THE ASSESSMENT OF SUICIDE RISK
You are listening to ReachMD XM 157, the channel for
medical professionals. Knowing the risk factors for suicide, recognizing
warning signs and taking appropriate actions are the best ways to prevent
suicide. Depression is one of the greatest risk factors for suicide and
studies have found that physicians do not recognize or treat 40% to 60% of
patients with depression. How and when should clinician include a risk
assessment for suicide in their practice and how can medical professionals
enlist others to be on the lookout for warning signs that someone might be
contemplating suicide? Welcome to the clinician's roundtable. I am Dr.
Kathleen Margolin and joining me from Atlanta, Georgia is psychiatrist, Steven
Garlow of the Department of Psychiatry and Behavioral Sciences at Emory
University School of Medicine.
Welcome Dr. Garlow.
Thanks, it is a pleasure to be here.
Dr. Garlow, can we begin our discussion of suicide
prevention by going over some of the basics?
How prevalent is suicide and how prevalent are suicide
Those are excellent questions and they have two different
answers really. Suicide is overall the 11th leading cause of deaths in the
United States, approximately 1 person in the United States kills himself every
16 minutes, more or less depending on the age, but that risk is not universal
across all ages. For young people, for adolescent young adults, it is either
the third or second leading cause of death and for old people as well, it rises
to one of the higher leading causes of death. The risk is highest on a
capitated basis in elderly males.
And how are we defining elderly at what age?
It depends either 65 and above or 85 and above in the
old-old, and in particular, white males are at extremely high risk.
Let us talk about the warning signs of suicide.
The risks for suicide for completed suicide are there are we
refer to as modifiable risks factors or modifiable warning signs and some that
are not, so certain things you cannot really change like being male increases
risk, being older increases risk, being white increases risk. None of those
are really changeable, but things that you should be looking for in a person as
a physician as a clinician should be high degree of distress what is referred to
sometime as psychic pain or psychic tension, high degree of anxiety, high
degree of restlessness, affective instability that is person's emotions, they
burst out in tears easily. They are just no gating, no control on their
emotional state, or the herald state that really puts the person at risk. That
is a very high-risk state regardless of whether the person is sane or feeling
suicidal, are certainly the presence of suicidal ideation is a risk factor we
shall be speaking for and as clinician, as medical practitioners, we should
never by shy about asking about it. If we do not ask, our patients will never
You are describing the symptoms of clinical depression here.
More than just depression, really looking for somebody who
is really stirred up, who is feeling that there is no way out, there is no
escape, there is no solution, overwhelmed, feelings of tremendous distress,
coupled with feelings of depression or depression in itself increases risk, so
people who are sad and feeling forlorn and feeling helpless and having sleep
disturbance, all of the classic symptoms of depression that we think about or
part of the problem, are part of what we are looking for, but on top of that
looking for person who is anxious and agitated and restless and cannot sit
still and their emotions cannot sit still either, that is a person who is at
very high risk.
Hmm-hmm, so even among those who are depressed, we can
further distinguish even beyond suicidal ideation and look at the quality of
Right. Unfortunately suicidal ideation does not have a
great deal of specificity in terms of identifying people who ultimately commit
suicide. It is a fairly common occurrence in people and it is part of the
definition of major depression in people who have depression will have thoughts
of death and suicidal ideation, ultimately everybody who kill themselves at
some point have to have thought, "I am going to kill myself", but
most everybody who thinks that does not go on to end up dying by suicide.
And you mentioned that state of extreme agitation can almost
also be the flip side where someone is so lethargic and hopeless and!
Hopeless is the word. Not so much lethargic, but hopeless.
Person who has developed hopelessness and then comes to this as a solution to
this hopelessness that would be another common state. That is a very hard one
to pick up for clinicians because that is the person who is probably not going
to come to our attention; they are probably not going to end up in our office
or any other consultation. Because of that they are not going to come in front
of us, we need to be extensive to what we are looking for it. Person comes to
the physician's office to be looking for that kind of mood state, that kind of
emotional state, but very often that is a person who is going to do something in
a kind of an organized fashion to kill themselves and never have told anybody
And that leads to me think of this other phenomena that
happens is kind of tricky and it is that switch in affect that can occur in a
patient right before the suicide attempt.
Right. That has been recognized for many years, especially
people treated for depression that when they start getting better for some
reason, maybe they have more energy, they have more motivation, they are
feeling better, then suffers some minor setback, but early on in their course
of recovery, a window of risk open that they can respond and end up killing
themselves on upswing when they are getting better as opposed to when they are
down at the very bottom.
Clinicians often have such brief contact with patients and
sometimes feels the risk for suicide, hesitate to disclose all of these
symptoms that we have been discussing and it is just not as easily detectable
as an obvious physical condition would be. What do you think the clinician's
responsibility is when it comes to assessment and education?
Well, I am a psychiatrist, so every patient I see is subject
to a suicide risk assessment that is essential to psychiatric practice,
essential to mental status examination that I would conduct on patients for
somebody who is not in a mental health setting, being aware of it, being like I
said earlier not shy about asking about it, and being explicit. We cannot
speak in euphemism. We have to speak very directly, "are you thinking of
killing yourself?" questions like that or around that type of, "how
is your mood, how is your sleeping, are you feeling anxious, are you feeling
desperate", and one of the thing that happens in lot of practices is because
we do not have so much time, we do not want to open that door. Suddenly a
patient unstable they are having strong affective response and that is going to
take up more time. We have to get onto the next patient that can be
difficult. That is one on the tensions that we all face in practice nowadays.
Right, but it is just too important not to.
Do you also feel that physician, psychiatrist, and other
types of physicians have any kind of responsibility to educate the population
in general, not just those we think might be thinking about this, but just
whoever comes across your path so that more eyes are looking out for the signs
However, actually, we think this is something that we as
physicians and we as psychiatrists, I think, have to do a better job of
educating a larger medical community about the signs of depression, the risk
factors for suicide, to encourage people to be frank in their discussions, to
not be afraid to talk about it or to be embarrassed to talk about it, to be
forthright, as well I think we have an obligation to have outreach in education
to the community as well, to the lay community, to the patient community. I
feel for me, one of my obligation is to be available to do speaking, to go to
organizations and various types of entities and talk about suicide, suicide
risk, and not professional entities, lay organizations of various types to talk
about getting their involvement in prevention efforts and those sort of things.
If you just joined us, you are listening to Reach MD XM
157, the channel for medical professionals. I am Dr. Kathleen Margolin and my
guest is psychiatrist, Steven Garlow, and we discussing the assessment of
Dr. Garlow you just mentioned educating the lay community
and if physicians are going to hesitate at times to talk about the subjects, it
is very understandable that others would be as well. Can you talk about the
second important part of suicide prevention and that is taking appropriate
action? What is the recommended advice for clinicians and then for lay people?
Appropriate action can be defined along a wide spectrum. It
can be as much as hospitalizing the person, making a strong intervention if the
patient is eminently at risk. It can be recommending the person get into
treatment, encouraging the person to get into treatment, making some definitive
step towards treatment. One thing to keep in mind is depression is a very
treatable condition. Most suicidal crises are transient, and if we can help
safe harbor that person through that crisis, that is a life saved. One of the
things that we as physicians need to talk about again in terms of with our
patients looking at suicide risk assessment, we always have to ask about things
like weapons in the home and unsecured medication in the home, both to patient
directly as well as to
DICTATION ENDS ABRUPTLY