Will my patient attempt suicide again? Risk factors help you identify patients who need immediate hospitalization for safety ® Dowden Health Media s. J, age 32, comes to our mental health clinic seeking treatment for depression and anxi- Mety. She reportsCopyright she has attemptedFor personal suicide use only 3 times. Ms. J describes the first 2 attempts—both of which occurred when she was in her 20s after the end of a relationship—as “cries for attention” that were rela- tively innocuous. Her third suicide attempt, however, was an acetaminophen overdose approximately 1 year ago that resulted in hospitalization and irreversible liver damage. VEER Ms. J acknowledges that over the last several weeks / she has been thinking about suicide almost constantly, HAMELS especially as the anniversary of her fiancé’s death ap- proaches. She says she has a nearly full bottle of zolpi- LAURENT © dem in her medicine cabinet and fantasizes about taking all of them and just “going to sleep.” Elizabeth L. Jeglic, PhD Associate professor Department of psychology Many patients—especially those with depression—ex- John Jay College of Criminal Justice perience recurrent thoughts of death or a wish to die, New York, NY but only about 10% attempt suicide.1 To identify those who are at highest risk and warrant hospitalization, it is vital to assess how a history of suicidal behavior and other factors impact the risk for future suicide at- tempts. This article: • examines research on patients who have attempted suicide and risk factors for repeat suicide attempts • describes characteristics of patients with multiple attempts • explores the link between a history of self-injurious Current Psychiatry behavior and suicide attempts. Vol. 7, No. 11 19 continued For mass reproduction, content licensing and permissions contact Dowden Health Media. 19_CPSY1108 19 10/15/08 10:20:23 AM Table 1 remain consistently hopeless are more Repeated suicidal behavior: likely to kill themselves compared with Factors that increase risk those who have fl uctuating hopelessness levels.11,12 History of ≥1 suicide attempts Psychiatric diagnoses. More than 90% of Feelings of hopelessness persons who eventually commit suicide Suicide Presence of an Axis I or II disorder have a diagnosable mental disorder.8 Al- attempts High levels of perceived stress though almost all Axis I and II disorders History of physical or sexual abuse can increase the likelihood of a suicide at- tempt, certain disorders—including major Source: References 7,8 depression, bipolar disorder, schizophre- nia, substance use disorders, eating disor- ders, borderline personality disorder, and A strong predictor antisocial personality disorder—increase A previous suicide attempt is among the risk more than others.8 Clinical Point strongest predictors of future suicide at- Persons with a tempts.2-4 In a sample of clinically referred History of abuse—specifi cally sexual previous suicide European adolescents, those who had at- abuse—is associated with suicidal behav- tempted suicide were 3 times more likely ior. A study of depressed women age >50 attempt are 38 to try again during the 1-year follow-up found that among those who were sexu- times more likely to compared with those who had never at- ally abused before age 18, 83% reported commit suicide than tempted suicide.5 In addition, Harris et al6 1 suicide attempt and 67% made multiple 13 those with no past found that patients with a previous suicide attempts. Among women who had not attempt were 38 times more likely to even- experienced childhood sexual abuse, 58% attempts tually commit suicide than those with no reported a past suicide attempt and 27% past attempts. made multiple attempts.13 In a separate study of psychiatric inpa- tients, those who had been physically or Other risk factors sexually abused were more likely to have Other factors might help predict which made a suicide attempt than patients with individuals will continue to engage in sui- no such history.14 This study did not fi nd cidal behavior after a fi rst attempt (Table a difference in reported abuse between 1).7,8 Spirito et al7 followed 58 adolescent single and multiple suicide attempters. suicide attempters for 3 months after their initial attempt. Seven (12%) made a subse- Stressors. In many cases suicide attempts quent attempt, and 26 (45%) reported con- are precipitated by acute or chronic stress- tinued suicidal ideation. Depressed mood ors, including: was the strongest predictor of subsequent • job stress suicidal behavior, followed by poor fam- • chronic illness ily functioning, affect regulation diffi culty, • fi nancial problems and hopelessness. • relationship discord • retirement and declining physical Hopelessness. Beck et al9 found that pa- health (especially for older men) tients who scored ≥9 on the Beck Hope- • death of a loved one.15 lessness Scale (BHS)—the most common Anniversaries of the death of a loved self-report measure of hopelessness—were one or other diffi cult life events can in- approximately 11 times more likely to com- crease the risk for suicide attempts.16 mit suicide than patients who scored ≤8. A Risk is not necessarily cumulative—and study of hospitalized suicide attempters not all risk factors are weighted equally. In found that BHS scores were unique pre- general, however, the more risk factors a dictors of future suicide attempts.10 Sev- patient has, the greater the likelihood that Current Psychiatry 20 November 2008 eral studies have found that persons who he or she may attempt suicide.17 continued on page 27 20_CPSY1108 20 10/15/08 10:20:30 AM continued from page 20 Red fl ag: Multiple attempts Table 2 When assessing a patient’s suicide his- Common characteristics tory, ask about the number of attempts. A of multiple suicide attempters person who makes >1 suicide attempt—a multiple attempter—has a signifi cantly History of Axis I disorder (major depressive higher chance of making subsequent at- disorder, bipolar disorder, schizophrenia, tempts compared with those with 1 or no substance use disorders, eating disorders) attempts.18,19 High levels of perceived stress Persons who make multiple attempts High levels of depression share certain characteristics (Table 2).19- 21 Rudd et al19 compared 68 multiple at- Symptoms of borderline personality disorder tempters with 128 single attempters and Poor problem-solving skills found that multiple attempters had higher Family history of psychiatric illness levels of: Source: References 19-21 • suicide ideation • depression • hopelessness patients may not respond well to psycho- Clinical Point • perceived stress. logical interventions that focus on problem- Assess for self- Multiple attempters also had more Axis solving. injurious behavior I disorders and poorer social problem- solving skills and experienced their fi rst (SIB) because a psychiatric disorder at an earlier age than Self-harm and suicidal behavior history of SIB may single suicide attempters. Patients who engage in nonsuicidal self increase risk for 20 Similarly, Foreman et al found that harm—also called self-injurious behavior suicidal behavior compared with single suicide attempters, (SIB)—may be mistaken for suicide at- multiple attempters had higher levels of tempters. Although differences exist be- depression, hopelessness, and suicidal ide- tween suicide attempters and those who ation and met criteria for more Axis I diag- engage in SIB, evidence suggests that a noses. Multiple attempters also were more history of SIB increases risk for suicidal be- likely to be: havior.23,24 In a retrospective study of 4,167 • diagnosed with substance use disor- self-harmers, females who engaged in ≥4 ders, psychotic disorder, or borderline per- acts of SIB were more likely to die from sui- sonality disorder cide than those who engaged in ≤3 acts.25 A • unemployed and have relationship dif- cross-sectional analysis of data from 3,069 fi culties, a history of emotional abuse, and a students responding to a random Web- family history of psychiatric problems and based survey found that an increased in- suicide. cidence of SIB signifi cantly increased the Miranda et al21 found that compared odds of suicidal behavior.26 with single suicide attempters and suicide One hypothesis suggests that some per- ideators, multiple attempters had Axis I sons use SIB as a coping mechanism, and disorders more often and had a stronger SIB and suicide are on the same continuum wish to die during the attempt. In this of behaviors. Others postulate that suicide study, multiple suicide attempts increased attempters may use SIB to habituate them- by more than 4 times the likelihood that a selves to suicidal behavior. Joiner27 sug- person with a history of suicidal thoughts gests that individuals who commit suicide and/or behaviors would make another at- have rehearsed the suicidal behavior, thus tempt. Among 326 individuals in a military medical setting treated for suicidal behav- Want to know more? ior or severe suicidal ideation, multiple See this article at CurrentPsychiatry.com suicide attempters reported higher levels Suicide intervention: How to of ongoing distress that was unrelated to recognize risk, focus on patient safety Current Psychiatry specifi c life stressors.22 This suggests these SEPTEMBER 2007 Vol. 7, No. 11 27 27_R1_CPSY1108 27 10/16/08 1:16:02 PM Table 3 whether or not she requires hospitalization. Hospitalize? 4 questions Ms. J states that she is “pretty certain she will to guide your decision hurt herself” once she leaves the offi ce, so we hospitalize her. Are you having thoughts of hurting or killing yourself? If yes: What are you thinking/planning To determine if a patient requires immedi- to do? ate hospitalization, perform a specifi c sui- Suicide Do you have access to lethal means? cide inquiry. Although there is no surefi re attempts way to determine if a patient will kill him- What is the likelihood that you will hurt yourself? self or herself, asking specifi c questions can help you gauge risk.