood lability
  • Loss
  • Lethal agent
distal risk factors for suicide in eating disorder patients
Distal Risk Factors for Suicide in Eating Disorder Patients
  • Suicide - Personal history
  • Aggression and impulsivity - Cluster B personality
  • Difficult course - Poor treatment response, binging / purging, high obsessionality, lower BMI, longer course
  • Difficult patient
  • Abuse and trauma
  • Disconnection
  • Substance abuse
proximal risk factors for geriatric suicide
Proximal Risk Factors for Geriatric Suicide
  • Agitation - Insomnia, anxiety, traumatic grief
  • Ideation
  • Depression, decline and hopelessness
  • Instability
  • Loss of relationship; health, function (in self or spouse)
  • Lethal agent
distal risk factors for geriatric suicide
Distal Risk Factors for Geriatric Suicide
  • Suicidality - Personal and family history
  • Aggression - Not so prominent
  • Difficult course
  • Difficult patient
  • Abuse and trauma
  • Disconnection from supports
  • Substance abuse
why target depression
Why Target Depression?
  • 80% of attempters and 60% of completers are depressed
  • Depression increases the risk for suicidal behavior 10- to 50-fold
  • Quality improvement studies also suggest that improved treatment of depression reduces suicidality risk (Asarnow et al., 2005; Wells et al., 2001; Brown et al., 2001)
  • Pharmacoepidemiological studies show reduction in suicide with SSRI use
treatment of depression reduces suicidal risk
Treatment of Depression Reduces Suicidal Risk
  • Gotland study – Improvement in GPs ability to treat depression resulted in decreased suicide rate
  • PROSPECT – Collaborative care for depressed suicidal elders was more effective than TAU for reducing suicidality
  • Pharmaco-epidemiology studies – Increase in SSRI prescription related to decline in suicide, particularly in 15-24 year-olds
treatment of depression may not reduce suicidal risk
Treatment of Depression May NotReduce Suicidal Risk
  • The most suicidal individuals are excluded from clinical trials of depression
  • Suicidality is associated with other factors that also predict treatment non-response of depression (chronicity, severity, comorbidity, personality disorder)
storosum et al 2001 dutch studies 1983 1997
Storosum et al., 2001: Dutch Studies, 1983-1997

Short Term

Long Term

Suicide Rate %

Suicide Rate %0



changes in mood and suicidality not always closely related
Changes in Mood and Suicidality NotAlways Closely Related
  • Suicidal behavior is multifactoral
  • Studies of CBT, IPT, antidepressants differentially decrease depression, but not suicidal ideation, attempts (Brent, 1997; Lerner, 1990; Mufson, 1999; Khan et al., 2000; Storosum et al., 2001)
  • Studies that decrease suicidal ideation / attempts do not affect mood (Linehan, 1991; Harrington, 1998; Wood, 2001)
  • SSRIs may increase suicidal risk
ssris and suicidality a summary of the fda findings
SSRIs and Suicidality: A Summary of the FDA Findings
  • Rate of “suicidality” increased 1.78-fold
  • On average drug vs. placebo, 4% vs. 2%
  • Mostly new or worsened ideation, few attempts, no completions – question clinical significance
  • Early in treatment
  • Most common in trials that also showed increase in hostility
  • No difference in ideation on standard measures
  • More pronounced in non-depressed (e.g., anxious, OCD) subjects
pittsburgh meta analysis efficacy and suicidality in pediatric clinical trials for mdd ocd and anx
Pittsburgh Meta-Analysis: Efficacy and Suicidality in Pediatric Clinical Trials for MDD, OCD and ANX*

Response % SuicidalityIndication N Drug Placebo NNT Drug Placebo NNH

MDD 2,750 59.5 47.9 9 45/1,708 21/1,433 125

OCD 705 51.5 32.2 6 4/362 1/339 200

ANX 1,143 68.9 38.8 3 6/573 1/582 143

*Bridge et al., in preparation

suicidality and antidepressants
Suicidality and Antidepressants

Drug % Placebo % Pooled Pooled

Risk Difference* Relative Risk*

(95% CI) (95% CI)

MDD 2.6 1.5 0.8% 1.7

(-0.2%-1.8%) (0.97-2.8)

OCD 1.1 0.3 0.5% 1.8

(-0.1%-2.2%) (0.4-8.5)

ANX 0.4 0.2 0.7% 3.1

(-0.0%-1.8%) (0.6-16.8)

*Using random effects models


Rates of Suicide Attempts During the 3 Months Before and the 6 Months After Initial Antidepressant Prescriptiona

aBars indicate 95% confidence intervals

Simon et al., 2006

dialectical behavior therapy dbt
Dialectical Behavior Therapy (DBT)
  • Linehan et al., 1991: DBT vs. TAU: 64% vs. 96%
  • 1 year follow-up: DBT vs. TAU: 26% vs. 60% (parasuicide episodes), by 2 years, differences were gone
  • Van der Bosch 2002: lower DSH in BPD with SA
  • Bohus et al., 2004:lower DSH: 38% vs. 69%
cbt for prevention of recurrent attempts
CBT for Prevention of Recurrent Attempts
  • Chain analysis of attempt
  • Focus on cognitions leading to attempt
  • Safety plan
  • Case management
  • Two-fold reduction in re-attempt

Brown et al., 2005


Survival Curves of Time to Repeat Suicide Attempt*

*Brown, G. K. et al. JAMA 2005;294:563-570.

treatment studies with suicidal youth
Treatment Studies with Suicidal Youth

Harrington et al. (1998) – Home-based family intervention no better than TAU for adolescent overdose attempts. In non-depressed group family treatment reduced ideation

Wood et al (2001) – 6-session group treatment >TAU for reducing single (OR=.6) and recurrent attempts (OR=.16), anger, and conduct disorder, but not depression. More of experimental treatment better, more of TAU worse.

effects of long term contact on suicide
Effects of Long-Term Contact on Suicide*
  • 843 inpatients hospitalized for depression or suicidality and refused ongoing care
  • Randomized to contact or no contact
  • Contact letter with 24 contact, over 5 years
  • Significant in suicide rate difference at 2 years = 1.7-% vs. 3.6%

*Motto & Bostrom, 2001

aftercare postcards from the edge
Aftercare: Postcards from the Edge*
  • 772 patients who made overdose, ≥ 16 years of age
  • Received postcards (up to 8) and standard treatment vs. standard treatment alone
  • Proportion of repetition in experimental group is lower (15.1% vs. 17%)
  • RR=0.55
  • Reduction in bed-days=110

*Carter et al., 2005

pharmacologic targeting of impulsive aggression and or suicidal behavior
Pharmacologic Targeting of Impulsive Aggression and/or Suicidal Behavior
  • Lithium – decreases aggression, quasi-experimental findings, decreases suicide rate in adults
  • Neuroleptics – Risperidone decreases aggression in children, RCT clozapine > olanzapine for suicidal schizophrenics
  • SSRIs – decrease in impulsive aggression in one study, did not decrease recurrent suicide attempts in two studies

Forest Plot Showing Meta-Analysis of Suicides Plus

Deliberate Self-Harm in Randomized Trials Comparing

Lithium with Placebo or Active Comparators

Cipriani et al., 2005

lithium and odds of suicidal behavior
Lithium and Odds of Suicidal Behavior

*Baldessarini, 2003 †Coppen, 2000 ‡Goodwin, 2003

direct targeting of suicidal behavior clozapine
Direct Targeting of Suicidal Behavior: Clozapine*
  • 980 schizophrenic or schizoaffective patients
  • Randomized to clozapine or olanzapine
  • Suicide attempt rate lower in those treated with clozapine (34% vs. 55%, p=0.03)

*Meltzer et al., 2003

Montgomery et al., 1994: Prevention of Recurrent Suicide Attempts in Patients with Recurrent Brief Depression
tasa treatment of adolescent suicide attempters cbt
TASA (Treatment of Adolescent Suicide Attempters) CBT
  • Safety plan
  • Case management
  • Chain analysis of attempt
  • Focus on cognitions leading to attempt
  • Two-fold reduction in re-attempt in Brown et al. (2005)
  • Now being tested in multi-site study of adolescent attempters funded by NIMH
chain analysis of suicide attempt
Chain Analysis of Suicide Attempt
  • Precipitant
  • Motivation
  • Negative affect
  • Hopelessness
  • Emotion regulation
  • Environmental response

Management of “External Factors” in Treatment of Attempters



Availability of Lethal Agents

School Problems


Social Skills


Interpersonal Difficulties

Restrict Access to Means

Case Management

Adjust Expectation

Family Therapy , Education

Treatment of Parents


Management of “Internal Factors” inTreatment of Attempters

Negative Affect and other Disorders


Emotional Lability



Positive Health Habits


Cognitive Restructuring

Emotion Regulation

Distress, Tolerance, Treatment Disorder

in setting treatment priorities ask collaboratively
In setting treatment priorities, ask (collaboratively):
  • What will yield the greatest risk reduction for the least effort?
  • Is it something that can be changed?
  • Does the patient want to / have the capability to change this factor?
relapse prevention session
Relapse Prevention Session
  • Imagine situation that led to attempt
  • Role play how would cope now
  • Identify skills and resources necessary to stay well
treatment guidelines
Treatment Guidelines
  • Establish safety plan
  • Increase likelihood of adherence
  • Determine appropriate level/intensity of care
  • Increase hopefulness about treatment
  • Conduct chain analysis of the attempt
  • Target most relevant individual and environment factors to the suicide attempt
  • Increase protective factors (family connection)
  • Coping plan, hope kit
safety plan
Safety Plan
  • Will try to implement coping plan
  • Promises family and clinician not to engage in suicidal behavior OR
  • Will contact clinician/family/responsible adult if suicidal thoughts reoccur
  • Need 24-hour availability or back-up
  • Review precipitants, develop truce and conduct brief training in emotional regulation
  • Secure lethal agents
secure lethal agents
Secure Lethal Agents
  • Find out motivation for gun ownership
  • Find out who owns the gun
  • Negotiate most secure situation possible
  • Parental regulation of medication
  • Address hopelessness about treatment first
  • On a scale of 1-10, how hopeful are you that we can help you? What would increase/decrease it?
  • Establish concrete, realistic, achievable goals
  • Reasons for Living
  • Predict “bumps in the road” to prevent undue discouragement
  • Educate parents and families about depression as a chronic and recurrent illness
  • Depression is nobody’s fault
  • Help set reasonable expectations regarding chores, school, work
  • Often family members are worried and want information and reassurance from a withdrawn and secretive patient
  • Goal to teach family and patient how to monitor for treatment response, side effects, and long-term course
recognize intercorrelation of health risk behaviors
Recognize Intercorrelation of Health Risk Behaviors
  • Unprotected sex
  • Alcohol, drug, tobacco use
  • Weapon-carrying
  • Binge eating and obesity
  • Bullying/being bullied
increase protective factors
Increase Protective Factors
  • Improve family-patient connection, supervision, expectations
  • Improve school connection (when relevant)
  • Choice of friends and romantic attachments / marriage
  • Connection to social groups and institutions
education and anticipation relapse and recurrence prevention
Education and Anticipation: Relapse and Recurrence Prevention
  • Sleep hygiene
  • Avoidance of tobacco, alcohol and drugs
  • Pleasurable activities
  • Self-talk and practice of skills
  • Exercise
  • Detection of relapse
  • Provide a framework for assessing suicidal risk, examining proximal and distal risk factors
  • Discussed the management of the suicidal patient with regard to development and implementation of a safety plan
  • Reviewed empirical data base on interventions to decrease risk of suicidal behavior