Recognizing Suicide Risk Factors in Primary and Psychiatric Care

Larry Culpepper, MD, MPH


October 25, 2010

In This Article

How To Manage Risk Factors

Using the aforementioned information, the risk for suicide should be estimated and managed accordingly:

Imminent (eg, suicide might be attempted within the next 48 hours): Patients have an active plan or intent to harm themselves and have a lethal means readily accessible. Also at high risk are those who are psychotic (especially if they hear voices telling them to commit suicide), those who are cognitively impaired, or those who lack judgment. Such patients usually require immediate hospitalization via ambulance. In such individuals, and especially in those with no immediate supports, electroconvulsive therapy may be lifesaving.[3]

  • High but not imminent (eg, those with a desire to commit suicide but who do not have a specific plan): This group needs aggressive treatment, but not necessarily hospitalization. Interventions might include psychiatric treatment; control of substance use; mobilizing family and social supports; reducing access to firearms, medications, or other potentially lethal means; and ensuring frequent contact with helping professionals and supports. Contributing factors should be addressed, including precipitating events, ongoing life difficulties, and comorbid mental disorders.

Although contracting for safety has not been evaluated adequately, there is little evidence that it is effective. Consequently, such "contracts" may provide a false sense of security.[3] Maintaining a strong therapeutic alliance and direct communication and providing frequent re-evaluation are recommended. Supportive primary care counseling; referral for psychotherapy; and engagement of community, religious, and family supports can be helpful. Of note, cognitive-behavioral therapy might be particularly helpful in those in whom hopelessness is a concern.

Although the suicidality warning is present on the label of most antidepressants, this should be viewed as a reminder to educate and frequently re-evaluate patients in whom depression and suicidality are present. It should not be taken as a warning not to use antidepressants in such patients. The United States experienced a 91% increase in antidepressant prescriptions, accompanied by a 33% decline in completed suicide during the 5 years (1998-2003) preceding the addition of the warnings. The Netherlands had similar experience.[21] Warnings about a possible association between antidepressant use and suicidal thinking and behavior were issued by the US Food and Drug Administration and by several European regulators in 2003. This resulted in a 22% decrease in selective serotonin reuptake inhibitor prescriptions for youths in both the United States and The Netherlands and a resultant 14% increase in completed suicide in the United States (2003-2004) and a 49% increase in The Netherlands (2003-2005).[21] Therefore, antidepressants should not be avoided because of the concern that they might infrequently heighten suicidal thoughts.

The primary care physician should maintain regular follow-up contact with patients identified as at risk for suicide. Suicide risk fluctuates and should be reevaluated frequently. As part of monitoring previous suicidal patients, the clinician should determine whether there have been changes, such as a reemergence of precipitating events, adverse life circumstances, or worsening of mental disorders. Continued participation in interventions and treatment should be monitored.

The importance of primary care in reducing suicide is clear. Of patients who commit suicide, 75% had contact with their primary care clinician during the year before their death, compared with one third who had contact with mental health services. In the month before death, twice as many of those who commit suicide had contact with primary care providers as with mental health services (45% vs 20%).


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