Suicide — Assessing Potential Lethality

There’s no good data on how to determine who will attempt / commit suicide.  Lots of risk factors have been identified, but no decent way to predict.  Things to consider:

Plan  —  Have they decided how they’d commit suicide?  If so:
  • Are means available (does patient have / know how to buy a gun?
  • Is patient able to implement (e.g. know how to use a gun)?
  • Does it seem lethal?  A benign plan that’s perceived as lethal to patient is nonetheless concerning.  I had one patient attempt overdose on 8 amoxicillin capules, but she was real serious about it.
  • Is rescue likely?

Preparation  —  If there’s a plan, has patient decided on time & place?  Have they practiced?  Written suicide note / recent will?

Prior Attempt  —  This greatly increases risk.

Psychosis  —  Ask if the patient hears voices.  If so, what do they say?  Command hallucinations, i.e. voices telling patient to kill themselves, are the worst.

Determination  —  How determined are they to kill themselves?  How often do they think about it?

Substance Use / Impulsivity  —  Binging is the most dangerous type of substance use.  Persons who endorse acting impulsively in general are at high risk (especially adolescents)

Hopelessness  —  Of all the characteristics of depression, a sense of hopelessness is the one most associated with suicidality.  Makes sense.  Interestingly, it’s not included per se in DSM-4 diagnostic criteria of major depression.

WHAT TO DO ???    If a patient has suicidal ideation plus a realistic plan with imminent intent, call the police.  Not an ambulance, since EMTs don’t restrain people.