COMMENTARY

Recognizing Suicide Risk Factors in Primary and Psychiatric Care

Larry Culpepper, MD, MPH

Disclosures

October 25, 2010

In This Article

I've Detected Risk Factors: Now What?

Once the potential for suicide is recognized in a patient (for instance by positive response to the suicidality question on the PHQ-9), the next step in its management is to evaluate the presence, frequency, and duration of suicidal thoughts; their intensity and content; any changes in chronic thoughts; and whether or how the patient has been controlling these thoughts. Inquiry might start by asking whether the patients feels he or she would be better off dead, whether he or she has lost interest in living, or whether the patient has thought of ending his or her life. Inquiring about expectations from death may be useful. This might reveal motivations, such as reuniting with a loved one, punishing others, or escaping a painful situation.

Probing the patient's suicide plan can be helpful in assessing the severity of intent. Questions of interest include:

  • Has a plan been formulated or implemented, including a specific method, place, and time?

  • Have preparations been made (eg, gathering pills, changing wills, suicide notes)?

  • Has the patient practiced the suicidal act or has an actual attempt already been made?

  • What is the anticipated outcome of the plan?

  • Are the means of committing suicide available?

  • Does the patient know how to use these means?

  • What is the plan's lethality?

  • What is the patient's conception of lethality vs the objective lethality?

  • What is the likelihood of rescue?

  • What is the strength of the intent to carry out suicidal thoughts and plans, including the ability to control impulsivity?

Further inquiry should seek to identify any precipitating events, such as the death of a loved one; breakup of a marriage; work, school, or social failure; sexual identity crisis; or trauma. Determining the patient's sense of hopelessness ("what the future looks like") and any alcohol and substance abuse history, including binging, impulsivity, and family and social supports or stressors, may be helpful in selecting an appropriate management plan. Other important factors include whether the patient is engaged in and complying with treatment, recent stressors that might threaten the patient's ability to cope with difficulties and ability to participate in treatment planning, and any previous suicide attempts.

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