Dr. Grossi's Blog
There are psychiatrists who have had a patient commit suicide and there are psychiatrists who will have a patient commit suicide. High-risk patients in clinical practice are not uncommon. Assessment of the risks have been complicated by a variety of factors in the past. Among them were flaws in the precision of definitions and measurements. For example, an overdose of medication might be called a gesture, an accident, a threat, a cry for help, an attempt, or a manipulation. This imprecision hindered a more organized study of this problem.
A number of years ago the FDA convened a task force to study this problem. It was largely driven by development and introduction of a large number of antidepressants in the 1990s and the desire to determine whether these newer agents were implicated in increasing suicidal behavior. This led to the "black box" warnings that are present in the antidepressant entries in the Physician's Desk Reference. It also led to a more precise measurement of suicidal risk. What follows is a description of factors to consider in a more modern risk assessment.
The assessment of suicide is divided into three areas. First is that of suicidal ideation. This includes wishes to be dead, thoughts of wanting to end one's life, thoughts of suicide with some consideration of means, thoughts of suicide with some intent to act, thoughts with a detailed plan that has been developed. The second area is designated intensity of ideation. This includes the number of times a person has suicidal thoughts per day or week, the amount of time engaged with those thoughts, whether the individual can control or stop thinking the thoughts, whether there are deterrents such as children, family, etc. that stop the individual from thinking about suicide. This area also includes the reasons for thinking about suicide such as attention, revenge, pain, etc. The third and final area is suicidal behavior. This includes whether an attempt was made, how many attempts, type of attempts, any non-suicidal self-injurious behavior, any interrupted or aborted attempts and any preparatory acts or behavior.
The weighing of the above factors as well as considering whether the patient has a substance abuse problem, is psychotic, has a history that includes the suicide of significant others as well as the quality and strength of the relationship to the psychiatrist or therapist make the final judgment about suicidality of a particular individual a complex and challenging decision. Taking all these issues into account does help to make a reasonably accurate but not perfectly accurate response to the individual's question, "To be or not to be."