Preventing Patient Suicide: Clinical Assessment and Management

Robert Simon is one of a handful of psychiatrists with expertise in both law and psychiatry who has made important contributions to our understanding of the risk factors for suicide, aimed at enabling clinicians to protect their patients from suicide and themselves from being blamed for a death by suicide. Particularly noteworthy in this regard is Simon's strong advice not to rely on suicide assessment forms as a substitute for clinical assessment and judgment.

Simon views suicide as the result of many factors: diagnostic, epidemiological, genetic, familial, occupational, environmental, social, cultural, existential, and chance. Although he makes reference to all of these factors, primarily the first two, his focus is on behavior and symptoms in assessing suicide risk. He is concerned with “managing” risk, avoiding the use of the word “treatment.” Obviously, if you do not deal with risk, you will not have a patient to treat, but knowing and listening to patients as you do in psychotherapy has been an important source of our knowledge of suicide risk and the stimulus for research on this topic. Patients in treatment are an important part of the area of suicide research; not discussing them is a serious limitation of this otherwise fine book.

The unfortunate tendency in our profession to rely on treating symptoms leads many municipal hospitals to use a symptom checklist as a substitute for a case narrative. The patient's charts give no picture of what the patient is like and how patients differ from one another. Management of these cases in the hospitals and in those discussed in this book is largely restricted to medication, ECT, or hospitalization.

To avoid dealing with patients in treatment contributes to a lack of sensitivity to key factors in the psychology of suicide. Most important is suicidal patients' use of the possibility of their suicide to give them an illusory sense of being in control of their lives; the use of the threat of suicide serves to give them what, unfortunately, is often a not so illusory control over those who manage or treat them.

Simon recognizes the absence of a good therapeutic alliance as an important risk factor in the assessment of a suicidal patient, indicated by missing treatment sessions with patients or seeming not to care about them. His remedy is increased risk watchfulness. However, a high percentage of suicidal patients are resistant to evaluation, management, or treatment, but they have “defenses” that can be addressed.

Many years ago, I saw a young man who had shot himself in the chest. The bullet grazed his heart and came to rest a centimeter or two from his spinal cord, which was too close to be removed. No one in the hospital where he was taken had ever seen anyone survive such an entry wound. That he had come to see me under pressure from the doctors and his parents was evident before he said a word. When he did speak, his first remark to me was, “I will give you 6 months to make me feel better, and if you don't, the next time I won't miss.” We spent the next month discussing his view that he could leave his fate in my hands and be a passive participant in this therapy. His attitude toward treatment changed, and he was not suicidal again in the year I saw him. He is alive and well, and when he consulted me 30 years later, he reported no further suicide attempts, and the consultation had nothing to do with suicide.

What patients say often indirectly reveals their risk for suicide, and failure to understand such communications can contribute to a suicide. For example, a bipolar patient known to his psychiatrist to be at risk for suicide called her to say that he had mistakenly taken his medication twice in one day and asked whether this was an inadvertent suicide attempt. The therapist assured him that it was not. Underlying the patient's question appeared to be an increasing preoccupation with suicide that was left unaddressed. He killed himself a few days later (1).

In this book, Simon's exclusive focus on behavioral risk factors also contributes to a seeming lack of awareness of the role of intense affective states as key risk factors for suicide. An ongoing 25-year study with therapists of patients who were in treatment with them when they died by suicide, compared with comparably depressed patients who had never been suicidal and were treated by the same therapists, reported evidence that a group of affective states that were not simply present but intense (anxiety, rage, desperation, loneliness, hopelessness, abandonment, self-hatred, and guilt) were key determinants of short-term risk for suicide. The affective state that was most predictive was desperation. Many people can tolerate living with hopelessness, while desperation indicates that it does not matter whether they can eventually be helped because they cannot wait for relief. One study reported evidence that hopelessness and the other affects turn to desperation in the period before suicide (2). That study highlighted that cognitive-behavioral therapy, the most commonly used short-term therapy, is counterproductive for some suicidal patients who use it to hide emotional conflicts. Interpersonal therapy or psychodynamic psychotherapy is likely to be more effective in such cases.

To be fair, Simon accomplishes what he set out to do. His book is not written for psychiatrists who see suicidal patients in psychotherapy. It seems more directed toward psychiatrists who see suicidal patients for short intervals after they have been hospitalized or who see such patients monthly to renew their prescriptions. For both, safety inevitably becomes a primary concern. However, patient safety needs to be a major concern among all of us. Despite its limitations, I have not read a more thorough compilation of evidence-based studies dealing with suicide risk. I believe that anyone who evaluates or treats suicidal patients could benefit from reading this book.