Using an interview guide to assess suicidal ideation

More than 50% of Americans who commit suicide have seen their primary care provider in the weeks before their suicide. As primary care providers, we may miss opportunities to assess for suicidal ideation. Here, we present an interview guide that helps assess suicidal ideation in primary care patients.     

Suicidal behavior in psychiatric emergency room patients

BACKGROUND: Psychiatric emergency room (ER) patients are thought to be at increased risk of suicide. The prevalence and characteristics of suicidal behavior in a recent sample of patients who came to the ER for psychiatric evaluation were examined. METHODS: Charts of 311 consecutive psychiatric ER patients were reviewed. Suicidal behavior was considered present if current suicidal ideation or attempts within 24 hours of or during the emergency evaluation were noted in the chart. RESULTS: Suicidal behavior was present in 38% of the psychiatric ER patients. Younger age, white race, affective disorders in female patients, and substance abuse disorders in male patients were features of the suicidal group. Sex of the patient was not associated with suicidal behavior. CONCLUSIONS: Suicidal behavior is prevalent in the psychiatric ER. Effective suicide prevention in this setting will hinge on finding more specific risk factors.     

Suicide: a guide to risk factors, assessment, and treatment of suicidal patients

This article summarizes what is known about risk factors for suicide in both adolescent and adult populations. It also translates this knowledge base into practical considerations for the physician on the assessment and treatment of suicidal patients. Since most patients who commit suicide have seen a physician in the weeks to month prior to their deaths, and many kill themselves with medications prescribed by their doctors, the physician's early detection and treatment of suicidal behaviors and associated psychiatric disorders in his or her patients becomes a major suicide prevention strategy.     

Epilepsy and depression: risk factors for suicide?

Compared to the general population, the suicide rate in epilepsy is 5-fold increased. In particular, patients with temporal lobe epilepsy have a 25-fold increased risk of suicide. Certain psychiatric disorders, including primary mood disorders, also increase the risk for suicide. Among people with epilepsy, psychiatric comorbidity is common, with an elevated rate of Major Depression. A review of the literature about the association between epilepsy, depression and suicide highlights the lack of evaluation of intensity, pervasiveness and characteristics of suicidal ideation in epileptic patients compared with patients with a diagnosis of Major Depression.     

‘Promoting and preserving safety and a life‐oriented perspective’: A qualitative study of nurses’ interactions with patients experiencing suicidal ideation

Suicide prevention is an important imperative in psychiatric hospitals, where nurses have a crucial role in and make essential contributions to suicide prevention and promoting the recovery of patients experiencing suicidal ideation. The present qualitative grounded theory study aimed to uncover and understand the actions and aims of nurses in psychiatric hospitals during their interactions with patients experiencing suicidal ideation. Interviews were conducted with 26 nurses employed on 12 wards in four psychiatric hospitals. The data analysis was inspired by the Qualitative Analysis Guide of Leuven. The findings show that nurses’ actions and aims in their interactions with patients experiencing suicidal ideation are captured in the core element ‘promoting and preserving safety and a life‐oriented perspective’. This core element represents the three interconnected elements ‘managing the risk of suicide’, ‘guiding patients away from suicidal ideation’, and ‘searching for balance in the minefield’. The enhanced understanding of nurses’ actions and aims can inform concrete strategies for nursing practice and education. These strategies should aim to challenge overly controlling and directing nursing approaches and support nurses’ capacity and ability to connect and collaborate with patients experiencing suicidal ideation.     

Interpersonal problem solving and parasuicide

This study examined the relationship between interpersonal problem solving and suicidal behavior among psychiatric patients. Subjects were 123 psychiatric inpatients, admitted for current parasuicide, serious suicide ideation, or non-suicide-related complaints. A group of 16 orthopedic surgery patients was included to control for hospitalization trauma and current stress. All subjects completed a revised version of the Means-End Problem Solving Procedure, the Rathus Assertiveness Schedule, and a suicide expectancy measure. Psychiatric patients scored lower than the medical control group on the assertive schedule, but no differences were noted as a function of suicidal behavior status. Psychiatric patients expected suicide to solve problems more than did controls. Suicidal patients had higher expectancies than did nonsuicidal patients. Active interpersonal problem solving did not distinguish suicidal and nonsuicidal psychiatric patients but did separate parasuicides from suicide ideators. Among patients without a parasuicide history, less active and greater passive problem solving discriminated first-time parasuicides from suicide ideators and nonsuicidals. Results suggest that assertion deficits may characterize the psychiatric population in general, but suicidal behavior within psychiatric patients may be related to lower active problem solving.This research was supported by National Institute of Mental Health Grant NIMH No. 5 ROI MH34486-03 to Marsha M. Linehan.     

Do suicidal ideation and behaviour influence duration of psychiatric hospitalization?

Suicidal ideation and behaviour are sometimes considered to be manipulative, with the intention of escaping from intolerable situations leading to prolonged hospitalization. The present study examined the length of hospitalization of those who had attempted suicide or had suicidal ideation compared to non-suicidal patients, as measured by the Health of the Nation Outcome Scales in two private psychiatric hospitals. Suicidal patients had a significantly shorter length of hospitalization, despite their significantly greater degree of psychiatric morbidity. Results indicated that it is erroneous to preclude inpatient care for those who are suicidal on the assumption that it will promote prolonged hospitalization.     

Evaluation and treatment of the suicidal patient

Evaluation and treatment of a suicidal patient are challenging tasks for the physician. Because no validated predictive tools exist, clinical judgment guides the decision-making process. Although there is insufficient evidence to support routine screening, evidence shows that asking high-risk patients about suicidal intent leads to better outcomes and does not increase the risk of suicide. Important elements of the history that permit evaluation of the seriousness of suicidal ideation include the intent, plan, and means; the availability of social support; previous suicide attempts; and the presence of comorbid psychiatric illness or substance abuse. After intent has been established, inpatient and outpatient management should include ensuring patient safety and medical stabilization; activating support networks; and initiating therapy for psychiatric diseases. Care plans for patients with chronic suicidal ideation include these same steps, as well as referral for specialty care. In the event of a completed suicide, physicians should provide support for family members who may be experiencing grief complicated by guilt, while also activating their own support networks and risk management systems.     

Unrecognized suicidal ideation in ED patients: are we missing an opportunity?

Objective

To determine whether patients who disclosed suicidal ideation during a health-risk survey had their mental health symptoms documented by physicians and were given mental health referrals and to evaluate how many of these patients subsequently attempted suicide.

Methods

As part of a larger survey, patients responded to questions on a computer kiosk about general health risk behaviors and mental health symptoms. Fifteen months after initiating the survey, we reviewed medical records on those patients who had disclosed suicidal ideation. A standardized abstraction sheet was used to collect data regarding the ED diagnosis at the time of enrollment, physician documentation of suicidal ideation, and referral to psychiatric services, as well as subsequent ED and clinic visits and suicide attempts.

Results

Of the 165 patients who disclosed suicidal ideation on the computer survey, 118 charts (72%) were available. During the index ED visit, only 25% of patients had suicidal ideation or other mental health issues noted on the chart. The majority (76%) of patients were discharged home, 10% were transferred to psychiatric services, and 3% were admitted for medical reasons. Although 72 patients had no future visits to the ED or other hospital-affiliated clinics, 39% of patients had at least one subsequent visit to the ED, and 17% had at least one visit to the psychiatric services. Four patients attempted suicide after their initial index visit to the ED.

Conclusion

Suicidal ideation was self-disclosed frequently by waiting room patients in our urban ED, and patients who disclosed suicidal ideation did not always receive referrals for mental health services.     

Passive Suicidal Ideations in Older Adults: A Case Report

This case study presents the diagnosis and treatment of an older adult with depression and passive suicide ideation (SI). While treating depressed patients at risk for suicide, family nurse practitioners must stay grounded in patient data related to medications, ideally using the patient’s psychiatric condition (ie, depression with suicidal risk) as the separate and appropriate target of clinical intervention, and discuss the risks and benefits of medications targeting both conditions with the patient. The response and ongoing management of individuals with passive SI depend on determining their risk level.     

Suicidal ideation among Viennese high school students

OBJECTIVE: Suicidality spans a spectrum ranging from suicidal thoughts to suicidal acts, and suicidal ideation is more prevalent in youth populations, suggesting important developmental issues. We assessed the prevalence of lifetime suicidal ideation and associated psychosocial factors among Viennese high school students. METHOD: An anonymous self-report survey assessing demographic characteristics and the major psychiatric risk factors of teenage suicide was completed by students at three Viennese high schools (n = 214; mean age 15.4 years). RESULTS: Eighty-one (37.9%) high school students reported having had suicidal thoughts at some point in their lives, girls significantly more often than boys (48.5% vs. 29.1%, P = 0.004). Furthermore, lifetime suicidal ideation in Viennese high school students was associated with living in broken-home families, cigarette smoking, substance problems (alcohol/drugs), self-reported depression, and high school type (the highest prevalence was in grammar school). After adjusting for confounders, we found that female gender, substance problems, school type and cigarette smoking were significantly associated with lifetime suicidal ideation in Viennese high school students. CONCLUSIONS: The psychosocial factors associated with adolescent suicidal ideation require attention in the contexts of suicide prevention and mental health promotion.     

Thoughts of death and suicidal ideation in nonpsychiatric human immunodeficiency virus seropositive individuals

The present study examines the prevalence of death thoughts and suicidality in HIV infection. Subjects (n = 246) were examined for psychiatric morbidity and suicidality. Compared to high risk HIV seronegatives, HIV seropositives (HIV +) had significantly increased frequency and severity of both suicidal ideation and death thoughts. Two-thirds of seropositives had suicidal ideation at some point; half of the seropositives reported suicide plans and one quarter suicide attempts; and third of seropositives reported current suicidal ideation. Suicidal ideation did not increase with advancing disease. The high prevalence of suicidal ideation suggests inclusion of its assessment in HIV treatment regardless of stage.     

Thoughts of Death and Suicidal Ideation in Nonpsychiatric Human Immunodeficiency Virus Seropositive Individuals

The present study examines the prevalence of death thoughts and suicidality in HIV infection. Subjects (n = 246) were examined for psychiatric morbidity and suicidality. Compared to high risk HIV seronegatives, HIV seropositives (HIV +) had significantly increased frequency and severity of both suicidal ideation and death thoughts. Two-thirds of seropositives had suicidal ideation at some point; half of the seropositives reported suicide plans and one quarter suicide attempts; and third of seropositives reported current suicidal ideation. Suicidal ideation did not increase with advancing disease. The high prevalence of suicidal ideation suggests inclusion of its assessment in HIV treatment regardless of stage.     

Suicidal Thoughts and Behavior Among Adults With Self-Reported Pain Conditions in the National Comorbidity Survey Replication

We sought to examine whether the presence of a noncancer pain condition is independently associated with an increased risk for suicidal ideation, plan, or attempt after adjusting for sociodemographic and psychiatric risk factors for suicide and whether risk differs by specific type of pain. We analyzed data from the National Comorbidity Survey Replication, a household survey of U.S. civilian adults age 18 years and older (n = 5692 respondents). Pain conditions, nonpain medical conditions, and suicidal history were obtained by self-report. DSM-IV mood, anxiety, and substance use disorders were assessed using the World Health Organization's Composite International Diagnostic Interview. Antisocial and borderline personality traits were assessed with the International Personality Disorder Examination screening questionnaire. In unadjusted logistic regression analyses, the presence of any pain condition was associated with lifetime and 12-month suicidal ideation, plan, and attempt. After controlling for demographic, medical, and mental health covariates, the presence of any pain condition remained significantly associated with lifetime suicidal ideation (odds ratio, 1.4; 95% confidence interval, 1.1–1.8) and plan. Among pain subtypes, severe or frequent headaches and “other” chronic pain remained significantly associated with lifetime suicidal ideation and plan; “other” chronic pain was also associated with attempt.PerspectiveThe risk for suicidal thoughts and behaviors that may accompany back, neck, and joint pain can be accounted for by comorbid mental health disorders. There may be additional risk accompanying frequent headaches and “other” chronic pain that is secondary to psychosocial processes not captured by the mental disorders assessed.     

Suicidal intent in patients with chronic pain

Suicidal ideation among individuals suffering from chronically painful conditions has not been widely studied, although rates of completed suicide are believed to be elevated in this population relative to the general population. The psychiatric literature on suicide documents the importance of controlling for the severity of depression when studying factors associated with suicidal ideation, attempts, or completion. The present study examined the relationships between suicidal ideation and the experience of pain, pain-related disability, and pain coping efforts among a sample of individuals experiencing chronically painful conditions. Of 200 patients evaluated on an inpatient rehabilitation unit in a psychiatric service, 13 individuals (6.5%) reported suicidal intent on a commonly used self-report measure of symptoms of depression, the Beck Depression Inventory. This group was compared to a matched (age, sex, pain duration) group of similarly depressed individuals (N=13) and a matched group of non-depressed individuals (N=13) on measures of pain, disability, pain beliefs, and pain coping strategies. A history of a suicide attempt was associated with suicidal intent. Family history of substance abuse was significantly more prevalent among the depressed groups, regardless of suicidal thinking. The depressed/suicidal group and depressed/non-suicidal groups reported higher levels of pain, higher levels of pain-related disability, lower use of active coping, and higher use of passive coping compared to the non-depressed group. The depressed groups did not differ from one another on any of the measures of pain experience. Depression, not suicidal status, consistently predicted level of functioning. The prevalence of suicidal intent was comparable to rates observed in other studies and relatively low. When individuals with chronic pain report suicidal intent, it is imperative that measures preventing self-harm be implemented immediately and the patient's depression be treated aggressively.     

Literature-based Recommendations for Suicide Assessment in the Emergency Department: A Review

Background

Suicidal ideation and attempted suicide are important presenting complaints in the Emergency Department (ED). The Joint Commission established a National Patient Safety Goal that requires screening for suicidal ideation to identify patients at risk for suicide.

Objectives

Given the emphasis on screening for suicidal ideation in the general hospital and ED, it is important for Emergency Physicians to be able to understand and perform suicide risk assessment.

Methods

A review of literature was conducted using PubMed to determine important elements of suicide assessment in adults, ages 18 years and over, in the ED. Four typical ED cases are presented and the assessment of suicide risk in each case is discussed.

Results

The goal of an ED evaluation is to appropriately determine which patients are at lowest suicide risk, and which patients are at higher or indeterminate risk such that psychiatry consultation is warranted while the patient is in the ED. Emergency clinicians should estimate this risk by taking into account baseline risk factors, such as previous suicide attempts, as well as acute risk factors, such as the presence of a suicide plan.

Conclusion

Although a brief screening of suicide risk in the ED does not have the sensitivity to accurately determine which patients are at highest risk of suicide after leaving the ED, patients at lowest risk may be identified. In these low-risk patients, psychiatric holds and real-time psychiatric consultation while in the ED may not be needed, facilitating more expeditious dispositions from the ED.     

Brain-derived neurotrophic factor and suicidal behavior

Studies of the neurobiology of suicidal behavior have become an important and integral part of psychiatric research. Over the past several years, studies of the role of brain-derived neurotrophic factor (BDNF) in the pathophysiology of suicidality have attracted significant interest of researchers. Multiple lines of evidence including studies of levels of BDNF in blood cells and plasma of suicidal patients, postmortem brain studies in suicidal subjects with or without depression, and genetic association studies linking BDNF to suicide suggest that suicidal behavior may be associated with a decrease in BDNF functioning. Studies of the BDNF function are important for suicide research and prevention because of the multiple reasons including the following: (i) BDNF plays a role in the pathophysiology of depression, post-traumatic stress disorder, substance use disorders and other conditions associated with suicidal behavior. Treatment-induced enhancements of BDNF can facilitate neural integrity and recovery of function in psychiatric disorders, and consequently prevent suicidal behavior; (ii) abnormal BDNF function may be associated with elevated suicidality independently of psychiatric diagnoses. It is possible that treatment-induced improvement in the BDNF function prevents suicidal behavior independently of improvement in psychiatric disorders; (iii) BDNF may be a biological marker of suicidal behavior in certain patient populations. It is to be hoped that the studies of the neurobiology of suicidal behavior will lead to the development of new methods of suicide prevention.     

Depression and multiple sclerosis: Review of a lethal combination

Depression is the most frequent psychiatric disorder in multiple sclerosis (MS) patients. The etiology of depression is multifactorial and likely associated with psychosocial stress, focal demyelinating lesions, and immune dysfunction. Proper diagnosis and severity assessment are critical prior to initiation of therapy. Patients with suicidal ideation should be referred for immediate psychiatric consultation and be closely monitored. While more therapeutic trials for depression in MS are needed, MS patients have been shown to respond to current antidepressant medications and psychotherapy. Unfortunately, patients with MS and major depression or suicidal thoughts are often underassessed and therefore not diagnosed. Unlike other aspects of MS, depression is treatable. Early intervention in depression can prevent declines in quality of life and even death from suicide. This article reviews the unique features, assessment, and treatment of depression in MS. MS care providers should vigilantly assess depression and suicide risk in their patients.     

Suicidal ideation in outpatients with chronic musculoskeletal pain: an exploratory study of the role of sleep onset insomnia and pain intensity

OBJECTIVES: Sleep disturbance, depression, and heightened risk of suicide are among the most clinically significant sequelae of chronic pain. While sleep disturbance is associated with suicidality in patients with major depression and is a significant independent predictor of completed suicide in psychiatric patients, it is not known whether sleep disturbance is associated with suicidal behavior in chronic pain. This exploratory study evaluates the importance of insomnia in discriminating suicidal ideation in chronic pain relative to depression severity and other pain-related factors. METHODS: Fifty-one outpatients with non-cancer chronic pain were recruited. Subjects completed a pain and sleep survey, the Pittsburgh Sleep Quality Index, the Beck Depression Inventory, and the Multidimensional Pain Inventory. Subjects were classified as "suicidal ideators" or "non-ideators" based on their responses to BDI-Item 9 (Suicide). Bivariate analyses and multivariate discriminant function analyses were conducted. RESULTS: Twenty-four percent reported suicidal ideation (without intent). Suicidal ideators endorsed higher levels of: sleep onset insomnia, pain intensity, medication usage, pain-related interference, affective distress, and depressive symptoms (P < 0.03). These 6 variables were entered into stepwise discriminant function analyses. Two variables predicted group membership: Sleep Onset Insomnia Severity and Pain Intensity, respectively. The discriminant function correctly classified 84.3% of the cases (P < 0.0001). DISCUSSION: Chronic pain patients who self-reported severe and frequent initial insomnia with concomitant daytime dysfunction and high pain intensity were more likely to report passive suicidal ideation, independent from the effects of depression severity. Future research aimed at determining whether sleep disturbance is a modifiable risk factor for suicidal ideation in chronic pain is warranted.     

Subsequent Suicide Mortality among Emergency Department Patients Seen for Suicidal Behavior

Objectives: To determine whether suicide mortality rates for a cohort of patients seen and subsequently discharged from the ED for a suicide-related complaint were higher than for ED comparison groups.
Methods: This was a nonconcurrent cohort study set at a university-affiliated urban ED and Level 1 trauma center. All ED patients 10 years and older, with at least one ED visit between February 1994 and November 2004, were eligible. ED visit characteristics defined the cohort exposure. Patients with visits for suicide attempt or ideation, self-harm, or overdose (exposed) were compared with patients without these visits (unexposed). Exposure classification was determined from billing diagnoses, E-codes (E950–E959), and free-text searching of the ED tracking system data for suicide, overdose , and spelling variants. Emergency department patient data were probabilistically linked to state mortality records. The principal outcome was suicide death. Suicide mortality rates were calculated by using person-year (py) analyses. Relative rates (RR) and 95% confidence intervals (95% CIs) were calculated from Cox proportional hazards models.
Results: Among the 218,304 patients, the average follow-up was 6.0 years; there were 408 suicide deaths (incidence rate [IR]: 31.2 per 100,000 py). Males (IR: 48.3) had a higher rate than females (IR: 13.5; RR: 3.6; 95% CI = 2.8 to 4.6). A single ED visit for overdose (RR: 5.7; 95% CI = 4.5 to 7.4), suicidal ideation (RR: 6.7; 95% CI = 5.0 to 9.1), or self-harm (RR: 5.8; 95% CI = 5.1 to 10.6) was strongly associated with increased suicide risk, relative to other patients.
Conclusions: The suicide rate among these ED patients is higher than population-based estimates. Rates among patients with suicidal ideation, overdose, or self-harm are especially high, supporting policies that mandate psychiatric interventions in all cases.