Clinicians Aid to Assessing Suicidal Risk
Clinicians may find the following 22 factors useful in assessing suicidal risk. Four qualifications are key. First, the factors are general, and exceptions are frequent. In many instances, two or more factors may interact. For example, being married and being younger, taken as individual factors, tend to be associated with lower risk for suicide. However, married teenagers have historically shown an extremely high suicide rate (Peck & Seiden, 1975). Second, these factors are not static. New research enriches our understanding as well as reflects changes. The suicide rate for women, for example, has been increasing, bringing it closer to that for men. Third, the list is far from comprehensive. Fourth, these factors may be useful as guidelines but cannot be applied in an unthinking, mechanical, conclusive manner. Someone may rank in the lowest-risk category of each factor and still commit suicide. These factors can help us think through a situation but never replace a comprehensive, humane, and personal evaluation of a unique patient’s suicidal risk. Again it is worth returning to a central theme of this book’s approach to ethics: perhaps the most frequent threat to ethical behavior is the therapist’s inattention. Making certain that we consider such factors with each patient can help us prevent the ethical lapses that come from neglect.
- Direct verbal warning. A direct statement of intention to commit suicide serves as one of the most useful single predictors. Take any such statement seriously. Resist the temptation to reflexively dismiss such warnings as “a hysterical bid for attention,” “a borderline manipulation,” “a clear expression of negative transference,” “an attempt to provoke the therapist,” or “yet another grab for power in the interpersonal struggle with the therapist.” It may be any or all of those and yet still foreshadow suicide.
- Plan. The presence of a plan increases the risk (see, e.g., Stack, 2014). The more specific, detailed, lethal, and feasible the plan is, the greater the risk.
- Past attempts. Most, and perhaps 80% of, completed suicides follow a prior attempt. Schneidman (1975; see also Wong, Stewart, & Claassen, 2008) found that the client group with the greatest suicidal rate were those who had entered into treatment with a history of at least one attempt.
- Indirect statements and behavioral signs. People planning to end their lives may communicate their intent indirectly through their words and actions—for example, talking about “going away,” speculating on what death would be like, giving away their most valued possessions, or acquiring lethal instruments.
- Depression. The suicide rate for those with clinical depression is about 20 times greater than for the general population. Guze and Robins (1970; see also Stack, 2014; Taliaferro & Muehlenkamp, 2014; Vuorilehto, Melartin, & Isometsa, 2006), in a review of seventeen studies concerning death in primary affective disorder, found that 15% of the individuals suffering from this disorder killed themselves. Effectively treating depression may lower the risk of suicide (Gibbons, Hur, Bhaumik, & Mann, (2005); Mann, (2005).
- Hopelessness. The sense of hopelessness appears to be more closely associated with suicidal intent than any other aspect of depression (Beck, 1990; Beck, Kovaks, & Weissman, 1975; see also Maris, 2002; Martin, Dorken, Simpson, McKenzie, & Colman, 2014; Petrie & Chamberlain, 1983; Taliaferro & Muehlenkamp, 2014; Violanti, Andrew, Mnatsakanova, et al. 2015; Wetzel, 1976).
- Intoxication. Between one-fourth and one-third of all suicides are linked to alcohol as a contributing factor; a much higher percentage may be associated with the presence of alcohol (without clear indication of its contribution to the suicidal process and lethal outcome). Moscicki (2001; see also Buri, Von Bonin, Strik, et al., 2009; Crosby et al., 2009; Kõlves, Värnik, Tooding, & Wasserman, 2006; Sher, 2006; Sher et al., 2009) notes that perhaps as many as half of those who kill themselves are intoxicated at the time. Darke, Duflou, and Torok (2009) found that alcohol was more common where a suicide note was left and where relationship problems were involved. Pharmaceuticals were more common where a previous attempt was noted. Licit and illicit substances are strongly associated with suicide, even when the method does not involve drug overdose.
Hendin, Haas, Maltsberger, Koestner, and Szanto’s study, “Problems in Psychotherapy with Suicidal Patients” (2006), emphasized that “addressing and treating suicidal patients’ substance abuse, particularly alcohol abuse, is critical in effective treatment of other problems, including lack of response to antidepressant medication” (Zhang, Conner, & Phillips, (2010)).
- Marital separation (distinct from divorce). Wyder, Ward, and De Leo (2009) found that “for both males and females separation created a risk of suicide at least four times higher than any other marital status. The risk was particularly high for males aged 15 to 24.
- Clinical syndromes. People suffering from depression or alcoholism are at much higher risk for suicide. Other clinical syndromes may also be linked to an increased risk. Perhaps as many as 90% of those who take their own lives have a formal diagnosis (Moscicki, 2001). Kramer, Pollack, Redick, and Locke (1972) found that the highest suicide rates exist among clients diagnosed as having primary mood disorders and psychoneuroses, with high rates also among those having organic brain syndrome and schizophrenia (see also Draper, Peisah, Snowdon, & Brokaty, (2010); Novick, Schwartz, & Frank, (2010)). Palmer, Pankratz, and Bostwick ((2005); see also Brenner, Homaifar, Adler, et al., (2009); Loas et al., (2009); Pretti, Meneghelli, & Cocchi, 2009) found that the lifetime risk for suicide among people with schizophrenia was around 5%. Drake, Gates, Cotton, and Whitaker (1984) discovered that those suffering from schizophrenia who had very high internalized standards were at particularly high risk. In a long-term study, Tsuang (1983) found that the suicide rate among the first-degree relatives of schizophrenic and manic-depressive clients was significantly higher than that for a control group of relatives of surgery patients; furthermore, relatives of clients who had committed suicide showed a higher rate than relatives of clients who did not take their lives. Using meta-analytic techniques, Harris and Barraclough (1997) obtained results suggesting that “virtually all mental disorders have an increased risk of suicide excepting mental retardation and dementia. The suicide risk is highest for functional and lowest for organic disorders” (Chan et al., 2009).
- Sex. The suicide rate for men is more than three times that for women (CDC, 2010; see also Joiner, (2005) (2010)). For youths, the rate is closer to five to one (see Safer, (1997)). The rate of suicide attempts for women is about three times that for men.
- Age. A significant change occurred in this category. The earlier editions of this book had noted that the risk for suicide tended to increase over the adult life cycle. However, more recently suicide has peaked in middle age: “The highest rates of suicide by age group occurred among persons aged 45–54 years, 75–84 years, and 35–44 years (17.6, 16.4, and 16.3 per 100,000 population, respectively” (CDC, 2010). As noted earlier in this chapter, Hempstead and Phillips (2015) report that 1991 marked the start of a significant rise in middle-age suicide rates, a rise that speeded up beginning in 2007. Suicide risk assessment differs also according to whether the client is an adult or a minor. The assessment of suicidal risk among minors presents special challenges. Safer’s review of the literature indicated that the “frequent practice of combining adult and adolescent suicide and suicide behavior findings can result in misleading conclusions” (1997). Zametkin, Alter, and Yemini (2001) note that the rate of suicide among adolescents has significantly increased in the past 30 years. In 1998, 4153 young people aged 15 to 24 years committed suicide in the United States, an average of 11.3 deaths per day. Suicide is the third leading cause of death in this age group and accounts for 13.5% of all deaths. Children younger than 10 years are less likely to complete suicide, and the risk appears to increase gradually in children between 10 and 12 years of age. However, on average, 170 children 10 years or younger commit suicide each year.
- Race. Generally in the United States, Caucasians tend to have one of the highest suicide rates (CDC, 2010). Gibbs (1997) discusses the apparent cultural paradox: “African-American suicide rates have traditionally been lower than White rates despite a legacy of racial discrimination, persistent poverty, social isolation, and lack of community resources”. EchoHawk (1997) notes that the suicide rate for Native Americans is “greater than that of any other ethnic group in the U.S., especially in the age range of 15–24 years” (p. 60). In Canada, the Nunavut Inuit suicide rate is 13 times higher than the rate in the rest of Canada (“Suicide Numbers in Nunavut in 2013 a Record High; Nunavut Youth Decry Lack of Help for Those Thinking About Suicide,” 2014).
- Religion. The suicide rates among Protestants tend to be higher than those among Jews and Catholics.
- Living alone. The risk of suicide tends to be reduced if someone is not living alone, reduced even more if he or she is living with a spouse, and reduced even further if there are children.
- Bereavement. Bereavement tends to place survivors at increased risk of taking their own lives (Hollingshaus & Smith, 2015; Pitman, Osborn, King, & Erlangsen, 2014). Brunch, Barraclough, Nelson, and Sainsbury (1971) found that 50% of those in their sample who had committed suicide had lost their mothers within the past three years (compared with a 20% rate among controls matched for age, sex, marital status, and geographical location). Furthermore, 22% of the suicides, compared with only 9% of the controls, had experienced the loss of their father within the past five years. Krupnick’s review of studies (1984) revealed “a link between childhood bereavement and suicide attempts in adult life,” perhaps doubling the risk for depressives who had lost a parent compared to depressives who had not experienced the death of a parent. Klerman and Clayton ((1984); see also Beutler, (1985)) found that suicide rates are higher among the widowed than the married (especially among elderly men) and that among women, the suicide rate is not as high for widows as for the divorced or separated. The suicide risk tends to rise around the anniversary of the loss (Rostila, Saarela, Kawachi, & Hjern, 2015). Unemployment tends to increase the risk for suicide.
- Health status. Illness and somatic complaints are associated with increased suicidal risk, as are disturbances in patterns of sleeping and eating. Clinicians who are helping people with AIDS, for example, need to be sensitive to this risk (Pope & Morin, 1990).
- Impulsivity. Those with poor impulse control are at increased risk for taking their own lives (Rimkeviciene & De Leo, 2015; see also Maloney et al., 2009; Patsiokas, Clum, & Luscumb, 1979; Wu et al., 2009).
- Rigid thinking. Suicidal individuals often display a rigid, all-or-none way of thinking (Maris, (2002); Neuringer, (1964)). A typical statement might be, “If I can’t find a job by the end of the month, the only real alternative is suicide.”
- Stressful events. Excessive numbers of undesirable events with negative outcomes have been associated with increased suicidal risk (Cohen-Sandler, Berman, & King, (1982); Isherwood, Adam, & Homblow, (1982)). Bagley, Bolitho, and Bertrand (1997), in a study of 1,025 adolescent women in grades 7 to 12, found that “15% of 38 women who experienced frequent, unwanted sexual touching had ‘often’ made suicidal gestures or attempts in the previous 6 months, compared with 2% of 824 women with no experience of sexual assault” (p. 341; see also McCauley et al., (1997)). Some types of recent events may place clients at extremely high risk. For example, Ellis, Atkeson, and Calhoun (1982) found that 52% of their sample of multiple-incident victims of sexual assault had attempted suicide.
- Release from hospitalization. Beck ((1967), p. 57) has noted that “the available figures clearly indicate that the suicidal risk is greatest during weekend leaves from the hospital and shortly after discharge.” Hunt and colleagues’ study of “Suicide in Recently Discharged Psychiatric Patients: A Case-control Study” found that the weeks after discharge represent a critical period for suicide risk. Measures that could reduce risk include intensive and early community follow-up. Assessment of risk should include established risk factors as well as current mental state and there should be clear follow-up procedures for those who have self-discharged.
Francis (2009) points out the relationship between suicidal risk and release from hospitalization may be complex when borderline personality disorder is at issue:
People with borderline personality disorder (BPD) are sometimes admitted to inpatient wards due to risk to themselves. However, recent research indicates inpatient settings are detrimental to BPD and can worsen symptoms (unless they are planned short stays). Staff are often too fearful … to release them if they are still expressing suicidal thoughts. If the presentation is not different (no major crises have occurred, no major losses made) then clinically indicated risk-taking is the recommended course of action.
- Lack of a sense of belonging. Joiner’s review of the research and his own studies led him to conclude that an unmet need to belong is a contributor to suicidal desire: suicidal individuals may experience interactions that do not satisfy their need to belong (e.g., relationships that are unpleasant, unstable, infrequent, or without proximity) or may not feel connected to others and cared about. (2005, p. 97)
This is adapted from chapter 25 of the book Ethics in Psychotherapy and Counseling: A Practical Guide, 5th Edition by Kenneth S. Pope, Ph.D., ABPP & Melba J.T. Vasquez, Ph.D., ABPP, published by John Wiley. Copyright ©2016 John Wiley, an imprint of John Wiley, Publishers. It is presented here only for personal and individual use. Questions about any other use involving copyright should be addressed to John Wiley. Do not reproduce in any form or medium without prior written permission.