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Professional News
Several Signs Should Alert Clinicians to Suicide Risk
Psychiatric News
Volume 40 Number 13 page 10-54
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Robert Simon, M.D.: "Know thy patient" is the key to preventing a patient's suicide.  David Hathcox

There's no such thing as a suicidal patient, only a patient at risk for suicide, but assessing that risk takes more than a simple yes-or-no question, said Robert Simon, M.D., in accepting the Manfred S. Guttmacher Award at APA's annual meeting in Atlanta.

"If a patient wants to kill himself, the doctor is his worst enemy," said Simon. Understanding patients and their risk and protective factors can provide clinicians with a more accurate understanding of that risk.

Presented for the first time in 1972, the Manfred S. Guttmacher Award honors outstanding contributions to the literature on forensic psychiatry. The award is co-sponsored by APA and the American Academy of Psychiatry and the Law. Simon was cited this year for his book Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management (American Psychiatric Press Inc., 2004). He was a co-recipient of the Guttmacher Award in 1993 with Robert Sadoff, M.D., for the book Psychiatric Malpractice: Cases and Comments for Clinicians, also published by American Psychiatric Press Inc.

Evaluating a patient's likelihood of committing suicide is critical for both patient and physician, said Simon. "Psychiatrists are sued more often, and damage awards are the highest, for suicide by their patients than for any other reason."

A patient presenting in the emergency room who announces "I'm suicidal" may indeed be suicidal or may be looking for a warm bed on a winter night. Nonetheless, asking a direct question isn't enough. One case review found that 25 percent of people who committed suicide didn't admit suicidal ideation to their physicians, although they did tell their families.

A useful suicide-risk assessment is more complex, but represents a clinical mosaic identifying both modifiable risk factors and protective factors to inform treatment, said Simon. Support from significant others or having children under 18 years old in the home are important protective factors, he said. No absolute protective factor exists, however, and severity of mental illness can override such factors.

Most clinicians are aware of prodromal risk factors such as suicidal ideation or previous attempts. Treatable general risk factors include depression, anxiety, panic, impulsivity, sleep disorders, agitation, physical illness, drug side effects, family or work crises, or access to lethal means to carry out a suicide.

But Simon warns that patients may exhibit idiosyncratic warning patterns as well, recalling one patient who stuttered—except when he became suicidal.

"You have to know your patient, and it's hard to do that in a three- to five-day hospital admission," he said. "It's important to know both your limitations and the areas where you have control."

Simon offers a 30-second suicide risk alert for busy clinicians: severe agitation, insomnia, or panic attacks; suicidal ideation; suicide planning; prior attempts; hopelessness; substance abuse; or recent interpersonal loss.

"If you see any of these, take notice," he said. "If you see two or more, do a full risk assessment."

Suicidal ideation is always an important tip-off. Thirty-four percent of those expressing suicidal ideation plan a suicide attempt, and 72 percent who plan an attempt actually try to commit suicide. Thus a physician who spots suicidal ideation should treat the patient aggressively, since most patients who attempt suicide do so within a year of experiencing suicidal ideation.

So what should a doctor look for? Simon cited several crucial factors that can signal increased suicide risk:

In short, said Simon: "Know thy patient." Commit time and effort to the patient's care, he advised. Perform and document a suicide-risk assessment, then aggressively treat the patient for acute, modifiable risk factors. Mobilize the patient's protective risk factors, if any. Continue risk assessment over time, and evaluate the effectiveness of your interventions.▪

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Robert Simon, M.D.: "Know thy patient" is the key to preventing a patient's suicide.  David Hathcox

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