Suicide Risk Assessment and Management

American Psychiatric Association had defined suicide as a self-inflicted death

with evidence (either explicit or implicit) that the person intended to die (APA,
2003). According to Department of Statistics Malaysia, they mentioned that the
prevalence rate for suicide in this country was as low as 1 per 100,000 suicides per
year (National Suicide Registry Malaysia, 2007). Meanwhile, adjunct to that,
National Suicide Registry Malaysia had further elaborated the demographics data on
suicides in Malaysia as reported in the year of 2007, that male to female ratio of
suicides in Malaysia was 3:1; the mean age for suicide was at 38.24 years; Chinese
was the highest (43%) ethnic group which inflicted suicides and followed by Indian
(29%), Malay (11%), Indigenous group (8%) and others (9%); single (44%) and
married (47%) person were prone to suicides as this fact is contradicted to
international literature; secondary educational level showed the highest group that
was prone to inflict suicides; fulltime (57%) employment status was the highest
group that was prone to suicides and followed by unemployed (27%) and temporary
(5%)(National Suicide Registry Malaysia, 2007).
American Psychiatric Association (2003) had also clarified several definitions
which related to suicides, they are as followings:

Suicide attempt is defined as self-injurious behavior with a nonfatal outcome

accompanied by evidence (either explicit or implicit) that the person
attended to die
Aborted suicide attempt is defined as potentially self-injurious behavior with
evidence (either explicit or implicit) that the person intended to die but
stopped the attempt before physical damage occurred
Suicidal ideation is defined as thoughts of serving as the agent of ones own
death. Suicidal ideation may vary in seriousness depending on the specificity
of suicide plans and the degree of suicidal intent
Suicidal intent is defined as subjective expectation and desire for a selfdestructive act to end in death
Lethality of suicidal behavior is defined as objective danger to life associated
with a suicide method or action. Note that lethality is distinct from and may
not always coincide with an individual expectation of what is medically
dangerous
Deliberate self-harm is defined as willful self-inflicting of painful, destructive
or injurious acts without intent to die

There are several factors that influence suicides to take place. According to
Cowen, Burns and Harrison (2012), there were individual psychiatric and medical
factors, social factors, biological factors and psychological factors. The most
common psychiatric and medical conditions were personality disorders; almost 50%
of people diagnosed with personality disorders had suicide, mood disorder; about
6% of those who had mood disorder would commit suicide especially depressive

disorder whereby they majority of them died by suicide, alcohol misuse; patients
who were dependent on alcohol showed a lifetime risk of 7% with a continuing risk
of suicide and among them, it was more likely happened in male, older people, long
history of drinking, history of depression and of previous suicidal attempts, drug
misuse; relatively common among those who die by suicide, particularly in the
young age, and schizophrenia; suicide rate increased among young men early in the
disorder especially when relapses occur, presence of depressive symptoms and
when illness turned previous academic success into failure. The lifetime risk of those
having schizophrenia was estimated to be 5%. Others were past history of
deliberate self-harm and poor physical health especially epilepsy. Studies done by
Gunwell et al. (1995) and Whitley et al. (1999) that were stated by Cowen, Burns
and Harrison (2012) in Shorter Oxford textbook of Psychiatry revealed that higher
suicidal rates occurred in areas with high unemployment, poverty, divorce and
social fragmentation. Cowen, Burns and Harrison (2012) also mentioned that
Howton et al. (1999b) revealed that media coverage of suicide such as in television
programmes and films depicting suicide was another social factor that influence
rates of suicide where the rates increased. Biological factors of family history of
suicide also influence suicides in which the mechanism was due to genetics
influence as indicated in a study done by Wender et al. (1986) as mentioned by
Cowen, Burns and Harrison (2012). Decrease activity of brain 5-HT pathways was
also linked to suicidal behavior and may be related to increase impulsivity and
aggression. Psychological factors mainly hopelessness had the highest rates of
suicide. Predisposing factor for individual to act impulsively that associated with
suicidal behavior include impulsivity, dichotomous thinking, cognitive constriction,
problem-solving deficits and overgeneralized autobiographical memory. As a
conclusion, all those factors mentioned that were interacting influences of suicides.
Practical Guideline for the Assessment and Treatment of Patients with Suicidal
Behaviors which published by American Psychiatric Association in the year of 2003,
mentioned that there are several circumstances in which suicide assessment may
be indicated clinically. The indications are emergency department and crisis
evaluation, intake evaluation on either an inpatient or an outpatient basis, before a
change in observation status or treatment setting such as discontinuation of one-toone observation and discharge from inpatient setting, abrupt change in clinical
presentation either precipitous worsening or sudden, dramatic improvement, lack of
improvement or gradual worsening despite treatment, anticipation or experience of
significant interpersonal loss or psychosocial stressor such as divorce, financial loss,
legal problems, personal shame or humiliation and the onset of a physical illness
particularly if it was life threatening, disfiguring, or associated with severe pain or
loss of executive functioning. Besides that, four main components were included in
the assessment of patients with suicidal behaviors which are conducting a thorough
psychiatric evaluation, specifically inquiring about suicidal thoughts, plans and
behaviors, establishing a multiaxial diagnosis (not cover in here since this approach
is not longer use in DSM-5) and estimating suicide risk.

In order to conduct a thorough psychiatric evaluation, American Psychiatric

Association had mentioned several items that should be assessed during the
evaluation. One of the items that were included in psychiatric evaluation is
identifying psychiatric signs and symptoms. APA recommended that
psychiatrist should determine both the signs and symptoms associated with the
presence of specific psychiatric diagnoses and one should search for specific
psychiatric symptoms which may influence suicide risk. Examples of specific
psychiatric symptoms are aggression, violence toward others, impulsiveness,
hopelessness, agitation, psychic anxiety, anhedonia, global insomnia and panic
attack.
For the next item which was assessing past suicidal behavior,
including of self-injurious acts, psychiatrist should obtain details about the
attempt in term of its precipitants, timing, intent, consequences and medical
severity as well as delineate interpersonal aspects of the attempt in order to
understand the issues behind it. For example, person present at time of the attempt
or to whom the attempt was communicated. In addition, the psychiatrist should
determine the patients thoughts about the attempt such as perception of potential
for lethality, ambivalence toward living, visualization of death, degree of
premeditation, persistence of suicidal ideation and reaction to the attempt. Besides
that, reviewing past treatment history and treatment relationships is also
included in which review on psychiatric history; previous and comorbid diagnoses,
prior hospitalizations and other treatment and past suicidal ideation should be done.
Also, history of medical treatment should be reviewed which include, identify
medically serious suicide attempts and past or current medical diagnoses. The
strength and stability of current and past therapeutic relationships should be
included. Identifying family history of suicide, mental illness and
dysfunction specifically about suicide attempts and psychiatric hospitalizations,
including substance use disorders. Furthermore, the circumstances of suicide in
first-degree relatives, including the patients involvement and the patients and
relatives ages at the time should be determined. In addition, inquire about
childhood and current family milieu, including history of family conflict or
separation, parental legal trouble, family substance use, domestic violence and
physical and/or sexual abuse. Others which are identifying current psychosocial
situation and nature of crisis which are acute psychosocial crises or chronic
psychosocial stressor that may further increase suicide risk. As for example,
financial or legal difficulties, interpersonal conflicts or losses, stressors in gay,
lesbian or bisexual youths, housing problems, job loss and educational failure. The
last item was appreciating psychological strength and vulnerabilities of the
individual patient. Coping skills, personality traits, thinking style, developmental
and psychological needs which may affect the patients suicide risk and the
formulation of the treatment plan should be inquired.
Suicidal thoughts, plans and behaviors were also specifically inquired and to inquire
these, eliciting the presence or absence of suicidal ideation should be asked
by simply asking the patients feeling about living with questions such as How does

life seem to you at this point? or Have you ever felt that life was not worth living?
or Did you ever wish you could go to sleep and just not wake up?. If the suicidal
ideation is present, the nature, frequency, extent and timing of suicidal thoughts,
and consider their interpersonal, situational and symptomatic context should be
focused. Collateral history regarding suicidal ideation is needed to determine
whether the patient have observed behavior like recent purchase of a gun or have
been privy to thoughts that suggest suicidal ideation. However, if the patient is
found to be intoxicated with alcohol or other substances when initially interviewed,
the suicidal ideation should be reassessed at later time. The detailed information on
specific plans for suicides and any steps taken toward enacting them and the
patients belief toward lethality of suicidal method should also be evaluated. In
addition, the conditions under which the patient would consider suicide should also
be inquired for example, divorce, going to jail and housing loss and psychiatrist
should estimate the likelihood that such plan will be formed and completed in the
near future. Lastly, the presence of a firearm in home or workplace should be
inquired and psychiatrist should try to restrict the access to, securing, or removing
those weapons. The patients degree of suicidality, including suicidal intent
and lethality of plan should be assessed by determining motivation,
seriousness and extent of suicidal intents as well as associated behavior and
planning and lethality of the chosen method. The suicide assessment scales
were recognized to have very low predictive values and do not provide
reliable estimates of suicide risk. Nonetheless, it may be useful to provide
thorough line of questioning or opening communication regarding suicidal intention
with the patient.
The last component is estimation of suicidal risk. In order to estimate this risk,
identifying factors that may increase or decrease the patients level of risk
such as the presence of a psychiatric disorder and medical illness associated with
increased likelihood of suicide such as malignant neoplasm should be done. Besides
that, the factors that associated with protective effects for suicide should be
assesed such as children in the home, sense of responsibility to family, pregnancy,
religiosity, life satisfaction, reality testing ability, positive coping skills, positive
problem-solving skills, positive social support and positive therapeutic relationship.
American Psychiatric Association in its Practical Guideline for the Assessment and
Treatment of Patients with Suicidal behaviors also provide a guide for indications of
hospitalization, there are as followings; after a suicide attempt or aborted suicide
attempt, and patient is psychotic; attempt was violent or near lethal; precautions
taken by the patient to avoid rescue and discovery; persistent plan and/or intent is
present; increased distress and patient regrets upon surviving; male patient which
older than age 45 especially with recent onset of psychiatric illness or suicidal
thinking; poor family or social support; impulsiveness, agitation and poor judgment
and change in mental status which required further workup. In addition, those who
with the absence of a suicidal attempt but in the presence of suicidal ideation,

which with specific plan with high lethality and high suicidal intent also require
admission to the hospital.
APA had describes the management of suicidal behaviors by emphasizing following
elements in its management, 1) Establish and maintain therapeutic alliance. It
is necessary in order to address and explore suicidal ideation and behaviors. 2)
Attend to the patients safety. If available, consider observation on a one-to-one
basis or by continuous closed circuits television monitor until an assessment of
suicide risk is completed or if the patient bears significant suicide risk. Also, any
potentially hazardous items from the patients room should be removed and (if
available) patients should be screened for potentially dangerous items by searching
or scanning them with metal detectors. 3) Next to determine a treatment
setting. It should be aware that the treatment setting for this patient should be
least restrictive yet most likely to prove safe and effective which taken into
consideration about estimated suicide risk and potential for dangerousness to other.
4) Develop a plan of treatment. Provision of treatment plan should consider
potential beneficial and adverse effects of each option along with information about
the patients preferences. Also, if any, substance use disorder should be addressed.
One should remember that to provide more intense follow-up in the early stages of
treatment since the first week after discharge is the period of highest risk with 50%
chances (Hunt et al., 2009). 5) Coordinate care and collaborate with other
clinicians. One should establish clear role definition and communicate with other
caregivers who providing therapy. 6) Promote adherence to the treatment
plan. One should establish a positive physician to patient relationship and creating
an atmosphere in which the patient feels free to discuss any positive or negative
aspects of the treatment process. 7) Provide education to the patient and
family. 8) Reassess safety and suicide risk. One should repeat suicidal
assessments over time because of the waxing and waning nature of suicidality. 9)
Monitor psychiatric status and response to treatment. Monitor is important
during early phases of treatment since some medications may take several weeks
to provide their therapeutic benefit. 10) Obtain consultation, if indicated.
Consultation may be of help in monitoring and addressing counter transference
issues and it also may be important in affirming the appropriateness of the
treatment plan or suggesting other possible therapeutic approaches.
APA also describes somatic therapies for suicidal behaviors in its guideline; the use
of antidepressant is supported by the strong association between depressive
disorders and suicide; long-term maintenance treatment with lithium salts in
patients with recurring bipolar disorder and major depressive disorder is associated
with substantial reduction in risk of both suicide and suicidal attempts; no evidence
of reduction in risk of suicidal behavior with any other mood-stabilizing
anticonvulsant agents; there is also reduce risk of suicidal attempt and suicide in
schizophrenic patient who treated with clozapine. Besides that, other typical and
atypical antipsychotic may also reduce suicidal risk; the use of antianxiety agents

may have the potential to decrease suicidal risk since it is known that anxiety is a
significant and modifiable risk for suicide. However, benzodiazepines occasionally
disinhibit aggressive and dangerous behaviors and enhance impulsivity particularly
in patients with borderline personality disorder; ECT may reduce suicidal ideation, at
least in the short term. Beside those somatic therapies, psychotherapies should be
provided in this patient. Clinical consensus suggests that psychosocial interventions
and specific psychotherapeutic approaches are of benefits.
References:
Association, A. P. (2003) Practice guideline for the assessment and treatment of
patients with suicidal behaviors. Washington, D.C.: American Psychiatric
Association.
Cowen, P., Burns, T. and Harrison, P. J. (2012) Shorter Oxford textbook of psychiatry.
6th edn. Oxford: Oxford University Press.

Hayati A.N., Abdullah A.A., & Shah M.M. (Eds.). (2008). National Suicide Registry
Malaysia: Preliminary Report July Dec 2007. Kuala Lumpur: Suicide Registry
Unit.