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Douglas G. Jacobs, M.D., Chair
Ross J. Baldessarini, M.D.
Yeates Conwell, M.D.
Jan A. Fawcett, M.D.
Leslie Horton, M.D., Ph.D.
Herbert Meltzer, M.D.
Cynthia R. Pfeffer, M.D.
Robert I. Simon, M.D.
Originally published in November 2003. A guideline watch, summarizing significant developments in the scientific literature since publication of this guideline, may be available.
Practice Guideline for the Assessment and
Treatment of Patients With Suicidal Behaviors consists
of three parts (Parts A, B, and C) and many sections, not all of
which will be equally useful for all readers. The following guide
is designed to help readers find the sections that will be most
useful to them.
Part A, "Assessment, Treatment, and Risk Management
Recommendations," is published as a supplement to the American
Journal of Psychiatry and contains the general
and specific recommendations for the assessment and treatment of patients
with suicidal behaviors. Section I summarizes the key recommendations
of the guideline and codes each recommendation according to the
degree of clinical confidence with which the recommendation is made.
Section II discusses the assessment of the patient, including a
consideration of factors influencing suicide risk. Section III discusses
psychiatric management, Section IV discusses specific treatment
modalities, and Section V addresses documentation and risk management
Part B, "Background Information and Review of Available
Evidence," and Part C, "Future Research Needs," are
not included in the American Journal of Psychiatry supplement
but are provided with Part A in the complete guideline, which is
available in print format from American Psychiatric Publishing,
Inc., and online through the American Psychiatric Association (http://www.psych.org).
Part B provides an overview of suicide, including general information
on its natural history, course, and epidemiology. It also provides
a structured review and synthesis of the evidence that underlies
the recommendations made in Part A. Part C draws from the previous
sections and summarizes areas for which more research data are needed
to guide clinical decisions.
This practice guideline was developed under the auspices of
the Steering Committee on Practice Guidelines. The development process
is detailed in the document "APA Guideline Development Process," which
is available from the APA Department of Quality Improvement and
Psychiatric Services. Key features of this process include the following:
A comprehensive literature
Development of evidence tables
Initial drafting of the guideline by a work group that
included psychiatrists with clinical and research expertise in suicide
and suicidality
Production of multiple revised drafts with widespread
review; six organizations and more than 60 individuals submitted
significant comments
Approval by the APA Assembly and Board of Trustees
Planned revisions at regular intervals
Relevant literature was identified through a computerized
search of PubMed for the period from 1966 to 2002. Keywords used
were "suicides,""suicide,""attempted
suicide,""attempted suicides,""parasuicide,""parasuicides,""self-harm,""self-harming,""suicide,
attempted,""suicidal attempt," and "suicidal
attempts." A total of 34,851 citations were found. After
limiting these references to literature published in English that
included abstracts, 17,589 articles were screened by using title
and abstract information. Additional, less formal literature searches
were conducted by APA staff and individual members of the work group
on suicidal behaviors through the use of PubMed, PsycINFO, and Social
Sciences Citation Index. Sources of funding were not considered
when reviewing the literature.
This document represents a synthesis of current scientific
knowledge and rational clinical practice on the assessment and treatment
of adult patients with suicidal behaviors. It strives to be as free
as possible of bias toward any theoretical approach to treatment.
In order for the reader to appreciate the evidence base behind the
guideline recommendations and the weight that should be given to
each recommendation, the summary of treatment recommendations is
keyed according to the level of confidence with which each recommendation
is made. Each rating of clinical confidence considers the strength
of the available evidence and is based on the best available data.
When evidence is limited, the level of confidence also incorporates
clinical consensus with regard to a particular clinical decision.
In the listing of cited references, each reference is followed by
a letter code in brackets that indicates the nature of the supporting
Each recommendation is identified as falling into one of three
categories of endorsement, indicated by a bracketed Roman numeral
following the statement. The three categories represent varying
levels of clinical confidence regarding the recommendation:
[I] Recommended
with substantial clinical confidence.
[II] Recommended with moderate clinical
[III] May be recommended on the basis
of individual circumstances.
In this guideline, the following terms will be used:
death with evidence (either explicit or implicit) that the person intended
to die.
Suicide attemptself-injurious behavior with
a nonfatal outcome accompanied by evidence (either explicit or implicit)
that the person intended to die.
Aborted suicide attemptpotentially self-injurious
behavior with evidence (either explicit or implicit) that the person
intended to die but stopped the attempt before physical damage occurred.
Suicidal ideationthoughts of serving as the
agent of one's own death. Suicidal ideation may vary in
seriousness depending on the specificity of suicide plans and the
degree of suicidal intent.
Suicidal intentsubjective expectation and
desire for a self-destructive act to end in death.
Lethality of suicidal behaviorobjective danger
to life associated with a suicide method or action. Note that lethality
is distinct from and may not always coincide with an individual's
expectation of what is medically dangerous.
Deliberate self-harmwillful self-inflicting
of painful, destructive, or injurious acts without intent to die.
A detailed exposition of definitions relating to suicide has
been provided by O'Carroll et al. (1).
The psychiatric evaluation is the essential element of the
suicide assessment process [I]. During the evaluation,
the psychiatrist obtains information about the patient's
psychiatric and other medical history and current mental state (e.g.,
through direct questioning and observation about suicidal thinking
and behavior as well as through collateral history, if indicated).
This information enables the psychiatrist to 1) identify specific
factors and features that may generally increase or decrease risk
for suicide or other suicidal behaviors and that may serve as modifiable
targets for both acute and ongoing interventions, 2) address the
patient's immediate safety and determine the most appropriate
setting for treatment, and 3) develop a multiaxial differential
diagnosis to further guide planning of treatment. The breadth and
depth of the psychiatric evaluation aimed specifically at assessing
suicide risk will vary with setting; ability or willingness of the
patient to provide information; and availability of information
from previous contacts with the patient or from other sources, including
other mental health professionals, medical records, and family members.
Although suicide assessment scales have been developed for research
purposes, they lack the predictive validity necessary for use in
routine clinical practice. Therefore, suicide assessment scales
may be used as aids to suicide assessment but should not be used
as predictive instruments or as substitutes for a thorough clinical
evaluation [I].
Table 1 presents important domains of a suicide assessment,
including the patient's current presentation, individual
strengths and weaknesses, history, and psychosocial situation. Information
may come from the patient directly or from other sources, including
family members, friends, and others in the patient's support
network, such as community residence staff or members of the patient's
military command. Such individuals may be able to provide information
about the patient's current mental state, activities, and
psychosocial crises and may also have observed behavior or been
privy to communications from the patient that suggest suicidal ideation,
plans, or intentions. Contact with such individuals may also provide
opportunity for the psychiatrist to attempt to fortify the patient's
social support network. This goal often can be accomplished without
the psychiatrist's revealing private or confidential information
about the patient. In clinical circumstances in which sharing information
is important to maintain the safety of the patient or others, it
is permissible and even critical to share such information without
the patient's consent [I].
Current presentation of suicidality
Suicidal or self-harming thoughts, plans, behaviors,
and intent
Specific methods considered for suicide, including
their lethality and the patient's expectation about lethality,
as well as whether firearms are accessible
Evidence of hopelessness, impulsiveness, anhedonia,
panic attacks, or anxiety
Reasons for living and plans for the future
Alcohol or other substance use associated with the
current presentation
Thoughts, plans, or intentions of violence toward others
Psychiatric illnesses
Current signs and symptoms of psychiatric disorders
with particular attention to mood disorders (primarily major depressive
disorder or mixed episodes), schizophrenia, substance use disorders, anxiety
disorders, and personality disorders (primarily borderline and antisocial
personality disorders)
Previous psychiatric diagnoses and treatments, including
illness onset and course and psychiatric hospitalizations, as well
as treatment for substance use disorders
Previous suicide attempts, aborted suicide attempts,
or other self-harming behaviors
Previous or current medical diagnoses and treatments,
including surgeries or hospitalizations
Family history of suicide or suicide attempts or a
family history of mental illness, including substance abuse
Psychosocial situation
Acute psychosocial crises and chronic psychosocial
stressors, which may include actual or perceived interpersonal losses,
financial difficulties or changes in socioeconomic status, family
discord, domestic violence, and past or current sexual or physical
abuse or neglect
Employment status, living situation (including whether
or not there are infants or children in the home), and presence
or absence of external supports
Family constellation and quality of family relationships
Cultural or religious beliefs about death or suicide
Individual strengths and vulnerabilities
Coping skills
Personality traits
Past responses to stress
Capacity for reality testing
Ability to tolerate psychological pain and satisfy
psychological needs
It is important to recognize that in many clinical situations
not all of the information described in this section may be possible
to obtain. It may be necessary to focus initially on those elements
judged to be most relevant and to continue the evaluation during
subsequent contacts with the patient.
When communicating with the patient, it is important to remember
that simply asking about suicidal ideation does not ensure that
accurate or complete information will be received. Cultural or religious
beliefs about death or suicide, for example, may influence a patient's
willingness to speak about suicide during the assessment process
as well as the patient's likelihood of acting on suicidal
ideas. Consequently, the psychiatrist may wish to explore the patient's
cultural and religious beliefs, particularly as they relate to death
and to suicide [II].
It is important for the psychiatrist to focus on the nature,
frequency, depth, timing, and persistence of suicidal ideation [I].
If ideation is present, request more detail about the presence or
absence of specific plans for suicide, including any steps taken
to enact plans or prepare for death [I]. If other
aspects of the clinical presentation seem inconsistent with an initial
denial of suicidal thoughts, additional questioning of the patient
may be indicated [II].
Where there is a history of suicide attempts, aborted attempts,
or other self-harming behavior, it is important to obtain as much
detail as possible about the timing, intent, method, and consequences of
such behaviors [I]. It is also useful to determine
the life context in which they occurred and whether they occurred
in association with intoxication or chronic use of alcohol or other
substances [II]. For individuals in previous or
current psychiatric treatment, it is helpful to determine the strength
and stability of the therapeutic relationship(s) [II].
If the patient reports a specific method for suicide, it is
important for the psychiatrist to ascertain the patient's
expectation about its lethality, for if actual lethality exceeds
what is expected, the patient's risk for accidental suicide
may be high even if intent is low [I]. In general,
the psychiatrist should assign a higher level of risk to patients
who have high degrees of suicidal intent or describe more detailed
and specific suicide plans, particularly those involving violent
and irreversible methods [I]. If the patient has
access to a firearm, the psychiatrist is advised to discuss with
and recommend to the patient or a significant other the importance
of restricting access to, securing, or removing this and other weapons [I].
Documenting the suicide assessment is essential [I].
Typically, suicide assessment and its documentation occur after
an initial evaluation or, for patients in ongoing treatment, when
suicidal ideation or behaviors emerge or when there is significant
worsening or dramatic and unanticipated improvement in the patient's
condition. For inpatients, reevaluation also typically occurs with
changes in the level of precautions or observations, when passes
are issued, and during evaluation for discharge. As with the level
of detail of the suicide assessment, the extent of documentation
at each of these times varies with the clinical circumstances. Communications
with other caregivers and with the family or significant others
should also be documented [I]. When the patient
or others have been given specific instructions about firearms or
other weapons, this communication should also be noted in the record [I].
Suicide and suicidal behaviors cause severe personal, social,
and economic consequences. Despite the severity of these consequences,
suicide and suicidal behaviors are statistically rare, even in populations
at risk. For example, although suicidal ideation and attempts are
associated with increased suicide risk, most individuals with suicidal
thoughts or attempts will never die by suicide. It is estimated
that attempts and ideation occur in approximately 0.7% and
5.6% of the general U.S. population per year, respectively
(2). In comparison, in the United States, the annual incidence of suicide
in the general population is approximately 10.7 suicides for every
100,000 persons, or 0.0107% of the total population per
year (3). This rarity of suicide, even in groups known to be at higher
risk than the general population, contributes to the impossibility
of predicting suicide.
The statistical rarity of suicide also makes it impossible
to predict on the basis of risk factors either alone or in combination.
For the psychiatrist, knowing that a particular factor (e.g., major
depressive disorder, hopelessness, substance use) increases a patient's
relative risk for suicide may affect the treatment plan, including
determination of a treatment setting. At the same time, knowledge
of risk factors will not permit the psychiatrist to predict when
or if a specific patient will die by suicide. This does not mean
that the psychiatrist should ignore risk factors or view suicidal
patients as untreatable. On the contrary, an initial goal of the
psychiatrist should be to estimate the patient's risk through knowledgeable
assessment of risk and protective factors, with a primary and ongoing
goal of reducing suicide risk [I].
Some factors may increase or decrease risk for suicide; others
may be more relevant to risk for suicide attempts or other self-injurious
behaviors, which are in turn associated with potential morbidity
as well as increased suicide risk. In weighing risk and protective
factors for an individual patient, consideration may be given to
1) the presence of psychiatric illness; 2) specific psychiatric symptoms
such as hopelessness, anxiety, agitation, or intense suicidal ideation;
3) unique circumstances such as psychosocial stressors and availability
of methods; and 4) other relevant clinical factors such as genetics
and medical, psychological, or psychodynamic issues [I].
It is important to recognize that many of these factors are
not simply present or absent but instead may vary in severity. Others,
such as psychological or psychodynamic issues, may contribute to
risk in some individuals but not in others or may be relevant only
when they occur in combination with particular psychosocial stressors.
Once factors are identified, the psychiatrist can determine
if they are modifiable. Past history, family history, and demographic
characteristics are examples of nonmodifiable factors. Financial difficulties
or unemployment can also be difficult to modify, at least in the
short term. While immutable factors are important to identify, they
cannot be the focus of intervention. Rather, to decrease a patient's
suicide risk, the treatment should attempt to mitigate or strengthen
those risk and protective factors that can be modified [I].
For example, the psychiatrist may attend to patient safety, address
associated psychological or social problems and stressors, augment
social support networks, and treat associated psychiatric disorders
(such as mood disorders, psychotic disorders, substance use disorders,
and personality disorders) or symptoms (such as severe anxiety,
agitation, or insomnia).
Psychiatric management consists of a broad array of therapeutic
interventions that should be instituted for patients with suicidal
thoughts, plans, or behaviors [I]. Psychiatric
management includes determining a setting for treatment and supervision,
attending to patient safety, and working to establish a cooperative
and collaborative physician-patient relationship. For patients in
ongoing treatment, psychiatric management also includes establishing
and maintaining a therapeutic alliance; coordinating treatment provided
by multiple clinicians; monitoring the patient's progress
and response to the treatment plan; and conducting ongoing assessments
of the patient's safety, psychiatric status, and level
of functioning. Additionally, psychiatric management may include
encouraging treatment adherence and providing education to the patient
and, when indicated, family members and significant others.
Patients with suicidal thoughts, plans, or behaviors should
generally be treated in the setting that is least restrictive yet
most likely to be safe and effective [I]. Treatment
settings and conditions include a continuum of possible
levels of care, from involuntary inpatient hospitalization through
partial hospital and intensive outpatient programs to occasional
ambulatory visits. Choice of specific treatment setting depends
not only on the psychiatrist's estimate of the patient's
current suicide risk and potential for dangerousness to others,
but also on other aspects of the patient's current status, including
1) medical and psychiatric comorbidity; 2) strength and availability
of a psychosocial support network; and 3) ability to provide adequate
self-care, give reliable feedback to the psychiatrist, and cooperate
with treatment. In addition, the benefits of intensive interventions
such as hospitalization must be weighed against their possible negative
effects (e.g., disruption of employment, financial and other psychosocial
stress, social stigma).
For some individuals, self-injurious behaviors may occur
on a recurring or even chronic basis. Although such behaviors may
occur without evidence of suicidal intent, this may not always be
the case. Even when individuals have had repeated contacts with
the health care system, each act should be reassessed in the context
of the current situation [I].
In treating suicidal patients, particularly those with severe
or recurring suicidality or self-injurious behavior, the psychiatrist
should be aware of his or her own emotions and reactions that may
interfere with the patient's care [I].
For difficult-to-treat patients, consultation or supervision from
a colleague may help in affirming the appropriateness of the treatment
plan, suggesting alternative therapeutic approaches, or monitoring
and dealing with countertransference issues [I].
The suicide prevention contract, or "no-harm contract," is
commonly used in clinical practice but should not be considered
as a substitute for a careful clinical assessment [I].
A patient's willingness (or reluctance) to enter
into an oral or a written suicide prevention contract should not
be viewed as an absolute indicator of suitability for discharge
(or hospitalization) [I]. In addition, such contracts
are not recommended for use with patients who are agitated, psychotic,
impulsive, or under the influence of an intoxicating substance [II].
Furthermore, since suicide prevention contracts are dependent on
an established physician-patient relationship, they are not recommended
for use in emergency settings or with newly admitted or unknown
inpatients [II].
Despite best efforts at suicide assessment and treatment,
suicides can and do occur in clinical practice. In fact, significant
proportions of individuals who die by suicide have seen a physician within
several months of death and may have received specific mental health
treatment. Death of a patient by suicide will often have a significant
effect on the treating psychiatrist and may result in increased
stress and loss of professional self-esteem. When the suicide of
a patient occurs, the psychiatrist may find it helpful to seek support
from colleagues and obtain consultation or supervision to enable
him or her to continue to treat other patients effectively and respond
to the inquiries or mental health needs of survivors [II].
Consultation with an attorney or a risk manager may also be useful [II].
The psychiatrist should be aware that patient confidentiality extends
beyond the patient's death and that the usual provisions
relating to medical records still apply. Any additional documentation
included in the medical record after the patient's death
should be dated contemporaneously, not backdated, and previous entries
should not be altered [I]. Depending on the circumstances, conversations
with family members may be appropriate and can allay grief [II].
In the aftermath of a loved one's suicide, family members
themselves are more vulnerable to physical and psychological disorders
and should be helped to obtain psychiatric intervention, although
not necessarily by the same psychiatrist who treated the individual
who died by suicide [II].
In developing a plan of treatment that addresses suicidal
thoughts or behaviors, the psychiatrist should consider the potential
benefits of somatic therapies as well as the potential benefits
of psychosocial interventions, including the psychotherapies [I].
Clinical experience indicates that many patients with suicidal thoughts,
plans, or behaviors will benefit most from a combination of these treatments [II].
The psychiatrist should address the modifiable risk factors identified
in the initial psychiatric evaluation and make ongoing assessments
during the course of treatment [I]. In general, therapeutic
approaches should target specific axis I and axis II psychiatric
disorders; specific associated symptoms such as depression, agitation,
anxiety, or insomnia; or the predominant psychodynamic or psychosocial
stressor [I]. While the goal of pharmacologic
treatment may be acute symptom relief, including acute relief of
suicidality or acute treatment of a specific diagnosis, the treatment
goals of psychosocial interventions may be broader and longer term,
including achieving improvements in interpersonal relationships,
coping skills, psychosocial functioning, and management of affects.
Since treatment should be a collaborative process between the patient
and clinician(s), the patient's preferences are important
to consider when developing an individual treatment plan [I].
Evidence for a lowering of suicide rates with antidepressant
treatment is inconclusive. However, the documented efficacy of antidepressants
in treating acute depressive episodes and their long-term benefit
in patients with recurrent forms of severe anxiety or depressive
disorders support their use in individuals with these disorders
who are experiencing suicidal thoughts or behaviors [II].
It is advisable to select an antidepressant with a low risk of lethality
on acute overdose, such as a selective serotonin reuptake inhibitor
(SSRI) or other newer antidepressant, and to prescribe conservative quantities,
especially for patients who are not well-known [I].
For patients with prominent insomnia, a sedating antidepressant
or an adjunctive hypnotic agent can be considered [II].
Since antidepressant effects may not be observed for days to weeks
after treatment has started, patients should be monitored closely
early in treatment and educated about this probable delay in symptom
relief [I].
To treat symptoms such as severe insomnia, agitation, panic
attacks, or psychic anxiety, benzodiazepines may be indicated on
a short-term basis [II], with long-acting agents
often being preferred over short-acting agents [II].
The benefits of benzodiazepine treatment should be weighed against their
occasional tendency to produce disinhibition and their potential
for interactions with other sedatives, including alcohol [I].
Alternatively, other medications that may be used for their calming effects
in highly anxious and agitated patients include trazodone, low doses
of some second-generation antipsychotics, and some anticonvulsants
such as gabapentin or divalproex [III]. If benzodiazepines
are being discontinued after prolonged use, their doses should be
reduced gradually and the patient monitored for increasing symptoms
of anxiety, agitation, depression, or suicidality [II].
There is strong evidence that long-term maintenance treatment
with lithium salts is associated with major reductions in the risk
of both suicide and suicide attempts in patients with bipolar disorder, and
there is moderate evidence for similar risk reductions in patients
with recurrent major depressive disorder [I].
Specific anticonvulsants have been shown to be efficacious in treating
episodes of mania (i.e., divalproex) or bipolar depression (i.e.,
lamotrigine), but there is no clear evidence that their
use alters rates of suicide or suicidal behaviors [II].
Consequently, when deciding between lithium and other first-line
agents for treatment of patients with bipolar disorder, the efficacy
of lithium in decreasing suicidal behavior should be taken into
consideration when weighing the benefits and risks of treatment
with each medication. In addition, if lithium is prescribed, the
potential toxicity of lithium in overdose should be taken into consideration
when deciding on the quantity of lithium to give with each prescription [I].
Clozapine treatment is associated with significant decreases
in rates of suicide attempts and perhaps suicide for individuals
with schizophrenia and schizoaffective disorder. Thus, clozapine treatment
should be given serious consideration for psychotic patients with
frequent suicidal ideation, attempts, or both [I].
However, the benefits of clozapine treatment need to be weighed
against the risk of adverse effects, including potentially fatal
agranulocytosis and myocarditis, which has generally led clozapine
to be reserved for use when psychotic symptoms have not responded
to other antipsychotic medications. If treatment is indicated with
an antipsychotic other than clozapine, the other second-generation
antipsychotics (e.g., risperidone, olanzapine, quetiapine, ziprasidone,
aripiprazole) are preferred over the first-generation antipsychotic
agents [I].
ECT has established efficacy in patients with severe depressive
illness, with or without psychotic features. Since ECT is associated
with a rapid and robust antidepressant response as well as a rapid diminution
in associated suicidal thoughts, ECT may be recommended as a treatment
for severe episodes of major depression that are accompanied by
suicidal thoughts or behaviors [I]. Under certain
clinical circumstances, ECT may also be used to treat suicidal patients
with schizophrenia, schizoaffective disorder, or mixed
or manic episodes of bipolar disorder [II]. Regardless
of diagnosis, ECT is especially indicated for patients with catatonic
features or for whom a delay in treatment response is considered
life threatening [I]. ECT may also be indicated
for suicidal individuals during pregnancy and for those who have
already failed to tolerate or respond to trials of medication [II]. Since
there is no evidence of a long-term reduction of suicide risk with
ECT, continuation or maintenance treatment with pharmacotherapy
or with ECT is recommended after an acute ECT course [I].
Psychotherapies and other psychosocial interventions play
an important role in the treatment of individuals with suicidal
thoughts and behaviors [II]. A substantial body
of evidence supports the efficacy of psychotherapy in the treatment
of specific disorders, such as nonpsychotic major depressive disorder
and borderline personality disorder, which are associated with increased
suicide risk. For example, interpersonal psychotherapy and cognitive
behavior therapy have been found to be effective in clinical trials
for the treatment of depression. Therefore, psychotherapies such
as interpersonal psychotherapy and cognitive behavior therapy may
be considered appropriate treatments for suicidal behavior, particularly
when it occurs in the context of depression [II].
In addition, cognitive behavior therapy may be used to decrease
two important risk factors for suicide: hopelessness [II] and
suicide attempts in depressed outpatients [III].
For patients with a diagnosis of borderline personality disorder,
psychodynamic therapy and dialectical behavior therapy may be appropriate treatments
for suicidal behaviors [II], because modest evidence
has shown these therapies to be associated with decreased self-injurious
behaviors, including suicide attempts. Although not targeted specifically
to suicide or suicidal behaviors, other psychosocial treatments
may also be helpful in reducing symptoms and improving functioning
in individuals with psychotic disorders and in treating alcohol
and other substance use disorders that are themselves associated
with increased rates of suicide and suicidal behaviors [II].
For patients who have attempted suicide or engaged in self-harming
behaviors without suicidal intent, specific psychosocial interventions
such as rapid intervention; follow-up outreach; problem-solving
therapy; brief psychological treatment; or family, couples, or group
therapies may be useful despite limited evidence for their efficacy [III].
The assessment of the suicidal patient is an ongoing process
that comprises many interconnected elements (Table 1). In addition,
there are a number of points during patients' evaluation
and treatment at which a suicide assessment may be indicated (Table 2).
Emergency department or crisis evaluation
Intake evaluation (on either an inpatient or an outpatient
Before a change in observation status or treatment
setting (e.g., discontinuation of
one-to-one observation, discharge from inpatient setting)
Abrupt change in clinical presentation (either precipitous
worsening or sudden, dramatic improvement)
Lack of improvement or gradual worsening despite treatment
Anticipation or experience of a significant interpersonal
loss or
psychosocial stressor (e.g., divorce, financial loss, legal problems,
personal shame or humiliation)
Onset of a physical illness (particularly if life threatening,
disfiguring, or associated with severe pain or loss of executive
The ability of the psychiatrist to connect with the patient,
establish rapport, and demonstrate empathy is an important ingredient
of the assessment process. For suicidal patients who are followed on
an ongoing basis, the doctor-patient relationship will provide the
base from which risk and protective factors continue to be identified
and from which therapeutic interventions, such as psychotherapies
and pharmacotherapies, are offered.
At the core of the suicide assessment, the psychiatric evaluation
will provide information about the patient's history, current
circumstances, and mental state and will include direct questioning
about suicidal thinking and behaviors. This evaluation, in turn,
will enable the psychiatrist to identify specific factors and features
that may increase or decrease the potential risk for suicide or
other suicidal behaviors. These factors and features may include
developmental, biomedical, psychopathologic, psychodynamic, and
psychosocial aspects of the patient's current presentation
and history, all of which may serve as modifiable targets for both
acute and ongoing interventions. Such information will also be important
in addressing the patient's immediate safety,
determining the most appropriate setting for treatment, and developing
a multiaxial differential diagnosis that will further guide the planning
of treatment.
Although the approach to the suicidal patient is common to
all individuals regardless of diagnosis or clinical presentation,
the breadth and depth of the psychiatric evaluation will vary with
the setting of the assessment; the ability or willingness of the
patient to provide information; and the availability of information
from previous contacts with the patient or from other sources, including
other mental health professionals, medical records, and family members.
Since the approach to assessment does vary to some degree in the
assessment of suicidal children and adolescents, the psychiatrist
who evaluates youths may wish to review the American Academy of
Child and Adolescent Psychiatry's Practice
Parameter for the Assessment and Treatment of Children and Adolescents
With Suicidal Behavior (4). In some circumstances,
the urgency of the situation or the presence of substance intoxication may
necessitate making a decision to facilitate patient safety (e.g.,
instituting hospitalization or one-to-one observation) before all
relevant information has been obtained. Furthermore, when working with
a team of other professionals, the psychiatrist may not obtain all
information him- or herself but will need to provide leadership
for the assessment process so that necessary information is obtained and
integrated into a final assessment. Since the patient may minimize
the severity or even the existence of his or her difficulties, other
individuals may be valuable resources for the psychiatrist in providing
information about the patient's current mental state, activities,
and psychosocial crises. Such individuals may include
the patient's family members and friends but may also include
other physicians, other medical or mental health professionals,
teachers or other school personnel, members of the patient's
military command, and staff from supervised housing programs or
other settings where the patient resides.
The psychiatric evaluation is the core element of the suicide
risk assessment. This section provides an overview of the key aspects
of the psychiatric evaluation as they relate to the assessment of
patients with suicidal behaviors. Although the factors that are
associated with an increased or decreased risk of suicide differ
from the factors associated with an increased or decreased
risk of suicide attempts, it is important to identify factors modulating
the risk of any suicidal behaviors. Additional details on specific
risk factors that should be identified during the assessment are
discussed in Sections II.E, "Estimate Suicide Risk", and III.H, "Reassess Safety and Suicide Risk".
For further discussion of other aspects of the psychiatric evaluation,
the psychiatrist is referred to the American Psychiatric Association's Practice
Guideline for Psychiatric Evaluation of Adults (5)
(included in this volume). Additional information on details of
the suicide assessment process is reviewed elsewhere (6, 7).
It is important to identify specific psychiatric signs and
symptoms that are correlated with an increased risk of suicide or
other suicidal behaviors. Symptoms that have been associated with
suicide attempts or with suicide include aggression, violence toward
others, impulsiveness, hopelessness, and agitation. Psychic anxiety,
which has been defined as subjective feelings of anxiety, fearfulness, or
apprehension whether or not focused on specific concerns, has also
been associated with an increased risk of suicide, as have anhedonia,
global insomnia, and panic attacks. In addition, identifying other
psychiatric signs and symptoms (e.g., psychosis, depression) will
aid in determining whether the patient has a psychiatric syndrome
that should also be a focus of treatment.
A history of past suicide attempts is one of the most significant
risk factors for suicide, and this risk may be increased by more
serious, more frequent, or more recent attempts. Therefore, it is important
for the psychiatrist to inquire about past suicide attempts and
self-destructive behaviors, including specific questioning about
aborted suicide attempts. Examples of the latter would include putting
a gun to one's head but not firing it, driving to a bridge
but not jumping, or creating a noose but not using it. For each
attempt or aborted attempt, the psychiatrist should try to obtain
details about the precipitants, timing, intent, and consequences
as well as the attempt's medical severity. The patient's
consumption of alcohol and drugs before the attempt should also
be ascertained, since intoxication can facilitate impulsive suicide
attempts but can also be a component of a more serious suicide plan.
In understanding the issues that culminated in the suicide attempt,
interpersonal aspects of the attempt should also be delineated.
Examples might include the dynamic or interpersonal issues leading
up to the attempt, significant persons present at the time of the
attempt, persons to whom the attempt was communicated, and how the
attempt was averted. It is also important to determine the patient's
thoughts about the attempt, such as his or her own perception of
the chosen method's lethality, ambivalence toward living,
visualization of death, degree of premeditation, persistence of suicidal
ideation, and reaction to the attempt. It is also helpful to inquire
about past risk-taking behaviors such as unsafe sexual
practices and reckless driving.
A review of the patient's treatment history is another
crucial element of the suicide risk assessment. A thorough treatment
history can serve as a systematic method for gaining information
on comorbid diagnoses, prior hospitalizations, suicidal ideation,
or previous suicide attempts. Obtaining a history of medical treatment
can help in identifying medically serious suicide attempts as well
as in identifying past or current medical diagnoses that may be
associated with augmented suicide risk.
Many patients who are being assessed for suicidality will
already be in treatment, either with other psychiatrists or mental
health professionals or with primary care physicians or medical
specialists. Contacts with such caregivers can provide a great deal
of relevant information and help in determining a setting and/or
plan for treatment. With patients who are currently in treatment,
it is also important to gauge the strength and stability of the
therapeutic relationships, because a positive therapeutic alliance
has been suggested to be protective against suicidal behaviors.
On the other hand, a patient with a suicide attempt or suicidal
ideation who does not have a reliable therapeutic alliance may represent
an increased risk for suicide, which would need to be addressed
Identifying family history is particularly important during
the psychiatric evaluation. The psychiatrist should specifically
inquire about the presence of suicide and suicide attempts as well
as a family history of any psychiatric hospitalizations or mental
illness, including substance use disorders. When suicides have occurred
in first-degree relatives, it is often helpful to learn more about
the circumstances, including the patient's involvement
and the patient's and relative's ages at the time
of the suicide.
The patient's childhood and current family milieu
are also relevant, since many aspects of family dysfunction may
be linked to self-destructive behaviors. Such factors include a
history of family conflict or separation, parental legal trouble,
family substance use, domestic violence, and physical and/or
sexual abuse.
An assessment of the patient's current psychosocial
situation is important to detect acute psychosocial crises or chronic
psychosocial stressors that may augment suicide risk (e.g., financial
or legal difficulties; interpersonal conflicts or losses; stressors
in gay, lesbian, or bisexual youths; housing problems; job loss;
educational failure). Other significant precipitants may include
perceived losses or recent or impending humiliation. An understanding
of the patient's psychosocial situation is also essential
in helping the patient to mobilize external supports, which can
have a protective influence on suicide risk.
In estimating suicide risk and formulating a treatment plan,
the clinician needs to appreciate the strengths and vulnerabilities
of the individual patient. Particular strengths and vulnerabilities
may include such factors as coping skills, personality traits, thinking
style, and developmental and psychological needs. For example, in
addition to serving as state-dependent symptoms, hopelessness, aggression,
and impulsivity may also constitute traits, greater degrees of which
may be associated with an increased risk for suicidal behaviors.
Increased suicide risk has also been seen in individuals who exhibit
thought constriction or polarized (either-or) thinking as well in
individuals with closed-mindedness (i.e., a narrowed scope and intensity
of interests). Perfectionism with excessively high self-expectation
is another factor that has been noted in clinical practice to be
a possible contributor to suicide risk. In weighing the strengths
and vulnerabilities of the individual patient, it is also helpful to determine
the patient's tendency to engage in risk-taking behaviors
as well as the patient's past responses to stress, including
the capacity for reality testing and the ability to tolerate rejection, subjective
loneliness, or psychological pain when his or her unique psychological
needs are not met.
In general, the more an individual has thought about suicide,
has made specific plans for suicide, and intends to act on those
plans, the greater will be his or her risk. Thus, as part of the
suicide assessment it is essential to inquire specifically about
the patient's suicidal thoughts, plans, behaviors, and
intent. Although such questions will often flow naturally from discussion
of the patient's current situation, this will not invariably
be true. The exact wording of questions and the extent of questioning will
also differ with the clinical situation. Examples of issues that
the psychiatrist may wish to address in this portion of the suicide
assessment are given in Table 3.
Begin with questions that address the
patient's feelings about living
Have you ever felt that life was not worth living?
Did you ever wish you could go to sleep and just not
wake up?
Follow up with specific questions that
ask about thoughts of death, self-harm, or suicide
Is death something you've thought about recently?
Have things ever reached the point that you've
thought of harming yourself?
For individuals who have thoughts of
self-harm or suicide
When did you first notice such thoughts?
What led up to the thoughts (e.g., interpersonal and
psychosocial precipitants, including real or imagined losses; specific
such as mood changes, anhedonia, hopelessness, anxiety, agitation,
How often have those thoughts occurred (including frequency,
obsessional quality, controllability)?
How close have you come to acting on those thoughts?
How likely do you think it is that you will act on
them in the future?
Have you ever started to harm (or kill) yourself but
stopped before doing something (e.g., holding knife or gun to your
but stopping before acting, going to edge of bridge but not jumping)?
What do you envision happening if you actually killed
yourself (e.g., escape, reunion with significant other, rebirth,
reactions of others)?
Have you made a specific plan to harm or kill yourself?
(If so, what does the plan include?)
Do you have guns or other weapons available to you?
Have you made any particular preparations (e.g., purchasing
specific items, writing a note or a will, making financial arrangements,
taking steps to avoid discovery, rehearsing the plan)?
Have you spoken to anyone about your plans?
How does the future look to you?
What things would lead you to feel more (or less) hopeful
about the future (e.g., treatment, reconciliation of relationship,
resolution of stressors)?
What things would make it more (or less) likely that
you would try to kill yourself?
What things in your life would lead you to want to
escape from life or be dead?
What things in your life make you want to go on living?
If you began to have thoughts of harming or killing
yourself again, what would you do?
For individuals who have attempted suicide
or engaged in self-damaging action(s), parallel questions to those
in the previous section can address the prior attempt(s). Additional
questions can be asked in general terms or can refer to the specific
method used and may include:
Can you describe what happened (e.g., circumstances,
precipitants, view of future, use of alcohol or other substances,
method, intent,
seriousness of injury)?
What thoughts were you having beforehand that led up
to the attempt?
What did you think would happen (e.g., going to sleep
versus injury versus dying, getting a reaction out of a particular
Were other people present at the time?
Did you seek help afterward yourself, or did someone
get help for you?
Had you planned to be discovered, or were you found
How did you feel afterward (e.g., relief versus regret
at being alive)?
Did you receive treatment afterward (e.g., medical
versus psychiatric, emergency department versus inpatient versus
Has your view of things changed, or is anything different
for you since the attempt?
Are there other times in the past when you've
tried to harm (or kill) yourself?
For individuals with repeated suicidal
thoughts or attempts
About how often have you tried to harm (or kill) yourself?
When was the most recent time?
Can you describe your thoughts at the time that you
were thinking most seriously about suicide?
When was your most serious attempt at harming or killing
What led up to it, and what happened afterward?
For individuals with psychosis, ask specifically
about hallucinations and delusions
Can you describe the voices (e.g., single versus multiple,
male versus female, internal versus external, recognizable versus
What do the voices say (e.g., positive remarks versus
negative remarks versus threats)? (If the remarks are commands,
determine if they are for harmless versus harmful acts; ask for
How do you cope with (or respond to) the voices?
Have you ever done what the voices ask you to do? (What
led you to obey the voices? If you tried to resist them, what made
it difficult?)
Have there been times when the voices told you to hurt
or kill yourself? (How often? What happened?)
Are you worried about having a serious illness or that
your body is rotting?
Are you concerned about your financial situation even
when others tell you there's nothing to worry about?
Are there things that you've been feeling
guilty about or blaming yourself for?
Consider assessing the patient's
potential to harm others in addition to him- or herself
Are there others who you think may be responsible for
what you're experiencing (e.g., persecutory ideas, passivity
Are you having any thoughts of harming them?
Are there other people you would want to die with you?
Are there others who you think would be unable to go
on without you?
Inquiring about suicidal ideation is an essential component
of the suicide assessment. Although some fear that raising the topic
of suicide will "plant" the issue in the patient's
mind, this is not the case. In fact, broaching the issue of suicidal
ideation may be a relief for the suicidal patient by opening an
avenue for discussion and giving him or her an opportunity to feel
In asking about suicidal ideas, it is often helpful to begin
with questions that address the patient's feelings about
living, such as, "How does life seem to you at this point?" or "Have
you ever felt that life was not worth living?" or "Did
you ever wish you could go to sleep and just not wake up?" If the
patient's response reflects dissatisfaction with life or
a desire to escape it, this response can lead naturally into more
specific questions about whether the patient has had thoughts of
death or suicide. When such thoughts are elicited, it is important
to focus on the nature, frequency, extent, and timing of them and
to understand the interpersonal, situational, and symptomatic context
in which they are occurring.
Even if the patient initially denies thoughts of death or
suicide, the psychiatrist should consider asking additional questions.
Examples might include asking about plans for the future or about
recent acts or thoughts of self-harm. Regardless of the approach
to the interview, not all individuals will report having suicidal
ideas even when such thoughts are present. Thus, depending on the
clinical circumstances, it may be important for the psychiatrist
to speak with family members or friends to determine whether they
have observed behavior (e.g., recent purchase of a gun) or have
been privy to thoughts that suggest suicidal ideation (see Section
V.C, "Communication With Significant Others"). In addition, patients who are initially interviewed
when they are intoxicated with alcohol or other substances should
be reassessed for suicidality once the intoxication has resolved.
If suicidal ideation is present, the psychiatrist will next
probe for more detailed information about specific plans for suicide
and any steps that have been taken toward enacting those plans.
Although some suicidal acts can occur impulsively with little or
no planning, more detailed plans are generally associated with a
greater suicide risk. Violent and irreversible methods, such as
firearms, jumping, and motor vehicle accidents, require particular
attention. However, the patient's belief about the lethality
of the method may be as important as the actual lethality of the
method itself.
If the patient does not report a plan, the psychiatrist can
ask whether there are certain conditions under which the patient
would consider suicide (e.g., divorce, going to jail, housing loss)
or whether it is likely that such a plan will be formed or acted
on in the near future. If the patient reports that he or
she is unlikely to act on the suicidal thoughts, the psychiatrist
should determine what factors are contributing to that expectation,
as such questioning can identify protective factors.
Whether or not a plan is present, if a patient has acknowledged
suicidal ideation, there should be a specific inquiry about the
presence or absence of a firearm in the home or workplace. It is
also helpful to ask whether there have been recent changes in access
to firearms or other weapons, including recent purchases or altered
arrangements for storage. If the patient has access to a firearm, the
psychiatrist is advised to discuss with and recommend to the patient
or a significant other the importance of restricting access to,
securing, or removing this and other weapons. Such discussions should
be documented in the medical record, including any instructions
that have been given to the patient and significant others about
firearms or other weapons.
Regardless of whether the patient has developed a suicide
plan, the patient's level of suicidal intent should be
explored. Suicidal intent reflects the intensity of a patient's
wish to die and can be assessed by determining the patient's
motivation for suicide as well as the seriousness and extent of
his or her aim to die, including any associated behaviors or planning
for suicide. If the patient has developed a suicide plan, it is
important to assess its lethality. The lethality of the plan can
be ascertained through questions about the method, the patient's
knowledge and skill concerning its use, and the absence of intervening
persons or protective circumstances. In general, the greater and
clearer the intent, the higher the risk for suicide will be. Thus,
even a patient with a low-lethality suicide plan or attempt may
be at high risk in the future if intentions are strong and the patient
believes that the chosen method will be fatal. At the same time,
a patient with low suicidal intent may still die from suicide by erroneously
believing that a particular method is not lethal.
Although a number of suicide assessment scales have been developed
for use in research and are described more fully in Part B of the
guideline, their clinical utility is limited. Self-report rating
scales may sometimes assist in opening communication with the patient
about particular feelings or experiences. In addition, the content
of suicide rating scales, such as the Scale for Suicide Ideation (8)
and the Suicide Intent Scale (9), may be helpful to psychiatrists
in developing a thorough line of questioning about suicide and suicidal
behaviors. However, existing suicide assessment scales suffer from
high false positive and false negative rates and have very low positive
predictive values (10). As a result, such rating scales cannot substitute
for thoughtful and clinically appropriate evaluation and are not
recommended for clinical estimations of suicide risk.
In conceptualizing suicide risk, it is important for the psychiatrist
to develop a multiaxial differential diagnosis over the
course of the psychiatric evaluation. Studies have shown that more than
90% of individuals who die by suicide satisfy the criteria
for one or more psychiatric disorders. Thus, the psychiatrist should
determine whether a patient has a primary axis I or axis
II diagnosis. Suicide and other suicidal behaviors are also more
likely to occur in individuals with more than one psychiatric diagnosis.
As a result, it is important to note other current or past axis
I or axis II diagnoses, including those that may currently be in
Identification of physical illness (axis III) is essential
since such diagnoses may also be associated with an increased risk
of suicide as well as with an increased risk of other suicidal behaviors.
For some individuals, this increase in risk may result from increased
rates of comorbid psychiatric illness or from the direct physiological
effects of physical illness or its treatment. Physical illnesses
may also be a source of social and/or psychological stress,
which in turn may augment risk.
Also crucial in determining suicide risk is the recognition
of psychosocial stressors (axis IV), which may be either acute or
chronic. Certain stressors, such as sudden unemployment, interpersonal loss,
social isolation, and dysfunctional relationships, can increase
the likelihood of suicide attempts as well as increase the risk
of suicide. At the same time, it is important to note that life
events have different meanings for different individuals. Thus,
in determining whether a particular stressor may confer risk for
suicidal behavior, it is necessary to consider the perceived importance
and meaning of the life event for the individual patient.
As the final component of the multiaxial diagnosis, the patient's
baseline and current levels of functioning are important to assess
(axis V). Also, the clinician should assess the relative change
in the patient's level of functioning and the patient's
view of and feelings about his or her functioning. Although suicidal
ideation and/or suicide attempts are reflected in the Global
Assessment of Functioning (GAF) scoring recommendations, it should
be noted that there is no agreed-on correlation between a GAF score
and level of suicide risk.
The goal of the suicide risk assessment is to identify factors
that may increase or decrease a patient's level of suicide
risk, to estimate an overall level of suicide risk, and to develop
a treatment plan that addresses patient safety and modifiable contributors
to suicide risk. The assessment is comprehensive in scope, integrating
knowledge of the patient's specific risk factors; clinical
history, including psychopathological development; and interaction
with the clinician. The estimation of suicide risk, at the culmination
of the suicide assessment, is the quintessential clinical judgment, since
no study has identified one specific risk factor or set of risk
factors as specifically predictive of suicide or other suicidal
Table 4 provides a list of factors that have been associated
with increased suicide risk, and Table 5 lists factors that have
been associated with protective effects. While risk factors are
typically additive (i.e., the patient's level of risk increases
with the number of risk factors), they may also interact in a synergistic
fashion. For example, the combined risk associated with comorbid
depression and physical illness may be greater than the sum of the
risk associated with each in isolation. At the same time, certain
risk factors, such as a recent suicide attempt (especially one of
high lethality), access to a firearm, and the presence of a suicide
note, should be considered serious in and of themselves, regardless
of whether other risk factors are present.
Suicidal thoughts/behaviors
Suicidal ideas (current or previous)
Suicidal plans (current or previous)
Suicide attempts (including aborted or interrupted
Lethality of suicidal plans or attempts
Suicidal intent
Psychiatric diagnoses
Major depressive disorder
Bipolar disorder (primarily in depressive or mixed
Anorexia nervosa
Alcohol use disorder
Other substance use disorders
Cluster B personality disorders (particularly borderline
personality disorder)
Comorbidity of axis I and/or axis II disorders
Physical illnesses
Diseases of the nervous system
Multiple sclerosis
Huntington's disease
Brain and spinal cord injury
Seizure disorders
Malignant neoplasms
Peptic ulcer disease
Chronic obstructive pulmonary disease, especially in
Chronic hemodialysis-treated renal failure
Systemic lupus erythematosus
Pain syndromes
Functional impairment
Psychosocial features
Recent lack of social support (including living alone)
Drop in socioeconomic status
Poor relationship with familya
Domestic partner violenceb
Recent stressful life event
Childhood traumas
Sexual abuse
Physical abuse
Genetic and familial effects
Family history of suicide (particularly in first-degree
Family history of mental illness, including substance
use disorders
Psychological features
Psychic paina
Severe or unremitting anxiety
Panic attacks
Shame or humiliationa
Psychological turmoila
Decreased self-esteema
Extreme narcissistic vulnerabilitya
Behavioral features
Aggression, including violence against others
Cognitive features
Loss of executive functionb
Thought constriction (tunnel vision)
Polarized thinking
Demographic features
Male genderc
Widowed, divorced, or single marital status, particularly
for men
Elderly age group (age group with greatest proportionate
risk for suicide)
Adolescent and young adult age groups (age groups with
highest numbers of suicides)
White race
Gay, lesbian, or bisexual orientationb
Additional features
Access to firearms
Substance intoxication (in the absence of a formal
substance use disorder diagnosis)
Unstable or poor therapeutic relationshipa
aAssociation with increased rate of suicide is based
on clinical experience rather than formal research evidence.
bAssociated with increased
rate of suicide attempts, but no evidence is available on suicide
rates per se.
cFor suicidal attempts,
females have increased risk, compared with males.
Children in the homea
Sense of responsibility to familyb
Life satisfaction
Reality testing abilityb
Positive coping skillsb
Positive problem-solving skillsb
Positive social support
Positive therapeutic relationshipb
aExcept among those with
postpartum psychosis or mood disorder.
bAssociation with decreased rate
of suicide is based on clinical experience rather than formal research evidence.
The effect on suicide risk of some risk factors, such as particular
life events or psychological strengths and vulnerabilities, will
vary on an individual basis. Risk factors must also be assessed
in context, as certain risk factors are more applicable to particular
diagnostic groups, while others carry more general risk. Finally,
it should be kept in mind that, because of the low rate of suicide
in the population, only a small fraction of individuals with a particular
risk factor will die from suicide.
Risk factors for suicide attempts, which overlap with but
are not identical to risk factors for suicide, will also be identified
in the assessment process. These factors should also be addressed
in the treatment planning process, since suicide attempts themselves
are associated with morbidity in addition to the added risk that
they confer for suicide.
In epidemiologic studies, a number of demographic factors
have been associated with increased rates of suicide. However, these
demographic characteristics apply to a very broad population of people
and cannot be considered alone. Instead, such demographic parameters
must be considered within the context of other interacting factors
that may influence individual risk.
Suicide rates differ dramatically by age. In addition, age-related
psychosocial stressors and family or developmental issues may influence
suicide risk. The age of the patient can also be of relevance to
psychiatric diagnosis, since specific disorders vary in
their typical ages of onset.
Between age 10 and 24 years, suicide rates in the general
population of the United States rise sharply to approximately 13
per 100,000 in the 20- to 24-year-old age group before essentially plateauing
through midlife. After age 70, rates again rise to a high of almost
20 per 100,000 in those over age 80 (Figure 1). These overall figures
can be misleading, however, since the age distribution of suicide
rates varies as a function of gender as well as with race and ethnicity.
For example, among male African Americans and American Indians/Alaska
Natives, suicide rates rise dramatically during adolescence, peak
in young adulthood, and then fall through mid- and later life. Thus,
in adolescence and young adulthood, the suicide rates of African
American men are comparable with those of white men, although overall,
African American males are half as likely to die from suicide as
white males. While suicide rates in many age groups have remained
relatively stable over the last 50 years, the rate among adolescents
and young adults has increased dramatically, and the rate among
the elderly has decreased. Among the 14- to 25-year-old age group,
suicide is now the third leading cause of death, with rates that
are triple those in the 1950s (12).
Suicide rates are higher in older adults than at any other
point in the life course. In 2000 in the United States there were
approximately 5,300 suicides among individuals over age 65, a rate
of 15.3 per 100,000. Whereas older adults made up 12.6% of
the population, they accounted for 18.1% of suicides. In
addition, the high suicide rate in those over age 65 is largely
a reflection of the high suicide rate in white men, which reaches
almost 60 per 100,000 by age 85. While rates in Asian men also increase
after age 65 and rates in Asian women increase dramatically after
age 80, the rate for all other women is generally flat in late life.
Thoughts of death are also more common in older than in younger
adults, but paradoxically, as people age they are less likely to
endorse suicidal ideation per se (13). Attempted suicide is also
less frequent among persons in later life than among younger age
groups (14). Whereas the ratio of attempted suicides to suicides
in adolescents may be as high as 200:1, there are as few as one
to four attempts for each suicide in later life (15). However, the
self-destructive acts that do occur in older people are more lethal.
This greater lethality is a function of several factors, including
reduced physical resilience (greater physical illness burden), greater
social isolation (diminished likelihood of rescue), and a greater
determination to die (15). Suicidal elders give fewer warnings to
others of their plans, use more violent and potentially deadly methods,
and apply those methods with greater planning and resolve (15, 16).
Therefore, compared with a suicide attempt in a younger person,
a suicide attempt in an older person confers a higher level of future
suicide risk.
In virtually all countries that report suicide statistics
to the World Health Organization, suicide risk increases with age
in both sexes, and rates for men in older adulthood are generally
higher than those for women (17). One exception is China, where
the suicide rate of women is much greater than that of men (18).
In the United States, death by suicide is more frequent in men than
in women, with the suicide rate in males approximately four times
that in females (Figure 1). In the psychiatric population, these
gender differences are also present but are less prominent. In terms
of murder-suicide, the male predominance is more pronounced, with
identified typologies including young men with prominent sexual
jealousy and elderly men with ailing spouses (19, 20). From age
65 on, there are progressive increases in suicide rates for white
men and for Asian men as well as for men overall. With the exception
of high suicide rates in Asian women over age 80, women in the United
States are at highest risk in midlife (11).
A number of factors may contribute to these gender differences
in suicide risk (21). Men who are depressed are more likely to have
comorbid alcohol and/or substance abuse problems than women, which
places the men at higher risk. Men are also less likely to seek
and accept help or treatment. Women, meanwhile, have factors that
protect them against suicide. In addition to their lower rates of
alcohol and substance abuse, women are less impulsive, more socially
embedded, and more willing to seek help. Among African American
women, rates of suicide are remarkably low, a fact that has been
attributed to the protective factors of religion and extended kin
networks (22). At the same time, women have higher rates of depression
(23) and respond to unemployment with greater and longer-lasting
increases in suicide rates than do men (24).
Overall, for women in the general population, pregnancy is
a time of significantly reduced suicide risk (25). Women with young
children in the home are also less likely to kill themselves (26). Nonetheless,
women with a history of depression or suicide attempts are at greater
risk for poor outcomes postpartum. Although suicide is most likely
to occur in the first month after delivery, risk continues throughout
the postpartum period. Teenagers, women of lower socioeconomic status,
and women hospitalized with postpartum psychiatric disorders may
be at particularly increased risk postpartum (27, 28).
Women tend to choose less lethal suicide methods than men
do (e.g., overdose or wrist cutting versus firearms or hanging).
Such differences may in part account for the reversal in the gender
ratio for suicide attempters, with women being reported to attempt
suicide three times as often as men (29). This female predominance
among suicide attempters varies with age, however, and in older adults
the ratio of women to men among suicide attempters approaches 1:1
(11, 30). Rates of suicidal ideation and attempts are also increased
in individuals with borderline personality disorder and in those
with a history of domestic violence or physical and/or
sexual abuse, all of which are more common among women (31–36).
In addition, the likelihood of suicide attempts may vary with the phase
of the menstrual cycle (37, 38).
Variations in suicide rates across racial and ethnic groups
have been mentioned earlier in the discussion of the influences
of age and gender on suicide risk. Overall, however, in the United
States, age-adjusted rates for suicide in whites and in non-Hispanic
Native Americans are approximately double those observed in Hispanics,
non-Hispanic African Americans, and Asian-Pacific Islanders (12.1
and 13.6 per 100,000 versus 6.1, 5.8, and 6.0 per 100,000, respectively)
(11). For immigrant groups, in general, suicide rates tend to mirror
the rates in the country of origin and converge toward the rate
in the host country over time (39–41).
In the United States, racial and ethnic differences are also
seen in the rates of suicide across the lifespan, with the highest
suicide rates occurring in those over age 65 among non-Hispanic
whites, Hispanics, and Asian-Pacific Islanders (11). In contrast,
among Native Americans and African Americans, the highest suicide
rates occur during adolescence and young adulthood (11). Such figures
may be deceptive, however, since each of these groups exhibits a
striking degree of heterogeneity that is rarely addressed in compilations
of suicide rates.
Racial and ethnic differences in culture, religious beliefs,
and societal position may influence not only the actual rates of
suicide but also the views of death and suicide held by members
of a particular group. For some groups, suicide can be considered
a traditionally accepted way of dealing with shame, distress, and/or
physical illness (42). In addition, cultural values about conveying
suicidal ideas may differ; in some cultures, for example, suicidal
ideation may be considered a disgraceful or private matter that
should be denied. Cultural differences, particularly in immigrants
and in Native Americans and Alaska Natives, may generate acculturative
stresses that in turn may contribute to suicidality (43, 44). Thus,
knowledge of and sensitivity to common contributors to suicide in
different racial and ethnic groups as well as cultural differences
in beliefs about death and views of suicide are important when making
clinical estimates of suicide risk and implementing plans to address
suicide risk.
Suicide risk also varies with marital status, with the suicide
rate of single persons being twice that of those who are married.
Divorced, separated, or widowed individuals have rates four to five
times higher than married individuals (45, 46). Variations in suicide
rates with marital status may reflect differing rates of baseline
psychiatric illness but may also be associated with psychological
or health variations. The presence of another person in the household
may also serve as a protective factor by decreasing social isolation,
engendering a sense of responsibility toward others, and increasing
the likelihood of discovery after a suicide attempt. For women,
the presence of children in the home may provide an additional protective
effect (26, 47). It is also important to note that although married adults
have lower rates of suicide overall, young married couples may have
increased risk, and the presence of a high-conflict or violent marriage
can be a precipitant rather than a protective factor for suicide.
Although no studies have examined rates of suicide among gay,
lesbian, and bisexual individuals, available evidence suggests that
they may have an increased risk for suicidal behaviors. Many recent studies
involving diverse sample populations and research methods have consistently
found that gay, lesbian, and bisexual youths have a higher risk
of suicide attempts than matched heterosexual comparison groups
(48–53). The female-to-male ratio for reported suicide
attempts in the general population is reversed in lesbian and gay
youths, with more males than females attempting suicide (48). While
some risk factors leading to suicide, such as psychiatric and substance
use disorders, are shared by both gay, lesbian, and bisexual youths
and heterosexual youths, others are unique to being gay,
lesbian, or bisexual (e.g., disclosure of sexual orientation to
friends and family, experience of homophobia and harassment, and
gender nonconformity). Aggressive treatment of psychiatric and substance
use disorders, open and nonjudgmental support, and promotion of
healthy psychosocial adjustment may help to decrease the risk for
suicide in gay, lesbian, and bisexual youths and adults.
Occupational groups differ in a number of factors contributing
to suicide risk. These factors include demographics (e.g., race,
gender, socioeconomic class, marital status), occupational stress (54, 55), psychiatric morbidity (56), and occupationally associated opportunities
for suicide (56, 57). Physicians have been consistently found to
be at higher risk for suicide than persons in other occupations
including professionals (57, 58). After basic demographic correlates
of suicide across 32 occupations were controlled, risk was found
to be highest among dentists and physicians (with multivariate logistic
regression odds ratios of 5.43 and 2.31, respectively) and was also
increased among nurses, social workers, artists, mathematicians,
and scientists (54). Although evidence is more varied, farmers may
be at somewhat higher risk, whereas risk in police officers generally
does not appear to differ from that of age- and sex-matched comparison
subjects (54, 57).
The presence of a psychiatric disorder is probably the most
significant risk factor for suicide. Psychological autopsy studies
have consistently shown that more than 90% of persons who
die from suicide satisfy the criteria for one or more psychiatric
disorders (59, 60). The psychological autopsy method involves a
retrospective investigation of the deceased person, within several
months of death, and uses psychological information gathered from
personal documents; police, medical, and coroner records; and interviews
with family members, friends, co-workers, school associates, and
health care providers to classify equivocal deaths or establish
diagnoses that were likely present at the time of suicide (61–63).
In addition to there being high rates of psychiatric disorder
among persons who die by suicide, almost all psychiatric disorders
with the exception of mental retardation have been shown to increase suicide
risk as measured by standardized mortality ratios (SMRs) (64) (Table 6). An SMR reflects the relative mortality from suicide in individuals
with a particular risk factor, compared with the general population.
Thus, the SMR will be equal to 1.0 when the number of observed suicide
deaths is equivalent to the number of expected deaths by suicide
in an age- and sex-matched group in the general population. Values
of the SMR for suicide that are greater than 1.0 indicate an increased
risk of suicide, whereas values less than 1.0 indicate a decreased
risk (i.e., a protective effect). It is also important to note that
SMRs do not correspond precisely to the incidence or prevalence
of suicide and may vary in their reliability depending on the number
of suicides in the sample, the time period of the study, and the
representativeness of the study population. Thus, SMRs should be
viewed as estimates of relative risk and not as reflections of absolute
risk for individuals with a particular disorder. It is equally necessary
to appreciate distinctions in risk across disorders and variations
in risk at differing points in the illness course in the effort
to differentiate high-risk patients within an overall at-risk population
identified in terms of standardized mortality.
Number of Studies
Standardized Mortality Ratio (SMR)b
Annual Suicide
Rate (%)
Estimated Lifetime
Suicide Rate (%)
Previous suicide attempts
Psychiatric disorders
Eating disorders
Major depression
Sedative abuse
Mixed drug abuse
Bipolar disorder
Opioid abuse
Obsessive-compulsive disorder
Panic disorder
Personality disorders
Alcohol abuse
Pediatric psychiatric disorders
Cannabis abuse
Mental retardation
on a meta-analysis by Harris and Barraclough (6464) of 249 reports
published between 1966 and 1993. Table adapted with permission.
bThe SMR is the ratio of the observed
mortality to the expected mortality and approximates the risk of
mortality resulting from suicide in the presence of a particular
condition. For the general population, the value of the SMR is 1.0,
with an annual suicide rate of 0.014% per year and a lifetime
rate of 0.72%.
Study after study has confirmed that the presence of a major
mood disorder is a significant risk factor for suicide. Not surprisingly,
mood disorders, primarily in depressive phases, are the diagnoses
most often found in suicide deaths (59, 65–67). Although
most suicides in individuals with bipolar disorder occur during
depressive episodes, mixed episodes are also associated with increased
risk (68–70). Suicidal ideation and attempts are also more
common during mixed episodes than in mania (71).
When viewed from the standpoint of lifetime risk, mood disorders
are associated with an increased risk of mortality that has been
estimated to range from a 12-fold increase in risk with dysthymia
to a 20-fold increase in risk with major depression (64). Lifetime
suicide risk in bipolar disorder has generally been found to be
similar to that in unipolar major depression (69, 72). However,
several longitudinal studies of patients followed after an index
hospitalization have demonstrated suicide risks in patients
with major depressive disorder that are greater than those in patients
with either bipolar I disorder or bipolar II disorder (73–75).
Particularly for younger patients, suicides are more likely
to occur early in the course of illness (68, 73, 75, 76). Nonetheless,
risk persists throughout life in major depressive disorder as well
as in bipolar disorder (73, 74). Suicide risk also increases in
a graduated fashion with illness severity as reflected by the level
of required treatment. Lifetime suicide rates in psychiatric outpatients
ranged from 0.7% for those without an affective disorder
to 2.2% for those with affective disorders, whereas lifetime
suicide rates for individuals requiring hospitalization ranged from
4% for those whose admission for depression was
not prompted by suicidal behavior or risk to 8.6% for those
whose admission was the result of suicidality (77). Illness severity
may also be an indicator of risk for suicide attempts (75, 78).
Among patients with mood disorders, lifetime risk also depends
on the presence of other psychiatric symptoms or behaviors, some
of which are modifiable with treatment. For example, patients with
mood disorders who died by suicide within 1 year of initial evaluation
were more likely to have panic attacks, severe psychic anxiety,
diminished concentration, global insomnia, moderate alcohol abuse,
and severe loss of pleasure or interest in activities (79). At later
time points, hopelessness has been associated with increased
suicide risk in mood disorder patients (78, 79). Suicidal ideation
and a history of suicide attempts also augment risk (74, 79). Comorbid
anxiety, alcohol use, and substance use are common in patients with
mood disorders and may also increase the risk of suicide and suicide
attempts (see Sections II.E.2.f, "Alcohol Use Disorders" and II.E.2.g, "Other Substance Use Disorders").
Although a greater risk for suicide or suicidal behaviors among
patients with psychotic mood disorders has been seen in some studies
(80–83), this relationship has not been found in other
studies (84–88).
Compared to the risk in the general population, the risk of
suicide in patients with schizophrenia is estimated to be about
8.5-fold higher (64), with even greater increments in risk in patients
who have been hospitalized (89). Although earlier research suggested
a 10%–15% lifetime risk of suicide among
patients with schizophrenia (90–93), such estimates were
likely inflated by biases in the patient populations and length
of follow-up. More recent estimates suggest a lifetime risk of suicide in
schizophrenia of about 4% (94).
Suicide may occur more frequently during the early years of
the illness, with the time immediately after hospital discharge
being a period of heightened risk (83, 89, 90, 95–98).
However, risk continues throughout life (99, 100) and appears to
be increased in those with a chronic illness course (83, 89, 101),
multiple psychiatric hospitalizations (89, 95), or a previous suicide
attempt (89, 90, 95, 100). Other consistently identified factors
that confer an increased risk of suicide in patients with schizophrenia
include male sex (83, 89, 90, 95, 102, 103), younger age (<30
years) (83, 90, 102), and social isolation (97, 104).
In individuals with schizophrenia or schizoaffective disorder,
psychotic symptoms are often present at the time of a suicide attempt
or suicide (105–107). However, command hallucinations seem
to account for a relatively small percentage of suicides, and there
is limited evidence on whether they increase suicide risk. Nonetheless,
they may act as a precipitant to a suicide attempt or to suicide in
some individuals (106, 108) (see Section II.E.3.c, "Command
Hallucinations"). Suicide in
patients with schizophrenia may be more likely to occur during periods
of improvement after relapse or during periods of depressed mood
(83, 89, 90, 95, 100, 109–111), including what has been termed
postpsychotic depression (112, 113). Also, patients with schizoaffective
disorder appear to be at greater risk for suicide than those with
schizophrenia (114).
Suicide risk may paradoxically be increased in those who have
insight into the implications of having a schizophrenic illness,
particularly if this insight is coupled with a feeling of hopelessness. Suicide
risk is also increased in those who recognize a loss of previous
abilities and are pessimistic about the benefits of treatment in
restoring those abilities (93, 101, 115). This pattern is consistent with
the increased risk of suicide observed in individuals with schizophrenia
who had a history of good premorbid and intellectual functioning
(83, 89, 103) as well as with the decreased risk of suicide in patients
with prominent negative symptoms (83, 89, 103, 116).
Suicidal ideation and suicide attempts are common among individuals
with schizophrenia and need to be identified and addressed in the
assessment process. In series of hospitalized or longitudinally
followed patients with schizophrenia, 40%–53% reported
having suicidal ideation at some point in their lives and 23%–55% reported
prior suicide attempts (80, 93, 108, 117). For individuals with schizoaffective
disorder, these figures are likely to be even higher (80). Patients
often reported that suicide attempts were precipitated by depression,
stressors, or psychotic symptoms (108). In addition, suicide attempts
among individuals with schizophrenia or schizoaffective disorder
were often medically serious and associated with a high degree of
intent (108), both of which would confer greater future risk for
Although studies of lifetime suicide risk in anxiety disorders
are more limited than for mood disorders, evidence suggests anxiety
disorders are associated with a six- to 10-fold increase in suicide
risk (64, 118, 119). Among persons who die from suicide, rates of
anxiety disorders appear to be lower than rates of mood disorders,
with one psychological autopsy study identifying an anxiety disorder
in only 11% of persons who died from suicide (120). However,
the prevalence of anxiety disorders may be underestimated because
of the masking of anxiety by affective disorders and by alcohol
use (121).
Of the anxiety disorders, panic disorder has been studied
in the most detail. In psychological autopsy studies, panic disorder
is present in about 1% of persons who die from suicide
(120), whereas other studies of panic disorder show an SMR for suicide
that is about 10 times that of the general population (64). As with
anxiety disorders in general, comorbid depression, alcohol use,
or axis II disorders are often present in individuals with panic
disorder who die by suicide (122, 123).
Suicidal ideation and suicide attempts are common in individuals
with anxiety disorders, but their rates vary with the patient population
and with the presence of comorbid diagnoses. In panic disorder, for
example, reported rates of prior suicide attempts range from 0% to
42% (124–129). In other anxiety disorders, the
relative risks of suicidal ideation and suicide attempts also appear
to be increased (118, 130). In addition, in patients with major
depression, the presence of a comorbid anxiety disorder appears
to increase the risk of suicidal ideation or suicide attempts (131, 132). Less clear, however, is whether anxiety disorders are associated
with an increased risk for suicide and other suicidal behaviors
in the absence of comorbid diagnoses (130, 132–136) or
whether the observed increases in risk can be accounted for solely
on the basis of comorbid disorders (127, 137). Nonetheless, suicide
risk may be diminished by identifying masked anxiety symptoms and
anxiety disorders that are misdiagnosed as medical illness as well
as by explicitly assessing and treating comorbid psychiatric diagnoses
in individuals with anxiety disorders.
Eating disorders, particularly anorexia nervosa,
are a likely risk factor for suicide as well as being associated
with an increased risk of mortality in general (64, 138, 139). Exact
risk is difficult to determine, however, as data on rates of suicide
in eating disorders may be subject to underreporting bias (140).
Suicide attempts are also common, particularly in individuals with
bingeing and purging behaviors and in those with comorbid mood disorders,
aggression, or impulsivity (141, 142). Conversely, suicide attempters
may have increased rates of abnormal eating behaviors (142). The role
of comorbid diagnoses in increasing the risk of suicidal behaviors
remains to be delineated. It is also not clear whether the self-imposed
morbidity and mortality associated with severe caloric restriction
or bingeing and purging should be viewed as a self-injurious or
suicidal behavior. Regardless, clinicians conducting a suicide risk
assessment should be attentive to the presence of eating disorders
and especially the co-occurrence of eating disorders with behaviors
or symptoms such as deliberate self-harm or depression.
The relationship between attention deficit hyperactivity disorder
(ADHD) and suicidal behavior is unclear, with some studies indicating
an association between the diagnosis of ADHD and suicide attempts
or completions (143, 144) and other studies indicating no such connection
(145, 146). However, individuals with ADHD, combined type, may be
at greater risk than those with ADHD, inattentive type, perhaps
because of an increased level of impulsivity in the combined type
of the disorder (144). In addition, the presence of ADHD may increase
suicide risk through comorbidity with conduct disorder, substance
abuse, and/or depressive disorder (143).
Alcoholism is associated with an increased risk for suicide,
with suicide mortality rates for alcoholics that are approximately
six times those of the general population (64, 94). In fact, abuse
of substances including alcohol may be the second most frequent
psychiatric precursor to suicide (147). Although suicide rates among
alcoholics are higher in Europe and older literature indicated a
lifetime risk for suicide in the 11%–15% range,
recent literature suggests the lifetime risk of suicide among alcoholics
in the United States is as low as 3.4% (148). In addition,
in psychological autopsy studies, alcohol abuse or dependence is
present in 25%–50% of those who died
by suicide (59, 149–151).
Several factors, including recent or impending interpersonal
losses and comorbid psychiatric disorders, have been specifically
linked to suicide in alcoholic individuals. The loss or disruption
of a close interpersonal relationship or the threatened loss of
such a relationship may be both a consequence of alcohol-related
behavior and a precipitant to suicide (110, 152–154). Suicide
is also more likely to occur among alcoholics who suffer
from depressive episodes than in persons with major depression or
alcoholism alone. In addition, studies have found major depressive
episodes in half to three-fourths of alcoholics who die by suicide
(67, 120, 149, 152, 155–157). As a result, psychiatrists
should systematically rule out the presence of a comorbid depressive
disorder and not simply assume that depressive symptoms result from
alcohol use or its psychosocial consequences.
Whereas full-time employment appears to be a protective factor
in alcoholics, factors that increase suicide risk include communications
of suicidal intent, prior suicide attempts, continued or heavier drinking,
recent unemployment, living alone, poor social support, legal and
financial difficulties, serious medical illness, other psychiatric
disorders, personality disturbance, and other substance use (64,
149, 152, 154, 156, 158, 159). In terms of gender, alcoholic men
are more likely to die by suicide, but female alcoholics appear
to have a greater standardized mortality due to suicide than men
(64), indicating an increased risk of suicide in alcoholics regardless
of gender. While the likelihood of a suicidal outcome increases
with the total number of risk factors (149, 160), not all of these
factors suggest an immediate risk. In fact, in contrast to suicide
in depressed and schizophrenic patients, suicide in alcoholics appears
to be a relatively late sequela of the disease (161),
with communications of suicidal intent usually being of several
years' duration and health, economic, and social functioning showing
a gradual deterioration (149).
In addition to being associated with an increased risk of
suicide, alcohol use disorders are associated with a greater likelihood
of suicide attempts (162, 163). For suicide attempts among alcoholics,
greater rates are associated with female sex, younger age, lower
economic status, early onset of heavy drinking and alcohol-related problems,
consumption of greater amounts of alcohol when drinking, and having
a first- or second-degree relative who abused alcohol (164–167).
The risk of suicide attempts among alcoholics is also increased
by the presence of a comorbid psychiatric diagnosis, particularly
major depression, other substance use disorders, antisocial personality
disorder, or an anxiety disorder (165–171).
Thus, individuals with alcohol use disorders are at increased
risk for suicide attempts as well as for suicide. Family histories
of alcoholism and comorbid psychiatric disorders, particularly mood disorders
and other substance use disorders, are frequent in alcoholics who
die by suicide and who attempt suicide. Interpersonal loss and other
adverse life events are commonly noted to precede suicide in alcoholics.
These factors may act as precipitants, or, conversely, alcohol use
disorders may have a deteriorating effect on the lives
of alcoholics and culminate in suicide. Together, however, these
findings suggest the need to identify and address comorbid psychiatric
diagnoses, family history, and psychosocial factors, including recent
interpersonal losses, as part of the suicide assessment of persons
with alcohol use disorders.
Although the role of alcoholism in suicide has been widely
studied and recognized, abuse of other substances is also associated
with increased rates of suicide (172). Substance use disorders
are particularly common among adolescents and young adults who die
by suicide (110, 145, 173, 174). In fact, it has been suggested
that the spread of substance abuse may have contributed to the two-
to fourfold increase in youth suicide since 1970 (147). For many
individuals, substance abuse and alcoholism are co-occurring, making
it difficult to distinguish the contributions of each to rates of suicide
(153, 172, 173). In addition, other comorbid psychiatric disorders,
particularly mood disorders and personality disorders, may add to
the risk of suicide in patients with substance use disorders (145,
Substance use disorders also seem to make an independent contribution
to the likelihood of making a suicide attempt (176, 177). In addition,
a history of suicide attempts is common among individuals with substance
use disorders (31, 178–180). Even after other factors,
including comorbid psychiatric disorders and demographic characteristics,
are controlled, it is the number of substances used, rather than
the type of substance, that appears to be important (176). As with
suicide in individuals with alcohol use disorders, the loss of a
significant personal relationship is a common precipitant for a
suicide attempt (179). Suicide attempts are also more likely in
individuals with substance abuse who also have higher childhood
trauma scores for emotional neglect (180, 181). Moreover, a substance
use disorder may complicate mood disorders (182), increasing susceptibility
to treatment resistance, increasing psychological impairment, and
contributing to an elevated risk for suicide attempts. Thus, it
is important to identify patterns of substance use during the psychiatric
evaluation and to note comorbid psychiatric diagnoses or psychosocial
factors that may also affect the likelihood of suicidal behaviors among
individuals with substance use disorders.
Diagnoses of personality disorders have been associated with
an increased risk for suicide, with estimated lifetime rates of
suicide ranging from 3% to 9% (183–185).
Compared with the general population, individuals with personality
disorders have an estimated risk for suicide that is about seven
times greater (64). Specific increases in suicide risk have been
associated with borderline and antisocial personality disorders,
with possible increases in risk associated with avoidant and schizoid personality
disorders (186). Psychological autopsy studies have shown personality
disorders to be present in approximately one-third of those who
die by suicide (174, 183, 186, 187). Among psychiatric outpatients,
personality disorders are present in about one-half of patients
who die by suicide (78, 188).
In individuals with personality disorders, suicide risk may
also be increased by a number of other factors, including unemployment,
financial difficulty, family discord, and other interpersonal conflicts
or loss (189, 190). In individuals with borderline personality disorder,
in particular, impulsivity may also increase suicide risk (185).
Although comorbid diagnoses do not account for the full increase
in suicide risk with personality disorders (184, 185), comorbid
diagnoses are frequent and augment suicide risk. In fact, for individuals
with personality disorders, concurrent depressive symptoms or substance
use disorders are seen in nearly all individuals who die by suicide
Among individuals who attempt suicide, diagnoses of personality
disorders are also common, with overall rates of about 40% (31, 177, 184). Individuals with personality disorders tend to attempt suicide
more often than individuals with other diagnoses (191–193),
with 40%–90% of individuals with personality
disorders making a suicide attempt during their lifetime (184).
Comorbid psychiatric diagnoses, including mood disorders and substance
use disorders, are quite prevalent among suicide attempters with
personality disorders and independently contribute to risk (131,
184, 191, 192, 194, 195). Impulsivity has also been shown to increase
the risk of suicide attempts in some (196, 197) but not all studies
(191). Rates of suicide attempts in those with personality disorder
may also vary with treatment setting, with greater risk in individuals
who are receiving acute inpatient treatment (198).
Of personality disorder diagnoses, borderline personality
disorder and antisocial personality disorder confer an added risk
of suicide attempts (31, 177, 191, 193). In individuals with borderline personality
disorder, there is some evidence of increased risk being associated
with the number and severity of symptoms (195). Among female suicide
attempters, rates of borderline personality disorder are higher
than among male suicide attempters (199, 200). These findings suggest
that personality disorders, particularly borderline personality
disorder and antisocial personality disorder, should be identified
and addressed as part of the suicide assessment process.
As discussed in preceding sections, comorbid psychiatric diagnoses
(most commonly, major depression, borderline and antisocial personality
disorders, and alcohol and other substance use disorders) increase
suicide risk and are often present in individuals who die by suicide
(13, 59, 120, 174, 201). Comorbid medical diagnoses may also increase
suicide risk, as will be discussed in Section II.E.5, "Physical
Illness". In general, the greater the number of
comorbid diagnoses that are present, the greater will be the increase
in risk. Furthermore, even in the absence of a formal comorbid diagnosis,
suicide is more likely to occur when there are high levels of additional
psychiatric symptoms (67, 185, 202–204).
In patients with a mood disorder, either bipolar disorder
or major depression, the risk of suicide is particularly increased
in the presence of comorbid alcohol or substance use (68, 205–207),
with some studies suggesting that males are at additional risk (68, 205). Comorbid alcohol use may also increase suicide risk in patients with schizophrenia (107). In addition, suicide in schizophrenia may be more likely to occur during periods of depression (83, 90, 109–113). In anxiety disorders and particularly in panic disorder, individuals who die by suicide often have experienced
comorbid depression, alcohol use, or axis II disorders (122, 123).
Similarly, when suicide occurs in individuals with eating disorders,
it is often associated with a comorbid mood disorder or substance
use disorder (138).
For individuals with alcohol use disorders, major depression
is found in half to three-fourths of individuals who die by suicide
(67, 120, 149, 152, 155–157), and alcoholics who suffer
from depressive episodes are more likely to die from suicide than
persons with major depression or alcoholism alone. Serious medical
illness and other psychiatric disorders, including personality disturbance
and other substance use disorders, also increase suicide risk in
alcoholics (64, 149, 152, 154, 156, 158, 159). For many individuals,
substance abuse and alcoholism are co-occurring, making it difficult
to distinguish the contributions of each to rates of suicide (153,
172, 173, 208). Furthermore, it appears to be the number of substances
used, rather than the specific substance, that determines risk (176).
Individuals who die by suicide and who abuse or are dependent
on substances other than alcohol are typically adolescents or young
adults. Comorbid mood disorders are commonly seen in both males and
females (66, 145, 204). In addition, borderline personality disorder
is relatively frequent in females with substance use disorders (175),
whereas young males with substance use disorders who die by suicide
more commonly have comorbid antisocial personality disorder (120,
159, 173, 204). The presence of ADHD may increase suicide risk through
comorbidity with conduct disorder, substance abuse, and/or
depressive disorder (143). For individuals with personality disorders,
concurrent depressive symptoms or substance use disorders augment
suicide risk (184, 185, 209, 210) and are seen in nearly all suicides
Comorbid diagnoses are also essential to identify and address
because of their role in increasing the risk of suicide attempts
(199). Furthermore, the likelihood of a suicide attempt
appears to increase with an increasing number of comorbid
diagnoses (166, 176, 177, 211). In addition, the number and severity
of symptoms may play a role in increasing risk, regardless of whether
the full criteria for a separate diagnosis are met. The specific
comorbid disorders that augment the risk of suicide attempts are
similar to those that are commonly seen to augment the risk of suicide
and include comorbid depression (129, 131, 193, 195, 197, 211),
alcohol and other substance use disorders (31, 129, 167, 168, 170,
180, 182, 191, 199, 211–214), anxiety disorders (127, 130–135, 137, 211, 215), and personality disorders (184, 191), particularly
borderline personality disorder (31, 195, 200) and antisocial personality
disorder (165, 204, 216). Thus, given the evidence that comorbidity
increases the risks for suicide and for suicide attempts, the suicide
risk assessment should give strong consideration to all current
and previous psychiatric diagnoses.
Anxiety appears to increase the risk for suicide (79, 217, 218). Specifically implicated has been severe psychic anxiety consisting
of subjective feelings of fearfulness or apprehension, whether or not
the feelings are focused on specific concerns. Clinical observation
suggests that anxious patients may be more inclined to act on suicidal
impulses than individuals whose depressive symptoms include psychomotor
slowing. Studies of suicide in patients with affective disorders
have shown that those who died by suicide within the first year
after contact were more likely to have severe psychic anxiety or
panic attacks (79, 219). In an inpatient sample, severe anxiety,
agitation, or both were found in four-fifths of patients in the
week preceding suicide (218). Similar associations of anxiety with
suicide attempts have been noted in some (212) but not all (220)
studies. Since severe anxiety does seem to increase suicide risk,
at least in some subgroups of patients, anxiety should be viewed as
an often hidden but potentially modifiable risk factor for suicide
(109). Once identified, symptoms of anxiety can be addressed with
psychotherapeutic approaches and can also respond rapidly to aggressive
short-term treatment with benzodiazepines, second-generation antipsychotic
medications, and possibly anticonvulsant medications.
Hopelessness is well established as a psychological dimension
that is associated with increased suicide risk (10, 78, 79, 217, 221–223). Hopelessness may vary in degree from having a
negative expectation for the future to being devoid of hope and
despairing for the future. In general, patients with high levels of
hopelessness have an increased risk for future suicide (78, 221–225).
However, among patients with alcohol use disorders, the presence
of hopelessness may not confer additional risk (226, 227). For patients
with depression, hopelessness has been suggested to be the factor
that explains why some patients choose suicide, whereas others do
not (222). Hopelessness also contributes to an increased likelihood
of suicidal ideation (192, 228) and suicide attempts (197, 212, 229–231) as well as an increased level of suicidal intent (197, 232, 233).
Hopelessness often occurs in concert with depression as a "state-dependent" characteristic,
but some individuals experience hopelessness on a primary and more
enduring basis (221). High baseline levels of hopelessness have
also been associated with an increased likelihood of suicidal behaviors (234).
However, patients experiencing similar levels of depression may
have differing levels of hopelessness (222), and this difference,
in turn, may affect their likelihood of developing suicidal thoughts (228).
Whatever the source or conceptualization of hopelessness, interventions
that reduce hopelessness may be able to reduce the potential for
suicide (10, 222, 235–237).
Command hallucinations, which order patients to carry out
tasks or actions, can occur in individuals with psychotic disorders,
primarily schizophrenia (238). Evidence for the association of command
hallucinations with suicide is extremely limited (102, 239). The
presence of auditory command hallucinations in inpatients does not
appear to increase the likelihood of assaultiveness or of suicidal
ideation or behavior over that associated with auditory hallucinations
alone (240). Furthermore, in patients who do experience auditory
command hallucinations, reported rates of compliance with commands
vary widely from 40% to 84% (106, 241–244).
Variables that have been associated with a propensity to obey command
hallucinations include being able to identify the hallucinatory
voice, having more severe psychotic disturbance, having
a less dangerous command, and experiencing the commands for the
first time or outside of a hospital environment (241, 242, 245).
Thus, at least for some individuals, suicidal behaviors can occur
in response to hallucinated commands, and individuals with prior
suicide attempts may be particularly susceptible (106). Consequently,
in the psychiatric evaluation, it is important to identify auditory
command hallucinations, assess them in the context of other clinical
features, and address them as part of the treatment planning process.
Impulsivity, hostility, and aggression may act individually
or together to increase suicide risk. For example, many studies
provide moderately strong evidence for the roles of impulsivity
and hostility-related affects and behavior in suicide across diagnostic
groups (89, 217, 246–248). Multiple other studies have
also demonstrated increased levels of impulsivity and aggression
in individuals with a history of attempted suicide (31, 193, 197, 212, 220, 249–252). Many patients with borderline personality disorder exhibit self-mutilating behaviors, and, overall, such behaviors
are associated with increased impulsivity (251). However, for many
self-mutilating patients, these behaviors are premeditated rather
than impulsive (253). Consequently, self-mutilatory behaviors alone
should not be regarded as an indicator of high impulsivity. Moreover,
measures of aggression and impulsivity are not highly correlated
(253), making aggression a poor marker of impulsivity as well. Thus, impulsivity,
hostility, aggression, and self-mutilating behaviors should be considered
independently in the psychiatric evaluation as well as in estimating
suicide risk.
In addition to the increased suicide risk conferred by alcohol
abuse or dependence, intoxication itself appears to play a role
in alcoholic as well as nonalcoholic populations (254). Autopsies
have found alcohol to be present in 20%–50% of
all persons who die by suicide (121, 255). Those who consume alcohol
before suicide are more likely to have experienced a recent breakup
of an interpersonal relationship but less likely to have sought
help before death (255). They are also more likely to have chosen
a firearm as a suicide method (151, 256, 257). Alcohol intoxication
at the time of suicide may also be more common in younger individuals
(154, 255, 258), in men (121, 255), and in individuals without any
lifetime history of psychiatric treatment (154). Among suicide attempters who
later died by suicide, alcohol appeared to contribute to death in
more than a third (259). In addition, a study of the interaction
of employment and weekly patterns of suicide emphasizes the role
of intoxication in suicides and indicates that employment may be
a stabilizing factor that curbs heavy drinking during the work week
(260), thereby decreasing rates of suicide. Consequently, in some
subsets of patients, alcohol consumption appears to contribute to
the decision to die by suicide (255).
Alcohol use is also a common prelude to suicide attempts (258).
Some estimates show that more than 50% of individuals have
used alcohol just before their suicide attempt. Among alcoholics, heavier
drinking adds to risk (64, 149, 165). Suicide attempts that involve
alcohol are more likely to be impulsive (258). Indeed, the majority
of acutely intoxicated alcoholics either did not remember the reason
for their attempt or had done it on a sudden impulse (258). Thus,
alcohol consumption may make intervention more difficult by simultaneously
limiting the communication of intent (255, 261), increasing impulsivity,
decreasing inhibition, and impairing judgment (262).
Alcohol use in conjunction with attempted suicide is more
common in men than in women (258), although among younger attempters,
females may be more likely than males to consume alcohol (258). Alcohol
use in conjunction with a suicide attempt has also been associated
with repeated suicide attempts and future suicide (263). In some
individuals, intentionally drinking to overcome ambivalence about
suicide may signify serious suicidal intent. Thus, since intoxication
is a risk factor for suicide attempts as well as for suicide, the
clinician should inquire about a patient's drinking habits
and consider the effect of alcohol intoxication when estimating
suicide risk.
Individuals who have made a suicide attempt constitute a distinct
but overlapping population with those who die by suicide. As with
individuals who die by suicide, a high preponderance of suicide attempters
have one or more axis I or II diagnoses, with major depression and
alcohol dependence observed most commonly for axis I and borderline
personality disorder observed most commonly for axis II (199, 200, 264). However, suicide attempts are about 10–20 times more
prevalent than suicide (265), with lifetime prevalence ranging from
0.7% to 6% per 100,000 in a random sample of U.S. adults
(2). Although a substantial percentage of individuals will die on
their initial suicide attempt (266), a past suicide attempt is one
of the major risk factors for future suicide attempts (164, 267)
and for future suicide (64, 78, 79, 266, 268–271).
After a suicide attempt, there can be significant mortality
from both natural and unnatural causes (259, 272). A suicide attempt
by any method is associated with a 38-fold increase in suicide risk,
a rate that is higher than that associated with any psychiatric
disorder (64). Depending on the length of the follow-up, from 6% to
27.5% of those who attempt suicide will ultimately die
by suicide (64, 273), and similar results have been suggested for
acts of deliberate self-harm (274). Some studies have found that
suicide risk appears to be particularly high during the first year
after a suicide attempt (259, 275). An additional increase in risk
may be associated with aborted suicide attempts (276, 277) or repeated
suicide attempts (64, 259, 263, 272, 274, 278). Thus, the increase
in suicide mortality subsequent to attempted suicide emphasizes
the need for aftercare planning in this heterogeneous population.
In the context of a suicide attempt, a number of other factors
are associated with increases in suicide risk. For example, risk
is augmented by medical and psychiatric comorbidity, particularly comorbid
depression, alcohol abuse, or a long-standing medical illness (64).
Low levels of social cohesion may also increase risk (64). Risk
of later suicide in males, particularly younger males, appears to
be two to four times greater than that in females after a suicide
attempt (275). In addition, serious suicide attempts are associated
with a higher risk of eventual suicide, as are having high intent (164),
taking measures to avoid discovery, and using more lethal methods
that resulted in physical injuries (263).
Given this increased likelihood of additional suicide attempts
and suicide deaths after a suicide attempt or aborted suicide attempt,
psychiatric evaluation should be incorporated into emergency medical
assessments of suicide attempters (279) and the importance of follow-up
should be emphasized (2, 280).
A history of childhood abuse has been associated with increased
rates of suicidal behaviors in multiple studies. Rates of suicide
in individuals with a history of childhood abuse have not been widely
studied, but available evidence suggests that suicide rates are
increased at least 10-fold in those with a history of childhood
abuse (36). In addition, a number of studies have demonstrated
that individuals with a history of childhood abuse have an increased
risk of suicide attempts (230, 281–283), suggesting that
risk of later suicide will also be increased. Rates of suicide attempts
are increased in individuals who report experiencing childhood physical
abuse (196, 250, 284–290) as well as in individuals who
report experiencing childhood sexual abuse (33, 35, 36, 164, 196, 250, 284, 285, 288–294). Rates of suicidal ideation are similarly increased in individuals with a childhood history of abuse
Since many traumatized individuals have experienced both sexual
and physical abuse during childhood, it is often difficult to establish
the specific contributions of each form of abuse to the risk of
suicide and other suicidal behaviors. In addition, the duration
and severity of childhood abuse vary across individuals and can
also influence risk. It appears, however, that the risk of suicide
attempts is greater in individuals who have experienced both physical
and sexual abuse in childhood (288) and that greater levels of risk
are associated with increasing abuse severity (285, 286, 291).
Childhood trauma can also be associated with increased self-injurious
behaviors, including self-cutting and self-mutilation, without associated
suicidal intent. Sexual abuse may be a particular risk factor for
such behaviors, which can often become repetitive (164).
Indeed, deliberate self-harm is common in patients with posttraumatic
stress disorder and other traumatic disorders and serves to reduce
internal tension and provide nonverbal communication about their
self-hate and intense distress (295). As a result, inquiring about
the motivations of self-injurious behavior may help to inform estimates
of suicide risk.
Gender may also influence the risk of suicidal behaviors in
those with a history of childhood abuse. This influence, in part,
relates to differences in the prevalence of childhood abuse between
men and women, with rates of childhood physical abuse being higher
in men and rates of childhood sexual abuse being higher in women
(288). However, in individuals who have a history of childhood sexual abuse,
the risk of a suicide attempt may be greater in men than in women
Given the significant rates of childhood physical and/or
sexual abuse, particularly among psychiatric patient populations
(35, 284, 288, 292), and the increased risk for suicidal behaviors
that such abuse confers, it important to assess for a history of
physical abuse and sexual abuse as part of the psychiatric evaluation.
In addition, the duration and severity of childhood abuse should
be determined, as these factors will also influence risk.
Domestic partner violence has been associated with
increased rates of suicide attempts and suicidal ideation; however,
there is no information about its effects on risk for suicide per
se. The risk for suicide attempts in individuals who have experienced
recent domestic partner violence has been estimated to
be four- to eightfold greater than the risk for individuals without
such experiences (34, 296–300). Conversely, among women
presenting with suicide attempts, there is a severalfold increase in
their risk for experiencing domestic partner violence (230, 301).
Although much more commonly experienced by women, domestic
partner violence is also experienced by men and can increase their
risk for suicide attempts (302). Men with a history of domestic violence
toward their partners may also be at increased risk for suicide
(303). Furthermore, domestic violence in the home may increase the
risk for suicide attempts among children who are witnesses to such
violence (281).
Given the clear increase in risk for suicide attempts in individuals
experiencing domestic partner violence and the likely association
of suicide attempts with an increased risk for suicide, it is important to
specifically ask about domestic partner violence as a part of the
suicide assessment. Such inquiry may also help to identify individuals
in addition to the identified patient who may be at increased risk
for suicidal behaviors.
Multiple studies have shown that greater treatment intensity
is associated with greater rates of eventual suicide (64, 77, 198).
Although hospitalization generally occurs because a patient has
a more severe illness and is deemed to be at increased risk for
suicide, for some patients, hospitalization could conceivably result
in increased distress and thus an increase in suicide risk. Thus,
as a general rule, a past history of treatment, including a past
history of hospitalization, should be viewed as a marker that alerts
the clinician to increased suicide risk.
Temporally, the risk for suicide appears to be greatest after
changes in treatment setting or intensity (304), with recently admitted
and recently discharged inpatients showing increased risk (64, 72, 91, 95, 305–308). This increase in rates of suicide after
hospital discharge is seen across diagnostic categories and has
been observed in individuals with major depressive disorder, bipolar
disorder, schizophrenia, and borderline personality disorder. Rates
decline with time since discharge but may remain high for as long
as several years (91, 306, 309). Similar findings are seen with
suicide attempts, which are also more frequent in the period after
hospitalization (267, 305, 308). These observations suggest a need
for close follow-up during the period immediately after discharge.
In some psychiatric disorders, suicide risk is greater at
certain points in the illness or episode course. For example, in
the course of major depressive disorder, suicidality tends to occur
early, often before a diagnosis has been made or treatment has begun
(304, 310–312). In patients with major depressive disorder
(73, 313), as well as in those with bipolar disorder (73, 74, 305)
or schizophrenia (83), suicide has been noted to be more likely
during the first few episodes, early in the illness (314, 315).
After a suicide attempt, the risk for suicide is also greatest initially,
with most suicides occurring in the first year after the attempt
(275). Although risks of suicide and suicide attempts later in the
illness course are less than they are earlier on, these risks remain
greater than those for the general population (74, 100, 316–318).
These findings highlight the need for early identification of these
disorders and for therapeutic approaches that will treat the illness
while simultaneously promoting longer-term treatment adherence.
Risk may also vary with severity of symptoms. For example,
higher levels of depression have been associated with increased
risk of suicide in at least one study (319), whereas greater numbers of
symptoms of borderline personality disorder have been associated
with an increased risk for suicide attempts (195). In addition,
higher levels of suicidal ideation and subjective hopelessness also increase
risk for suicide (78) and suicide attempts (31). In contrast, higher
levels of negative symptoms have been associated with decreased
suicide risk in individuals with schizophrenia (320). It is also
important to recognize that other factors such as age will modulate
the effects of symptom severity on risk. With older adults, for
example, milder symptoms may be associated with greater risk than
moderate symptoms in younger adults (207, 321). Consequently, clinicians
should consider the severity of a patient's illness and
psychiatric symptoms in the context of other patient-specific factors
when assessing suicide risk.
Identification of medical illness (axis III) is also an essential
part of the assessment process. Such diagnoses will need to be considered
in developing a plan of treatment, and they may influence suicide risk
in several ways. First, specific medical disorders may themselves
be associated with an increased risk for suicide. Alternatively,
the physiological effects of illness or its treatment may lead to
the development of psychiatric syndromes such as depression, which
may also increase suicide risk. Physical illnesses are also a source
of social and/or psychological stress, which in turn augments
risk. Physical illnesses such as hepatitis C or sexually transmitted
diseases may signal an increased likelihood of impulsive behaviors
or comorbid substance use disorders that may in turn be associated
with greater risk for suicidal behaviors. Finally, when physical
illness is present, psychiatric signs and symptoms may be ascribed
to comorbid medical conditions, delaying recognition and treatment
of the psychiatric disorder.
Data from clinical cohort and record linkage studies indicate
clearly that medical illness is associated with increased likelihood
of suicide (Table 7). Not surprisingly, disorders of the nervous
system are associated with an elevated risk for suicide. The association
between seizure disorders and increased suicide risk is particularly
strong and consistently observed (64, 322–328). Presumably
because of its close association with impulsivity, mood disorders,
and psychosis, temporal lobe epilepsy is associated with increased
risk in most (322, 327, 328) but not all (325) studies. Suicide
attempts are also more common among individuals with epilepsy (329–331).
Other neurological disorders that are associated with increased
risk for suicide include multiple sclerosis, Huntington's
disease, and brain and spinal cord injury (25, 323, 332–334).
Mortality Ratio (SMR)b
Spinal cord injury
Brain injury
Huntington's chorea
bThe SMR is the ratio of the observed
mortality to the expected mortality and approximates the risk of
mortality resulting from suicide in the presence of a particular
Other medical disorders that have also been associated with
an increased risk for suicide include HIV/AIDS (25, 335, 336), malignancies (especially of the head and neck) (25, 333, 337, 338), peptic ulcer disease (25), systemic lupus erythematosus (25),
chronic hemodialysis-treated renal failure (339), heart disease
(337), and, in men, chronic obstructive pulmonary disease and prostate
disease (337). In contrast, studies have not demonstrated increased
suicide risk in patients with amyotrophic lateral sclerosis (ALS),
blindness, cerebrovascular disease, hypertension, rheumatoid arthritis,
or diabetes mellitus (25, 337).
Beyond the physical illness itself, functional impairments
(321, 333, 338), pain (340–342), disfigurement, increased
dependence on others, and decreases in sight (333) and hearing increase suicide
risk. Furthermore, in many instances, the risk for suicide associated
with a medical disorder is mediated by psychiatric symptoms or illness
(321, 342, 343). Indeed, suicidality is rarely seen in individuals
with serious physical illness in the absence of clinically significant
mood disturbance. Finally, the risk for suicide or suicide attempts
may also be affected by characteristics of the individual patient,
including gender, coping style, availability of social supports,
presence of psychosocial stressors, previous history of suicidal
behaviors, and the image and meaning to the individual of the illness itself.
In individuals with a history of suicide among relatives,
the risk of suicidal behaviors is increased, apparently through
genetic as well as environmental effects. An increased relative
risk for suicide or suicide attempts in close relatives of suicidal
subjects has been demonstrated repeatedly (31, 82, 202, 214, 312, 344–364). Overall, it appears that the risk of suicidal
behaviors among family members of suicidal individuals is about
4.5 times that observed in relatives of nonsuicidal subjects (365–368; R. Baldessarini, personal communication, 2002). Furthermore, this
increase in the risk of suicidal behaviors among family members
seems, at least in part, to be independent of genetic contributions
from comorbid psychiatric diagnoses (355, 361, 367, 368).
Twin studies also provide strong support for the role of a
specific genetic factor for suicidal behaviors (365, 368, 369),
since there is substantially higher concordance of suicide and suicide attempts
in identical twins, compared with fraternal twin pairs (370–375).
Adoption studies substantiate the genetic aspect of suicide risk
in that there is a greater risk of suicidal behavior among biologic than
among adopted relatives of individuals with suicidal behavior or
depression (376–378).
Despite the fact that family, twin, and adoption methods provide
highly suggestive evidence of heritable factors in risk of suicide
as well as some evidence for nonlethal suicidal behavior, the mode of
transmission of this genetic risk remains obscure. Thus far, molecular
genetic approaches have not yielded consistent or unambiguous evidence
of a specific genetic basis for suicide risk (16). In addition,
genetic associations with suicide risk may be confounded by the
heritability of other factors such as mood disorders or substance
use disorder that are also associated with increased risk for suicidal
Unemployment has long been associated with increased rates
of suicide (379, 380). In recent case-control and longitudinal studies,
higher rates of unemployment have been consistently noted in suicide
attempters (78, 149, 361, 381–383) and in persons who died by suicide (24, 190, 384, 385). Compared with individuals in control
groups, unemployed persons have a two- to fourfold greater risk
for suicide. Risk is particularly elevated in those under age 45
and in the years closest to job loss, with even greater and longer-lasting
effects noted in women (24). Parallel increases in rates of suicide and
suicide attempts are also seen in socioeconomically deprived geographical
areas, which have larger numbers of unemployed people (386).
For many individuals, unemployment occurs concomitantly with
other factors that affect the risk of suicidal behaviors. For example,
with job loss, financial and marital difficulties may increase. Alternatively,
factors such as psychiatric illness (380) or adverse childhood experiences
(361) may affect rates of suicidal behaviors but also influence
the likelihood of gaining and maintaining employment. Thus, while
unemployment appears to be associated with some independent increase in
risk, a substantial fraction of the increase in risk for suicidal
behaviors among unemployed persons can be accounted for by co-occurring
factors (361, 381, 384, 385).
Among individuals with alcohol use disorders, particularly
those under age 45, unemployment is one of a number of stressors
that is a common precipitant to suicide (149, 382, 387). Even in
those without substance use disorders, unemployment may result in
increased drinking, which in turn may precipitate self-destructive
behavior (154). Conversely, in those with substance use disorders,
full-time employment protects against suicidal behaviors, a finding
that may in part relate to decreases in use of alcohol or other
substances during the work week (260). Thus, unemployment may serve as
a risk factor for suicide, whereas employment may have protective
effects on suicide risks.
The likelihood of suicide may also vary with religious beliefs
as well as with the extent of involvement in religious activities.
In general, individuals are less likely to act on suicidal thoughts
when they have a strong religious faith and believe that suicide
is morally wrong or sinful. Similar findings of low suicide rates
are found in cultures with strong religious beliefs that the body
is sacred and not to be damaged intentionally. In the United States,
Catholics have the lowest rate of suicide, followed by
Jews, then Protestants (388). Among other religious groups, Islamic
tradition has consistently regarded suicide as morally wrong, and
some Islamic countries have legal sanctions for attempted suicide
(389, 390). In some countries, suicide rates among Muslims appear
to be greater than those among Hindus (391, 392), although suicide
rates across countries do not appear to vary with the proportion
of Muslims in the population (393).
Additional evidence suggests that it is the strength of the
religious beliefs and not the specific religion per se that alters
suicide rates (43, 394–398). In the African American community,
for example, religion is viewed as a source of social solidarity
and hope (22). Religious involvement may also help to buffer acculturative
stress, which is associated with depression and suicidal ideation (43).
The religious belief system itself and the practice of spiritual
techniques may also decrease suicide risk by acting as a coping
mechanism and providing a source of hope and purpose.
Although protective effects can be afforded by religious beliefs,
this is not invariably the case. For example, suicide may be more
likely to occur among cultures in which death by suicide is a traditionally
accepted way of dealing with distress or in religions that deemphasize
the boundaries between the living and the dead. Particularly for
adolescents, belief in an afterlife may lead to suicide in an effort
to rejoin a deceased loved one. Thus, it is important to gain an
understanding of the specific religious beliefs and religious involvement
of individuals and also to inquire how these religious beliefs relate
to thoughts and conceptions of suicide.
The presence of a social support system is another factor
that may reduce suicide risk (399, 400). Consequently, communicating
with members of the patient's support network may be important
in assessing and helping to strengthen social supports (see Section
V.C, "Communication With Significant Others"). Although social supports typically include family
members or friends, individuals may also receive support from other
sources. For example, those in the military and those who belong
to religious, community, or self-help organizations may receive
support through these affiliations.
In addition to determining whether a support system is present,
the clinician should assess the patient's perception of
available social supports. Individuals who report having more friends
and less subjective loneliness are less likely to have suicidal
ideation or engage in suicidal behaviors (401). By the same token,
if other social supports are not available, living alone may increase
suicide risk (149, 385, 402), although this is not invariably true
(343, 403, 404). Family discord, other relationship problems, and
social isolation may also increase risk (403, 405, 406). Risk of
suicidal behaviors may also increase when an individual rightly
or wrongly fears that an interpersonal loss will occur (149). Thus, in
estimating suicide risk, the clinician should assess the patient's
support network as well as his or her perception of available social
An additional protective factor against suicidal behaviors
is the ability to cite reasons for living (231, 407), which reflects
the patient's degree of optimism about life. A sense of
responsibility to family, particularly children, is a commonly cited
reason for living that makes suicide a less viable option to escape
from pain. The presence of children in the home as well as the number
of children appear to decrease the risk for suicide in women (26, 47). Although less well-studied, a smaller effect on suicide potential
may also be present in men who have children under age 18 within
the home (408). Thus, knowledge of the patient's specific
reasons for living, including information about whether there are
children in the home, can help inform estimates of suicide risk.
Estimates of suicide risk should also incorporate an assessment
of the patient's strengths and vulnerabilities as an individual.
For example, healthy and well-developed coping skills may buffer stressful
life events, decreasing the likelihood of suicidal actions (409).
Conversely, lifelong patterns of problematic coping skills are common
among those who die by suicide (410). Such factors may be particularly
important in patients with substance use or personality disorders,
for whom heightened suicide risk may be associated with life stressors
or interpersonal loss.
In addition to the diagnosis of categorical axis II disorders,
as discussed elsewhere, dimensional and trait approaches
to personality can also inform estimates of suicide risk.
Although the positive correlation value of individual personality
traits with suicide is low, increased suicide risk may be associated
with antisocial traits (411) as well as with hostility, helplessness/dependency,
and social disengagement/self-consciousness (246).
Extensive clinical literature and clinical consensus support
the role of psychodynamics in assessing a patient's risk
for suicidal behavior (409, 410, 412–419). Suicide may
have multiple motivations such as anger turned inward or a wish
of death toward others that is redirected toward the self. Other
motivations include revenge, reunion, or rebirth. Another key psychodynamic
concept is the interpretation of suicide as rooted in a triad of
motivations: the wish to die, the wish to kill, and the wish to
be killed (415). Other clinicians have conceptualized these motivations
as escape (the wish to die), anger or revenge (the wish to kill),
and guilt (the wish to be killed). The presence of one or several
of these motivations can inform the psychiatrist about a patient's
suicide risk.
Object relations theories offer important concepts for psychodynamic
formulations of suicide. Suicidal behavior has been associated with
poor object relations, the inability to maintain a stable, accurate, and
emotionally balanced memory of the people in one's
life (413). In some cases the wish to destroy the lives of the survivors
is a powerful motivator (415, 420). For other individuals,
a sadistic internal object is so tormenting that the only possible
outcome is to submit to the tormentor through suicide (416, 417).
Other important psychodynamic concepts for the clinician to
assess are shame, worthlessness, and impaired self-esteem. Early
disturbance in parent-child relationships through failure of empathy or
traumatic loss can result in an increased vulnerability to later
injuries of self-esteem. These patients are vulnerable to narcissistic
injuries, which can trigger psychic pain or uncontrollable negative affects.
In these situations some patients may experience thoughts of death
as peaceful, believing that their personal reality is emotionally
intolerable and that it is possible to end pain by stopping consciousness.
Suicidal individuals are often ambivalent about making a suicidal
action. As a result, suicide is less likely if an individual sees
alternative strategies to address psychological pain (410). However, certain
traits and cognitive styles limit this ability to recognize other
options. For example, thought constriction and polarized, all-or-nothing thinking
are characterized by rigid thinking and an inability to consider
different options and may increase the likelihood of suicide (410,
421–423). Individuals who are high in neuroticism and low
in "openness to experience" (affectively blunted
and preferring the familiar, practical, and concrete) may also be
at greater risk for suicide (424). Perfectionism with excessively
high self-expectation is another factor that has been noted in clinical
practice to be a possible contributor to suicide risk (425). As
already discussed, pessimism and hopelessness may also act in a
trait-dependent fashion and further influence individual
In estimating suicide risk it is therefore important for the
clinician to appreciate the contributions of patients' individual
traits, early or traumatic history, ability to manage affects including
psychological pain, past response to stress, current object relations,
and ability to use external resources during crises. Identifying
these issues may help the psychiatrist in assessing suicide risk.
In addition, gaining an empathic understanding of the patient's
unique motivations for suicide in the context of past experiences
will aid in developing rapport as well as in formulating and implementing
a psychotherapeutic plan to reduce suicide risk (410, 412, 421,
Suicidal ideation is an important determinant of risk because
it precedes suicide. Moreover, suicidal ideation is common, with
an estimated annual incidence of 5.6% (2) and estimated
lifetime prevalence of 13.5% (427). Since the majority
of individuals with suicidal ideation will not die by suicide, the
clinician should consider factors that may increase risk among individuals
with suicidal ideation. Although current suicidal ideation increases
suicide risk (78, 79), death from suicide is even more strongly
correlated with the worst previous suicidal ideation (273, 428).
Thus, during the suicide assessment, it is important to determine
the presence, magnitude, and persistence of current as well as past
suicidal ideation.
In addition to reporting suicidal ideation per se, patients
may report thoughts of death that may be nonspecific ("life
is not worth living") or specific ("I wish I were
dead"). These reports should also be assessed through further
questioning since they may serve as a prelude to later development
of suicidal ideas or may reflect a sense of pessimism and hopelessness
about the future (see Section II.E.3.b, "Hopelessness").
At the same time, individuals with suicidal ideation will often
deny such ideas even when asked directly (218, 429–431).
Given these associations of suicide with suicidal ideation, the
presence of suicidal ideation indicates a need for aggressive intervention.
At the same time, since as many as a quarter of suicide attempts
occur impulsively (432), the absence of suicidal ideation does not
eliminate risk for suicidal behaviors.
Determining whether or not the patient has developed a suicide
plan is a key part of assessing suicide risk. For many patients,
the formation of a suicide plan precedes a suicidal act, typically within
1 year of the onset of suicidal ideation (427). A suicide plan entails
more than simply a reference to a particular method of harm and
includes at least several of the following elements: timing, availability
of method, setting, and actions made in furtherance of the plan
(procuring a method, "scoping out" the setting,
rehearsing the plan in any way). The more detailed and specific the
suicide plan, the greater will be the level of risk. Plans that
use lethal methods or are formulated to avoid detection are particularly
indicative of high risk (433). Access to suicide methods, particularly
lethal methods, also increases suicide risk. Even in the absence
of a specific suicide plan, impulsive actions may end in suicide
if lethal methods are readily accessible. Thus, it is important to
determine access to methods for any patient who is at risk for suicide
or displays suicidal ideation.
In the United States, geographic variations in rates of firearm
suicide parallel variations in the rates of gun ownership (434).
Although individuals may opt for a different suicide method when
a particular method is otherwise unavailable, studies show some
decreases in overall suicide rates with restrictions in access to
lethal suicide methods (e.g., domestic gas and paracetamol) (435–437).
Men are most likely to use firearms in suicidal acts, but other
specific populations at increased risk of using firearms include
African Americans, elderly persons, and married women. In adolescents
and possibly in other age groups, the presence of firearms may be
an independent risk factor for suicide (438). Consequently, if the
patient has access to a firearm, the psychiatrist is advised to
discuss with and recommend to the patient or a significant other
the importance of restricting access to, securing, or removing this
and other weapons.
In addition to addressing access to firearms, clinicians should
recognize the potential lethality of other suicide methods to which
the patient may have access. As with restrictions for firearms,
it is important for the psychiatrist to work with the patient, family
members, and other social support persons in restricting the patient's
access to potentially lethal suicide methods, particularly during periods
of enhanced risk. Removal of such methods from a patient's
presence does not remove the risk for suicide, but it removes the
potential for the patient to impulsively gain access to the means with
which to carry out a suicidal wish.
Suicidal intent refers to the patient's subjective
expectation and desire to die as a result of a self-inflicted injury.
This expectation may or may not correspond to the lethality of an
attempt, which represents the medical likelihood that death will
result from use of a given method. For example, some patients may
make a nonlethal attempt with the intention of being saved and getting
help, whereas others may make a nonlethal attempt, thinking it will
kill them. From the standpoint of suicide risk assessment, the strength
of the patient's intent to die and his or her subjective
belief about the lethality of a method are more relevant than the
objective lethality of the chosen method (439, 440). The presence
of a suicide note also indicates intensification of a suicidal idea
and/or plan and generally signifies premeditation and greater
suicidal intent. Regardless of whether the patient has attempted
suicide or is displaying suicidal ideation, the clinician should
assess the timing and content of any suicide note and discuss its
meaning with the patient. The more specifically a note refers to
actual suicide or steps to be taken after death, the greater the
associated increase in suicidal intent and risk. Factors separating
suicide attempters who go on to make future fatal versus nonfatal
attempts include an initial attempt with high intent (164, 441),
having taken measures to avoid discovery (224), and having used more
lethal methods that resulted in physical injuries (263), all of
which indicate a greater degree of suicidal intent. Consequently,
suicidal intent should be assessed in any patient with suicidal
ideation. In addition, for any patient who has made a prior suicide
attempt, the level of intent at the time of the suicide attempt
should be determined.
Patients are often admitted to an inpatient unit in the midst
of an acute suicidal crisis with either overt suicidal behavior
or intense suicidal ideation. Even when a patient who is not in
an acute suicidal crisis is admitted, the symptoms and disorders
that typically lead to psychiatric hospitalization are associated
with an increased suicide risk. There do not appear to be specific
risk factors that are unique to the inpatient setting, with about
half of inpatient suicides in a recent study involving individuals
with prior suicide attempts and about half occurring in individuals
with psychosis (218). Inpatient suicides also cannot be predicted
by the reason for hospitalization, since fewer than half of the
patients who die by suicide in the hospital were admitted with suicidal
ideation and only a quarter were admitted after a suicide attempt.
However, extreme agitation or anxiety (218) or a rapidly fluctuating
course (442) is common before suicide. Thus, it is important to
conduct a suicide risk assessment, as discussed earlier, when individuals
are admitted for inpatient treatment, when changes in observation
status or treatment setting occur, when there are significant changes
in the patient's clinical condition, or when acute psychosocial
stressors come to light in the course of the hospitalization. For
patients with repeated hospitalizations for suicidality, each suicidal
crisis must be treated as new with each admission and assessed accordingly.
An initial evaluation of a patient in an office-based setting
should be comprehensive and include a suicide assessment. The intensity
and depth of the suicide assessment will depend on the patient's clinical
presentation. In following outpatients over time, the psychiatrist
should be aware that suicidality may wax and wane in the course
of treatment. Sudden changes in clinical status, which may include
worsening or precipitous and unexpected improvements in reported
symptoms, require that suicidality be reconsidered. Furthermore,
risk may also be increased by the lack of a reliable therapeutic
alliance, by the patient's unwillingness to engage in psychotherapy
or adhere to medication treatment, or by inadequate family or social
supports. Again, however, the frequency, intensity, and depth of
the suicide assessment will depend on the patient's clinical
state, past history, and other factors, including individual strengths,
vulnerabilities, and stressors that will simultaneously influence
risk. These factors will also be important in judging when family
members or other significant support persons may need to be contacted.
Regardless of the patient's presenting problem, the
suicide assessment is an integral part of the psychiatric evaluation
in an emergency setting. As in the inpatient setting, substantial
numbers of individuals present to emergency settings with suicidal
ideation or after having made a suicide attempt (443–447).
Even when suicidality is not a part of the initial presentation,
the majority of individuals seen in emergency psychiatric settings
have diagnoses that are associated with an increased risk of suicide
(268, 269, 271, 275, 448).
As the suicide assessment proceeds, the psychiatrist should
be alert for previously unrecognized symptoms of trauma or toxicity
resulting from ingestions. Ambivalence is a key element in individuals
presenting with suicidality, and individuals may simultaneously
seek help yet withhold information about recent ingestions (449)
or self-induced trauma. Thus, in addition to initially assessing
the patient's vital signs, the psychiatrist should investigate
any changes in the patient's physical condition or level
of consciousness that may develop during the course of the evaluation. For
patients who are administered medications in the emergency area
or who have concomitant alcohol or substance use, serial monitoring
of vital signs is important to detect adverse events or signs of
substance withdrawal.
Simultaneous presentation with intoxication and suicidality
is common in emergency settings (444, 450–454) and requires
some modification in the assessment process. Depending on the severity of
the intoxication, medical intervention may be needed before psychiatric
assessment begins. Also, it is often necessary to maintain the patient
in a safe setting until the intoxication resolves and a thorough
suicide assessment can be done. In this regard, some institutions
find it helpful to quantify the level of intoxication (with serum
alcohol levels or breath alcohol measurements), since some individuals
may not show physical symptoms of intoxication despite substantially
elevated blood alcohol concentrations (455). At some facilities,
short-term observation beds are available in the emergency area
or elsewhere for monitoring and serial assessments of intoxicated
individuals who present with suicidality. At other facilities, such
observation may need to be carried out in a more typical medical
or psychiatric inpatient setting.
Although obtaining collateral information is useful with all
suicidal individuals, in the emergency setting such information
is particularly important to obtain from involved family members,
from those who live with the patient, and from professionals who
are currently treating the patient. Patients in emergency settings
may not always share all of the potentially relevant aspects of
their recent symptoms and their past psychiatric history, including
treatment adherence. In addition, most psychiatrists who evaluate
patients in emergency settings do not have the benefit of knowing
and working with the patient on a longitudinal basis. Corroboration
of history is particularly important when aspects of the clinical
picture do not correspond to other aspects of the patient's
history or mental state. Examples include patients who deny suicidal
ideas and request discharge yet who made a highly lethal suicide
attempt with clear suicidal intent or those who request admission
on the basis of command hallucinations while seeming relaxed and
jovial and without appearing to respond to internal stimuli.
The process by which the patient arrived at the emergency
department can provide helpful information about his or her insight
into having an illness or needing treatment. Typically, individuals who
are self-referred have greater insight than those who are brought
to the hospital by police or who reluctantly arrive with family
members. For individuals who are brought to the emergency department by
police (or as a result of a legally defined process such as an emergency
petition), it is particularly important to address the reasons for
the referral in estimating suicide risk.
When evaluating patients in long-term care facilities, psychiatrists
and staff should be aware of the varied forms that suicidality may
take in such settings. In particular, it is important to recognize that
indirect self-destructive acts are found among both men and women
with chronic medical conditions (456–459) and are a common
manifestation of suicide in institutional settings (460). Despite
these occurrences, suicide rates in long-term care facilities are
generally lower than expected (460, 461), perhaps as a result of
greater supervision and residents' limited access to potentially
lethal means and physical inability to carry out the act as well
as underreporting or misattribution of self-destructive behaviors
to accident or natural death (66).
Risk factors for suicide and other self-destructive behaviors
are similar to those assessed in other settings of care. For example,
90% or more of randomly sampled residents of long-term
care facilities have been shown to have a diagnosable psychiatric
illness (462, 463), with the prevalence of depression in nursing
homes estimated to range from 15% to 50% (66).
Physical illness, functional impairment, and pain are associated
with increased risk for suicide and are ubiquitous factors in long-term
care facilities. Hopelessness (228) and personality styles that
impede adaptation to a dependent role in the institutional setting
also play a role (464).
When treating individuals in long-term care facilities, the
psychiatrist should be mindful of the need for follow-up assessments,
even when initial evaluation does not show evidence of depression
or increased risk for suicide or other self-injurious behaviors.
To facilitate early intervention, safety and suicide risk should
be reassessed with significant changes in behavior, psychiatric
symptoms, medical status, and/or level of functional disability.
Psychiatrists can also play a critical role in educating long-term
care providers about risk factors and warning signs for suicide
in residents under their care.
In jails, prisons, and other correctional facilities, most
initial mental health assessments are not done by psychiatrists
(465, 466); however, psychiatrists are often asked to perform urgent
suicide assessments for individuals identified as being at risk.
The actual rates of suicide in jails and in prisons are somewhat
controversial, and reported rates depend on the method by which
they are calculated (467). The U.S. Department of Justice Bureau
of Justice Statistics reported that the rate of suicide per 100,000
prison inmates was 14 during 1999, compared with 55 per 100,000
jail inmates (468). However, reported rates are generally based
on the average daily census of the facility. Since jails are local
facilities used for the confinement of persons awaiting trial and
those convicted of minor crimes, whereas prisons are usually under
state control and are used to confine persons serving sentences
for serious crimes, jails have a much more rapid turnover of detainees
than prisons. This turnover results in a higher reported rate of
suicides per 100,000 incarcerated persons in jails relative to prisons,
since annual jail admissions are more than 20 times the average
daily jail census, whereas the annual number of persons admitted
to prisons nationwide is about 50% of the average daily
prison census. Reported suicide rates in jails are also elevated
relative to those in prisons because the majority of suicides in
jail occur during the first 24 hours of incarceration (469, 470).
The importance of identification and assessment of individuals
at increased risk for suicide is underscored by the fact that suicide
is one of the leading causes of death in correctional settings.
For example, from July 1, 1998, to June 30, 1999, natural causes
other than AIDS barely led suicide as the leading cause of death
in jails. Between 1995 and 1999, suicide was the third leading cause
of death in prisons, after natural causes other than AIDS and deaths
due to AIDS (468). In relative terms, suicides among youths in juvenile
detention and correctional facilities are about four times more frequent,
suicide rates for men in jails are about nine to 15 times greater,
and the suicide rate in prisons is about one-and-a-half
times greater than the suicide rate in the general population (471).
Factors that increase risk in other populations are very prevalent
and contribute to increased risk in correctional populations (472, 473). Persons who die by suicide in jails have been consistently shown
to be young, white, single, intoxicated individuals with a history
of substance abuse (470, 474–476). Suicide in correctional
facilities generally occurs by hanging, with bed clothing most commonly
used (470, 474, 476–478). It is not clear whether first-time
nonviolent offenders (474, 476) or violent offenders (473, 477)
are at greater risk. Most (473, 474, 476, 479) but not all (480) investigators
have reported that isolation may increase suicide in correctional
facilities and should be avoided. While inmates may become suicidal
anytime during their incarceration, there are times when the risks
of suicidal behavior may be heightened. Experience has shown that
suicidal behaviors increase immediately on entry into the facility,
after new legal complications with the inmate's case (e.g.,
denial of parole), after inmates receive bad news about loved ones
at home, or after sexual assault or other trauma (471).
There is little doubt that successful implementation of suicide
prevention programs results in a significantly decreased suicide
rate in correctional facilities (469, 481–483). Consequently,
the standards of the National Commission on Correctional Health
Care (NCCHC) require jails and prisons to have a written policy
and defined procedures for identifying and responding to suicidal inmates,
including procedures for training, identification, monitoring, referral,
evaluation, housing, communication, intervention, notification,
reporting, review, and critical incident stress debriefing (484, 485). Other useful resources include a widely used instrument
for suicide screening (486) and the detailed discussions of specific
approaches to suicidal detainees that are provided in a later NCCHC
publication (487).
Psychiatric management consists of a broad array of interventions
and approaches that should be instituted by psychiatrists for all
patients with suicidal behaviors. Psychiatric management serves
as the framework by which the patient and psychiatrist will collaborate
in the ongoing processes of assessing and monitoring the patient's
clinical status, choosing among specific treatments, and coordinating
the various treatment components. Psychiatric management includes
establishing and maintaining a therapeutic alliance; attending to
the patient's safety; and determining the patient's psychiatric
status, level of functioning, and clinical needs to arrive at a
plan and setting for treatment. For individuals with suicidal behaviors,
such treatment planning will encompass interventions targeted to
suicidality per se as well as therapeutic approaches designed to
address psychosocial or interpersonal difficulties and any axis
I and axis II disorders that may be present. Once a plan of treatment
has been established with the patient, additional goals of psychiatric
management include facilitating treatment adherence and providing
education to patients and, when indicated, family members and significant
Beginning with the initial encounter with the patient, the
psychiatrist should attempt to build trust, establish mutual respect,
and develop a therapeutic relationship with the patient. Suicidal
ideation and behaviors can be explored and addressed within the
context of this cooperative doctor-patient relationship, with the
ultimate goal of reducing suicide risk. This relationship also provides
a context in which additional psychiatric symptoms or syndromes
can be evaluated and treated. At the same time, the psychiatrist
should recognize that an individual who is determined to die may
not be motivated to develop a cooperative doctor-patient relationship
and indeed may view the psychiatrist as an adversary. Appreciating
the patient's relationship to and with significant others
can help inform the clinician about the patient's potential
to form a strong therapeutic relationship. In addition, the therapeutic
alliance can be enhanced by paying careful attention to the concerns
of patients and their family members as well as their wishes for
treatment. Empathy (488, 489) and understanding of the suicidal
individual (488–491) are also important in establishing
a therapeutic psychiatrist-patient relationship, helping
the patient feel emotionally supported, and increasing the patient's
sense of possible choices other than suicide (492). In this manner,
a positive and cooperative psychotherapeutic relationship can be
an invaluable and even life-sustaining force for suicidal patients.
In caring for potentially suicidal patients, the psychiatrist
will need to manage the often competing goals of encouraging the
patient's independence yet simultaneously addressing safety.
In addition, the psychiatrist should be aware of his or her own
emotions and reactions to the suicidal patient that may influence
the patient's care (488). Psychiatrists should acknowledge
the unique place that they may hold in a patient's life,
often seeming to be the only source of stability or consistency.
At the same time, the clinician must guard against falling into
the role of constant savior (490, 491). Suicidal patients may wish
to be taken care of unconditionally (493, 494) or alternatively,
to assign others the responsibility for keeping them alive (490).
Therapists who are drawn into the role of savior with suicidal patients
often operate on the conscious or unconscious assumption that they
can provide the love and concern that others have not, thus magically
transforming the patient's wish to die into a desire to
live (420, 490). Under such circumstances, or if the therapist uses
defensive reaction formation to deny hostile feelings toward the
patient, the therapist may go to great lengths to assure the patient
that he or she has only positive feelings about the patient and
will do whatever is necessary to save the patient's life.
In the worst-case scenario, this need to demonstrate one's
caring may contribute to boundary crossings or outright boundary
violations (495). Also, by producing false or unrealistic hopes,
the psychiatrist may ultimately disappoint the patient by not fulfilling
those expectations. Thus, the psychiatrist must remember that taking
responsibility for a patient's care is not the same as
taking responsibility for a patient's life.
Suicidal patients can also activate a clinician's
own latent emotions about death and suicide, leading to a number
of defensive responses on the part of the clinician (426). On one
hand, there is a potential to develop countertransference hate and
anger at suicidal patients (496) that may be manifested by rejecting
behavior on the part of the clinician (488). At the other extreme,
the clinician may avoid patients who bring up his or her own anxieties
surrounding suicide (426, 490). Clinicians may also overestimate
the patient's capabilities, creating unrealistic and overwhelming
expectations for the patient. Conversely, they may become enveloped
by the patient's sense of hopelessness and despair and
become discouraged about the progress of treatment and the patient's
capacity to improve (488). Thus, management of the therapeutic alliance
should include an awareness of transference and countertransference
issues, regardless of the theoretical approach used for psychotherapy
and regardless of whether these issues are directly addressed in
treatment. In this regard, the use of consultation with a senior
colleague with experience and some expertise in the management of suicidal
patients may be helpful. It is also important to keep in mind that
the course and conduct of treatment may be influenced by gender
and cultural differences between patients and therapists as well
as by cultural differences between patients and other
aspects of the care delivery system.
Although it is impossible to prevent all self-injurious actions
including actual suicide, it is critically important to attend to
the patient's safety and work to minimize self-endangering
behaviors throughout the evaluation and treatment process. The preceding
sections have discussed an orderly process for assessing the patient,
estimating suicide risk, and then instituting interventions to target
that risk. In actual practice, however, some interventions may be
needed to address the patient's safety while the initial
evaluation proceeds. For example, in emergency or inpatient settings,
specific interventions may include ordering observation of the patient
on a one-to-one basis or by continuous closed-circuit television
monitoring, removing potentially hazardous items from the patient's
room, and securing the patient's belongings (since purses
and backpacks may contain weapons, cigarette lighters or matches,
and medications or other potentially toxic substances). If restraints
are indicated, continuous observation is also recommended (497, 498). Some institutions screen patients for potentially dangerous
items by searching patients or scanning them with metal detectors
(499). In addition, some institutions have policies prohibiting
any guns in emergency areas, since police or security officers' weapons
may be taken by suicidal patients. In other circumstances, such
as with agitated, uncooperative, intoxicated, or medically ill patients,
significant time may elapse before it will be possible to complete
a full psychiatric evaluation, including a suicide assessment. Under
such conditions, the psychiatrist will need to use the information
that is available to make a clinical judgment, with steps being
taken to enhance the patient's safety in the interim.
Treatment settings include a continuum of possible levels
of care, from involuntary hospitalizations to partial hospital and
intensive outpatient programs to more typical ambulatory settings.
In general, patients should be treated in the setting that is least
restrictive yet most likely to prove safe and effective. In addition,
the optimal treatment setting and the patient's ability
to benefit from a different level of care should be reevaluated
on an ongoing basis throughout the course of treatment.
The choice of an appropriate site of treatment will generally
occur after the psychiatrist evaluates the patient's clinical
condition, including specific psychiatric disorder(s) and symptoms
(e.g., hopelessness, impulsiveness, anxiety), symptom severity,
level of functioning, available support system, and activities that
give the patient a reason to live. The psychiatrist should also
consider whether or not the current suicidality is related to an
interpersonal crisis such as a recent separation, loss of a loved
one, or other trauma. The estimate of suicide risk will obviously
be an important component of the choice of treatment setting, and
the potential for dangerousness to others should also be taken into consideration.
Under some clinical circumstances, a decision for hospitalization
may need to be made on the basis of high potential dangerousness
to self or others, even if additional history is unavailable or
if the patient is unable to cooperate with the psychiatric evaluation
(e.g., in the presence of extreme agitation, psychosis, or catatonia).
At the same time, the benefits of intensive interventions such as hospitalization
must be weighed against their possible negative effects (e.g., disruption
of employment, financial and other psychosocial stress, persistent
societal stigma). Other aspects to be incorporated into the determination
of a treatment setting include the patient's ability to
provide adequate self-care, understand the risks and benefits of
various treatment approaches, understand what to do in a crisis
(e.g., contact family members or other support persons, contact
the psychiatrist, seek emergency care), give reliable
feedback to the psychiatrist, and cooperate with treatment planning
and implementation. Consequently, choice of a specific treatment
setting will not depend entirely on the estimate of suicide risk
but rather will rely on the balance between these various elements.
An overview of factors to consider in determining a setting for
treatment is provided in Table 8.
Admission generally indicated
After a suicide attempt or aborted suicide attempt
Patient is psychotic
Attempt was violent, near-lethal, or premeditated
Precautions were taken to avoid rescue or discovery
Persistent plan and/or intent is present
Distress is increased or patient regrets surviving
Patient is male, older than age 45 years, especially
with new onset of psychiatric illness or suicidal thinking
Patient has limited family and/or social support,
including lack of stable living situation
Current impulsive behavior, severe agitation, poor
judgment, or refusal of help is evident
Patient has change in mental status with a metabolic,
toxic, infectious, or other etiology requiring further workup in
a structured setting
In the presence of suicidal ideation with:
Specific plan with high lethality
High suicidal intent
Admission may be necessary
After a suicide attempt or aborted suicide attempt,
except in circumstances for which admission is generally indicated
Major psychiatric disorder
Past attempts, particularly if medically serious
Possibly contributing medical condition (e.g., acute
neurological disorder, cancer, infection)
Lack of response to or inability to cooperate with
partial hospital or outpatient treatment
Need for supervised setting for medication trial or
Need for skilled observation, clinical tests, or diagnostic
assessments that require a structured setting
Limited family and/or social support, including
lack of stable living situation
Lack of an ongoing clinician-patient relationship or
lack of access to timely outpatient follow-up
In the absence of suicide attempts or reported suicidal
ideation/plan/intent but evidence from the psychiatric
evaluation and/or history from others suggests a high level
of suicide risk and a recent acute increase in risk
Release from emergency department with
follow-up recommendations may be possible
After a suicide attempt or in the presence of suicidal
ideation/plan when:
Suicidality is a reaction to precipitating events (e.g.,
exam failure, relationship difficulties), particularly if the patient's
view of situation has changed since coming to emergency department
Plan/method and intent have low lethality
Patient has stable and supportive living situation
Patient is able to cooperate with recommendations for
follow-up, with treater contacted, if possible, if patient is currently
in treatment
Outpatient treatment may be more beneficial
than hospitalization
Patient has chronic suicidal ideation and/or
self-injury without prior medically serious attempts, if a safe
and supportive living situation is available and outpatient psychiatric
care is ongoing
Hospitalization should always be viewed as a possible intervention
and should be considered whenever the patient's safety
is in question. Hospitalization, by itself, is not a treatment.
Rather, it is a treatment setting that may facilitate the evaluation
and treatment of a suicidal person. In addition, inpatient settings
can implement approaches such as constant observation, seclusion,
or physical or pharmacological restraint that may restrict an individual's
ability to act on suicidal impulses. Although such interventions
may delay suicide and permit initiation of treatment approaches,
there is no empirical evidence that these methods reduce the incidence
of suicide in the long term (77, 500, 501). In addition, hospitals
must balance requirements for security against the patient's
need to prepare to return to independent living in the community.
Since patients cannot be continuously observed or restrained, they
can and do die by suicide while hospitalized. In fact, it is estimated
that approximately 1,500 inpatient suicides occur in the United
States each year, with about a third of these occurring while patients
are on one-to-one observation or every-15-minute checks (218).
Although no guidelines regarding hospitalization decisions
can be absolute, inpatient care is usually indicated for individuals
who are considered to pose a serious threat of harm to themselves
or others. Other indications for hospitalization include factors
based on illness (e.g., symptom severity, violent or uncontrollable
behavior) and those based on the intensity of services needed (e.g.,
a need for continuous skilled observation; complicated medication
trials, particularly for an elderly or a medically fragile patient;
ECT; clinical tests or diagnostic evaluation that cannot be performed
on an outpatient basis). Severely ill individuals may
require hospitalization if they cannot be maintained safely in a
less restrictive environment or if they lack adequate structure
and social support outside of a hospital setting. More intensive
treatment will also be called for whenever there is a new, acute
presentation that is not part of a repetitive pattern. Additionally,
those patients who have complicating psychiatric or general medical
conditions or who have not responded adequately to outpatient treatment
may need to be hospitalized. Inpatient care may also be necessary
at lower levels of suicide risk in geographic areas where partial
hospital or intensive outpatient programs are not readily
accessible. If the clinician is not the patient's regular
health care provider, does not have an ongoing relationship with
the patient, or otherwise does not know the patient well and does
not have access to the patient's history or medical records,
hospitalization may be necessary until further data can be collected.
More intensive treatment may also be necessary even for patients
with lesser degrees of suicidality if the patient lacks a strong
psychosocial support system, is unable to gain timely access to
outpatient care, has limited insight into the need for treatment,
or is unable to adhere to recommendations for ambulatory follow-up.
The hospital length of stay should similarly be determined
by the ability of the patient to receive the needed care safely
in a less intensive environment. In addition, before the patient
is transitioned to a less restrictive setting, the patient's
condition should show evidence of being improved and more stable
both in the estimated level of suicide risk and in the symptoms
of any associated psychiatric disorders.
Less intensive treatment may be more appropriate if suicidal
ideation or attempts are part of a chronic, repetitive cycle and
the patient is aware of the chronicity. For such patients, suicidal
ideation may be a characteristic response to disappointment or a
way to cope with psychological distress. If the patient has a history
of suicidal ideation without suicidal intent and an ongoing
doctor-patient relationship, the benefits of continued treatment
outside the hospital may outweigh the possible detrimental effects
of hospitalization even in the presence of serious psychiatric symptoms.
When considering hospitalization, the risk of suicide is not
the only factor to take into account. Patients may feel humiliated
or frightened in the hospital rather than experience a
sense of emotional relief. Hospitalization can also be associated
with realistic life stressors, including the social and financial
burdens of having received inpatient treatment. For some patients,
treatment in a restrictive setting such as an inpatient unit may
foster dependency and a regressive, vicious cycle of intensifying suicidal
thoughts requiring ever more restrictive care. Such individuals,
most notably those with personality disorders, suffer chronic morbidity
if they are never supportively challenged to bear painful feelings.
In addition, some patients may gain positive reinforcement from
hospitalization and repeatedly harm themselves with the goal of
regaining admission. Psychiatric hospitalization may also arouse
unrealistic expectations in patients, family members, therapists,
and medical and nursing staff members. Often, a plea for hospitalization
comes from a sense of exasperation on the part of an individual
involved with the patient's situation. When hospital treatment
does not meet these unrealistic expectations, the associated disillusionment
may contribute to hopelessness and have a negative effect on future
therapeutic relationships. The inpatient admission process itself
may also cause the patient to mistrust mental health professionals,
particularly when hospitalization occurs on an involuntary basis.
Thus, the clinician's key responsibility is to weigh the
risks and benefits of hospitalization before and during admission
(especially around decisions related to therapeutic passes and privilege
levels) and ultimately when contemplating discharge (502). Moreover,
a person's right to privacy and self-determination (which
includes the right to be treated in the least restrictive environment)
must be balanced against the issue of potential dangerousness to
self or others.
If hospitalization is indicated, the psychiatrist must next
decide whether it should occur on a voluntary or involuntary basis.
This decision will also depend on multiple factors, including the
estimated level of risk to the patient and others, the patient's
level of insight and willingness to seek care, and the legal criteria
for involuntary hospitalization in that jurisdiction. In general,
patients at imminent risk for suicide will satisfy the criteria
for involuntary hospitalization; however, the specific commitment
criteria vary from state to state (503), and in some states, willingness
to enter a hospital voluntarily may preclude involuntary
admission. To that end, psychiatrists should be familiar
with their specific state statutes regarding involuntary hospitalization.
Patients who are not assessed to be at imminent risk for suicide
and who do not require inpatient treatment for other reasons may
be suitable for treatment on an outpatient basis. Outpatient treatment may
vary in its intensity from infrequent office visits for stable patients
to more frequent office visits (up to several times per week) to
intensive outpatient or partial hospital treatment. Either of the
latter settings may function as a "step-down" from
inpatient treatment or as a "step-up" from outpatient therapy,
if once- or twice-a-week therapy is insufficient to maintain the
patient's stabilization. For patients at significant risk
for suicide in these treatment programs, a member of the treatment
team must be available to respond to emergencies by telephone, beeper,
or other means of contact. In military settings, "unit
watch" protocols may be activated to look after the patient
between treatment sessions. For patients who continue to be followed
by an outside therapist or psychiatrist while in a partial hospital
or intensive outpatient treatment program, regular communication
among treating professionals is important. Communication with significant
others is also helpful, and appropriate supervision and supports
should be available and may include a plan for continued after-hours monitoring.
If such supervision is not possible, a higher level of care (i.e.,
inpatient admission) may be needed to maintain the patient's
safety even at lower levels of suicide risk. Worsening of a patient's condition,
with a concomitant increase in the risk of suicide, requires the
careful assessment of the patient's risk for suicide and
possible hospitalization. Discharge planning should include appropriate continuing
treatment to maintain stability gains and to continue monitoring
of suicide risk.
Under some circumstances, individuals who are not currently
engaged in outpatient treatment may be referred for care after a
suicide attempt or emergency department visit in which suicidality was
at issue. Since adherence is often a problem when individuals are
referred for outpatient follow-up from emergency departments (448, 504), it may be helpful to discuss the referral with the patient during
the course of the interview and if possible arrange a specific appointment
time (505–507). When determining a treatment setting in
emergency situations, it is also important to consider the potential
effects of countertransference and lack of knowledge about suicidality
on clinical decision making, since individuals who present with
suicidal ideas or attempts may engender a broad range of countertherapeutic
reactions in medical professionals, including antipathy, anger,
helplessness, and indifference (445, 450, 508–510).
Individuals with suicidal thoughts, plans, or behaviors may
benefit from a variety of treatments. If the patient is at risk
for suicide, a plan that integrates a range of biological and psychosocial therapies
may increase the likelihood of a successful outcome. Choosing among
possible treatments requires knowledge of the potential beneficial
and adverse effects of each option along with information about
the patient's preferences. In addition, treatment decisions
should be continually reassessed as new information becomes available,
the patient's clinical status changes, or both. For patients
in ongoing treatment, this may mean that existing treatment plans
will require modification as suicidal ideas or behaviors emerge
or wane. Thus, treatment planning is an iterative process in which
the psychiatrist works with the patient to implement and modify
treatments over time, depending on the patient's responses
and preferences. Depending on the clinical circumstances, it may
be important for the treatment planning process to include family
members or other significant supports (e.g., military unit personnel,
community residence or adult home providers, case management staff).
More detail on the specific therapeutic approaches discussed subsequently
can be found in APA practice guidelines that discuss treatment of
specific psychiatric disorders (all included in this volume), including
major depressive disorder (511), bipolar disorder (512), schizophrenia
(513), panic disorder (514), and borderline personality disorder
Psychiatrists should be cautioned against developing a treatment
plan in which the stated goal is to "eliminate" suicide
risk; this is impossible to do for the reasons already discussed.
Instead, the goals of treatment should include a comprehensive approach
to treatment with the major focus directed at reducing
risk. Since individuals with suicidal behaviors often have axis
I and axis II disorders, reducing risk frequently involves treating
an associated psychiatric illness. Given the high rates of comorbid
alcohol and substance use among individuals with suicidal behaviors,
it is particularly important to address substance use disorders
in the treatment plan (516). Medical disorders and treatments for
those disorders will also need to be considered in developing a
plan of treatment for the patient with suicidal behaviors.
In the early stages of treatment, more intense follow-up may
be needed to provide support for the patient as well as to monitor
and rapidly institute treatment for relevant symptoms such as anxiety, insomnia,
or hopelessness. In addition, it is during the early stages of illness
that denial of symptoms and lack of insight into the need for treatment
are likely to be most prominent, and, therefore, specific education
and supportive psychotherapy are required to target these issues.
Appreciating the patient's past responses to stress, vulnerability
to life-threatening affects, available external resources,
death fantasies, and capacity for reality testing may help the clinician
to weigh the strengths and vulnerabilities of the individual patient
(412) and may aid in the planning of treatment. For patients treated in
ambulatory settings, it is also important for the psychiatrist to
review with the patient guidelines for managing exacerbations of
suicidal tendencies or other symptoms that may occur between scheduled
sessions and could contribute to increased suicide risk.
Providing optimal treatment for patients with suicidal behaviors
frequently involves a multidisciplinary treatment team that includes
several mental health professionals. While ongoing coordination
of the overall treatment plan is generally easier to implement in
inpatient or partial hospital settings as opposed to less integrated
ambulatory settings, useful strategies for coordination in any treatment
setting include clear role definitions, regular communication among
team members, and advance planning for management of crises. It
is also helpful to clarify with the patient that a number of individuals
will be involved in his or her care and to outline the specific
roles of each. In this regard, it is important for patients to understand
that treatment team members assist the psychiatrist in many respects
and may supply clinical information that will influence decisions
about the level of precautions, readiness for discharge, medications,
and other aspects of treatment planning.
Many patients have ongoing medical illnesses for which they
receive care from one or more physicians. Particularly for individuals
whose medical disorders or treatments interface with their psychiatric
symptoms or treatments, it is helpful to communicate with the patient's
primary care physician as well as with any specialists who are actively
involved in the patient's care.
In inpatient settings, the treatment team generally consists
of a psychiatrist, nurses, social workers, psychologists,
and other mental health workers, with the psychiatrist acting as
the team leader. In this capacity, with input from the other members
of the treatment team, the psychiatrist will make the critical decisions
regarding the patient's care. Such decisions include but
are not limited to the patient's diagnosis, specific medications,
level of precautions, passes, discharge, and follow-up treatment
plan. Given the key roles and observations of other treatment team
members in such decisions, the psychiatrist should encourage open
communication among the staff members regarding historical and clinical
features of the patient.
In an outpatient setting, there may also be other professionals
involved in the care of the patient. In some instances, the patient
may be referred to individuals with expertise in symptom-specific treatments
(e.g., cognitive behavior therapy for hopelessness or dialectical
behavior therapy for recurrent suicidal behavior). In
other instances, the psychiatrist may be providing primarily psychopharmacologic
management, with another psychiatrist or other mental health professional
conducting the psychotherapy. During visits with the patient, it
is important for the psychiatrist to review the patient's
response to all aspects of the treatment. In addition, it is useful
for the psychiatrist to communicate with the therapist and to establish
guidelines or expectations as to when and under what conditions
the therapist and the psychiatrist should be contacted in the event
of a significant clinical change in the patient. Moreover, if the
psychiatrist has direct supervisory responsibilities for the therapist,
the level of communication should be increased and may
include a chart review.
The successful treatment of many psychiatric disorders requires
close adherence to treatment plans, in some cases for long or indefinite
durations. With individuals whose clinical symptoms include suicidal
thoughts, plans, or behaviors, it is particularly important that
management be optimized through regular adherence with the treatment
plan. Facilitating adherence begins with the initial establishing
of the physician-patient relationship and the collaborative
development of a plan of care that is attentive to the needs and
preferences of the individual patient. Within the therapeutic relationship
the psychiatrist should create an atmosphere in which the patient
can feel free to discuss what he or she experiences as positive
or negative in the treatment process. Side effects or requirements
of treatment are common causes of nonadherence. Other common contributors
include financial constraints, scheduling or transportation difficulties,
perceived differences of opinion with the clinician, and misunderstandings
about the recommended plan of treatment or dosing of medications.
Especially while symptomatic, patients may be poorly motivated,
less able to care for themselves, or unduly pessimistic about their
chances of recovery with treatment, or they may suffer from memory
deficits or psychosis. In some instances, psychiatric disorders
are associated with reductions in insight about having an illness
or needing treatment, making adherence less likely. Particularly
during maintenance phases of treatment, when symptoms are less salient,
patients may tend to undervalue the benefits of treatment and instead
focus on its burdens. The psychiatrist should recognize these possibilities,
encourage the patient to articulate any concerns regarding adherence, and
emphasize the importance of adherence for successful treatment and
for minimizing the risk of future suicidal behaviors (306). Specific
components of a message to the patient that have been shown to improve
adherence include 1) when and how often to take the medicine,
2) the fact that some medications may take several weeks before
beneficial effects may be noticed, 3) the need to take medication
even after feeling better, 4) the need to consult with the doctor
before discontinuing medication, and 5) what to do if problems or
questions arise (517).
To facilitate adherence, it is helpful to reassess the treatment
plan on a regular basis in collaboration with the patient and attempt
to modify it in accord with the patient's preferences and
needs. Some patients, particularly elderly patients, have been shown
to have improved adherence when both the complexity of medication
regimens and the costs of treatments are minimized. When a patient
does not appear for appointments or is nonadherent in other ways,
outreach, including telephone calls, may be helpful in reengaging
the patient in treatment. This outreach can be carried out by the
psychiatrist or other designated team members in consultation with
the psychiatrist. For patients in an involuntary outpatient treatment
program, the judicial system may also be involved in outreach efforts.
Severe or persistent problems of nonadherence may represent psychological
conflicts or psychopathology, for which psychotherapy should be
considered. Educating patients about medications, aspects of suicidality,
and specific psychiatric disorders and their management can be useful.
When family members or other supportive individuals are involved
(e.g., military command personnel, supported housing staff), they
can also benefit from education and can be encouraged to play a
helpful role in improving adherence.
Most patients can benefit from education about the symptoms
and disorders being treated as well as about the therapeutic approaches
employed as part of the treatment plan. When appropriate, and with the
patient's permission, education should also be provided
to involved family members. Understanding that psychiatric disorders
are real illnesses and that effective treatments are both necessary
and available may be crucial for patients who attribute
their illness to a moral defect or for family members who are convinced
that there is nothing wrong with the patient. Patients and family
members can also benefit from an understanding of the role of psychosocial
stressors and other disruptions in precipitating or exacerbating
suicidality or symptoms of psychiatric disorders. Education regarding available
treatment options will help patients make informed decisions, anticipate
side effects, and adhere to treatments. Patients also need to be
advised that improvement is not linear and that recovery may be
uneven. Certain patients or family members may become overwhelmed
or devastated by a recurrence of symptoms or a temporary worsening
of symptoms after the initiation of treatment. Since suicidal patients
tend to be overly critical of themselves, a recurrence or worsening
of symptoms may be seen as evidence of personal failure; they need
to be reassured that this can be part of the recovery process.
It is also useful to have an open discussion with the patient
about the phenomenon of suicide. When there has been a family history
of suicide, some patients will feel that it is their fate to die
from suicide as well. The age at which a family member died or the
specific anniversary of the family member's death may take
on special significance for some patients. Education for the patient
and the family should emphasize that a family history of suicide
may increase risk of suicide, but it does not make suicide inevitable.
It can be helpful to educate the patient and involved family members about
how to identify symptoms, such as insomnia, hopelessness, anxiety,
or depression, that may herald a worsening of the patient's
clinical condition. In addition, patients and family members should be
encouraged to think about other symptoms, specific to the individual
patient, that have been associated with suicidality in the past.
Furthermore, patients and family members should be aware that thoughts
of suicide may return and that they should inform the psychiatrist
or a significant other as soon as possible if that occurs. There
should also be an open discussion about what to do in
the event of an emergency and how to obtain emergency services.
Under some circumstances, this discussion may include an explanation
of methods for involving the police to facilitate an involuntary evaluation.
Some family members, particularly those of patients with borderline
personality disorder, mistakenly view suicide attempts or communications
of suicidal intent as "manipulative" or "attention-seeking" behaviors.
Thus, it is important to provide family members with education about
the lifetime risks of suicide in such patients and to help family
members learn ways to respond in a helpful and positive manner when
the patient is experiencing a suicidal crisis.
The waxing and waning nature of suicidality is one of the
difficult challenges in the care of the suicidal patient and often
requires that suicide assessments be repeated over time (Table 2).
Although a full suicide assessment is not required at each encounter
with the patient, the psychiatrist should use reasonable judgment
in determining the extent of the repeat assessment needed to estimate
the patient's current suicide risk. In inpatient
settings, repeat suicide assessments should occur at critical stages
of treatment (e.g., with a change in level of privilege, abrupt
change in mental state, and before discharge). When a reassessment
is done, the psychiatrist often finds that a patient who initially reported
suicidal ideation with lethal intent no longer reports suicidal
ideation at a subsequent visit. As stated earlier, it is not possible
to predict which individuals with recent suicidal ideation will experience
it again nor which patients will deny suicidal ideation even when
it is present. Nonetheless, if a patient is assessed as being at
high risk for suicide, a plan to address this risk must be implemented and
documented. This plan may include changes in the setting of care
or level of observation, changes in medication therapy or psychotherapy,
or both kinds of changes.
Patients with a recent onset of severe suicidal ideation should
be treated with particular caution. For those experiencing suicidal
ideation in the context of an underlying depressive disorder, it
can be useful to monitor other depressive symptoms. The psychiatrist
also needs to be mindful of other symptoms that may be associated
with increased suicide risk, such as hopelessness, anxiety,
insomnia, or command hallucinations. Behaviors that may be associated
with an acute increase in risk include giving away possessions,
readying legal or financial affairs (e.g., finalizing a will, assigning
a power of attorney), or communicating suicidal intentions or "goodbye" messages.
Patients who are responding to ongoing treatment or who are
in remission with continuation or maintenance treatment should be
assessed for suicide risk when there is evidence of an abrupt clinical change,
a relapse or recurrence, or some major adverse life event. In this
context, the new emergence of suicidality should be responded to
by an alteration of the treatment plan. The nature of this alteration
depends on the clinical situation and can include a change in treatment
setting or level of observation, increased visits, a change of medication
or psychotherapeutic approach, inclusion of a significant other
person, and consultation. With changes in clinical status or as
new information becomes available, the psychiatrist must also be
prepared to reevaluate the patient's psychiatric diagnosis
and also evaluate the nature and strength of the therapeutic alliance.
There will be times when a patient in ongoing treatment is
in an acute suicidal crisis and the psychiatrist has to respond
immediately. There may be communications directly from the patient,
the family, or significant others, including employers or co-workers.
In urgent situations, it may be necessary to have telephone calls
traced or involve the police. The challenge for the psychiatrist
is not only to evaluate the extent of the emergency but also to
assess the content of the communication and its source. To better
assess the situation, it is critical to speak with the patient directly,
if at all possible. In addition, the psychiatrist should remain
mindful of issues relating to confidentiality and breach confidentiality
only to the extent needed to address the patient's safety
(see also Section V.C, "Communication With Significant
Under some circumstances, the psychiatrist may need to refer
a suicidal patient to an emergency department for evaluation or
hospitalization. When doing so, it is important for the psychiatrist
to communicate with the psychiatric evaluator in the emergency department.
Although such communication may not always be possible because of
the exigencies of the emergency situation, such contact does provide
hospital personnel with the context for the emergency. Particularly
when a patient is brought to the hospital by police, it is not unusual
for the patient to minimize the symptoms and reasons for the referral
after arriving in the emergency setting. Adequate information about
the reasons for the emergency department referral and about the
patient's previous and recent history can be crucial in
helping the emergency department evaluator determine a safe and
appropriate setting for treatment. When hospitalization is recommended
by the referring psychiatrist, the reasons for that recommendation
should similarly be communicated to the emergency department evaluator
who will be making the final determination about the need for hospital
For some individuals, self-injurious behaviors and/or
suicidality are chronic and repetitive, resulting in frequent contacts
with the health care system for assessment of suicide potential.
It is important to recognize that self-injurious behaviors may or
may not be associated with suicidal intent (518). Although self-injurious
behaviors are sometimes characterized as "gestures" aimed
at achieving secondary gains (e.g., receiving attention, avoiding
responsibility through hospitalization), patients' motivations
for such behaviors are quite different. For example, without having
any desire for death, individuals may intentionally injure themselves
to express anger, relieve anxiety or tension, generate a feeling
of "normality or self-control," terminate a state
of depersonalization, or distract or punish themselves (519, 520).
Conceptualizing such behaviors as "gestures" is
also problematic because suicide attempts may be downplayed when
associated with minimal self-harm. Self-destructive acting out can
also result in accidentally lethal self-destructive behaviors even
in the absence of suicidal intent. Furthermore, a past or current history
of nonlethal self-injurious behaviors does not preclude
development of suicidal ideas, plans, or attempts with
serious intent and lethality (521). In fact, among suicide attempters
with suicidal intent, those who also had histories of self-injurious
behaviors without suicidal intent were more likely to underestimate
the objective lethality of their attempt and to have symptoms associated
with greater suicide risk (251). Thus, in assessing chronic self-injurious
behaviors, it is important to determine whether suicidal intent
is present with self-injury and, if so, to what extent and with
what frequency. In addition, an absence of suicidal intent or a
minimal degree of self-injury should not lead the psychiatrist to
overlook other evidence of increased suicide risk.
For patients who are prone to chronic self-injurious behavior,
each act needs to be assessed in the context of the current situation;
there is not a single response to self-injurious behaviors that
can be recommended. For example, there are times when outpatient
management is most appropriate; under other circumstances, hospitalization
may be indicated. In general, for such individuals, hospitalization
should be used for short-term stabilization, since prolonged hospital
stays may potentiate dependency, regression, and acting-out behaviors.
When chronic self-injurious behaviors are present, behavioral techniques
such as dialectical behavior therapy can be helpful (522, 523).
In addition, at times when care of the patient is being transitioned
to another clinician, the risk of suicidal behaviors may increase.
Diagnostically, severe personality disorders, particularly
borderline (521) and antisocial personality disorders, predominate
among patients who exhibit chronic self-injurious behaviors
without associated suicidal intent. Such individuals may also have
higher rates of comorbid panic disorder and posttraumatic stress
disorder (524). Patients with schizoaffective disorder, bipolar
disorder, and schizophrenia may also be represented, but more often
such patients have ongoing thoughts of suicide or repeated suicide
attempts in the presence of suicidal intent. There is evidence that
the presence of comorbid personality disorders or substance use
disorders not only increases suicide risk in these individuals but
also decreases treatment response. For example, patients with a
combination of affective disorder and personality disorder are prone
to frequent suicidal crises, difficulties with mood instability
and impulse control, and problems with treatment adherence. Consequently,
for patients whose nonadherence contributes to a chronic risk for
suicide, psychiatrists should be familiar with statutes on involuntary
outpatient treatment, if it is applicable in their jurisdiction (525).
When treating chronically suicidal individuals, it is important
for the psychiatrist to monitor his or her own feelings, including
countertransference reactions. Careful attention to the treatment relationship
and the psychosocial context of the patient is also critical. Consistency
and limit-setting are often needed, but the latter needs to be established
on the basis of clinical judgment and should not be framed in punitive
terms. Helping patients develop skills for coping with self-injurious impulses
is often a valuable part of treatment.
In outlining a detailed treatment plan, it is helpful to incorporate
input from the patient and significant others, when clinically appropriate.
During periods of crisis, disagreements may occur about the need
for hospitalization. In some circumstances, the psychiatrist may
view hospitalization as essential, whereas the patient or family
members may not. Alternatively, the patient, family members, or
other involved persons may demand hospitalization when outpatient
management may seem more appropriate. When such disagreements occur,
power struggles are best avoided. Instead, gaining a deeper understanding
of the conflicting viewpoints will often lead to a successful resolution. In
addition, educational efforts with the patient and others should
discuss the fact that risk in chronically suicidal individuals will
be increased on an ongoing basis. Thus, the risk of suicide outside of
the hospital must be balanced against the potentially detrimental
effects of hospitalization (see Section III.C, "Determine
a Treatment Setting").
In addition to reassessing the patient's safety and
degree of suicidality, it is equally important for the psychiatrist
to monitor the patient's psychiatric status and response
to treatment. This is particularly the case during the early phases
of treatment, since some medications, particularly antidepressants,
may take several weeks to reach therapeutic benefit. Also, with
the exception of suicides in persons with alcoholism, suicides tend
to occur early in the course of most psychiatric disorders, when
individuals are least likely to have insight into having an illness
and are least likely to adhere to treatment. Moreover, clinical
observations suggest that there may be an early increase in suicide
risk as depressive symptoms begin to lift but before they are fully
resolved. Thus, ongoing monitoring of the patient's clinical
condition is needed to determine the patient's symptoms
and response to treatment (e.g., determining the optimal dose of
a drug and evaluating its efficacy). Often the course of treatment
is uneven, with periodic setbacks, for example, at times of stress.
Such setbacks do not necessarily indicate that the treatment is
ineffective. Nonetheless, ultimate improvement should be a reasonably
expected outcome. Furthermore, as treatment progresses, different features
and symptoms of the patient's illness may emerge or subside.
Significant changes in a patient's psychiatric status or
the emergence of new symptoms may indicate a need for a diagnostic reevaluation,
a change in treatment plan, or both. Such modifications may include
a change in treatment setting, medication, or frequency of visits;
involvement of significant others; referral for additional treatments
(e.g., dialectical behavior therapy, ECT) that are targeted at specific
symptoms or syndromes; and consultation.
In treating suicidal patients, particularly those with severe
or chronic suicidality, consultation may be helpful from a number
of standpoints. The use of consultation or supervision from a colleague
may be of help in monitoring and addressing countertransference
issues. Since clinical judgments regarding assessment and treatment
issues with suicidal patients may be quite difficult, input from
other colleagues may be important in affirming the appropriateness
of the treatment plan or suggesting other possible therapeutic approaches.
For complex clinical presentations in which alcohol or other substance
use disorders might be present, referral to a psychiatrist specializing
in the treatment of addictive disorders may be helpful for consultation,
management, or involvement in a program of recovery. However, in
the context of a suicidal crisis, psychiatrists need to be careful
in referring a long-term patient for consultation. Some patients
may perceive such a referral as the first step to termination of therapy
and may need to be reassured that the referral is only for consultation.
For the purposes of this practice guideline, psychiatrists
should be familiar with specific psychotropic medicines that have
been found to be useful in the care of the suicidal patient. In
general, somatic therapies such as antidepressants, antipsychotics,
or mood-stabilizing agents will be targeted to specific axis I and/or
axis II psychiatric disorders. However, early use of supplemental
medicines, including sedative-anxiolytics or low doses of second-generation
antipsychotics, may also be helpful to rapidly address agitation,
anxiety, and insomnia, which are additional risk factors for suicide.
A mainstay of the treatment of suicidal patients suffering
from acute, recurrent, and chronic depressive illness is the administration
of antidepressant medication in an adequate dose (526). Antidepressants
also have demonstrated efficacy in the treatment of anxiety disorders
(526). They have also been used successfully in treating suicidal
patients with comorbid depression and substance use disorders (527).
Remarkably, however, there is relatively limited evidence that antidepressant treatment
reduces risk (69, 526, 528–533). On the basis of a large
number of short-term randomized, placebo-controlled trials for acute
major depression (534–546) that were subjected to meta-analysis (533),
antidepressant treatment has not been shown to reduce rates of suicide
or suicide attempts. Studies using data on antidepressants from
Food and Drug Administration clinical trial databases also do not
show differences in rates of suicide or suicide attempts with antidepressant
treatment (546–548). However, reductions in risk might
not be observed as readily over short time periods or in studies
in which suicidality was used as an exclusion criterion. Furthermore,
long-term studies with relevant data are rare and too
small to support any conclusions (526). However, since the late 1980s,
suicide rates in several countries, regions, or subpopulations have
fallen appreciably (69, 531, 532, 549, 550), coinciding with the
increasing clinical use of nontricyclic and non–monoamine oxidase
inhibitor (non-MAOI) antidepressants in adequate doses and perhaps
providing indirect evidence for a role of antidepressant treatment
in the treatment of suicidal behaviors.
After publication of several case reports suggesting that
SSRI antidepressants might be associated with increased risks of
aggressive or impulsive acts, including suicide (551–553),
a number of investigators retrospectively analyzed clinical trial
data to determine whether suicidality and/or suicide rates
are increased with SSRI treatment (537, 548, 554, 555). These studies
did not show evidence that suicide or suicidality is increased by
treatment with specific types of antidepressants. At the same time,
these medications are prescribed in order to treat disorders that
may have anxiety, agitation, and suicidality as part of the illness
course, making it difficult to distinguish the etiology of symptoms that
emerge in the course of treatment. Thus, as treatment begins, it
is important to determine baseline levels of symptoms and then to
observe patients for symptoms such as anxiety, agitation, or sleep
disturbance as well as for the development of mixed states or psychosis,
all of which may increase their subjective sense of distress and
increase suicide risk. In addition, antidepressant therapy typically
involves a substantial delay before clinically obvious improvements
occur. During initial, partial recovery, it is possible that suicidal
impulses as well as the energy to act on them may increase. Patients should
be forewarned of this likely delay in treatment effects and should
be given encouragement and monitored especially closely in the initial
days and weeks of treatment. If full response to treatment is not
observed, adjustments in medication dosage or a change to a different
antidepressant medication may be necessary. Nontricyclic, non-MAOI
antidepressants are relatively safe and present virtually negligible
risks of lethality on overdose (526). Nevertheless, it is wise to
request that conservative quantities of medication be dispensed
for suicidal patients, especially for patients who are not well
known. Although the tricyclic antidepressants and MAOIs are much
more toxic in overdose and more limited in their use, they may still
be valuable in treating individuals with suicidal behaviors and
depressive disorders who have not responded to treatment with SSRIs
or other newer antidepressants (526, 556, 557). Overall, from a
clinical perspective, the strong association between clinical depression
and suicide and the availability of reasonably effective
and quite safe antidepressants support their use, in adequate doses
and for an adequate duration, as part of a comprehensive program
of care for potentially suicidal patients, including long-term
use in patients with recurrent forms of depressive or severe anxiety
There is strong and consistent evidence in patients with recurring
bipolar disorder and major depressive disorder that long-term maintenance
treatment with lithium salts is associated with major reductions
in risk of both suicide and suicide attempts (69, 558–565).
A recent meta-analysis (563) of available studies of suicide rates
with versus without long-term lithium maintenance treatment (76,
534, 559, 565–595) found a highly statistically significant
decrease in suicidal acts (i.e., suicide or suicide attempts) of
almost 14-fold. For suicide, lithium maintenance treatment was associated with
an 80%–90% decrease in risk, whereas
the reduction in suicide attempt rates was more than 90%.
Although suicide rates during lithium treatment are still greater
than those in the general population, maintenance therapy with lithium
for bipolar disorder patients is associated with substantial and
significant reductions in suicide risk, compared to non-lithium-treated
bipolar disorder patients. As with antidepressants, the potential
lethality of lithium in overdose (596) should be taken into consideration
when deciding on the quantity of lithium to give with each prescription. However,
given the long-term benefits of lithium in reducing risks of suicidal
behaviors, the potential for overdose effects should not preclude
treatment of suicidal patients with lithium when it is clinically
Despite the increased use and antimanic efficacy of specific
anticonvulsant and antipsychotic agents (e.g., divalproex, olanzapine),
their long-term effectiveness in protecting against recurrent mood
episodes is less well established. Moreover, there is no established
evidence of a reduced risk of suicidal behavior with any other "mood-stabilizing" anticonvulsants.
Although treatment with these agents may be associated with some
decrease in suicidal behaviors, lithium treatment is still associated
with a greater diminution in rates of suicidal acts than treatment
with carbamazepine or divalproex (592, 597, 598). Consequently,
when deciding between lithium and other first-line agents for treatment
of patients with bipolar disorder, the efficacy of lithium in decreasing
suicidal behavior should be taken into consideration when weighing
the benefits and risks of treatment with each medication.
Analogous to the use of antidepressants for patients with
depression, the antipsychotic medications have been the mainstay
of somatic treatment for suicidal patients with psychotic disorders.
First-generation antipsychotic agents are highly effective in treating
delusions and hallucinations as well as agitation, aggression, and
confusion and may also have some beneficial actions in major affective disorders.
Their potential effects in limiting suicidal risk in psychotic patients
are unknown, although annual rates of suicide associated with schizophrenia
have not fallen appreciably since their introduction (599–602).
Particularly in highly agitated patients, the beneficial effects
of first-generation and modern antipsychotics may serve to reduce
suicide risk (603). However, use of older neuroleptic agents may also
be associated with adverse effects, including extrapyramidal neurological
side effects and possible worsening of depression as a result of
induction of akathisia (603–606). Given the fact that treatment
of psychotic disorders with second-generation antipsychotic agents
is associated with lower risks of some, particularly extrapyramidal-neurological,
adverse effects (512, 513, 596), use of first-generation antipsychotics
in individuals with suicidal behaviors currently is usually reserved
for those needing the enhanced treatment adherence afforded by depot
forms of medication or those whose psychosis has not responded to
a second-generation antipsychotic, or when economic considerations are
In the United States, the second-generation antipsychotic
medications, such as aripiprazole, clozapine, olanzapine, quetiapine,
risperidone, and ziprasidone, are now used to treat the majority
of individuals with schizophrenia or schizoaffective disorder. In
addition to their use as first-line agents in the treatment of schizophrenia,
the second-generation antipsychotic agents may also be indicated for
use in individuals with other psychotic disorders as well as in
patients with bipolar disorder, particularly during manic episodes.
Among the second-generation antipsychotic agents, clozapine has
generally been reserved for use when psychotic symptoms have not
responded to other antipsychotic medications. As for effects on
suicide attempts and suicide, clozapine is the best studied of any
of the antipsychotic agents. Reductions in the rates of suicide
attempts and suicides have been reported in specific studies of
patients with schizophrenia treated with clozapine (607) as well
as in registry studies (533, 606, 608–613), which may include
patients with other psychotic diagnoses. Earlier studies could not
eliminate the possibility that suicide rates were decreased by a
nonspecific effect of increased clinical contact due to hematologic
monitoring during clozapine therapy. However, significant reductions
in suicide attempts and hospitalization for suicidality were also
seen in a more recent blinded study comparing clozapine
and olanzapine (603). The reduction of suicide attempts in both
groups, compared to the rate in the year preceding the study, suggests
that olanzapine may also offer some protection against suicide attempts.
These findings suggest that use of clozapine might be considered
earlier in the treatment of individuals with schizophrenia or schizoaffective disorders.
At the same time, the potential benefits of treatment with clozapine
need to be weighed against the potential for adverse effects with
long-term clozapine treatment, including agranulocytosis, myocarditis,
weight gain, and glucose dysregulation. Further study is needed
to determine whether clozapine can reduce suicide risk in patients
with other diagnoses or whether other second-generation antipsychotic
drugs may reduce suicide risk in schizophrenia in comparison with
one another or with first-generation antipsychotic drugs.
Since anxiety is a significant and modifiable risk factor
for suicide, utilization of antianxiety agents may have the potential
to decrease this risk. More specifically, before accompanying depression
has resolved, acute suicide risk may be associated with severe psychic
anxiety, panic attacks, agitation, and severe insomnia (79). Although
these symptoms may be reduced by aggressive short-term benzodiazepine
treatment (lasting 1–4 weeks), research on suicide risk
with antianxiety treatment is quite limited, with no clinical trial
of antianxiety treatment showing short- or long-term antisuicide
effects. However, a recent analysis of data obtained in controlled
trials of treatments for anxiety disorders showed no significant
differences in rates of suicidal behavior between those treated
with active agents and those taking placebo (118).
To minimize severe recurrent (rebound) anxiety/agitation,
long-acting benzodiazepines may be preferable to short-acting ones.
At the same time, long-acting benzodiazepines may be more likely to
cause daytime sedation. Psychiatrists should also keep in mind that
benzodiazepines occasionally disinhibit aggressive and dangerous
behaviors and enhance impulsivity, particularly in patients with borderline
personality disorder (614, 615). For patients treated with benzodiazepines
on a chronic basis, discontinuation of the benzodiazepine may be
associated with an increase in suicide risk (616). As alternatives
to benzodiazepines, second-generation antipsychotic medications
or anticonvulsant medications such as divalproex or gabapentin may
be helpful, although no specific research information on their potential
to limit anxiety is available. Persistent, severe insomnia is also
a modifiable risk factor for suicide and can be addressed with the
use of benzodiazepines or sedating second-generation antipsychotics
(617–619). Choice of a sedating antidepressant can also
be considered for depressed patients with prominent insomnia.
ECT is sometimes used to treat patients who are acutely suicidal,
and available evidence suggests that ECT reduces short-term suicidal
ideation (620–622). The efficacy of ECT is best established
in patients with severe depressive illness, but ECT may also be
used in treating individuals with manic or mixed episodes of bipolar
disorder, schizoaffective disorder, or schizophrenia, under certain clinical
circumstances (623). ECT is especially likely to be considered for
patients for whom a delay in treatment response is considered life-threatening.
Such patients may include individuals who are refusing to eat because
of psychosis or depressive symptoms as well as those with catatonic
features or prominent psychosis. ECT may also be indicated for suicidal
individuals during pregnancy and for those who have already failed
to tolerate or respond to trials of medication. Although ECT is often
raised as a possible treatment for chronically suicidal individuals
with borderline personality disorder, ECT in such patients should
target comorbid disorders that may be present, particularly comorbid
major depressive disorder. In the absence of another indication
for use, ECT is not indicated for the treatment of suicidality in
borderline personality disorder. For further details on the clinical use
of ECT, including the pre-ECT evaluation, the informed consent process,
the numbers of treatments generally given, and the technical aspects
of ECT administration, the reader is referred to APA's
2001 report, The Practice of Electroconvulsive Therapy:
Recommendations for Treatment, Training, and Privileging: A Task
Force Report of the American Psychiatric Association (623).
Since there is no evidence for long-term or sustained reduction
of suicide risk after an acute course of ECT, close clinical supervision
and additional treatment with psychotropic medications are usually
required during subsequent weeks and months.
In addition to pharmacotherapies and ECT, psychotherapies
play a central role in the management of suicidal behavior in clinical
practice. Although few rigorous studies have directly examined whether
these interventions reduce suicide morbidity or mortality per se,
clinical consensus suggests that psychosocial interventions and
specific psychotherapeutic approaches are of benefit to the suicidal
patient. Furthermore, in recent years, studies of psychotherapy
have demonstrated its efficacy in treating disorders such as depression
and borderline personality disorder that are associated with increased
suicide risk. For example, cognitive behavior therapy, psychodynamic
therapy, and interpersonal psychotherapy have been found effective
in clinical trials for the treatment of these disorders (511, 515).
A small randomized, controlled trial of psychoanalytically oriented
partial hospital treatment for individuals with borderline personality
disorder showed a beneficial effect on suicide attempts and self-harming
behaviors during treatment and follow-up (624, 625). These observations
as well as clinical experience lend support to the use of such psychotherapeutic approaches
in the treatment of suicidal ideation and behaviors.
A number of other specific and nonspecific interventions have
been assessed in small methodologically sound, randomized, controlled
trials involving individuals with suicidal ideation or attempts
as well as other forms of deliberate self-harm (626, 627). Dialectical
behavior therapy has been studied for effects in a narrow range
of potentially suicidal patients, particularly chronically suicidal
or self-harming women with personality disorders. By targeting deficits
in specific skills, such as emotional regulation, impulse control,
anger management, and interpersonal assertiveness, dialectical behavior
therapy may be effective in reducing suicide attempts when applied
over longer time frames, especially for patients with personality
disorders. There is also some preliminary evidence that cognitive
and behavioral psychotherapy may reduce the incidence of suicide
attempts in depressed outpatients (236, 626). However, other forms
of cognitive behavior therapy that include a problem-solving component
have shown mixed results (524, 628–632), suggesting the
need for additional study. Other nonspecific interventions have been
studied in relatively small samples and have similarly shown mixed
results. Most of these studies are limited in the size and scope
of the patient population and provide only narrow support for an
effect on suicidal behaviors (633).
Risk management is an important component of psychiatric practice,
especially in the assessment and management of patients at risk
for suicide. Clinically based risk management is patient centered and
supports the therapeutic alliance and the treatment process. The
most frequent lawsuits, settlements, and verdicts against psychiatrists
are for patients' suicides. Thus, when treating a patient with
suicidal behaviors, it is important to be aware of and pay attention
to certain general risk management considerations, which are summarized
in Table 9.
Good collaboration, communication, and alliance between
clinician and patient
Careful and attentive documentation, including:
Risk assessments
Record of decision-making processes
Descriptions of changes in treatment
Record of communications with other clinicians
Record of telephone calls from patients or family members
Prescription log or copies of actual prescriptions
Medical records of previous treatment, if available,
particularly treatment related to
past suicide attempts
Critical junctures for documentation:
At first psychiatric assessment or admission
With occurrence of any suicidal behavior or ideation
Whenever there is any noteworthy clinical change
For inpatients, before increasing privileges or giving
passes and before discharge
Monitoring issues of transference and countertransference
in order to optimize clinical judgment
Consultation, a second opinion, or both should be considered
when necessary
Careful termination (with appropriate documentation)
If present, document instructions given to the patient
and significant others
If absent, document as a pertinent negative
Planning for coverage
Documentation of patient care is a cornerstone of medical
practice, but it is also essential to risk management (634, 635).
If a malpractice claim is brought against the psychiatrist, documentation
of suicide risk assessments assists the court in evaluating the
many clinical complexities and ambiguities that exist in the treatment
and management of patients at suicide risk. The failure to document
suicide risk assessments and interventions may give the court reason
to conclude they were not done. For patients who are hospitalized,
it is also important to document the aspects of the risk assessment
that justify inpatient treatment, particularly when it is occurring
on an involuntary basis (636). Thus, it is crucial for the suicide
risk assessment to be documented in the medical record.
Despite the time burdens faced by the psychiatrist, documentation
is best done just after the suicide assessment is completed. Reference
to the reason for the assessment (e.g., relapse, worsening, a reversal
in the patient's life) will set the context for the evaluation.
Subsequent discussion reviews the factors that may contribute to
increased shorter-term or longer-term suicide risk as well as the reasoning
process that went into the assessment. Clinical conclusions and
any changes in the treatment plan should also be noted, along with
the rationale for such actions. If other interventions or actions
were considered but rejected, that reasoning should be recorded
as well.
Consider the example of a patient who was in remission after
a prior hospitalization for a suicide attempt but who recently had
a relapse or a recurrent episode. The psychiatrist may document
that suicidal ideation is present but that there is no evidence
of a specific plan or specific symptoms that would augment risk
(i.e., agitation, severe anxiety, severe insomnia). It may also
be noted that the patient is under increased stress and is in some
distress but is responsive to support. On the basis of the patient's
willingness to accept help and the lack of evidence of acute suicide
risk factors, continued outpatient management may be reasonable,
with changes in the treatment plan, such as increasing the frequency
of visits, perhaps increasing anxiolytic medication doses temporarily,
and perhaps talking with a supportive relative or friend to obtain
more information and to solidify the patient's support
In all settings, the psychiatrist should be aware that suicide
risk assessment is a process and never simply an isolated event.
Specific points at which reassessment may be indicated have been
detailed in Table 2. On inpatient units, important points of documentation
of assessment occur at admission, changes in the level of precautions
or observations, transitions between treatment units, the issuance of
passes, marked changes in the clinical condition of the patient,
and evaluation for discharge (637). In particular, the determination
of the level of suicide precautions (one-to-one versus every-15-minute checks,
etc.) should be based on the patient's clinical presentation
and be supported by a clinical rationale. Because care in inpatient
settings is generally delivered by a multidisciplinary treatment team,
it is important for the psychiatrist either to review the patient's
records regularly or to communicate verbally with staff throughout
the patient's hospital stay. At the time of the patient's discharge
from the hospital, risk-benefit assessments for both continued hospitalization
and discharge should be documented, and follow-up arrangements for
the patient's outpatient care should be recorded.
In outpatient settings, the process of suicide risk assessment
and documentation typically occurs during the initial interview;
at the emergence or reemergence of suicidal ideation, plans, or
behavior; and when there are other significant changes in the patient's
condition. Revisions of the treatment plan are appropriately noted
at these times. For patients in psychoanalysis or modified psychoanalytic treatment,
the psychiatrist may elect to follow the charting recommendations
of the psychoanalytic subspecialty practice guideline (638).
As originally designed, the suicide prevention contract, which
is sometimes known as a no-harm contract, was intended to facilitate
management of the patient at suicide risk (639). Although in the era
of managed care, suicide prevention contracts are increasingly being
used with patients at risk for suicide, the patient's willingness
(or reluctance) to enter into a suicide prevention contract should not
be viewed as an absolute indicator of suitability for discharge
(or hospitalization). In addition, since the utility of the suicide
prevention contract is based on subjective belief rather than objective evidence,
it is overvalued as a clinical or risk management technique.
Furthermore, the suicide prevention contract is not a legal document
and cannot be used as exculpatory evidence in the event of litigation
(640). Thus, the suicide prevention contract cannot and should not
take the place of a thorough suicide risk assessment (637).
Although suicide prevention contracts are commonly used in
clinical practice (429), no studies have shown their effectiveness
in reducing suicide. In fact, studies of suicide attempters and
of inpatients who died by suicide have shown that a significant
number had a suicide prevention contract in place at the time of
their suicidal act (212, 218, 430). Consequently, although verbal
and written suicide prevention contracts have each been proposed
as aids to assessing the therapeutic alliance, their limitations
should also be clearly understood (641). Relying on suicide prevention
contracts may reflect the clinician's understandable but
not necessarily effective attempt to control the inevitable
anxiety associated with treating patients at suicide risk. At the
same time, undue reliance on a patient's suicide prevention
contract may falsely lower clinical vigilance without altering the patient's
suicidal state.
Some clinicians gauge the patient's suicidal intent
by his or her willingness to formalize the alliance by a written
or an oral contract. For example, when discussing a suicide prevention
contract, some patients will state openly that they cannot be sure
that they can (or will want to) call the psychiatrist or other treatment
team members if self-destructive impulses threaten. Patients
who reject a suicide prevention contract are communicating that
they see the therapeutic alliance as suboptimal or that they feel
unable to adhere to such a contract. Consequently, patients who
refuse to commit to contracts against suicide put the clinician
on notice that the therapeutic alliance and the level of suicide
risk should be reassessed. An alternative approach to
suicide prevention contracts proposed by Miller et al. (642) relies
on the basic tenets of informed consent and includes discussion
of the risks and benefits of treatment and management options with
the patient as a means of assessing his or her ability to develop
and maintain a therapeutic alliance. In inpatient settings such
discussions can emphasize the availability of the clinical staff
and be used as a way to educate the patient about options for dealing
with suicidal impulses.
Regardless of their potential advantages, suicide prevention
contracts are only as reliable as the state of the therapeutic alliance.
Thus, with a new patient, the psychiatrist may not have had sufficient time
to make an adequate assessment or to evaluate the patient's
capacity to form a therapeutic alliance, creating little or no basis
for relying on a suicide prevention contract. As a result, the use of
suicide prevention contracts in emergency settings or with newly
admitted and unknown inpatients is not recommended. Furthermore,
patients in crisis may not be able to adhere to a contract because of
the severity of their illness. Suicide prevention contracts are
also ill-advised with agitated, psychotic, or impulsive patients
or when the patient is under the influence of an intoxicating substance.
For these individuals, as for all patients presenting with suicidal
behaviors, the psychiatrist must be ever mindful of the need for
ongoing suicide assessments.
The confidential nature of the doctor-patient relationship
is a fundamental aspect of the psychotherapeutic process. Consequently,
the psychiatrist will need to manage the tension between this requirement
and the wish to act in the patient's best interest. The
default position is to maintain confidentiality unless the patient
gives consent to a specific intervention or communication. However, in
maintaining a safe environment for the patient, significant others
may need to be contacted to furnish historical information or carry
out specific tasks such as removing firearms from the home. If the
psychiatrist determines that the patient is (or is likely to become)
dangerous to him- or herself or to others and the patient will not
consent to interventions that aim to reduce those risks, then the psychiatrist
is justified in attenuating confidentiality to the extent needed
to address the safety of the patient and others. More specifically,
the 2001 edition of The Principles of Medical Ethics
With Annotations Especially Applicable to Psychiatry states: "[P]sychiatrists
at times may find it necessary, in order to protect the patient
or the community from imminent danger, to reveal confidential information
disclosed by the patient" (Section IV, Annotation 8) (643).
As with many situations involving the suicidal patient, such decisions
require much clinical judgment in weighing the effects of breaching
confidentiality on the therapeutic relationship against the potential
safety risks for the patient or others. It should also be noted
that the psychiatrist can listen to information provided by friends
or family without violating confidentiality by disclosing information
about the patient to the informant. In addition, in an emergency
situation, necessary information about the patient can be communicated
with police and with emergency personnel, including medical staff
and emergency medical technicians.
Because psychiatrists work with individuals who are by definition
at increased risk for suicide, suicides can and do occur in clinical
practice despite the best efforts at suicide assessment and treatment
(489, 491). At least half of psychiatrists can expect in the course
of their practice that one of their patients will die from suicide
(644, 645). A patient's suicide is among the most difficult
professional experiences encountered by a psychiatrist. It can lead
to symptoms of posttraumatic stress disorder, shock, anger, grief,
guilt, isolation, shame, diminished self-esteem, and concern about
reactions of colleagues (646, 647). In one study (644), approximately
half of the psychiatrists who had lost a patient to suicide experienced
stress levels comparable with those of persons recovering from a
parent's death. The significant effects of a patient's
suicide on the psychiatrist, especially posttraumatic stress responses
(644), suggest that support for the psychiatrist and a review of
events leading to the suicide are warranted. Specific training may
also be useful in helping the psychiatrist deal with the aftermath
of a patient's suicide (644). In addition to
receiving support from colleagues after a patient's suicide,
some psychiatrists find it helpful to seek consultation or supervision
to enable them to continue to respond effectively in working with
other patients.
After a patient's suicide, clinicians may experience
conflicting roles and concerns. However, a number of steps can be
taken to facilitate the aftercare process. Many psychiatrists find
it helpful to consult with a colleague or with an attorney. In addition,
the psychiatrist should ensure that the patient's records
are complete. Any additional documentation included in the medical
record after the patient's death should be dated contemporaneously,
not backdated, and previous entries should not be altered.
Conversations with family members can be appropriate and can
allay grief and assist devastated family members in obtaining help
after a suicide. This recommendation is based primarily
on humanitarian concerns for survivors, but this approach may also
have a powerful, though incidental, risk management aspect. Nonetheless,
attorneys advise clinicians in two very different ways on the issue of
suicide aftercare. After a bad outcome, some attorneys recommend
that the case be sealed and no communication be established with
the family, except through the attorney. Other attorneys encourage
judicious communication or consultation, if indicated. If this approach
is taken, the psychiatrist should concentrate on addressing the
feelings of the family members rather than specific details of the
patient's care. In addition, in speaking with survivors,
care must be exercised not to reveal confidential information about
the patient and not to make self-incriminating or self-exonerating
statements, since these statements may further distress the family
and provide a spur to litigation. The individuals who lived with
the patient before the suicide not only currently experience intense
emotional pain but also shared it with the patient before death.
Thus, a number of lawsuits are filed because of the clinician's
refusal to express, in any way, feelings of condolence, sadness,
sympathy, or regret for the patient's death. A number of
states have statutes that prohibit statements, writings, or benevolent
human expressions of sympathy such as condolences and regrets from
being admissible as evidence of an admission of liability
in a civil action (648). However, statutes often distinguish between
the part of a statement that is an expression of sympathy and the
part of a statement that expresses fault, e.g., in the case of an
automobile accident, "I'm sorry you were hurt" (inadmissible
as evidence of liability) versus "I was using my cell phone
and just didn't see you coming" (admissible as
evidence of liability). Consequently, it may be useful for psychiatrists
to know whether an apology statute is applicable within their jurisdiction
and, if so, to know the specific provisions of the statute. The
individual psychiatrist must use his or her clinical judgment to
decide whether attending the patient's funeral would be
appropriate. It may also be helpful to include a risk manager in
this decision process.
Many occasions arise in which information is requested after
a patient's death. As a general rule, written authorization
should be obtained from the executor or administrator of the deceased
patient's estate before releasing a copy of the medical
records. If the estate has been settled and an executor or administrator
no longer exists, a copy of the medical records should be released
only to properly appointed legal representatives (649).
The survivors of suicide are more vulnerable to physical and
psychological disorders and are at increased risk of suicide themselves
(see Section II.E.6, "Family History").
Although there are relatively few systematic studies of adult bereavement
after suicide, existing studies suggest that emotional, social,
and physical conditions of survivors are significantly changed after
the suicide of a relative. Within 6 months after a suicide, 45% of
bereaved adults report mental deterioration, with physical deterioration
in 20% (650). Symptoms of depression, posttraumatic stress,
guilt, and shame as well as somatic complaints are prevalent during
that period and are more severe among parents of deceased children
(650–652). While the majority of bereaved adults within
6 months after a suicide acknowledge a need for intervention, only
approximately 25% seek psychiatric treatment (650). Despite
this low rate of treatment, the majority of bereaved adults adapt
well in the long term (653, 654).
The most comprehensive data on bereavement after suicide exist
for youths. These data indicate that within 6 months after
the suicide of a friend or sibling, symptoms of major depressive
and posttraumatic stress disorders are prevalent among bereaved
youths (145, 651, 655). The long-term outcomes, up to 18 months,
of adolescents whose friends had died by suicide suggest the incidence of
major depressive disorder is higher in those who had depression
before the friend's suicide, intermediate in those who
developed depression immediately after the suicide, and lowest in
those who were not depressed immediately after the suicide (656).
Those who became depressed after the death were closer to the friend
who died by suicide, showed more intense grief, and had more intense exposure
to the suicide. Within 6 years of the suicide of a friend,
adolescents with syndromal levels of traumatic grief were five times
more likely to report suicidal ideation than those without traumatic grief
(657). However, there was no greater incidence of suicide attempts
among adolescents with a friend who had died by suicide than among
adolescents who did not know someone who died by suicide. Adolescent
siblings of youths who died by suicide had a sevenfold increased
risk for developing major depressive disorder within 6 months (651).
However, in a related 3-year follow-up of siblings of adolescents
who died by suicide, the siblings suffered more significant grief
than the friends of the adolescents who died by suicide, although
the rates of psychiatric disorders in follow-up were similar to
those for adolescents who did not have a friend or sibling who died
by suicide (651).
These studies suggest an increased risk of psychiatric symptoms
and impairment after the suicide of a relative. As a result, psychiatric
intervention should be offered to family members shortly after the
death and maintained to reduce risk for psychiatric impairment.
Such intervention is particularly important for youths and for those
who witnessed the suicide or were at the scene of the death. The goals
of psychiatric intervention include the identification and treatment
of major depressive and posttraumatic stress disorders as well as
related symptoms (658, 659). Longer-term follow-up with evaluation
and intervention for adolescents bereaved after the suicide of a
relative or friend is also indicated to decrease the risk for recurrent
depression and other morbidities (660). Furthermore, a family approach
to evaluation and intervention is needed for those who are bereaved
after an adolescent's suicide. Evaluation and treatment
of grief may be similarly important in reducing risk for suicidal
ideation among youths who are bereaved as a result of the suicide
of a person who is emotionally important to them. For all family
members and close friends of individuals who die by suicide, referral
to a survivor support group can be helpful.
As shown in Table 10, suicide rates vary with age, gender,
and race or ethnicity. Annual rates in the general U.S. population
rise sharply in adolescence and young adulthood, plateau through
midlife, then rise again in individuals over age 65. The increased
rates of suicide in youths are even more dramatic in some ethnic
and racial subgroups of the population. For example, the suicide
rate among American Indian males between ages 15 and 34 years averaged
about 36 per 100,000 during the period from 1979 to 1993, whereas
Alaska Native males between ages 14 and 19 years had an even more
dramatic rate, at 120 per 100,000 (661). Black male youths, who
were historically at low risk for suicide, now have a suicide rate
comparable to their white peers. Although the suicide rate in adolescents,
like the overall U.S. suicide rate, has dropped in the past decade,
the relative suicide risk of youths remains high, and this has been
attributed to increases in alcohol and substance abuse (662), breakdown
in extended family and intergenerational support, and increased
availability of firearms, especially for young African American
males (663).
Non-Hispanic White
Non-Hispanic Black
American Indian/
Alaska Native
Age (years)
rates per 100,000 in the United States in the year 2000 for ICD-10
codes X60–X84, Y87.0. From the Web-Based Injury Statistics
Query and Reporting System, National Center for Injury Prevention
and Control, Centers for Disease Control and Prevention (1111).
Individuals over age 65 are disproportionately represented
among those who die by suicide. Compared with suicide rates in men
ages 55 to 64 years, suicide rates in men over age 85 are two- to
threefold higher for all races except African Americans. For elderly
women, suicide rates are relatively unchanged with increasing age,
with the exception of Asian women over age 85, whose suicide rate
increases threefold from middle age.
Overall suicide rates among those over age 65 have decreased
substantially over the course of the last century, with a further
decrease over the past decade. Although the reasons for the decline
are unknown, a variety of mechanisms have been postulated, including
improved access to social and health care resources by older adults
with the implementation of Social Security and Medicare legislation and
the more widespread use of safe and effective antidepressant medications
(664). The incidence of suicide among elderly persons may increase
again, however, as the large, post–World War II baby boom
generation continues to age. Relative to age groups born in earlier
or later periods, baby boomers have been distinguished by suicide
rates that have been comparatively higher at all ages (665). Of
additional concern is the fact that elders are the fastest growing
segment of the U.S. population. Thus, as large numbers of this high-risk
cohort enter the phase of life associated with greatest risk, the
absolute number of suicides among older adults may increase dramatically
Suicidal ideation and suicide attempts are more frequent in
younger age groups than in later life (14). Kuo et al. (29), using
prospectively gathered data from the Epidemiologic Catchment Area (ECA)
survey, found a progressive decrease in the annual incidences of
suicidal ideation and suicide attempts with increasing age. Compared
with the rate in individuals over age 65, the rate of suicide attempts
was 10-fold greater in those ages 18 to 29 years, at approximately
310 per 100,000 person-years. The rate of suicidal ideation in individuals
ages 18 to 29 was approximately 630 per 100,000 person-years, a
rate that was sixfold greater than that in those over age 65. Duberstein
et al. (13), in a study of adults age 50 years and older, also found
that people are less likely to report suicidal ideation as they
In other studies, estimates of the prevalence of suicidal
ideation in older adults have varied with the population sampled
and the site, time frame, and study methods. Lish and colleagues
(667) found that 7.3% of an older sample in Department
of Veterans Affairs (VA) primary care practices had thoughts of
suicide, and elders with a history of mental health treatment were
at far greater risk. Callahan and colleagues (668) used a far more
stringent definition of suicidal ideation, limited ascertainment
to within the past week, and required the ideation to include a
specific suicide plan. They found that 0.7%–1.2% of
elders in primary care had suicidal ideation, all of whom had a simultaneous
mood disorder. Skoog et al. (669), in a survey of nondemented
Swedes age 85 years and older, inquired about the presence of both
active and passive suicidal ideation in the month preceding the
interview. They found that 16% of the subjects had thoughts
of suicide. Again, the rate was higher in subjects with mental disorder,
in those taking anxiolytic and neuroleptic agents, and in those
with significant physical illness. Among community-dwelling Floridians
60 years of age and older, less than 6% reported ever having
had suicidal thoughts in a study by Schwab et al. (670), while in
the Berlin Aging Study (671) 21% of subjects over age 70
reported having had suicidal ideation. Again, psychiatric illness
was present in virtually all subjects, suggesting a need for careful screening
for psychiatric disorder in elders with suicidal ideation.
In the United States, epidemiologic data show that suicide
is more frequent in men than in women. For example, data from the
National Center for Health Statistics for the year 2000 showed an
age-adjusted suicide rate for males that was approximately 4.5-fold
that for females (18.08 per 100,000 and 4.03 per 100,000, respectively)
(11). This differential is comparable to the male-to-female ratio for
suicide found in the National Longitudinal Mortality Study for the
years 1979 to 1989 (672). Within the U.S. population, males are
disproportionately represented among deaths by suicide in all racial
and ethnic groups, with rates that range from more than 5.5-fold
greater than that for females among African Americans and Hispanics
to threefold greater than that for females among Asian/Pacific
Islanders. This is not the case in other parts of the world, however.
For example, in China the suicide rate for women is 25% higher
than that for men (18).
The male-to-female predominance in suicide in the United States
persists across the lifespan. Adolescent and young adult males are
about 5.5 times more likely to die from suicide than females, whereas
in midlife the male-to-female ratio is approximately 3.5 to 1. After
about age 65, however, there is a steadily widening male-to-female
ratio of suicide rates in all groups except Asians, with differences
of more than 10-fold after age 80.
Differences in suicide risk with gender may be explained in
part by factors that contribute to risk in general but that are
present to differing degrees in men and in women. For example, men
are less likely than women to seek help, admit the severity of their
symptoms, or accept treatment, increasing their likelihood of suicide.
In contrast, women tend to be less impulsive, have more social support, and
have lower rates of comorbid alcohol and substance use disorders,
all of which may have a protective effect (21). Among African American
women, the potential protective factors of religion and extended
kin networks have been suggested as possible explanations for this
group's very low rate of suicide (22).
Despite their lower rate of suicide, women have higher rates
of depressive illness than men (23, 673). Furthermore, in a 10-year
follow-up study using data from the National Longitudinal Mortality Study,
unemployment was associated with a greater and longer-lasting effect
on the suicide rate of women compared to men (24). Compared to men,
women also have an increased likelihood of having been physically
or sexually abused, which may also increase the risk for
suicide (36). The relative lethality of the suicide methods chosen
by women remains less than those chosen by men; however, the recent,
more frequent use of firearms among women suggests that this distinction
may be diminishing (11, 674).
Suicide rates have also been examined in pregnant women and
during the postpartum period. Dannenberg et al. (675) reviewed New
York City medical examiner records of 293 pregnant or recently pregnant
women ages 15 to 44 years who died of injury during a 4-year period.
Of these, 15 died by suicide, a rate that was not significantly
different from the expected age- and race-specific rates in the
general population. However, Marzuk et al. (676) analyzed autopsy
data from female residents of New York City who were of childbearing
age and found the standardized mortality rate for suicide during
pregnancy to be one-third the expected rate. Appleby (677), using
retrospective population data for England and Wales from 1973 to
1984, also noted decreased rates of suicide among pregnant women
and among women during the first year after childbirth, with SMRs
of 0.05 and 0.17, respectively. In contrast to decreased
suicide rates for women in general during pregnancy and the puerperium,
Appleby et al. (27) subsequently found an extremely high suicide
rate among women who had been psychiatrically hospitalized during
the postpartum period. In this study of 1,567 women admitted
to Danish psychiatric hospitals within the first year after childbirth,
the SMR for suicide within 1 year was more than 70 times the expected
rate. Although risk was greatest within the first month postpartum,
it persisted throughout the initial year after childbirth. In addition,
women who died by suicide after childbirth often used violent methods.
Thus, although evidence is limited, women with severe postpartum
psychiatric disturbances appear to be at significantly increased
risk during the initial year after childbirth. Other groups with
a particularly increased postpartum risk include teenagers and women
of lower socioeconomic status (27, 28). For women as a group, however,
a protective effect seems to be present during pregnancy and the
postpartum period (25).
In terms of suicide attempts, women in the United States are
reported to attempt suicide three times as often as men. This female
predominance of suicide attempters varies with age, however, and
in older adults the ratio of female-to-male suicide attempters approaches
1:1 (11). Similar trends are observed in the incidence of suicidal
ideation. For example, Kuo et al. (29), using data from 3,481 prospectively
followed individuals from the Baltimore ECA study, found that females
ages 18 to 29 years had a higher incidence of suicidal ideation
and suicide attempts than their male peers. However, this female-to-male
predominance in suicidal ideation and suicide attempts was not observed
for older age groups or for the sample as a whole.
As noted earlier, women are more likely to have experienced
domestic violence or physical or sexual abuse, all of which have
been associated with higher rates of suicidal ideation and suicide attempts
(32–34). In a study of psychosocial outcomes in 1,991 same-sex
twin pairs, Nelson et al. (35) found that childhood sexual abuse
was three times more common in women and was associated with an
increased risk of attempting suicide. Borderline personality disorder
is also present more often in women (515) and is itself associated
with increased rates of suicidal ideation, suicide, suicide attempts,
and other self-injurious behaviors. In addition, borderline
personality disorder is particularly common in women who have experienced
childhood sexual abuse, physical abuse, or both (31). As a result,
physical and sexual abuse and domestic violence should be given
particular consideration in the assessment and treatment of women
with suicidal ideation, suicide attempts, and other self-injurious behaviors.
Race, ethnicity, and culture are all associated with variations
in rates of suicide. In the United States for the year 2000, the
overall age-adjusted rates of suicide were highest in Native Americans and
non-Hispanic whites, at 13.6 and 12.1 per 100,000, respectively
(11). In contrast, the age-adjusted rate of suicide in Hispanics
was substantially less, at 6.13 per 100,000, and was similar to
the rates for non-Hispanic African Americans and Asian/Pacific
Islanders, at 5.8 and 6.0 per 100,000, respectively.
For immigrant groups, suicide rates in general tend to mirror
rates in the countries of origin, with trends converging toward
the host country over time (40, 41). In a large epidemiological
study, Singh and Siahpush (39) found that between 1979 and 1989,
foreign-born men in the United States were 52% less likely
to die by suicide than native-born men, but the difference narrowed
in the older age cohorts. Data for immigrant women were not statistically
significant because of the small number of deaths.
In the United States, racial and ethnic differences are also
seen in the rates of suicide across the lifespan (Table 10). Among
European-American non-Hispanic whites, Hispanics, and Asian/Pacific Islanders,
the highest suicide rates occur during the senior years, in those
over age 65. In contrast, among Native Americans and African Americans,
the highest suicide rates occur during adolescence and young adulthood.
For example, in Native American and African American males ages
15 to 24, suicide rates in the year 2000 were 36.81 and 14.66 per
100,000, respectively. Young African American men have been described
as being caught in a cycle of drug abuse, criminal activity, and self-devaluation
and may view an early death as inevitable or as an alternative to
the wearying struggle that life has become (678). Additional risk
factors for suicide in young African American males include substance
abuse (662, 679), presence of a firearm (663), and in particular
the combination of cocaine abuse and the presence of a firearm (679).
Suicidal ideation and suicide attempts are also common in urban
African American young adults, with 6-month prevalences of 1.9% and
0.4%, respectively (680).
In contrast to young African American males, African American
women have a very low rate of suicide. Gibbs (22) attributes this
low rate to the protective factors of religion, including the role
of religion in the civil rights movement, women's central
involvement in the church, and strong values for endurance in the
face of adversity. Women-dominated kinship networks are also believed
to be protective, providing flexible roles, resource sharing, and
social support (681).
Although black women are less likely to die from suicide than
white women, they attempt suicide and express negative emotional
states such as hopelessness and depression just as frequently. In addition,
both black men and black women are less likely than their white
counterparts to pursue professional counseling in the face of depression
or other mental illness. Instead, African Americans are more likely
to view depression as a "personal weakness" that
can be successfully treated with prayer and faith alone some or
almost all of the time (682). When depression is discussed, it may
be described in different terms such as having "the blues" or "the
aching misery" or "being down" (678). Consequently,
sensitivity to language and beliefs about illness are important
in recognizing depression and other risk factors for suicide among
African Americans.
Among Native Americans (American Indians and Alaska Natives),
suicide also is predominately an epidemic of the young and is the
second leading cause of death for Native Americans between ages
15 and 24 years. As with other racial and ethnic groups, Native
American and Alaska Natives are a very heterogeneous population,
with different tribal identities, varying degrees of urbanization, different
levels of tribal organization, and diverse approaches to historical
and cultural integration. For example, in a study of three groups
of Native Americans in New Mexico, the Apache had the highest suicide
rate (43.3 per 100,000) and the highest degree of acculturation
but also had the lowest degree of social integration and generally
viewed religion as unimportant (683). In contrast, the Navajo had
the lowest suicide rate (12.0 per 100,000) and the lowest level
of acculturation but had moderate social integration and were organized
into bands with a strong matrilineal clan influence. In the third
group, the Pueblo, the subgroup with the most acculturation, had
a higher suicide rate than the most traditional subgroup, again
suggesting an effect of acculturation on suicide risk. Acculturation
has also been proposed as a contributor to the extremely high suicide
rate in Alaska Native youths, which in one study approached 120
per 100,000 (661). Theories to explain these high rates tend to
rely on family disintegration, social disruption, and alcohol use
(684), as well as rapid social and cultural changes associated with
intensive energy development projects in the Arctic and the resulting
stress of acculturation. In contrast, in Hawaiian youths, the relationship
between acculturation and suicidal behavior is less clear, with
increased numbers of suicide attempts in those with stronger Hawaiian
cultural affiliation (685).
Research on suicide among Hispanics in the United States is
limited and rarely differentiates among different Hispanic
groups. In addition, many individuals of Hispanic origin
are undocumented workers who are not represented in census data
or epidemiological studies. Large-scale grouping of diverse ethnic
groups also obscures intracultural variations in important social
and economic categories. For example, Cuban American women and Mexican
Americans and Puerto Ricans of both genders were reported to have
lower than expected suicide rates, relative to 1-year prevalence of
major depression, than were whites, blacks, and Cuban American males
(23). In terms of suicidal ideation, higher levels have been reported
in Central American immigrants experiencing heightened levels of
acculturative stress (43). In addition, lifetime age- and gender-adjusted
rates of suicidal ideation were significantly lower for Mexican
Americans born in Mexico (4.5%) than for Mexican Americans
born in the United States (13%) or for non-Latino whites
(19.2%) (686). Similarly, rates of suicide attempt were
lower among Mexican Americans born in Mexico (1.6%) and
higher among both Mexican Americans born in the United States (4.8%)
and non-Latino whites (4.4%). The rate of suicide
attempt is also elevated among Hispanic youths, who had higher numbers
of reported suicide attempts compared to non-Hispanic youths
in a nationwide survey of high school students (687).
The suicide rate for Asians overall is the lowest of all of
the major American ethnic groups, but Asian Americans themselves
have diverse ethnic backgrounds, languages, and cultures. Some groups,
such as the Japanese, have been in the United States for generations.
Others, such as the Chinese, include both recent immigrants and
descendants of 19th-century immigrants, whereas the Vietnamese have
arrived in large numbers only since the 1960s. These individuals
bring with them attitudes toward coping and suicide from their home
countries, which can influence the circumstances of suicidal behavior
(688). In Japan, for example, suicide is permissible or even appropriate
in particular contexts, and ritual suicide has been an honorable
solution to certain social dilemmas. For example, the disgrace of
bankruptcy in Japan can shame the family for generations, making
suicide a preferable way to resolve debt. When it is culturally
important for a man to be physically healthy and able to support
his family, suicide may be viewed as an option if a serious physical
illness impairs his ability to function. For example, in Hawaii,
20.5% of suicides by Japanese American men occurred in
individuals with health problems, in contrast to only 11.8% of
suicides by Caucasian men and 3.0% by Hawaiian men (42).
In addition, for individuals who come from a culture in which mental
illness is highly stigmatized, receipt of a psychiatric diagnosis
may increase the risk for suicide. Although Chinese societies have
not generally codified suicide as socially acceptable, more recent
suicide rates in China are quite high, particularly in women and
in rural settings, where use of agricultural poisons is a common
suicide method (18).
In the United States, acculturation and acculturative stress
may be a contributor to suicide risk among Asian Americans. For
most Asian Americans, the family unit is central to identity. Children
are socialized into awareness that their individual actions reflect
upon the entire family, including extended family members (689).
While this feature may impede a family's willingness to
seek treatment for a troubled relative, the strong sense of family
as a support and source of obligation protects against suicide as
well. At the same time, family conflict as a reason for suicide
is more common in Eastern societies (42). For example,
if a young woman from a traditional society experiences conflicts
with her in-laws that have no apparent solution, the woman may be
more likely to view suicide as an option than would someone from
a different family system in which close family relationships are
not as imperative. Transition to the individualistic, communication-oriented
U.S. society is a major and stressful change for many families (44).
The group most at risk appears to be traditionalists who live in
tight-knit groups resistant to acculturative processes. They appear
to function relatively well until their elderly years, when the
culture clash between the values of the larger society and the Confucian
tradition of strong family identity results in alienation of elders
and contributes to suicide in the style of the old country (44).
For example, a major factor in the high suicide rate of elderly
Asian/Pacific Islander women was reported to be the failure
of younger family members to provide support for their elderly parents,
especially widowed mothers (690). Such deaths occurred predominantly
by hanging, which was traditionally seen as an act of revenge, since
someone who died by hanging was believed to return to haunt the
living as a ghost (690).
In summary, race, ethnicity, and culture may all influence
population-based rates of suicide and suicide attempts. Of equal
importance to the clinician, however, each of these factors may
modify suicide risk within the individual. Views of death and cultural
beliefs regarding suicide can vary widely, even among members of
apparently homogeneous racial, ethnic, or cultural groups. Thus,
as part of the assessment and treatment planning process, it can
be helpful for the psychiatrist to explore the patient's
beliefs about death and suicide and the role of cultural and family
dynamics in these beliefs.
Marital status has been correlated with variations in suicide
mortality in a number of studies. Smith et al. (691) used data from
the U.S. National Center for Health Statistics for the years 1979
to 1981 to calculate age-adjusted suicide rates for each marital status.
Regardless of age or racial group, the suicide rate was consistently
lowest in married individuals. An intermediate rate was seen in
those who had never been married, with a relative risk that was
about twice that in married individuals. The highest suicide rate
was found for divorced or widowed individuals, with a relative risk
that was about threefold greater than that in married individuals.
Whereas divorced women had a higher age-adjusted suicide rate than
widowed women, the opposite was true among men, with a particularly striking
rate of suicide in young widowed men.
Kposowa (672) applied Cox proportional hazards regression
models to data from the 1979–1989 follow-up of the National
Longitudinal Mortality Study and made adjustments for age, sex,
race, education, family income, and region of residence to estimate
the effect of marital status on suicide risk. Although in this sample
being single or widowed had no significant effect on suicide risk, divorced
and separated persons had suicide rates that were more than twice
that of married persons. Stratification of the sample by sex showed
that the effect of marital status on suicide rates occurred only
among men.
Luoma and Pearson (46) also examined whether marital status
is associated with variations in suicide rates. Suicide rates broken
down by race, 5-year age groups, sex, and marital status were calculated
by using data compiled from the U.S. National Center for Health
Statistics Multiple-Cause-of-Death Files for the years 1991 to 1996.
Widowed white and African American men under age 50 were found to
have substantial elevations in suicide rates, with 17-fold and ninefold
higher rates, respectively, compared with married men under age
50. At younger ages, for women as well as for men, being widowed
was associated with a higher suicide rate, compared with being married.
Using data from the National Suicide Prevention Project in
Finland, Heikkinen et al. (402) investigated age-related variations
in marital status as well as other social factors in a sample of
1,067 individuals who died by suicide during a 1-year period and
for whom relevant data were available. Compared with the general
population, individuals who died by suicide were more commonly divorced,
widowed, or never married. Among individuals under age 50 who died
by suicide, more males than females had never been married.
Among those over age 50, more women than men were widowed.
Other data from Finland obtained through the Finnish Population
Register and cause-of-death files also suggest that the rate of
suicide is elevated among widowed individuals (45). Among 95,647
persons who were widowed during 1972–1976 and followed
up to the end of 1976, 7,635 deaths were observed, of which 144
were due to suicide. During the initial month of bereavement, men
had a much greater increase in suicide mortality than women (17.2-fold
versus 4.5-fold), but this disproportionate ratio primarily resulted
from occurrences of homicide-suicide. In the remaining first year
of bereavement, men had a 3.1-fold increase in suicide mortality
and women a 2.2-fold increase, and rates remained higher than expected
throughout the follow-up period.
Overall, these studies suggest that married individuals have
a significantly lower rate of suicide than unmarried individuals.
In addition, elevations in the suicide rate are especially striking
for widowed men in general and young widowed men in particular.
What remains unclear is whether this protective effect of marriage
on the suicide rate relates to specific benefits of marriage, such
as a greater likelihood of social integration. In contrast, the
decrease in social integration and the psychological experience
of loss with widowhood and with divorce may increase the tendency
for suicide. The suicide rate among divorced individuals could also
be higher because individuals who stay married have a greater likelihood
of stable mental health at baseline. Other confounding factors,
such as differences in substance use or socioeconomic status with
marital status, could play additional roles that should be considered in
the assessment process.
It remains unclear whether suicide rates in gay, lesbian,
and bisexual individuals differ from the suicide rate among heterosexual
individuals. One psychological autopsy study compared gay males to
all other similarly aged males in the sample and did not find any
characteristics that distinguished the two groups (692). However,
research on suicide among gay, lesbian, and bisexual individuals
is particularly complex because of many factors, including small
sample sizes, difficulties in achieving random sampling, problems
in obtaining baseline prevalences, and problems in reliability of postmortem
reports of sexual orientation. In addition, individuals may choose
not to disclose their sexual orientation to researchers or may engage
in same-sex behavior but not identify themselves as gay or lesbian.
The risks for suicide attempts and suicidal ideation in gay,
lesbian, and bisexual individuals have been assessed by using several
approaches. Fergusson et al. (51), analyzing longitudinal data gathered on
a New Zealand birth cohort, found that those who identified themselves
as gay, lesbian, and bisexual or reported having a same-sex partner
since the age of 16 had elevated rates of suicidal ideation (odds
ratio=5.4) and suicide attempts (odds ratio=6.2).
A study by Cochran and Mays (50) examined lifetime prevalences of
suicide-related symptoms among men with same-gender partners and
found that approximately one-half (53.2%) of the men reported
experiencing at least one suicide-related symptom in their lifetime,
with a suicide attempt reported by 19.3%. In contrast,
in men with female partners only, 33.2% had at least one
suicide-related symptom and 3.6% reported a suicide attempt.
Corresponding figures for those with no sexual partners were 28.1% and
0.5%, respectively. Using the population-based Vietnam
Era Twin Registry, Herrell et al. (52) identified a subsample of 103
middle-aged male twin pairs in which one of the twins from each
pair reported having a male sexual partner after age 18 while the
other did not. Suicide attempts were more common in the men with
same-gender sexual orientation, with 15% reporting a suicide
attempt, compared with only 4% of their twin brothers.
In the Twin Registry sample as a whole, which included 16 twin pairs concordant
for having a male sexual partner after age 18 and 6,434 twin pairs
concordant for having no adult same-gender partners, the men with
same-gender sexual orientation had more than a fourfold increase
in suicidal ideation and more than a 6.5-fold increase in suicide
Gay, lesbian, and bisexual youths may be at particular risk
for suicidal behaviors. Paul et al. (53), in a study of a large
urban population–based telephone probability sample of
gay men, found that 21% had made a suicide plan and 12% had
attempted suicide. Of the latter, almost one-half had made multiple
attempts, and most had made their first attempt before age 25. The
importance of sexual orientation to suicidal behaviors in youths
is also highlighted by the findings of a statewide population-based
study of public high school students by Remafedi et al. (48). In
this study, suicide attempts were reported by 28.1% of
bisexual/homosexual males, 20.5% of bisexual/homosexual
females, 14.5% of heterosexual females, and 4.2% of
heterosexual males. For males, but not for females, a bisexual/homosexual
orientation was associated with suicidal intent (odds ratio=3.61)
and with suicide attempts (odds ratio=7.10).
Thus, although evidence is limited, there is clearly an elevated
risk for suicide attempts among cohorts of gay, lesbian, and bisexual
individuals that is particularly striking among youths. In addition
to addressing risk factors such as psychiatric and substance use
disorders in the assessment and treatment planning processes, it
is also important for the clinician to address stresses that are
unique to being gay, lesbian, or bisexual (e.g., disclosure of sexual
orientation to friends and family, homophobia, harassment, and gender nonconformity).
Since suicide attempts themselves increase the risk for later suicide,
it is presumed that suicide rates may also be increased in gay,
lesbian, and bisexual individuals. However, this hypothesis remains
to be tested empirically.
Occupational groups differ in a number of factors contributing
to suicide risk. These factors include demographics (e.g., race,
gender, socioeconomic class, and marital status), occupational stress,
psychiatric morbidity, and occupationally associated opportunities
for suicide. Although many studies have reported increased rates
of suicide in specific occupational groups, most have not controlled
for other suicide risk factors. In one study, however, that controlled
for basic demographic correlates of suicide across 32 occupations
(54), risk was found to be highest among dentists and physicians,
compared with the rest of the working-age population, with multivariate
logistic regression odds ratios of 5.43 and 2.31, respectively.
The odds of suicide were also significantly higher in nurses (1.58
times the risk), social workers (1.52 times the risk), mathematicians
and scientists (1.47 times the risk), and artists (1.30 times the
risk). Rates of suicide among physicians have also been found to
be elevated, compared with rates for other white male professionals,
with white male physicians having a 70% greater proportionate
mortality ratio for suicide (58). In well-designed epidemiological
studies, police officers have generally not been found to be at
higher risk for suicide than age- and sex-matched comparison subjects
(54, 57).
Factors that may play a role in the increased suicide rates
in specific professions may include occupational stresses, as is
seen in helping professionals (54), or social isolation, as is seen
in sheepherders, who had the highest suicide rate of 22 occupational
groups studied in Washington State (56). Although data are inconsistent,
additional work stress may occur with infrequent role sets such as
female laborers or pilots (55, 57) or in nontraditional occupations
(693). In some occupations, suicide rates may be influenced by greater
access to lethal methods such as medications or chemicals, as in
health care professionals, scientists, and agricultural workers
Differential rates of psychiatric illness may be present in
some occupations and may predate employment. Artists, for example,
have higher rates of psychiatric morbidity and suicide than the general
population. Highly educated people with depressive disorders also
have a higher suicide rate. Among physicians, such individuals may
tend to specialize in psychiatry (56).
In general, specific occupations do seem to be associated
with an increased risk for suicide, but more research is needed
to distinguish occupational from nonoccupational stressors (56)
and to determine whether it is the occupation itself or associated
factors such as psychiatric morbidity that affect suicide risk.
Major depressive disorder and other depressive syndromes are
the most commonly and most consistently identified axis I diagnoses
in individuals who die by suicide (694, 695). For example, Robins
et al. (60) found that among 134 persons who died by suicide, 98% were
psychiatrically ill and most had depression or chronic alcoholism.
Barraclough et al. (65), in a similar study, found that of 100 individuals
who died by suicide, 93% were mentally ill and 85% had
either depression or alcoholism. Henriksson et al. (59), using psychological
autopsy methods to investigate current mental disorders among a
random sample of 229 persons who died by suicide during a 1-year
period in Finland, found that 93% of those persons had
received at least one axis I diagnosis and that 59% had a
depressive disorder.
In patients with bipolar disorder who die by suicide, the
majority are experiencing either a depressive or mixed episode of
illness (69, 72, 315). For example, Isometsa et al. (68) noted that among
31 patients with bipolar disorder identified in a group of 1,397
persons who died by suicide in Finland in a 12-month period, 79% died
while in a major depressive episode and 11% while in a mixed
state. In a study of more than 300 patients who were discontinued
from lithium treatment, Baldessarini et al. (696) found that the
majority of suicidal acts occurred either during a major depressive
episode (73%) or during a dysphoric-mixed episode
In addition to being highly prevalent in individuals who die
from suicide, mood disorders have long been associated with an increased
risk for suicide. For example, in 1970, Guze and Robins (697) reviewed
17 studies that assessed the risk of suicide in individuals with
primary affective disorders and calculated the frequency of suicide
as a percentage of all deaths. High suicide rates were found, with
the ultimate risk of suicide estimated to be about 15%,
or approximately 30 times that seen in the general population. For
major depression, review of the literature suggests that overall
rates of suicide mortality range from 5% to 26% and
are about twice as high for men as for women (694). However, these
studies generally assessed severely ill patient populations and
individuals early in the course of their illness, when suicide rates
are known to be highest.
Several investigators have subsequently reexamined these estimates
of lifetime suicide risk in individuals with mood disorders. For
example, Inskip et al. (94), using cohort-based curve-fitting techniques
and data from previous studies, estimated the lifetime risk for
suicide in mood disorders to be 6%. In addition, Bostwick
and Pankratz (77) used data from prior studies to calculate case
fatality prevalences (the ratio of suicides to the total number
of subjects) to determine suicide risks for three groups of patients
with affective disordersoutpatients, inpatients, and suicidal
inpatients. With this method, which provides a less biased estimate
of risk, they found a gradation in suicide risk that varied with treatment
setting as well as with hospitalization for suicidality. For example,
in patients with mood disorders who were previously hospitalized
for suicidality, the estimated lifetime prevalence of suicide was
8.6%, compared to a lifetime risk of 4% for those
with a psychiatric hospitalization for any reason. For mixed inpatient/outpatient
populations, the prevalence of suicide was 2.2%, whereas
for the populations without affective illness, it was
less than 0.5%. For individuals with major depressive
disorder, Blair-West et al. (205) used age- and gender-stratified
calculations to arrive at comparable estimates for lifetime suicide
risk of 3.4%, with a lifetime risk for males more than
six times than for females (6.8% versus 1.1%).
Harris and Barraclough (64), in their meta-analysis of suicide
as an outcome in psychiatric illness, assessed relative suicide
risk in mood disorder by calculating SMRs. Their analysis used data
from published English-language studies that had mean or median
follow-up periods of at least 2 years and that provided sufficient
data to calculate ratios of observed to expected numbers of suicides.
For patients with major depressive disorder, 23 studies that included
a total of 351 suicides among more than 8,000 patients yielded an
SMR of 20.35, or a 20-fold increase in risk. A key finding was that risk
in patients with major depressive disorder was highest immediately
after hospital discharge (698, 699). For patients with bipolar disorder,
data from 15 studies including a total of 93 suicides among 3,700
subjects yielded an SMR for suicide of 15.05. Although patients
with dysthymia also had an elevated SMR for suicide, of 12.12, the
nine studies that contributed to this estimate were extremely heterogeneous
in their findings and most had extremely small samples, which raises
some question about the validity of this approximation.
Several studies have examined rates of suicide in longitudinal
follow-up in individuals hospitalized for mood disorder. Hoyer et
al. (75) used data from the Danish Psychiatric Case Register to determine
SMRs for suicide among 54,103 patients (19,638 male and 34,465 female
patients) who had an initial admission to a Danish psychiatric hospital
between 1973 and 1993 and who received a mood disorder diagnosis.
During the study period, 29% of the patients died, and
of those, suicide occurred in 20%. Standardized mortalities
for suicide were comparable for patients with ICD-8 diagnoses of
unipolar major depression, psychotic reactive depression, and bipolar
disorder, with SMRs of 19.33, 18.67, and 18.09, respectively. In
contrast, the SMR for suicide in patients with neurotic depression
was significantly less, at 10.51. In all diagnostic subgroups and
regardless of age and gender, the risk of suicide was greatest during
the first year after the initial admission, decreased over the subsequent
5 years, and then stabilized. Overall, the risk for suicide was
comparable in men and women, except in patients with bipolar disorder,
for whom the SMR for suicide was somewhat greater in women than
in men (20.31 versus 18.09).
In a similarly designed study using data from a Swedish inpatient
register, Osby et al. (73) obtained the date and cause of death
for patients hospitalized between 1973 and 1995 with a diagnosis
of bipolar disorder (N=15,386) or unipolar depressive
disorder (N= 39,182). SMRs for suicide were found to be
significantly increased in women and in patients with a unipolar
depressive disorder diagnosis (15.0 for male bipolar disorder patients,
20.9 for male unipolar depressive disorder patients, 22.4 for female
bipolar disorder patients, and 27.0 for female unipolar depressive
disorder patients). Suicide mortality was more pronounced in younger
individuals and with shorter intervals from the index hospitalization.
Although SMRs decreased in all age groups with increasing time of
follow-up, some suicide risk persisted even at long follow-up intervals.
Baxter and Appleby (188) used the Salford (U.K.) Psychiatric
Case Register to identify 7,921 individuals who had received psychiatric
or mental health care and determined their mortality rates (estimated
as rate ratios) over a follow-up period of up to 18 years. Among
individuals with affective disorders, there was a 12.2-fold elevation
in observed suicide mortality in men, compared to expected mortality
based on population rates. For women, the relative increase in suicide
mortality was even greater, with a 16.3-fold elevation.
Angst et al. (74) followed a sample of 406 hospitalized patients
with mood disorders (220 with bipolar disorder and 186 with unipolar
depressive disorder) on a prospective basis for 22 years or more
and found an overall standardized mortality rate for suicide of
18.04, comparable to the SMRs found in the Swedish and Danish longitudinal
follow-up studies. Sixty-one percent of the sample had manifested
psychotic symptoms at least once over their lifetime, suggesting
that this was a particularly ill group of patients. The suicide
rate was greatest near the age of illness onset; however, from ages
30 to 70 years, the rate was remarkably constant, suggesting a persistence
of risk throughout the illness course. The suicide mortality in
women was greater than that in men (SMR of 21.87 for women, compared
to 13.49 for men), in part reflecting the greater rate of suicide
for men in the general population. Patients with unipolar depressive
disorder had a significantly higher rate of suicide than patients
with bipolar I disorder or bipolar II disorder, with an SMR for
suicide of 26.7, compared with 12.3 for bipolar disorder patients.
The SMR for suicide did not differ significantly between bipolar
I disorder patients and bipolar II disorder patients.
Some evidence suggests that in individuals with mood disorders,
the rate of suicide may be increasing over time. For example, Harris
and Barraclough (64) noted that the suicide risk for patients with
major depression in cohorts treated before 1970 was increased by
17-fold in contrast to a 36-fold increase in risk for cohorts treated
after 1970. In the study described earlier, Hoyer et al. (75) noted
an increase in both the absolute and relative risks for suicide
over the 20-year study time period, and they suggested that the
increase may have been related to changes in the health care delivery system
and the availability of psychiatric inpatient services. In addition,
Baldessarini et al. (563) observed that the annualized rates of
suicide and suicide attempts in patients with major affective disorders
appear to have risen across the decades since 1970. This trend was
sustained and statistically significant for both suicides and suicide
attempts, as well as for treated and untreated samples considered
separately. Although this apparent secular trend could reflect increased
recruitment of more severely ill patients to more recent studies
or increased reporting of suicidal behaviors, the percentage
reduction of suicide risk with lithium treatment did not decline
across the years, suggesting that the patient populations are in
fact comparable and that the prevention of suicide in major affective
disorders is becoming increasingly challenging (558). Furthermore,
suicide attempts that do occur in individuals with major mood disorders
may be more lethal than suicide attempts by individuals in the general
population. The reported ratio of suicide attempts to deaths from
suicide averages between 3:1 and 5:1 among persons with mood disorders,
whereas in the general population the suicide attempt rate has been
estimated to be about 10–20 times (average, 18
times) greater than the suicide rate, or about 0.3% per
year (700).
For individuals with mood disorders, it is also important
to note factors that are particularly associated with increased
risk. Fawcett et al. (79, 313) determined time-related predictors
of suicide in a sample of 954 psychiatric inpatients in the NIMH
Collaborative Program on the Psychobiology of Depression, about
one-third of whom had bipolar disorder and the rest of whom had
other mood disorders. During the initial 10 years of follow-up,
34 patients died by suicide, an overall rate that was extremely
low, at 0.36% per year. The first year of follow-up was
the time of highest risk, with 38% of suicides occurring
during that period. Within 1 year of admission, six factors were
associated with suicide: panic attacks, severe psychic anxiety,
diminished concentration, global insomnia, moderate alcohol abuse,
and anhedonia. The three factors associated with suicide that occurred
after 1 year were severe hopelessness, suicidal ideation, and history
of previous suicide attempts. By 14 years, among individuals for
whom follow-up information was available, 36 had died by suicide, 120
had attempted suicide, and 373 had no recorded suicide attempt (247).
Analysis at that time point showed that patients who died by suicide
and patients with suicide attempts shared core characteristics,
including a history of previous suicide attempts, alcohol and substance
abuse, impulsivity, and psychic turmoil within a cycling/mixed
bipolar disorder. In contrast to suicide within 12 months of intake,
which was predicted by clinical variables, suicide beyond 12 months
was prospectively predicted by temperament attributes, such as higher
levels of impulsivity and assertiveness. Stressful life events (701),
executive dysfunction (702), and higher levels of depression (10,
78, 221, 222, 703) may also be associated with greater risk, as
may an awareness of the discrepancies between a previously envisioned "normal" future
and the patient's likely degree of future chronic disability
In summary, mood disorders are consistently identified as
conferring a significant increase in the risk for suicide
as well as for suicide attempts. However, among individuals
with mood disorders, a variety of factors commonly modify that risk
and should be taken into consideration during
the assessment and treatment planning processes. These factors include
the specific mood disorder diagnosis and duration of illness, the
type and severity of the mood episode, the prior history of treatment,
the presence of comorbid diagnoses or specific psychiatric symptoms
such as severe anxiety or agitation, and the occurrence of significant
psychosocial stressors. It is important to note, however, that this
increased risk of suicidal behaviors among individuals with mood
disorders has been consistently shown to be modifiable with treatment
(see Section VI.D, "Somatic Therapies").
Schizophrenia has also been associated with an increase risk
of suicide in multiple studies. Harris and Barraclough (172), for
example, analyzed data from 38 studies that had follow-up periods
of up to 60 years. Acknowledging that some heterogeneity
in the diagnosis of schizophrenia across studies was likely as a
result of changes in diagnostic criteria, the authors noted 1,176
suicides among more than 30,000 patients with schizophrenia, yielding
an SMR for suicide in schizophrenia of 8.45. Baxter and Appleby
(188), in a case registry study of long-term suicide risk in the
United Kingdom, found an even higher 14-fold increase in rate ratios
for suicide among individuals with schizophrenia. In contrast, using
cohort-based curve-fitting techniques and data from 29 studies of
mortality in schizophrenia, Inskip et al. (94) estimated the lifetime
risk for suicide as 4%.
In addition to assessing suicide rates among patients with
schizophrenia, longitudinal follow-up studies have also examined
factors associated with increased risk of suicide. Black et al.
(98) found that suicide occurred in 14 of 688 schizophrenia patients
(2%) who were admitted to an Iowa psychiatric hospital
over a 10-year period, with the majority of deaths occurring within
2 years of hospital discharge. Although women were found to be at
relatively greater risk, the numbers of suicides significantly exceeded
expected rates for both male and female patients. Nyman and Jonsson
(101) found that suicide occurred in 10 of 110 (9%) young
patients with schizophrenia who were hospitalized between 1964 and
1967 and followed for up to 17 years. In this group, suicide was
associated with a more chronic course as well as with social and
financial dependency. Dingman and McGlashan (103) longitudinally
followed 163 Chestnut Lodge patients with a diagnosis of schizophrenia
and noted that the 13 patients who died by suicide were predominantly
male and had a later onset of illness, less chronic illness, better
premorbid functioning, and a greater ability for abstract and conceptual
thinking. At a later follow-up (mean=19 years), 6.4% of
the Chestnut Lodge sample had died by suicide, and this group had
exhibited fewer negative symptoms but more severe delusions and
suspiciousness at index admission than those who did not die by
suicide (93). A group of young psychotic patients who had not exhibited
a chronic course was followed after discharge from an index hospitalization
by Westermeyer et al. (83), who found that 36 patients died by suicide
and 550 did not. Suicide occurred in about 9% of individuals
with schizophrenia and was more likely during the early years of
their illness, particularly within 6 years of initial hospitalization.
At greater risk for suicide were unmarried white male patients with
chronic symptoms, relatively high IQs, and a gradual onset of illness.
De Hert et al. (89) studied outcomes for 870 patients (536
men and 334 women) with schizophrenia (87%) or schizoaffective
disorder (13%) after a mean duration of follow-up of 11.4
years. Sixty-three individuals died by suicide, yielding a suicide
rate of 635 per 100,000 per year and an SMR for suicide of 39.7.
The frequency of suicide in men was twice that in women, although
the SMR and the age at the time of suicide did not differ significantly
between the sexes. Of the suicides, 33 (52.4%) occurred while
the patient was hospitalized (although only nine actually took place
in the hospital) and 12 (19.1%) occurred during the first
6 months after discharge. When the patients who died by suicide were
compared with an age- and sex-matched group of 63 patients from
the remaining sample, a number of differences between the groups
were observed. Those who died by suicide were more likely to have
a family history of suicide, had had more and shorter hospitalizations
and more past suicide attempts, and were more likely to have used
a highly lethal method in prior suicide attempts. They also had
higher total WAIS IQ scores and were more likely to have been psychotic
or depressed or to have suffered a major loss in the 6 months
before death or follow-up. Compared with control subjects, the patients
who died by suicide were also less likely to have received community-based care
and were less likely to have had a useful daily activity, remission
of symptoms, or an early onset of prominent negative symptoms.
Among individuals with schizophrenia who die by suicide, a
number of demographic factors seem to be present more often than
in living control subjects. In a cohort of 9,156 patients with schizophrenia,
Rossau and Mortensen (95) individually matched 10 control subjects
to each of 508 individuals who were admitted to Danish hospitals
between 1970 and 1987 and who later died by suicide. They found
suicide risk to be particularly high during the first 5 days after
discharge, with some excess suicides during temporary hospital leaves.
Increases in risk were also associated with multiple psychiatric
admissions during the previous year, previous suicide attempts,
previous diagnosis of depression, male sex, and previous admissions
to general hospitals for physical disorders. Breier and Astrachan
(102) compared 20 schizophrenia patients who died by suicide with a
randomly selected sex-matched group of nonsuicidal schizophrenia
patients and a group of persons without schizophrenia who died by
suicide. Patients with schizophrenia who died by suicide were more
likely to be men and tended to be young, white, and never married.
In contrast to the persons without schizophrenia who died by suicide,
the schizophrenia patients who died by suicide tended not to show
a temporal relationship of suicide with suicide attempts or stressful
life events.
Among individuals who died by suicide, comparisons have also
been made between those with schizophrenia and those with other
diagnoses. Heila et al. (100) used psychological autopsy data for 1,397
individuals who died by suicide over a 1-year period in Finland
and compared the 92 individuals with schizophrenia (7%)
to the remainder of the sample. They found that suicide occurred
at any point during the course of schizophrenia and over a large
age range. In addition, among the individuals with schizophrenia,
71% had a history of suicide attempts, and, particularly
in women, active illness and depressive symptoms were often observed
immediately before the suicide. Significant life events, however,
were seen less often before suicide in individuals with schizophrenia
than in those with other diagnoses (46% and 83%,
Other studies have found suicidal ideation and suicide attempts
to be common among individuals with schizophrenia. For example,
in the Chestnut Lodge sample, over an average of 19 years of follow-up,
40% of the patients with schizophrenia spectrum disorders
reported suicidal ideation since their initial hospitalization,
and 23% reported at least one suicide attempt (93). Radomsky
et al. (80) evaluated lifetime rates of suicidal behavior among
1,048 consecutively admitted psychiatric inpatients with
DSM-III-R psychotic disorders. Of the 454 individuals with a diagnosis
of schizophrenia, 27.3% reported at least one lifetime
suicide attempt, with an additional 26.4% reporting suicidal
ideation only. For the 159 patients with schizoaffective disorder,
42.8% and 27% reported suicide attempts and suicidal
ideation, respectively. Roy et al. (117) found that 55% of
a series of 127 consecutively admitted patients with chronic schizophrenia
had previously made a suicide attempt. Harkavy-Friedman et al. (108),
in a sample of 104 individuals with schizophrenia or schizoaffective
disorder, found that 33% had made a suicide attempt, with
60% of those reporting multiple attempts. Attempts were
often medically serious, requiring medical inpatient care in 57% of cases
and emergency medical evaluation in an additional 11%,
and were associated with strong suicidal intent (in the 76% of
patients for whom this information was available). As with suicide
in schizophrenia, initial suicide attempts tended to occur early
during the course of the illness.
A number of specific factors appear to increase the likelihood
of a suicide attempt among individuals with schizophrenia. For example,
in the study by Roy et al. (117), those who had attempted suicide
had significantly more psychiatric admissions and were more likely
to have experienced a major depressive episode or received antidepressant
treatment, compared with those who had not attempted suicide. Young
et al. (704), in a longitudinal study of 96 individuals with recent-onset schizophrenia
who were followed for a 1-year period, noted that depression was
moderately correlated with concurrent suicidality but was not independently
associated with future suicidality, whereas the presence of suicidal
ideation even at low levels increased the risk for significant suicidal ideation
or a suicide attempt during the subsequent 3 months. In
their sample, Harkavy-Friedman et al. (108) found that suicide attempts
were reported to be precipitated by depression (27%), loss
of a significant other or other stressful life event (24%),
being bothered by psychotic symptoms (11%), and responding
to command hallucinations (4%). In a subsequent study of
100 individuals with schizophrenia, Harkavy-Friedman et al. (106)
found that 8% of suicide attempts were associated with command
auditory hallucinations for suicide and that individua