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.▪