Will my patient attempt suicide again?

Persons who make multiple attempts share certain characteristics (Table 2).^19-21 Rudd et al¹⁹ compared 68 multiple attempters with 128 single attempters and found that multiple attempters had higher levels of:

• suicide ideation
  
• depression
  
• hopelessness
  
• perceived stress.
  

Multiple attempters also had more Axis I disorders and poorer social problem-solving skills and experienced their first psychiatric disorder at an earlier age than single suicide attempters.
Similarly, Foreman et al²⁰ found that compared with single suicide attempters, multiple attempters had higher levels of depression, hopelessness, and suicidal ideation and met criteria for more Axis I diagnoses. Multiple attempters also were more likely to be:

• diagnosed with substance use disorders, psychotic disorder, or borderline personality disorder
  
• unemployed and have relationship difficulties, a history of emotional abuse, and a family history of psychiatric problems and suicide.
  

Miranda et al²¹ found that compared with single suicide attempters and suicide ideators, multiple attempters had Axis I disorders more often and had a stronger wish to die during the attempt. In this study, multiple suicide attempts increased by more than 4 times the likelihood that a person with a history of suicidal thoughts and/or behaviors would make another attempt.

Among 326 individuals in a military medical setting treated for suicidal behavior or severe suicidal ideation, multiple suicide attempters reported higher levels of ongoing distress that was unrelated to specific life stressors.²² This suggests these patients may not respond well to psychological interventions that focus on problem-solving.

Table 2

Common characteristics of multiple suicide attempters

History of Axis I disorder (major depressive disorder, bipolar disorder, schizophrenia, substance use disorders, eating disorders)
High levels of perceived stress
High levels of depression
Symptoms of borderline personality disorder
Poor problem-solving skills
Family history of psychiatric illness
Source: References 19-21

Self-harm and suicidal behavior

Patients who engage in nonsuicidal self harm—also called self-injurious behavior (SIB)—may be mistaken for suicide attempters. Although differences exist between suicide attempters and those who engage in SIB, evidence suggests that a history of SIB increases risk for suicidal behavior.^23,24 In a retrospective study of 4,167 self-harmers, females who engaged in ≥4 acts of SIB were more likely to die from suicide than those who engaged in ≤3 acts.²⁵ A cross-sectional analysis of data from 3,069 students responding to a random Web-based survey found that an increased incidence of SIB significantly increased the odds of suicidal behavior.²⁶

One hypothesis suggests that some persons use SIB as a coping mechanism, and SIB and suicide are on the same continuum of behaviors. Others postulate that suicide attempters may use SIB to habituate themselves to suicidal behavior. Joiner²⁷ suggests that individuals who commit suicide have rehearsed the suicidal behavior, thus rendering it less foreign and enabling increased lethality.

Although the link between SIB and suicide attempts remains unclear, evidence suggests SIB is a risk factor for suicidal behavior and therefore should be assessed when evaluating a patient’s suicide risk.

CASE CONTINUED: At high risk

Ms. J has several risk factors for making another suicide attempt. She has 3 previous attempts, and because her last attempt caused liver damage we know she is capable of lethal behavior. In addition, the anniversary of the death of her fiancé is approaching. Ms. J also reports almost constant suicidal ideation, with a specific plan (to overdose). Her fantasies of taking pills could be interpreted as mental rehearsal and desensitization to the behavior.

Because we believe Ms. J is at high risk for a serious, if not lethal, suicide attempt we conduct a 4-question suicide inquiry. It is clear that Ms. J had suicidal thoughts and a plan. Her answer to “How likely is it that once you leave my office you will do something to hurt yourself?” is the key to determining whether or not she requires hospitalization. Ms. J states that she is “pretty certain she will hurt herself” once she leaves the office, so we hospitalize her.

To determine if a patient requires immediate hospitalization, perform a specific suicide inquiry. Although there is no surefire way to determine if a patient will kill himself or herself, asking specific questions can help you gauge risk. Based on evidence²⁸ and my clinical experience, I focus on patients’ answers to 4 questions (Table 3). Affirmative answers to these questions are a strong indication that a patient requires hospitalization.