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This issue of RECOVERe-works is dedicated to the memory of Robin Williams.

Suicide FAQs

Elizabeth Saenger, PhD

What are the risk factors for suicide?

In the US, bipolar disorder and major depression are associated with the highest rates of suicide. Other diagnoses linked to elevated suicide rates include substance use disorders, eating disorders, schizophrenia, borderline and antisocial personality disorders, and PTSD.

The strongest personal risk factor is a history of suicide attempts. Other factors include a familial history of suicide, childhood trauma, impulsivity, and the length of time since a person has been hospitalized for psychiatric reasons. One study of patients with schizophrenia found that 16% of post-discharge suicides occurred on the first day after release.

How should this information affect us as clinicians?

We should look at these factors when we do intakes and assessments, and be more vigilant with discharge planning and follow up. Perhaps, before discharge, we could collaboratively develop a checkup plan with each patient, particularly those at risk for suicide. This might begin with a call to touch base on the day of discharge, and continue until the patient connects with the next treating professional, or reaches an appropriate milestone in post-discharge life.

And just as cognitive behavioral therapists ask clients to start homework at the end of session to increase the chance that clients will complete homework on their own, hospitals could consistently encourage patients to work on discharge goals, such as making appointments for follow-up care, before they leave. Such care might include assignment to a peer specialist, since apart from humane and clinical considerations, peer specialist care for an entire ward is probably less expensive than a single suicide or suicide.

Perhaps our sense of duty and responsibility could become more like that of an ophthalmologist I knew. He apologetically interrupted a weekend in Key West to call patients on whom he had recently operated.

“I always tell them to call me with questions,” he told me, “but they rarely do, especially the elderly ones. They feel they’d be interrupting. So I call them.” It seemed that in under five minutes, he could call several patients. A few would be greatly relieved to find out that they no longer had to worry about something. I imagine this one-minute check-in method would be even more vital to detect serious problems, and intervene, in ophthalmology and behavioral health.

What can we do to protect our clients when we think they may be suicidal?

In addition to asking standard assessment questions about ideation, intent, and method, you can:

Let clients know you care. Sometimes feeling cared about makes a huge difference to a client. Explain you are worried about them. Communicate a “granite belief” that their lives are “a life worth living”—the sentiment psychologist Kay Jamison, PhD, attributed to the psychiatrist who kept her alive when she was suicidal.

Remind them that the hopelessness they feel is a symptom of the depression, and not reality. This reassurance often takes seconds, but can have a big impact.

Tell patients the urge to kill themselves will ebb and flow—and negotiate. Help individuals figure out how to minimize the chance they will act when they feel most desperate. For example, one client refused to give me his gun for safekeeping because he wanted to retain the ability to use it. No amount of time in a hospital could erase his chronic risk factors for suicide. Therefore, we agreed he would store the bullets in another part of town, so he would need to have sustained suicidal intentions to actually load the gun.

Believe your client, but take everything with a grain of salt. Most people who commit suicide do not communicate their intentions to professionals. In one study, 76% of inpatients who committed suicide had denied suicidal ideation in their last communication with staff.

Explain the dangers of alcohol. Alcohol appears to act as a lubricant for suicide, even when it is not a primary cause. About a third of suicides involve victims with blood alcohol levels above the legal limit.

Is suicide related to other economic issues, such as recessions?

It appears so. For example, one study found that unemployment in the US was associated with a 3.8% increase in the suicide rate.

Is self-harm a dress rehearsal for suicide?

No. Although people who harm themselves are slightly more likely than the average person to commit suicide, self-harm is not a precursor for suicide.

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Resources

Do “No-suicide contracts” reduce suicide risk? It turns out there is no evidence that these contracts reduce risk, and they may give professionals a false sense of security. For other questions and answers, download the free, one-page SAMHSA brochure, “What To Do If You Think a Person Is Having Suicidal Thoughts.”

Reducing Suicide: A National Imperative. For much more information, the Institute of Medicine offers a free, 512-page report, and a one-page summary.

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Test Your Knowledge Of: Suicide Risk Factors

Elizabeth Saenger, PhD

Questions

1. In the absence of risk factors, which age group(s) should be screened for suicide risk by primary care clinicians?
1. Adolescents
2. Adults
3. Older adults
4. None of the above
   
   
2. The following are all risk factors for suicide EXCEPT:
1. Substance abuse
2. Female gender
3. Suicide of a family member
4. A history of having been bullied
   
   
3. Which of the following groups in the United States has the highest risk of suicide?
1. White
2. Black
3. Asian American
4. Native American

Answers

1. d. None of the above. In April 2014, the US Preventive Services Task Force concluded that “it is not clear how primary care clinicians can effectively identify and help people who are not already known to be at increased risk for suicide.” Therefore, they do not have a position for or against screenings based solely on age.
   
   
2. b. Female gender. Women are far more likely than men to attempt suicide, but far less likely to actually commit suicide.
   
   
3. d. Native American. The suicide rate for Native Americans is more than three times the national average, probably due to elevated risk factors, such as poverty, unemployment, domestic abuse, substance abuse, and trauma.

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The opinions expressed in RECOVERe-works do not necessarily reflect the views of the Editor or the Coalition of Behavioral Health Agencies.

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